Building Regional Dialysis Support System in Preparation for Massive Quake Disaster / 日本農村医学会雑誌

  A ground rule of dialysis support in the event of massive earthquake disaster is to perceive the necessity of evacuating patients quickly and to have a system fully equipped to collect information as to the situation of the designated disaster hospital in a region and other facilities and the capacity to take care of patients. Furthermore, building a network incorporating dialysis facilities in the neighboring areas is essential. Through this network, efforts have to be made to work out a practical dialysis support program without delay (annular support system). It is also important to create a support scheme which does not impose an excessively heavy burden on the staffs of damaged facilities. To put it concretely, the following measures should be taken:(1) to reduce the time needed for the transfer of patients to the mimimum;(2) to make the length of the patient's stay at a support facility the shortest possible;and (3) to get the data of dialysis patients ready and share the records with other dialysis facilities. To make the cooperative framework for tiding over a major earthquake disaster, it is important to establish the annular support system of dialysis facilities between the quake stricken area and its neighboring area. If a similar annular support system is not installed in many areas, cooperation does not function well. We must consider the ways and means to establish an ideal cooperative regional disaster prevention system in preparation of a large-scale earthquake, which may occur any time, while drawing a lesson from the previous earthquake disasters.

Effects of Dialyzer Membrane Characteristics on Serum Total Protein and Albumin Concentration in Hemodialysis Patients / 日本農村医学会雑誌

Recent studies showed that high biocompatibility and reduction of uremic toxin contributed to the improvement of freatment outcome in hemodialysis patients.Therefore, a high-flux membrane dialyzer, especially polysulfone (PS) membrane, was generally used in dialysis. However, it was suggested that the higher efficiency of reduction in uremic toxins might cause an increase in the albumin leakage through the dialyzer membrane during dialysis, resulting in a decrease in serum albumin concentration. In this study, we used two different dialyzer membranes with high biocompatibility, namely, ethylenevinylalcohol (EVAL) membrane and improved PS membrane with a very lower leakage of serum albumin. After using these two types of mambrane of six straight months, we examined the effect of each dialyzer membrane characteristic on the serum total protein and albumin concentration. The reduction rates of each uremic solute and serum total protein concentration were significantly higher. The serum albumin concentration and its rate of change with the passing of time tended to increase in the case of the PS membrane. But in the case of EVAL membrane, these values tended to decrease. These results suggested that the differences in the changes in the serum total protein and albumin concentration might result from the differences in the efficiency of the reduction of uremic toxins. Therefore, it is necessary to consider the usage of the dialyzer membrane with a higher reduction of uremic solutes and a lower leakage of serum albumin to add to the higher biocompatibility specially in hemodialysis patients with hypoproteinemia.

Nutritional Status in Hemodialysis Patients - Changes in Biochemical Parameters and Clinical Symptoms / 日本農村医学会雑誌

A strong earthquake (magnitude 6.8) off the Sea of Japan struck the Chuetsu area of Niigata Prefecture on July 16, 2007. By way of investigating the impact of the earthquake on the health of maintenance hemodialysis patients, we examined several biochemical parameters including nutritional markers and psychological stress markers and checked up on the incidence of earthquake-induced complications (heart failure and shunt obstruction). Blood samples were collected and the values of several biochemical parameters were measured. Incidences of clinical complications one, three and six months after the quake were scrutinized. Significant decreases in the nutritional markers and a significant increase in the incidence of complications were found one month after the quake. During this period, the supplies of electricity, city gas and water were completely recovered one after another. The significant changes in the nutritional levels and the incidence of complications coincided with the time of the complete recovery of these utilities. The levels of these parameters recovered and the incidence of complications reduced three months after the quake. However, the serum albumin level did not recover and remained significantly lower even six months after. The psychological stress markers increased significantly three months after. These suggested that there was the time lag between the decrease in the nutritional markers, the increase in the incidence of complications (1 month after earthquake) and the increases in the psychological stress markers (3 months after earthquake). We concluded that these findings provided important information for the total medical plan to maintain the physical and psychological states of hemodialysis patients in an earthquake- stricken district.

