The statistical survey of 3, 231 institutions by the Japanese Society for Dialysis Therapy at the end of 1999 resulted in responses from 3, 220 (99.66%) of these facilities. At the close of the same year there were 197, 213 chronic dialysis patients in Japan, up 6.4% (11, 891 patients) over a year earlier. From the end of 1998 until the end of 1999 the gross annual mortality rate was 9.7%, slightly higher than last year. The mean age of patients on dialysis was 63.4 (±13.9, ±STD) years, reflecting a higher age level. Moreover, the mean age of the overall dialysis population was 60.6 (±13.3) years, edging over the 60 mark. The primary disease among those on dialysis was mostly diabetic nephropathy (36.2%) followed by chronic glomerular nephritis (33.6).
New survey items for 1999 included the following: with/without reverse osmosis, with/without dialysate endotoxin measurement, dialysate endotoxin concentration, itchiness, previous existence of HBs antigen/antibody, HBe antigen/antibody, earlier hepatitis B vaccine inoculation, HCV antibody/HCV-RNA, serum glutamic pyruvic acid transaminase (GPT) activity, previous hepatocellular cancer and cirrhosis, previous limb amputation, history of cerebral infarction, brain hemorrhage or myocardial infarction, with/without loss of eyesight due to diabetic retinopathy or retinal circulatory disturbance, serum cholesterol level, no. cigarettes smoked, platelet count, leukocyte count, C-reactive protein, height, body mass index (BMI), and tuberculosis within the the past year. Moreover, the substitution fluid method and amount of substitution fluid for the hemodialysis ultrafiltration approach were also among the additions.
The use of the reverse osmosis approach was 93.0%. The endotoxin concentration tended to be lower in institutions with more patients. Some 56.7% of the patients experienced no itchiness, and no such treatment was performed. HBs antigen (-) antibody (-) was 84.7% and HBs antigen (+) antibody (-) was 1.9%, while HBs antigen (-) antibody (+) was 13.0%. 2.3% of patients had been inoculated with Hepatitis B vaccine. HCV antibody (+) was 16.1% and HCV-RNA (+) was 8.2%. There were 2.1% of the patients with cirrhotic complications and 0.6% had hepatocellular cancer complications. The mean serum total cholesterol level was 162.84mg/dl, and the mean BMI was 20.61kg/m².
From analysis by Cox's proportional hazards model, it was found that Kt/V of 1.4, a normalized protein catabolic rate of less than 0.9g/kg/day or more than 1.5g/kg/day, and a low creatinine production rate, were risk factors for hemodialysis patients with a 6-year mid-term prognosis.

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We examined PvuII and XbaI restriction fragment length polymorphisms (RFLPs) of the estrogen receptor (ER) in hemodialyzed patients. The genome DNA was isolated from the peripheral blood and a part of the ER gene locus between intron 1 and exon 1 was amplified by polymerase chain reaction. These products were digested by PvuII or XbaI to determine RFLPs. The biochemical bone markers including serum Ca, P, Al-P, tartrate-resistant Ac-P, intact-PTH, osteocalcin were measured by the standard methods, and the bone mineral density (BMD) of the lumbar spine (L2-L4) and the radius were measured by dual energy X-ray absorptiometry. The distributions of PvuII and XbaI RFLPs were PP 23.0%, Pp 51.6%, pp 25.4% in men (n=126), PP 19.8%, Pp 38.3%, pp 42.0% in women (n=81), XX 5.8%, Xx 37.5%, xx 56.7% in men (n=120), and XX 9.0%, Xx 38.5%, xx 52.6% (n=78) in women, respectively. The values of the bone parameters and Z scores of the lumbar spine and radius BMD were not significantly different in any RFLPs groups. The decrease in BMD was estimated from the slope of the linear regression line. The decreasing rate of female lumbar spine BMD was significantly larger in the PP group than in the Pp and pp groups (p<0.05). These rates were not significantly different in other RFLPs groups. Our results suggest that PvuII RFLPs of ER may be associated with the decrease in lumbar spine BMD in female hemodialysis patients.

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To evaluate the relation of insertion/deletion (I/D) polymorphism of angiotensin-converting enzyme (ACE) gene to the incidence of cardiovascular diseases in chronic hemodialysis patients, 534 patients on chronic hemodialysis were followed for two years after determining the ACE genotype. There were 208, 245 and 81 patients with II, ID and DD genotypes, respectively, and the frequencies of I and D allele were 0.62 and 0.38. Background characteristics such as age, gender, causative diseases of renal failure and complications of cardiovascular diseases at the time of study entry were comparable among the three genotype groups. Serum ACE activity was significantly higher in DD than in II or ID. However, plasma angiotensin II concentration did not significantly differ among the three groups. During two-year follow-up period, 33 fatal and 99 nonfatal cardiovascular events occurred. The incidence of these cardiovascular events was significantly associated with advanced age (p<0.001), diabetic nephropathy (p<0.001), preexistence of cardiovascular diseases (p<0.001), high cardio-thoracic ratio on chest roentgenogram (p=0.004), electrocardiographic abnormalities (p<0.001), and low serum Na (p<0.001). In addition, the incidence of cardiovascular events was higher among patients carrying the D allele (II 16.8%, ID 27.3%, DD 37.0%; p<0.001). It is suggested that the D allele of ACE gene polymorphism is a risk factor for cardiovascular complications in hemodialysis patients.

