Yohei Tofuku

Serum antioxidant activity in uremic patients.

Serum antioxidant activity (AOA) was examined in 35 healthy subjects and 111 patients with chronic renal failure (CRF), consisting of 13 patients in the predialysis stage, 11 requiring the start of regular dialysis therapy (RDT) and 87 undergoing RDT. Serum AOA was determined by assaying serum activity to inhibit malondialdehyde (MDA) generation. AOA levels were significantly lower in CRF patients, and the lowest levels were noticed in patients with uremic symptoms requiring the start of RDT. These levels were restored to a subnormal level during RDT. Defective serum AOA appears to be an endogenous metabolic consequence in uremia. Sera with low AOA tended to show high MDA levels, indicating that patients with low serum AOA were susceptible to cellular injury by lipid peroxidation. It is proposed that defective serum AOA may contribute to a certain uremic toxicity through peroxidative cell damage.

Treatment of Refractory Hyperparathyroidism in Patients on Hemodialysis by Intermittent Oral Administration of 1,25(OH)2Vitamin D3

Intermittent oral administration of high dose 1,25(OH)2vitamin D3 was conducted in 7 patients associated with treatment-resistant secondary hyperparathyroidism (2nd HPT) on hemodialysis (HD) therapy. Each patient had a long history of HD therapy (range: 101-181 months, 145 +/- 29 months). Although serum calcium levels were maintained under the upper limit of the normal range with the appropriate dose of 1 alpha(OH)vitamin D3 every day before the present therapy, 2nd HPT could not have been controlled. The dose of 2-3 micrograms of 1,25(OH)2vitamin D3 3 times a week could successfully suppress serum levels of parathyroid hormone (iPTH) in all 7 patients after 20-32 weeks. The vitamin was given in the evening before each HD session and the dose and frequency of administration were dependent of the serum calcium level in each patient. After 20 weeks the iPTH-C and iPTH-intact levels decreased significantly from 35.0 +/- 15.8 to 18.6 +/- 11.7 ng/ml and from 533.2 +/- 200.0 to 249.5 +/- 136.2 pg/ml, respectively. The frequency of harmful elevations of serum calcium levels was not significantly increased in comparison with that in the previous period of the study, because serum calcium levels were strictly monitored with frequent checks. In conclusion, we could safely obtain an effect similar to the intravenous administration of the vitamin through the intermittent administration of a high oral dose 1,25(OH)2vitamin D3 in the treatment of refractory 2nd HPT in patients on HD therapy.

Hypouricemia Due to Renal Urate Wasting

We present 2 patients associated with hypouricemia. Serum uric acid levels were 1.6 and 1.3 mg/l00 ml, and the ratios of urate clearance to creatinine clearance were 34.1 and 39.4%, respectively, whil

Allergic Bronchopulmonary Fungal Disease Caused by Saccharomyces cerevisiae

We describe a patient who presented with dry cough, low‐grade fever, and focal patchy shadow of pulmonary infiltrates. Remarkably, the prospective etiological agent, Saccharomyces cerevisiae was purely and repeatedly cultured from her sputum. Allergic bronchopulmonary mycosis (ABPM) was diagnosed based on clinical, serological, and pathological criteria. Although the patient described here satisfied only three of the criteria, the conclusion that the allergic bronchopulmonary disease in our case was induced by S. cerevisiae was made based on the following evidence: 1) S. cerevisiae was repeatedly isolated from the patients sputum, 2) anti‐S. cerevisiae antibody was detected in her serum, and 3) bronchoprovocation test to S. cerevisiae antigen was positive. We present here a case of allergic bronchopulmonary fungal disease caused by S. cerevisiae antigen.