Combination treatment of severe alcoholic hepatitis with continuous hemodiafiltration and steroid hormone: A case report and Literature review / 日本農村医学会雑誌

We experienced a case of severe alcoholic hepatitis. Combination treatment of continuous hemodiafiltration and steroid hormone was started immediately after admission. This treatment was very effective for severe alcoholic hepatitis, resulting in the shortening of the length of hospital stay. The reasons why this treatment was effective were; 1. The patient was younger, so the regeneration ability of liver cells was stronger. 2. The infection and bleeding of digestive organs except for acute renal failure were not found, resulting in the enhancement of the effectiveness for steroid hormone treatment. 3. The intensive blood purification treatment was started immediately. From this experience, we realized again that a fine collaboration of doctors, nurses and clinical engineers was very important in the intensive care of the severe diseases.

Water Diuresis Promotes Urine Acidification with Decreases in HCO3- Concentration / 日本農村医学会雑誌

It is known that the reabsorption of filtered HCO<SUB>3</SUB><SUP>-</SUP>depends on the tubular flowrate in the proximal uniferous tubule. In animal experiments, studies have demonstratedthat, when diuresis was induced, the pH of the collecting duct urine decreased, resulting from the decrease in HCO<SUB>3</SUB><SUP>-</SUP>concentration with no change in the pCO<SUB>2</SUB> level.The present study was designed to examine changes in urine acidification in humansunder a water diuretic state. Urine pH, pCO<SUB>2</SUB> levels, and HCO<SUB>3</SUB><SUP>-</SUP>concentration weremeasured before and after the drinking of water. In 120 minutes after hydration, theurine pH level fell about 0.5 pH unit from that before the intake of water. The urine HCO<SUB>3</SUB><SUP>-</SUP>concentration coincidentally decreased significantly. However, pCO<SUB>2</SUB> values remainedunchanged. These results indicated that also in humans, water diuresis promotesurine acidification, resulting from a decrease in HCO<SUB>3</SUB><SUP>-</SUP>concentration with nochange in the pCO<SUB>2</SUB> level, which may contribute to the prevention of the loss of plasmaHCO<SUB>3</SUB><SUP>-</SUP>into the urine when the urine flow rate increases.

Extinction of Hepatitis C Vrus During Hemodialysis Treatment: A Case Study / 日本農村医学会雑誌

At present, among the types of viral hepatitis, hepatitis C virus (HCV) appears to be the major cause of hepatitis in hemodialysis units. Previously, we took blood samples from the blood tubing at the inlet and the outlet of different dialyzers and measured serum HCV-RNA levels in hemodialysis patients with HCV. We found a significant reduction in serum HCV-RNA levels through the use of a polymethylmethacrylate (PMMA) membrane in dialysis. In the present paper, we report on a case in which HCV was extinct during hemodialysis treatment. The patient was a 72- year-old woman. The duration of hemodialysis was 259 months. The biochemical findings revealed high levels of serum alkaline phosphatase and TTT. The data of other liver enzymes were within normal range. The serum HCV-RNA level, which had been tending downward, was 32 KIU/ml, when the dialyzing membrane was changed to a PMMA membrane. Thereafter, the serum HCV-RNA level further reduced and reached below 0.5 KIU/ml in 12 months. This result suggests that HCV reduction efficiency should be considered when dialyzing membranes are selected from among many.

Characteristics of atherosclerosis in long-term survivors on maintenance hemodialysis / 日本農村医学会雑誌

Accelerated atherosclerosis has come to pose a great threat to the lives of hemodialysis patients. In the present study, to determine the characteristics of atherosclerosis in long-term survivors on maintenance hemodialysis (mean age : 57±3 years, mean duration of hemodialysis : 279±11 months), the reference to clinical, biochemical and physiological parameters pertaining to atherosclerosis were examined and the results were compared with those in age-matched short-term hemodialysis patients (mean age : 55±2 years, mean duration of hemodialysis : 23±3 months). Although hypertension is regarded as one of cardiovascular risk factors together with diabetes, smokings and hyperlipidemia, our study found that the incidence of hypertension was significantly lower in long-term survivors on hemodialysis (16.7%) than in short-term hemodialysis patients (83.3%). However, no significant differences in biochemiacal data and carotid artery intima-media thickness were found between the two groups of hemodialysis patients. Levels of pulse wave velocity (PWV) in both short-term hemodialysis patients (1912±165 cm/sec) and long-term survivors on hemodialysis (1627±97 cm/ sec) were significantly higher than those in age-matched healthy subjects (1382±44 cm /sec). The levels of PWV in long-term survivors on hemodialysis tended to be lower than those in short-term hemodialysis patients, although the difference was statistically not significant. These results suggest that atherosclerotic alterations have already advanced in non-dialyzed patients with end-stage renal disease. The relatively lower levels of PWV in long-term survivors on hemodialysis may reflect the higher incidence of cardiovascular-related complications in those patients with highly accelerated atherosclerosis who die or may drop out during hemodialysis treatment.