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Rectus sheath hematoma (RSH) is relatively uncommon disease. It's clinical characteristics is sudden onset of severe abdominal pain and it often mimics many other serious intraabdominal diseases.
We encountered 3 chronic hemodialysis patients with RSH in 1998. All patients were women aged 52 to 69 (average age: 63). Two patients presented with abdominal pain while recieving hemodialysis treatment, and one patient presented with pain just after dialysis ended. Two patients presented with palpable mass in the lower abdominal region. Two patients showed severe anemia and one showed hypotension requiring blood transfusion.
As predisposing factors, two had severe coughing, two had hypertension, and all patients recieved anticoagulants (Heparin) for hemodialysis treatment.
Hemodialysis patients have several predisposing factors that easily induce RSH. RSH should be included in the differential diagnosis of the acute onset of abdominal pain in patients receiving hemodialysis treatment.

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A 51-year-old man on maintenance hemodialysis for diabetic nephropathy was referred to our hospital for evaluation of symptoms including fever, nausea, vomiting, muscle weakness, and general malaise. Laboratory evaluation revealed accelerated inflammatory reaction, but there was no evidence of infection. Serum thyroid stimulating hormone level was reduced (0.1μU/ml), and free tri-iodothyronine and free thyroxine level were elevated (9.5pg/ml and 4.2ng/ml, respectively). Thyroid autoantibodies were not detected. Technetium scintigraphy showed remarkably reduced RI accumulation in the thyroid. After admission, his consciousness level was disturbed (disorientation), and laboratory data revealed hypercalcemia (13.2mg/dl). Subacute thyroiditis was diagnosed, and treatment consisting of hemodialysis and prednisolone (30mg/day) administration was initiated. His symptoms subsequently improved, and the serum calcium level and inflammatory reaction normalized with treatment. After prednisolone was tapered off, the patient complained of general malaise again and was readmitted. Laboratory data showed normal thyroid function, but both ACTH and cortisol levels were markedly reduced (5.1pg/ml and 0.6μg/dl, respectively). The diagnosis of isolated ACTH deficiency was confirmed by the anterior pituitary hormone stimulation test. His condition was improved after hydrocortisone treatment (20mg/day).
This case involved rare complications of subacute thyroiditis with isolated ACTH deficiency in a diabetic patient on maintenance hemodialysis. The present findings suggest that if adrenal function is reduced in chronic diabetic patients on hemodialysis, it might not be manifested by typical symptoms related to adrenal deficiency (hypotension, hypoglycemia, or hyponatremia). Thus, we must treat these patients carefully considering these possibilities.

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An 83-year-old woman with hypertention and hyperlipidemia underwent coronary angiography on February 8, 1999. About 3 weeks after the CAG, she developed purple toes and renal insufficiency. Though the serum creatinine peaked at 3.56mg/dl, it declined gradually to 1.65mg/dl in June without any changes in the coloring of her foot. Renal dysfunction presented again after the second CAG in June and resulted in maintenance hemodialysis. During the clinical course on hemodialysis, she developed liver dysfunction, fluctuating disturbance of consciousness and progression of skin lesion. Despite intensive supportive care, she died of cachexia on September 29. Post mortem examination showed cholesterol clefts in systemic organs including the kidney, liver, spleen, gastrointestinal tract and so on.
The prognosis for CCE with visceral lesion is very poor. Especially in a case of CCE reccurence, mortality becomes serious. Careful diagnosis and therapeutic management in CCE are important to avoid its reccurence.

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A cellular lesion characterized by segmental proliferative epithelial cell reaction has been considered one of the histologic variants of primary focal segmental glomerulosclerosis (FSGS) and postulated as an early morphologic feature in this disease. Moreover, a recent report indicated that patients with extensive cellular lesions showed a poor response to therapy and a rapid progression to end-stage renal disease.
This paper describes an 11-year-old boy with primary FSGS with a cellular lesion, who showed steroid resistance during the clinical course, but attained complete remission after additional low-density lipoprotein apheresis (LDL-A). Since the pathological finding of the cellular lesion in patients with primary FSGS predicts a poor prognosis, the results obtained in this case study suggest that combined therapy with LDL-A and prednisolone may contribute to a favorable outcome associated with remission of proteinuria in primary FSGS patients with a cellular lesion.

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