Committee on Infectious Diseases of Japanese Society for Dialysis Therapy (JSDT) tried to describe the prevalence of hepatitis C virus (HCV) infection in Japanese end-stage renal disease (ESRD) patients on chronic dialysis therapy.
Questionnaire on hepatitis C infection estimated by the second-generation antibodies were sent to 2, 309 dialysis institutions on February 1992. The response rate was 61.1% of the institutions, which covered 57.2% of hemodialysis (HD) and 52.1% of continuous ambulatory peritoneal dialysis (CAPD) populations. The recovery rates in seven areas in Japan were not different. The economical background of responded institutions were not different from those of all Japanese dialysis population.
The ratio of HCV antibody positive patients were 23.9% of HD patients and 11.2% of CAPD patients. The ratio in HD ranged from 19.6% in Tokyo to 26.7% in Shikoku-Kyushu. The ratio in CAPD ranged from 7.6% in Hokkaido-Tohoku to 14.0%. As complications of HCV infection, prevalence of HCV positive liver cirrhosis and hepatocellular carcinoma were 8.57 patients/1, 000 ESRD patients/year and 3.87 patients/1, 000 patients/year. Accidental needle punctures were reported in 15.2 stuffs/year/1, 000 stuffs, but only 1.14 stuffs/year/1, 000 stuffs turned out to be positive HCV antibody. Special instructions or manuals for the care of HCV-positive patients and accidental HCV-positive needle puncture were prepared only 21% and 25% of dialysis institutions, respectively.
Those results confirmed the increased prevalence of HCV virus infection into Japanese dialysis patients. The study to clarify how to deal with HCV infection in dialysis institutions should be done.

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The urea rebound phenomenon, a rapid increase in plasma urea concentration after HD therapy, is quite familiar. The urea rebound rate was calculated by measuring the post-hemodialysis plasma urea concentration after 92 hemodialyses in 23 patients. The course of the urea rebound phenomenon, its causes and its influence on Kt/V, TAC_urea and pcr calculations were investigated.
Urea rebound was observed after routine hemodialysis (4 hrs at 200ml/min blood flow). The urea rebound rate was 16%, and the plasma urea concentration became equilibrated within 30min after dialysis. Rebound was caused by entry of urea from a poorly cleared second pool and was not due to an actual increase in the rate of urea generation.
A significant correlation was found between the urea rebound rate and Kt/V. The different values of Kt/V, TAC_urea and pcr were calculated using the plasma urea concentration at the end of hemodialysis and 30min after dialysis, and compared. The former Kt/V (0.15, 15.6%) and pcr (0.08g/kg/day, 8.5%) values were higher and the TAC_urea (2.0mg/dl, 4.0%) value was lower than the latter.
Thus, if the urea rebound rate, is not taken into account the Kt/V, TAC_urea and pcr values calculated using the plasma urea concentrations immediately after hemodialysis could be higher or lower than expected and therefore misjudged in terms of their clinical evaluation.

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Prognosis and complications after returning to hemodialysis were studied in 89 patients with a rejected kidney allograft as a result of chronic rejection. The cumulative patient survival rate 1, 5 and 10 years after re-institution of hemodialysis was 92%, 83% and 77%, respectively. Within 3 months after re-instituting hemodialysis, 6 of 21 recipients died of complications related to immunosuppressive therapy, including sepsis, gastrointestinal bleeding and perforation. Therewere, 13 later deaths due to hemodialysis complications, such as heart failure, cerebrovascular hemorrhage, cancer and colon perforation. These findings show that early re-institution of hemodialysis and rapid reduction of immunosuppressive drugs are necessary to prevent the progression of immune deficiency and to reduce mortality to a minimum. After returning to hemodialysis, cyclosporine, azathioprine and mizoribine were rapidly withdrawn, and the dose of prednisolone was tapered to 5mg/day. Following the reduction of immunosuppressive drugs, symptoms resembling those of acute rejection, including high fever, hematuria, graft swelling and tenderness, appeared in 15 recipients in whom consequent graftectomy had been performed. Among 50 survivors with a rejected graft, prednisolone was administered at a dose of less than 5mg/day in 19 and discontinued completely in 24 without development of graft necrosis. There has been no difference between the long-term patient survival of recipients with a rejected graft and those who underwent graftectomy.