Electrocardiographic abnomalties and atherosclerosis in patients on maintenance hemodialysis / 日本農村医学会雑誌

Increasing medical knowledge and improved hemodialysis techniques have permitted longer survival in patients receiving hemodialysis. However, the risk of cardiovascular disease, which is mainly caused by atherosclerosis, substantially increases in proportion to the longer survival of hemodialysis patients. At present, cardiovascular disease is a major cause of morbidity and mortality. The present study was designed to investigate the relations between electrocardiographic abnormalities (e.g. ischemic change, left ventricular hypertrophy, arrhythmia and conduction block) and the progression of atherosclerosis, the atherosclerotic risk factors (e.g. diabetes, hypertension, hyperlipidemia and smoking) and aortic calcification in patients on maintenance hemodialysis. Pulse wave velocity (PWV) was used as the index of atherosclerosis. PWV levels were singficantly higher in ischemic change (1,993±99cm/s), left ventricular hypertrophy (2,103±120cm/s), arrhythmia (2,015±120cm/s), and condition block groups (2,014±119cm/s) than in the nomal group (1,627±69cm/s). Also, PWV levels corrected by diastolic blood pressure in all abnormal groups were significantly higher. Serum Creactive protein levels in all abnormal groups also tended to be higher than those in the normal group. With regard to atherosclerotic risk factors, the incidence of diabetes and hypertention tended to be higher in abnormal groups. Especially the incidence of hypertension was significantly higher in ischemic change (66.7%), left ventricular hypertrophy (50.0%) and conduction block groups (55.6%) than that in the normal group (16.7%). These results suggest that the electrocardiographic changes are related to the progression of atherosclerosis, and among atherosclerotic risk factors, hypertension most affects the electrocardiographic changes in patients on maintenance hemodialysis.

Initiation of Once-A-Week Hemodialysis / 日本農村医学会雑誌

Patients with chronic renal failure (CRF) have a great psychological burden before they start hemodialysis and when the treatment begins. We initiated once-a-week hemodialysis program, designed to reduce the psychological burden as well as to keep the residual renal function. A total of 13 CRF patients with an adequate urine volume participated in this program. Nutritional counseling was done in all the patients. They were on hemodialysis for five hours at a time. The blood flow rate of more than 200ml/min was secured. Dialyzers with the largest filtering membrane area possible were used, the physique of the patients taken into due consideration. The weekly hemodialysis treatment was continued, so long as the levels of serum urea nitrogen, serum creatinine and body weight gain were lower than 100 mg/dl, 13.0mg/dl, and 3.0kg/week, respectively. Pre-dialysis urine volume and creatinine clearance were 1, 370±160ml/ day and 4.7±0.4ml/min, respectively. The hemodialysis treatment continued for 25±5 times. There were no significant correlations between the duration and pre-dialysis levels of urine volume, creatinine clearance, serum urea nitrogen, serum creatinine, hematocrit, arterial blood pH and HCO<SUB>3</SUB><SUP>-</SUP>. Hemodialysis were discontinued when there were increases in body weight (7 patients), the increase in solutes (3 patients), and both (3 patients). The average monthly medical expenses involved in once-a-week hemodialysis was 55.1% of those entailed by hemodialysis treatment three times a week. Once-a-week hemodialysis is suitable for the conditions: 1. Patients have an ad quate urine volume and no severe edema. 2. Serum urea nitrogen and creatinine levels are not extremely high. 3. Patients fully comply with their dietitian's advice. 4. Shunt blood fl ow is kept enough. Provided these conditions are met, our study suggested, once-aweek hemodialysis should be considered as one of the treatment options, because it was proved effective in reducting CRF patients psychological burden, maintaining residual renal function, and cutting medical costs.

