Koji Hattori

Asymptomatic arteriovenous malformation of the pancreas. Demonstration by Doppler ultrasonography and magnetic resonance imaging.

SummaryWe reported a case of asymptomatic pancreatic AVM, incidentally found on routine ultrasonography and diagnosed noninvasively by means of Doppler ultrasonography and MRI. The diagnosis was confirmed by angiography. This is the first report to demonstrate the characteristics of pancreatic AVM by these two imaging techniques. They proved to be useful in identifying the vascular nature of AVM without the use of a contrast material, which is a definite advantage over DSA and CT. The quality of the image obtained was equivalent or superior to that obtained by DSA and contrast-enhanced CT. Doppler ultrasonography and MRI may serve as the primary imaging techniques of choice in suspected cases of AVM.

Long-Term Enalapril Therapy in Patients with Chronic Renal Failure on a Low-Protein Diet

The effect of enalapril (5–10 mg/day) on the progression of chronic renal failure (CRF) was compared with that of metoprolol (40–120 mg/day) in 28 patients for 24 months in a prospective study. Throughout the study, there was no significant difference between the 2 groups in protein intake and urinary sodium excretion. But there was a significant difference between the 2 groups in diastolic and mean arterial blood pressure at 6 months. In the serum creatinine level, there was a significant difference between the 2 groups at 6, 12, 18, and 24 months. In creatinine clearance, there was a significant difference between the 2 groups at 24 months. In addition, the progression of CRF was significantly faster in the metoprolol group than the enalapril group as estimated from the slope of creatinine clearance (p < 0.05) and the slope of glomerular filtration rate (p < 0.0005). In urinary protein excretion, there was a significant difference between the 2 groups at 6 and 18 months (p < 0.05). These findings indicate that enalapril has a suppressive effect on the progression of CRF and also has an antiproteinuric effect by a mechanism independent of its antihypertensive effect.

Role of renal kallikrein in the derangement of sodium and water excretion in cirrhotic patients.

The renal kallikrein-kinin system is involved in the regulation of intrarenal blood flow and natriuresis. To study whether deranged sodium and water excretion in terminal cirrhosis is associated with an altered renal kallikrein-kinin system, urinary kallikrein excretion (UkalV) was measured. Low UkalV excretion was found in cirrhosis. In particular, nine cirrhotics with ascites showed a significantly lowered ratio of UkalV to urinary aldosterone excretion when compared with eight cirrhotics without ascites. Continuous infusion in cirrhosis and ascites of prostaglandin E1 (0.1 ng/kg/min) for 3 days resulted in marked increases in both daily urine volume and urinary sodium excretion; this was associated with a significant elevation of UkalV. These results suggest that in cirrhosis the impairment in renal sodium and water excretion may be attributed, at least in part, to deficient activation of the renal kallikrein-kinin system.

A lithium clearance study of sodium reabsorption at the proximal tubule in liver cirrhosis with ascites.

SummarySince the reabsorption of lithium occurs almost exclusively in the proximal tubule and is associated with that of sodium, the fractional excretion of lithium (FELit) ws examined in 18 patients with cirrhosis in order to examine the reabsorption rate of sodium at the proximal tubule. As expected, the fractional excretion of sodium (FENa) was significantly lower in cirrhotic patients with ascites (0.43±0.10%, mean±SEM) than in cirrhotic patients without ascites (0.75±0.14%, P<0.05) and healthy controls (0.82±0.17%, P<0.05). By contrast, there was no significant difference in FELit among cirrhotic patients with ascites (16.7±2.0%), cirrhotic patients without ascites (15.4±2.0%) and controls (17.4±1.5%). It is unlikely, therefore, that in cirrhotic patients with ascites, the impaired sodium excretion is solely caused by the abnormal sodium reabsorption capacity of the proximal tubule.

Effect of simultaneous administration of glucagon and insulin on renal function in patients with liver cirrhosis and ascites.

SummarySince glucagon and insulin (G/I) have been suggested to be hepatotrophic substances, the effect of G/I infusion on the ability to excrete water and sodium was tested in seven patients with cirrhosis and ascites (decompensated group), and compared with that in seven cirrhotics without ascites (compensated group). A constant infusion of 1 U glucagon and 10 U regular insulin over 2 hours daily for 14 days resulted in a significant improvement of prothrombin time in the decompensated group. Concomitantly, an increase in urine volume (62%, p<0.02) and a tendency toward an increase in urinary sodium excretion (68%, 0.05<p<0.1) were observed only in the decompensated group after the G/I infusion. In addition, these were associated with increases in creatinine clearance and osmotic clearance. These results suggest that glucagon and insulin merit further study in hepatorenal syndrome cases.

Is Hospital Profiting from Terminal Care

終末期の医療で過剰な延命治療が行われ, それが医療費増の一因であるとの説がある。平成9年7月から同年12月までの期間に内科に入院した肺癌, 肝癌の患者, 外科に入院した胃癌, 大腸癌の患者計300例を, 積極的療法を受けたA群186例と対症療法を受けたB群114例に分け, 4種の悪性腫瘍について無作為にA・B群を10例ずつ, 計80例を選び, 医療費の推移を比較検討した。A群の医療費に比べB群は50%～70%有意に低かった。5日間ごとの医療費の推移をみると, 退院前6日までは4疾患のいずれでもA群はB群の医療費に比し有意に高いが, その後A群の医療費は激減し, B群では医療費に変化が少ないので退院前の5日間では, 肺癌, 肝癌, 胃癌でA・B群間の有意差は消失した。また, 肺癌, 肝癌については同時期の内科の入院平均医療費と, 胃癌, 大腸癌については同時期の外科の入院平均医療費と比較したところ, A群では肺癌, 肝癌, 胃癌で平均医療費よりそれぞれ5%～17%とわずかに高かったが, 大腸癌では有意差がなかった。B群ではいずれの疾患でも平均医療費の方が40%以上高かった。当病院の成績からは, 終末期の医療で過剰な延命治療が行われているとの証拠は見出せず, 延命医療による医療費増加説を否定する結果となった。終末期の過剰診療・医療費押上げ論が正しいか否かは, 医療側も支払い側も, 根拠となるデータを示して論じる必要がある。