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Fifty-two patients whose course was complicated by 55 malignant tumors, out of 1, 164 end stage renal disease patients in our hospital, were proposed for clinical investigation.
The mean age at the time of tumor discovery was 57.8 years, which is nearly equal to the mean age (58.1 years) at initiation of maintenance hemodialysis (MHD) patients. The mean duration from the initiation of MHD of the patients to the discovery of the malignant tumors was 4.1 years, and tumors in 16 patients (30.8%) were discovered within 1 year of the initiation of MHD. These results suggest that the incidence of malignant tumors might be high even in the pre-dialysis stage. Bleeding or periodic screening of tumors was the initial opportunity to discover tumors. Tumors of digestive organs were found most frequently followed by tumors of urinary tract organs. As to prognosis, 44.2% of all patients with malignant tumors survived. Operative cases were 61.5%, and 71.9% of them survived postoperatively.
In conclusion, patients with end stage renal disease are prone to a high incidence of malignant tumors before/after the initiation of MHD; however, the early diagnosis of tumors and surgical intervention can help patients survive longer.

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The usefulness of three-dimensional (3D) CT imaging of skeletal complications in hemodialysis patients was evaluated. In this study, CT HiLight Advantage from GE Medical Systems (Milwaukee, Wisconsin) was used. Since the 3D image can be manipulated in various ways, it is quite useful for the examination of anatomically complex areas such as hip joints and the spine. As a result, amyloid deposition in the femoral head and the pelvic bone, as well as a small pelvic fracture, were clearly demonstrated. Bone surface irregularity due to severe osteopenia was also evident with this method. 3D-CT imaging will enhance the accuracy of diagnoses of bone and joint diseases in hemodialysis patients.

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A clinical study of factors affecting the patency of vascular access in chronic hemodialysis patients was performed.
The following variables, including age at operation, primary causes of renal failure and hematocrit, were analyzed statistically.
Cumulative patency rates for total patients at 5 and 10 years were 68% and 59%, respectively.
Diabetic nephropathy and age at operation were found to have an influence on vascular patency. The other factors were not statistically significant.

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Carpal tunnel syndrome (CTS), which is diagnosed by burning sensations, numbness and stiffness of the hand, is common in patients undergoing long term hemodialysis. Some investigators have reported that CTS is due to the deposition of amyloid protein which consists of β₂-microglobulin (β₂-MG) in the carpal tunnel area. On the contrary, it was reported that macrophages migrated to the surrounding tissue of amyloid deposition and that connective tissue then proliferated in this area. However, the underlying mechanisms remain obscure. Seventy one patients undergoing long term hemodialysis entered this study. None of these patients had liver disease, rheumatoid arthritis, other inflammatory disease or cancer. Patients were divided into two groups; group 1 (n=40) served as the control without CTS while group 2 (n=31) had CTS. Serum β₂-MG, IL-6 and macrophage colony-stimulating factor (M-CSF) concentrations were measured. The difference in serum β₂-MG between the two groups was not significant. However, serum IL-6 in group 2 was significantly higher than that in group 1 (12.8±20.0pg/ml vs 6.2±2.5pg/ml). Furthermore, serum M-CSF in group 2 was also significantly higher than that in group 1 (4.43±0.73ng/ml vs 3.82±0.83ng/ml). Serum M-CSF correlated significantly with serum IL-6 (r=0.282, p<0.05). There may be a relationship between CTS and elevated IL-6 and M-CSF.