The State of Mind of Patients with Chronic Renal Failure at the Time of Hemodialysis: Influence of Weekly Hemodialysis / 日本農村医学会雑誌

Prior to the anticipated initiation of hemodialysis, the state of mind of patients with chronic renal failure is emotionally unstable. They are weighed down with anxiety. Recently, we started the once-a-week initiation method of hemodialysis in order to lighten the psychological burden in our renal unit. This study was disigned to examine the state of mind of patients receiving hemodialysis as well as the effect of the once-aweek initiation of hemodialysis on the state of mind. The psychological burden wasfound in 83.3% of patients. Particularly, the restriction of food and water intake (39.1%), the restriction of actions by repeated hemodialysis (20.9%), and the fear of complications and the anxiety about the future (15.5%) accounted for 75.5% of all psychological burdens. The initiation of hemodialysis once a week reduced various psychological burdens, the restriction of food and water intake (30.7%), the restriction of actions by repeated hemodialysis (23.1%), physical complications and the lowering ofphysical faculty (23.1%), the changes in the domestic position and role (15.4%) and the economical and social restriction (7.7%), in 72.2% of patients. These results indicate the necessity of the psychological counseling for the prognosis before the start of hemodialysis and the consideration for the choice of the initiation method of hemodialysis.

Transcranial Doppler Measurement of Middle Cerebral Artery Blood Flow Velocity in Patients with End-stage Renal Disease Referred for Hemodialysis Due to Chronic Glomerulonephritis and Diabetic Nephropathy / 日本農村医学会雑誌

It is known that the cerebral circulation is regulated spontaneously and always keep blood flow constant despite changes in perfusion pressure. This phenomenon has been called the autoregulation of cerebral blood flow. However, there is still considerable controversy regarding the influence of blood viscosity upon cerebral blood flow. Several studies have reported that in hemodialysis patients, the velocity of middle cerebra artery (MCA) blood flow decreased after hemodialysis, resulting from the decrease in body fluid and the increase in blood viscosity. In the present study, we evaluated changes in MCA blood flow velocity by hemodialysis in the patients with end-stage re -nal disease referred for hemodialysis due to chronic glomerulonephritis (CGN group) and diabetic nephropathy (DN group). No stenoses of the carotid artery were comfi rmed by ultrasonography in all subjects. We measured MCA blood flow velocity before and after hemodialysis using a 2-MHz pulsed-wave transcranial Doppler instrument with on-line spectrum analysis. Additionally, the measurements of mean blood pressure, body weight, hematocrit levels and arterial blood gas were made simultaneously. In the CGN and DN groups, mean MCA blood flow velocity was 52-56cm/sec and 49-53 cm/sec before hemodialysis and 51-53cm/sec and 51-53cm/sec after hemodialysis, respectively. No significant decreases in MCA blood flow velocity after hemodialysis were found in both groups, though body weight in both groups and mean blood pressure in the DN group alone decreased while pH, HCO<SUB>3</SUB><SUP>-</SUP>, and Ht levels in both groups increased significantly. PCO<SUB>2</SUB> and pO<SUB>2</SUB> levels remained unchanged. Also, no significant differences were found between both groups in the changes in MCA blood flow velocity. Pulsatility and resistive indices in the DN group were relatively higher than those in the CGN group. This result suggests the more progression of arteriosclerotic changes in MCA in the DN group compared with those in the CGN group.

The Prevalence of Serum Candida Antigen in Maintenance Hemodialysis Patients / 日本農村医学会雑誌

