An early recommendation was to change the site of the puncture for each hemodialysis treatment. However, there are some data indicating that insertion of the hemodialysis needles through a fixed puncture route for consecutive hemodialysis may actually cause fewer complications, compared to those occurring when using different needle insertion sites for each hemodialysis treatment. Twardowski and colleagues indicated that for a successful buttonhole puncture of the blood access vessel, the fistula has to be punctured by the same experienced technician. In many hemodialysis facilities, however, it may not be realistic for the same experienced person to be in charge of puncturing blood access vessels until good puncture sites are established. Therefore, we developed a timesaving method of creating a fixed puncture route. In this method, after hemodialysis is completed, we replace the cannula tube with a hollow polycarbonate stick. Then, by leaving this in place until the next hemodialysis, we create a fixed route through which a dull hemodialysis needle can be inserted into the blood access vessel, from then on. This buttonhole puncture approach using the fixed puncture route created this way has been used in 23 patients a total of 852 times to date. As a result, there was an obvious alleviation or disappearance of pain accompanying the buttonhole puncture in all patients. Moreover, among all 23 patients, only slight blood oozing at the puncture site was seen during 3 puncturings in 3 patients who had undergone buttonhole puncture up to 220 times. In one patient who had received 45 buttonhole punctures, there was a need to treat the bleeding only once. In all patients, the time needed to stop bleeding or treat infection at the puncture site was not prolonged. In conclusion, a fixed needle puncture route was made by a timesaving buttonhole method. This buttonhole puncture approach made it possible to reduce or eliminate the patient's pain when the blood vessel was punctured. Also, the short-term evaluation indicated that there were no complications whatsoever in connection with the use of this fixed needle puncture route.

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In recent years, there has been an increase in the number of institutions performing various types of apheresis therapy as part of the blood purification work in the kidney center. During a 5-year period, the total number of all apheresis procedures was 1739 and that for each type was: 423, plasma exchange (PE); 816, double filtration plasma apheresis (DFPP); 67, cryofiltration (CF); 191, low density lipoprotein apheresis (LDL-A); 47, bilirubin adsorption (Bil-AD); 168, other types of plasma perfusion (PP); and 27, endotoxin adsorption (EAD). According to diseases, the number of apheresis procedures was high for neurological diseases, collagen diseases, and liver diseases, being 154 in 30 patients with myasthenia gravis, 88 in 19 patients with Guillain-Barré syndrome, 307 in 45 patients with systemic lupus erythematosus (SLE), and 297 in 73 patients with hepatopathy.
Recently, there has been a tendency toward an increase in patients with arteriosclerosis obliterans (ASO) and familial hypercholesterolemia. The side effects during apheresis were a blood pressure fall and numbness of the four limbs, but there were no serious or persistent side effects. With expansion of the indications for apheresis, this therapy may be further diversified, and the role of the kidney center may markedly change. In the future, the proportion of apheresis therapy in blood purification therapy is expected to increase.

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We present a rare case of hyperthyroidism in a male hemodialysis patient. The patient was a 44-year-old male, who had received hemodialysis since 1974. In May 1996, he developed refractory diarrhea with a low grade fever following lose of body weight and pulmonary edema. He was admitted to another hospital for further examination, but he was discharged two months later with an unclear diagnosis. In September 1998, he was referred to our outpatient clinic. One month later, he was diagnosed with hyperthyroidism. Diarrhea and low grade fever disappeared shortly after thiamazole was given.
In this case, we evaluated the dialyzability of thiamazole using six kinds of dialyzers; PS-1.6UW, KF-18C, FLX-15GW, PAN-180SF, BK-2. 1U, M150B. The data showed its accumulation and dialyzability. As long as these six kinds of membranes were used, thiamzole can be administered to patients receiving hemodialysis in the same way as to patients with normal renal function.

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Effects of azinc compound, polaprezinc, on serum PTH level and related laboratory markers were examined in 11 hemodialytic patients with secondary hyperparathyroidism. When 150mg per day of polaprezinc was orally administered, 27% (p<0.01) and 31% (p<0.01) decreases in serum PTH were observed 1 and 2 months after the initiation of zinc supplement, respectively. There were no significant changes observed in serum Ca and Pi levels or the activity of alkaline phosphatase. Possible therapeutic use of the zinc compound for secondary hyperparathyroidism is discussed.