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In an attempt to evaluate the influences of psychological stress induced by changes in a patient's life circumstances, as well as indispensable management of CAPD, we investigated 15 patients undergoing CAPD who fulfilled the criteria of positive indications for entry into the CAPD program and were expected to follow a stable clinical course. They were divided into 2 groups. Patients belonging to group I had recurrent attacks of congestive heart failure (CHF) and peritonitis and group II patients had a stable clinical course without such complications. The former consisted of 2 unmarried men, 2 men having their own businesses, a young woman with an infant, and the owner of a company and the latter included one unmarried man who had undergone hemodialysis one year before, 3 married men having their own businesses and 5 middle aged housewives.
The psychological stress value estimated using the Social Readjustment Rating Scale of Homes and Rahe was 73±17 (53-159) in group I and 110±12 (53-212) in group II just after the initiation of CAPD. However, in group I patients, it was increased to 295±48 (118-480) just before the complications occurred (p<0.005). The causes of an increase in this value were as follows; admission of a family member taking care of the patient, a change in the patient's occupation, reshuffling, retirement, building of a new house, child care and decreased income.
Middle aged housewives could manage their diet and CAPD well, because their children had already grown up and did not need to be taken care of. However, two young unmarried men and the young woman with an infant often ate out and did not restrict salt intake and adhere to a low protein diet.
Technical support and active participation in the patient's treatment by family members were not adequate in group I patients as compared to group II patients (p<0.05).
These results suggest that psychological stress caused by changes in life circumstances, as well as by CAPD itself which requires lifelong management, disturbed diet control and handling of bag exchange, and thus might have induced complications.

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We examined the necessity of intravenous administration of recombinant human erythropoietin (rHuEPO), below 1, 500IU, in 4 hemodialyzed patients with progressive anemia since the minimal unit of rHuEPO is 1, 500IU. Progressive decreases in the hematocrit (Ht) levels disappeared following administration of 500IU rHuEPO 3 times weekly. Administration of rHuEPO from 500IU to 1, 000IU 3 times weekly increased the Ht level in a dose -dependent fashion and the effect of rHuEPO was stronger during periods in which the frequency of administration was greater than during periods in which the administered dose at one time was greater. Since it is important in terms of quality of life to maintain the Ht level, intravenous administration of low doses (500IU, 750IU, 1, 000IU) of rHuEPO is effective in the treatment of renal anemia.

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CT-guided stereotactic hematoma evacuation was performed on two cases of cerebral hemorrhage in hemodialysis patients. The first case, a 63-year-old male hemodialysis patient, had a left puterminal hemorrhage, the neurological grading was 3, and the CT-classification was III-a.
Surgery was performed on the second day following the attack.
The second case, a 59-year-old male hemodialysis patient, had a left thalamic hemorrhage, the neurological grading of which was 3, and the CT-classification was III-b. Surgery was performed 7 hours after the attack.
During neurological surgery on hemodialysis patients, CHDF (continuous hemodiafiltration) or PD (peritoneal dialysis) is recommended.
The risk facter for CT-guided stereotactic evacuation of a hematoma is low.
Therefore, we suggest, managing the general postoperative condition with HDF (hemodiafiltration) performed several times (4 to 6) per week, 3 hours per day.
CT-guided stereotactic hematoma evacuation is considered very effective.