Previously, we have reported that <I>Candida</I> strains were morefrequently detected in the oral cavity of hemodialysis patients, particularly long-term patients, than in that of the patients with chronic glomerulonephritis ans conservative chronic renal failure. In the present study, we conducted a screening test for the prevalence of serum <I>Candida</I> antigen in hemodialysis patients and determined <I>Candida</I> species in the oropharyngeal portion of those with serum <I>Candida</I> antigen. Serum <I>Candida</I> antigen was found in 18.75% of the hemodialysis paients in our renal unit. Furthermore, <I>Candida</I> strains were detected in the oropharyngeal portion in 75.0%of those with serum <I>Candida</I> antigen. The percentage was higher than that of hemodialysis patients without serum <I>Candida</I> antigen (50.0%). <I>Candida</I> species determined in the oropharyngeal portion of the hemodialysis patients with serum <I>Candida</I> antigen were <I>C. albicans</I> (66.7%), <I>C. glabrata</I> (55.6%), <I>C. krusei</I> (11.1%), and <I>C. parapsilosis</I> (11.1%). There were no significant differences in age, hemodialysis periods, and the serum values of the nutrional markers (serum total protein, albumin, transferrin, and total cholesterol) between the hemodialysis patients with serum <I>Candida</I> antigen and those without. Generally, it is well known that hemodialysis patients are theso-called immunocompromised host. Therefore, it is necessary to examine serum <I>Candida</I> antigen and to determine <I>Candida</I> species in the oropharyngeal portion, wherewas first possible portion of mycotic infection, beforehand so as to predict the occurrence of invasive <I>Candidiasis</I>

Ischemic Peripheral Circulatory Disorders and Ankle Brachial Pressure Index in Maintenance Hemodialysis Patients / 日本農村医学会雑誌

Ischemic peripheral circulatory disorders have been observed more and more frequently in maintenance hemodialysis patients in recent years. This tendency is associated with the progression of arteriosclerosis characteristic of such patients. In the present study, we made inquiries about the presence or absence of subjective symptoms of ischemic peripheral circulatory disorders in maintenance hemodialysis patients and examined pulsation of dorsal artery and cyanosis of foot to make early diagnosis of the circulatory disorders possible. Furthermore, we measured the ankle brachial pressure index (API) and examined the calcification in thoracic and abdominal aortae on X-rays. According to clinical symptoms, the subjects were classified into no clinical symptom, sensory disorder, and motor disorder. Of the participants in the present study, 31.0% had API below 1.0. The mean age and hemodialysis period of the patients with API below 1.0 were more than those of the patients with API 1.0 or over. However, the differences were not significant. Of the patients with no clinical symptom, 21.2% had API below 1.0. We found a patient with no clinical symtom who had no pulsation of dorsal artery and cyanosis of foot. Of the patients who complained sensory and motor disorders, 35.0% and 45.5%, respectively, had API below 1.0. In the examination of calcification of thoracic and abdominal aortae, 23.8% of the patients with no calcification, 22.2% of the patients with the calcification in thoracic aorta alone, 27.8% of the patients with the calcification in abdominal aorta alone, and 29.6% of the patients with the calcification in both thoracic and abdominal aortae had API below 1.0. We believe that these results will make for early diagnosis and care treatment of ischemic peripheral circulatory disorders in hemodialysis patients.

Successful Approach to Treatment of Dialysis Hypotension / 日本農村医学会雑誌

Dialysis hypotension is one of the most common complications observed during hemodialysis. As it may be due to vasodilatation, vasoconstrictors are usually given to patients to control blood pressure. Howerver, there are some patients who are resistant to the medication with vasoconstrictors. Recently, it has been reported that as one of the treatments of dialysis hypotension, the cooling of dialysate is effective in inducing vasoconstriction via stimulating the sympathetic nerve system. Also, the application of the interaction of citrus juices with some kinds of drugs to the treatment of dialysis hypotension has been reported effective. In the present study, we examined the effectiveness of those two methods in nine hemodialysis patients in whom dialysis hypotension had not been improved with vasoconstrictors. Dialysate temperatures were lowered from 36.0 to 35.0 C during hemodialysis and/or 100m1 of citrus juice (grapefruit juice) were given to the patients before hemodialysis in addition to vasoconstrictors. Lowering dialysate temperaturse reduced the incidence of intradialytic hypotension and helped improve the patients' quality of life after hemodialysis therapy. Body temperature remained unchanged between before and after hemodialysis. However, we observed cramps in two patients and an impairment of consciousness in one patient during hemodialysis. Thus, we concluded due caution should be exercise against the side effects during hemodialysis when dialysate temperatures are lowered. Meanwhile, the intake of grapefruit juice before hemodialysis was not effective for the improvement of intradialytic hypotension and the patients' quality of life.