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We report two cases of anemia improved by administration of 4500 units erythropoietin (rHuEPO) (epoetin beta) three times per week (high dosage) but not improved by 9000 units/week (conventional dosage) of rHuEPO. Case 1 was a 46-year-old male under hemodialysis treatment for 24 years who had been diagnosed with myelodysplastic syndrome with refractory anemia (MDS-RA). Anemia persisted during treatment by the conventional dosage and the patient complained of general fatigue and breathlessness. When anemia in case 1 was improved by high dosage administration of rHuEPO, subjective symptoms were alleviated and the quality of life was improved. Case 2 was a 43-year-old female with rheumatoid arthritis under hemodialysis treatment for 7 years. Subjective symptoms due to anemia increased when treated at the conventional dosage level, and the patient received blood transfusions frequently. After the rHuEPO dosage was increased to the high dosage level, hematocrit was similarly elevated, and subjective symptoms were improved. Iron deficiency anemia, hemorrhage, and hemolytic anemia were excluded in both cases.
Other cases of iron replete patients with an inadequate response to rHuEPO should be evaluated. MDS-RA was considered a main factor in rHuEPO hyporesponsiveness in case 1, and rheumatoid arthritis in case 2. High dosage treatment by rHuEPO effectively improved anemia without concomitant high blood pressure. There was no relapse in anemia even after gradually reducing the dosage to the conventional level. Temporary administration of high dose rHuEPO administration effectively improved anemia, improved QOL, and reduced the need for blood transfusion.

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We report a case of a diminished ultrafiltration due to high levels of intraabdominal pressure in a 72-year-old male CAPD patient. After surgery for abdominal artery aneurysm, the patient was undergoing hemodialysis 3 times weekly due to chronic glomerulonephritis. Recently, hypotension appeared during hemodialysis because cardiovascular disease deteriorated. To reduce cardiovascular stress, we recommended that continuous ambulatory peritoneal dialysis (CAPD) replace hemodialysis. The ultrafiltration volume decreased soon after the standard CAPD schedule was initiated. There was no effect on the glucose concentration or the dwelling time of the dialysate.
As dialysate leakage around the catheter and high abdominal tension appeared, we considered that ultrafiltration failure was caused by high levels of intraabdominal pressure. The intraabdominal pressures after in fusing 1000ml and 1500ml solution were 15cmH₂O and over 25cmH₂O, respectively. The exchange volume was decreased from 1500ml to 1000ml, which caused a significant increase in ultrafiltration volume and decrease in body weight.

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Acute pancreatitis is one of the most serious complications in dialysis patients. We report a hemodialysed patient with acute necrotizing pancreatitis showing hypoglycemia as the initial manifestation. A 65-year-old male on maintenance hemodialysis for 4 years was admitted to our hospital because of unconsciousness. The patient had a history of chronic thyroiditis for 5 years. However, there was no prior history of diabetes mellitus. On admission, his laboratory findings included marked hypoglycemia (13mg/dl), leukocytosis, and high LDH levels with scant abdominal symptoms. His initial serum amylase level was in the normal range (50IU/dl). After intravenous administration of dextrose, the patient regained consciousness immediately. He denied having taken oral hypoglycemic agents, or any other drugs modulating glycemic control. On the 12th hospital day, severe abdominal pain developed. Subsequently, the patient got into shock accompanied by severe hypoglycemia and lactic acidosis. At that time, abdominal CT scan was performed, and the diagnosis of acute pancreatitis was made. Despite the intensive treatments, the patient died from multiple organ dysfunction syndrome. Autopsy revealed widespread necrotizing pancreatitis.
Although hypoglycemia is a rare manifestation of acute pancreatitis, this combination has been reported in chronic hemodialysis patients. We conclude that hypoglycemia and lactic acidosis might be one of the clinical clues for diagnosing severe necrotizing pancreatitis in hemodialyzed patients.

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The incidence of renal cell carcinoma in chronic dialysis patients is higher than that in the general population. In our hospital and its affiliated hospital, routine examination including sonographic examination and CT scan have been performed since 1994. As a result, 5 cases were found to have bilateral renal cell carcinoma and were treated surgically. All cases were male, 47.2±3.3 years old, and treated by hemodialysis for 228.0±51.2 months.
Renal failure in these 5 cases was due to chronic glomerulonephritis in 3 cases, and idiopathic in 2 cases. None of these patients demonstrated diabetes mellitus. In 3 cases, clinical diagnosis and surgery on the left and right kidneys were performed at different times. In the other 2 cases, the left and right nephrectomy were performed simultaneously. In these 10 kidneys in 5 cases, clinical diagnosis was based on sonographic examination in all 10 kidneys, CT scan in 9 kidneys, angiography in 2 kidneys. Soon after surgery, anemia worsened transiently in one case, but blood pressure did not changed significantly in any case.

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