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We report a case of a 54-year-old male with acute renal failure due to eosinophilic interstitial nephritis.
The patient experienced head trauma and was admitted to a neurosurgery hospital on September 6, 1990. Diclofenac sodium, 50mg, was administered for the first 10 days and piperacillin, 4g, was administered intravenously for the next 4 days.
On day 32, the patient ate raw fish, and about 8 hours later he complained of severe abdominal pain, diarrhea and vomiting with high fever. Laboratory data showed serum creatinine 0.9mg/dl, BUN 13.6mg/dl and WBC 12, 900/μl with 18% eosinophils, The patient was placed on intravenous piperacillin (2g twice a day) on days 34, 35 and 36, but his symptoms persisted and his urine volume decreased to anuria.
On day 36, laboratory data showed serum creatinine 14.2mg/dl, BUN 80.4mg/dl and WBC 15, 400/μl with 76% eosinophils, whereupon he was admitted to our hospital on suspicion of peritonitis and acute renal failure.
Fibergastroscopy revealed a trace of Anisakis invasion in his gastric wall. Hemodialysis was necessary 7 times during the next two weeks until his renal function recovered in parallel with a decrease in eosinophils. Open renal biopsy showed interstitial edema and infiltration by eosinophils and lymphocytes.
Eosinophilia is reported to occur in response to certain drugs and parasites. The 76% eosinophilia in this case, however, was unusual. The acute renal failure and eosinophilia may have been induced by Anisakis gastroenteropathy, because the eosinophilia had been already detected when allergic symptoms developed before treatment with piperacillin the second time. However, a lymphocyte stimulation test was positive for piperacillin, and it is also possible that hypersensitivity to piperacillin and severe dehydration due to Anisakis gastroenteropathy exacerbated the acute renal failure.

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We report the case of a-year old male with chronic pancreatitis, complicated by spinal tumor and spondylolisthesis, undergoing CAPD. He had experienced two previous episodes of infectious peritonitis. Pancreatitis was suggested by abdominal CT and echography. The main causes of pancreatitis were 1) previous peritonitis and 2) glucose absorption by CAPD fluid. He was treated with gabexate mesilate and antibiotics, which resulted in substantial improvement. We removed the CAPD catheter because catheter-associated peritonitis persisted.
Low back pain is one complication of CAPD. We cannot, however, rule out spinal tumor or spondylolisthesis. Further examination, by mylography and MRI, is therefore necessary.

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Four patients suffering from severe heart disease and chronic renal failure were treated by CAPD for 25-40 months. They consisted of three men and one woman between 39 and 65 years of age. Their heart diseases were unstable angina pectoris with three vessel disease, congenital cyanotic heart disease (transposition of great arteries, pulmonary atresia, and aortic regurgitation), infectious endocarditis with right coronary artery (RCA)-right ventriculus (RV) fistula, and cardiomyopathy. Two patients successfully underwent coronary artery bypass surgery or aortic valve replacement and RCA-RV fistula closure. The patient with cardiomyopathy and the one with cyanotic heart disease also made satisfactory progress, but the former died from arrhythmia 35 months after the initiation of CAPD.
It is suggested that CAPD therapy has no deleterious effects on serious heart diseases.

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It is known that survival in thrombotic thrombocytopenic purpura (TTP), especially TTP associated with pregnancy, is low. Recently, plasma exchange has markedly improved this prognosis. There have, however, been few reports of patients with TTP who delivered an infant. In this paper, we report a patient with TTP who was treated with plasma exchange followed by successful delivery of an infant.
The patient, a 31-year-old house wife, had an attack of TTP in 1986, when she was 25 years old and her first embryo died at 22 weeks. Her illness was improved by artificial abortion, plasma exchange and splenectomy. Subsequently, she was often noted to have thrombocytopenia, necessitating transfusion of fresh frozen plasma (FFP). She became pregnant again in 1992, when she was 30 years old. She visited our hospital, when her embryo was at 6 weeks. She then entered our hospital because of thrombocytopenia, in 1992, when her embryo was at 35 weeks. Platelets were 3.2×10⁴/μl, Hb 10.4g/dl, LDH 2, 330IU/l. Thrombocytopenia was not improved by transfusion of FFP or fresh blood. As anemia also progressed, platelet transfusion and plasma exchange were performed, and her infant was subsequently delivered by cesarean section. Forty units of FFP (3, 200ml) and an anticoagulant, nafamostat mesilate, were used in plasma exchange along with hemodialysis. Plasma exchange was performed for 3 days. As a result, thrombocytopenia improved. The patient and her infant are presently in good health.

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