Dialyzer Blood Flow Less Affects Access Recirculation in Hemodialysis Patients with Higher Access Blood Flow / 日本農村医学会雑誌

It has been known that access recirculation is positively related to dialyzer blood flow and is negatively related to access blood flow in the vascular access in hemodialysis patients. The present study was designed to examine whether an increase in access recirculation generated by an increase in dialyzer blood flow is related to access blood flow. All patients had native end-to-side arteriovenous anastomoses at the radial site. We measured access recirculation at two different dialyzer blood flow rates (85 and 170 ml/min) using a three-needle technique. Access blood flow rates (mean 668 ml/min ranging from 493 to 1038 ml/min) were measured using Doppler ultrasound sonography. We confirmed that an increase in dialyzer blood flow rate led to an increase in access recirculation (5.4±1.1 vs. 9.9±1.9%, p<0.05), and that access recirculation was negatively related to the access blood flow rate (y=-30.78x+972.20, r=-0.79, p<0.05). We further found a negative correlation between the increase in access recirculation generated by the increase in dialyzer blood flow rate and access blood flow rate (y=-33.88x+821.57, r=-0.75, p<0.05). These results suggested that dialyzer blood flow less affects access recirculation when access blood flow is higher.

Effects of Hemodialysis Therapy on Local Hemodynamics in the Forearm with Arteriovenous Fistulas / 日本農村医学会雑誌

This study focused on the local hemodynamic changes created by hemodialysis therapy in the forearm with arteriovenous fistulas for hemodialysis. Arteriovenous fistulas were created in the distal site of the forearm in all the patients who participated in this study. We measured the blood flow volume and blood flow rate in the arteriovenous fistulas using the Doppler ultrasonic flowmeter, and oxygen saturation using the pulse oxymeter and wave height using the plethysmogram in all the fingers of the forearm with arteriovenous fistulas as makers of local hemodynamics before and after hemodialysis therapy was given. After hemodialysis therapy, the patients' body weight reduced by an average of 2.5kg. Reduction of body weight (body fluids) led to decreases in mean blood pressure (99±4 vs. 80±5mmHg) and increases in heart rate (68±2 vs. 72±3 bpm) and hematocrit level (35±1vs. 38±1%) compared with those before hemodialysis. Furthermore, the reduction of body weight tended to decrease the blood flow volume and blood flow rate in arteriovenous fistulas. However, no significant changes were found in blood flow volume and blood flow rate in arteriovenous fistulas between before and after hemodialysis. We further studied the changes in oxygen saturation and wave height in all the fingers of the forearm with arteriovenous fistulas. No significant change was found in oxygen saturation between before and after hemodialysis. However, wave height tended to decrease after hemodialysis.These results suggest that the changes in body weight (body fluid), blood pressure, heart rate, and blood viscosity created by an usual hemodialysis therapy less affect the local hemodynamics in the forearm with arteriovenous fistulas.

Changes in Salivary Bacterial Flora with the Progress of Glomerular Disease / 日本農村医学会雑誌

IgA nephropathy is the commonest form of chronic glomerular disease. The clinical manifestation of this disorder suggests an association with upper respiratory tract infections. Recently it has been reported that Haemophilus parainfluenzae has a role in the etiology of IgA nephropathy. Therefore, the relationship between glomerular disease and oral bacterial flora has attracted attention. Also, it is demonstrated that H. parainfluenzae can bind to high-molecular weight salivary mucins in a selective manner in humans. The present study focused on the changes in salivary bacterial flora, particular H. parainfluenzae species, with the progress of glomerular disease in patients with chronic glomerulonephritis (CGN), and chronic renal failure (CRF), and patients receiving hemodialysis (HD). With the progress of glomerular disease, the prevalence of Micrococcus, H. parainfluenzae, and Bacillus decreased, and the prevalence of Candida and CNS increased. The decrease in the prevalence of H. parainfluenzae was most remarkable. Serum complement (C3, C4, and CH50) levels decreased significantly in CRF and HD patients compared with those in CGN patients. Serum IgA levels in patients with H. parainfluenzae did not differ significantly from those in patient without H. parainfluenzae in each stage of glomerular disease. In conclusion, salivary bacterial flora changes with the progress of glomerular disease. The overwhelming prevalence of H. parainfluenzae in the stage of CGN compared with the stages of CRF and HD, may support the hypothesis that H. parainfluenzae has a role in the etiology of chronic glomerulonephritis.

Effects of Lactic Acid Bacteria Preparations and Lactulose and Their Combination in Hemodialysis Patients / 日本農村医学会雑誌

It is known that lactic acid bacteria preparations suppress the intestinal putrefaction and improves defecation, and that lactulose acidifies the intestinal contents and stimulates the proliferationof lactic acid bacteria in the intestines and further inhibits the absorption of ammonia from the intestine, resulting in the decrease in the synthesis of urea in the liver. For this clinical study, 15 patients receiving maintenance hemodialysis were selected and were divided into two groups. They received orally either lactic acid bacteria preparations or lactulose earlier for 6 weeks, followed by administration of their combination for 6 weeks. We examined the effects of each administration on the changes in peripheral blood counts, blood chemistries, intestinal bacterial flora in a lower portion of the rectum and bowel habits. Administration of lactulose combined with lactic acid bacteria preparations following the intake of lactulose alone induced a significant decrease in the serum triglyceride levels and a significant increase in serum phosphate levels. However, administration of lactic acid bacteria preparations in combination with lactulose following the intake of lactic acid bacteria preparations alone induced no significant changes. Plasma levels of ammonia and glycohemoglobin remained unchanged. Administration of lactic acid bacteria preparation and lactulose and their combination induced the increase in the percentages of Streptococcus, Enterococcus and Staphylococcus groups in the lower portion of the rectum, whereas <I>Candida albicans</I> was not detected. The improvement of bowel habits was observed after administration of their combination rather than administration of lactic acid bacteria preparations and lactulose alone. These results suggest that the environmental changes of the intestine produced by administration of lactulose earlier than of the combination with lactic acid bacteria preparations are effective in changing blood chemistries, and that administration of their combination has advantages in improving the bowel habits.

Association with Cryoglobulinemia and Renal Disorder in Patients with Hepatitis C Virus Infection. Their Relationships to the Presence of Hepatic Disorder / 日本農村医学会雑誌

It is considered that hepatitis C virus (HCV) infection may be a pathogenic factor in cryoglobulinemia and glomerulonephritis. The purpose of this study was to determine whether there is any relation between the presence of hepatic disorder due to HCV infection and the association with cryoglobulinemia and urinary abnormalities, i. e. proteinuria and/or hematuria, in HCV-infected patients. Cryoglobulinemia was found in 11.4% of our HCV patients. However, seropositivity of cryoglobulin detected in all the patients was low. The prevalence of the association with cryoglobulinemia in patients with hepatic disorder was significantly higher than that in patients without hepatic disorder. Urinary abnormalities were found in 10.0% of the HCV patients. No significant difference was observed in the prevalence of urinary abnormalities between patients with and without hepatic disorder. In addition, there was no significant difference in the prevalence of urinary abnormalities between the association with and without cryoglobulinemia. These results suggest the close relation between the presence of hepatic disorder due to HCV infection and the association with cryoglobulinemia. However, renal involvement may have no relation with the presence of hepatic disorder and cryoglobulinemia.

Use of a Dual-lumen Catheter with a Dacron Cuff as a Long-term Vascular Access for Hemodialysis in a Patient with Chronic Renal Failure: Influence on the Efficiency of Hemodialysis and Hemodynamics / 日本農村医学会雑誌

This report presents our experience in using a dual-lumen catheter with a Dacron cuff as longterm vascular access for homodialysis in an elderly patient. The female patient who at first treated with continuous ambulatory peritoneal dialysis for chronic renal failure, but the treatment could not be continued because she developed inveterate peritonitis. Thereafter, hemodialysis was performed. However, a lot of blood access troubles occurred and consequently peripheral access was exhausted. Therefore, we placed the catheter into a right internal jugular vein. This procedure made it possible to secure enough and stable blood flow during the hemodialysis session. Thus, the clearence ratios of blood urea nitrogen and serum creatinine and the value of KT/V increased. No complications have been observed since then. We further examined whether the placement of the catheter would affect hemodynamics in brain and upper extremities, using transcranial Doppler ultrasound and plethysmography. No remarkable difference in blood flow between right and left ophthalmic arteries and decrease in arterial blood flow of right finger tips were observed. Furthermore, venous dilatation, swelling in neck and right upper extremities, and facial edema were not found. The catheter, therefore, represents a significant advance, providing immediate, durable and relatively safe access for hemodialysis after repeated blood access troubles and exhausted peripheral access.