Treatment of Congenital Nephrogenic Diabetes insipidus with Hydrochlorothiazide and Amiloride in an Adult Patient

Aim: The effects of treatment with hydrochlorothiazide (HCTZ) combined with amiloride were elucidated and compared to HCTZ treatment alone and combined with acemetacin or triamterene in a Japanese adult patient with congenital nephrogenic diabetes insipidus. Methods: The study was divided into seven periods: (1) HCTZ and acemetacin; (2) control period; (3) HCTZ; (4) a second control period; (5) HCTZ and amiloride; (6) a third control period, and (7) HCTZ and triamterene. Fluid intake, urine volume, urinary Na, K, creatinine, and osmolality and serum Na, K, Cl, CO2, and osmolality were measured, and free water clearance and proximal and distal tubular Na reabsorption rates were calculated. Results: Without drug administration, the urine volume was about 8,000 ml/day. The urine volume was reduced to about 6,000 ml/day with HCTZ. A further urine volume reduction to about 5,000 ml/day was obtained with the second drug administration, and the effects were similar among the three regimens. Serum and urinary osmolality and free water clearance were also similar among the three combinations, whereas the urinary potassium excretion was the least, and the serum potassium concentration was the highest with HCTZ plus amiloride. Besides, no alkalosis was observed only with this combination. Conclusion: HCTZ plus amiloride may be superior to HCTZ plus acemetacin and HCTZ plus triamterene in preventing hyperkaliuria, hypokalemia, and metabolic alkalosis.

Impaired Metabolism of Guanidinoacetic Acid in Uremia

In order to investigate the guanidinoacetic acid (GAA) metabolism in uremia, we have measured serum guanidino compounds in patients with chronic renal failure (CRF) in comparison with normal subjects, and the renal content of GAA and glycine amidinotransferase (GAT) activity in the kidney of experimental CRF rabbits. Serum concentrations of guanidinosuccinic acid (GSA) and methylguanidine (MG) in the patients with CRF were higher than those in the normal subjects, as well as serum urea nitrogen (BUN) and creatinine (Cr) levels. The serum GAA levels were however, significantly lower and showed a tendency to decrease inversely with the elevation of BUN in the patients with CRF under conservative therapy. On the contrary, in the patients under maintenance hemodialysis (MHD) therapy, the serum GAA level did not decrease in spite of the elevation of BUN. Four anephric patients under MHD therapy showed a level of serum GAA similar to the other MHD patients. In the CRF rabbits, the renal GAA content was significantly lower than in the sham-operated rabbits and showed an inverse correlation with BUN. Renal GAT activity was also significantly lower in the CRF rabbits, showing a positive correlation with serum GAA concentration and an inverse correlation with BUN. These results indicate that renal GAT activity decreases as the BUN level rises in the course of renal damage, resulting in lower concentration of serum GAA in the uremic state; in a more advanced stage of renal failure, the inability of the kidney to synthesize GAA may be compensated by other organ(s). Some dialyzable substances which might inhibit renal GAT activity may also be present.

Prevalence of ATLV and HIV among Hemodialysis Patients in Japan

Human immunodeficiency virus (HIV) and adult T cell leukemia virus (ATLV) can both be transmitted through blood transfusions and blood products. HIV infections are up to the present time uncommon in Japan while the southwestern area of Japan is endemic for ATLV. This study examines the prevalence of HIV and ATLV among Japanese hemodialysis patients who may be at increased risk of viral exposure because they sometimes receive multiple blood transfusions. 1066 patients were examined including 66 from Okinawa--a highly endemic area for ATLV. 7 of the 1066 patients tested positive for HIV using an enzyme immunoassay but none were confirmed by Western Blot analysis. 30 patients tested positive for ATLV by both immunoassay and Western blot analysis. ATLV rates among hemodialysis patients were significantly higher than rates among local blood donor populations. HIV infections are currently not as serious in Japan among hemodialysis patients as ATLV infections. The prevalence of ATLV infections among these patients was related 1st to blood transfusions 2nd to prevalence in the local population and 3rd to migration from endemic areas. If blood bank screening begun in 1986 is successful the probability of these infections being transmitted by blood transfusions will be greatly reduced.

Prevalence of HTLV-1 Antibodies in Hemodialysis Patients in Japan

The southwestern region of Japan is known as a very high endemic area of human T-cell lymphotropic virus type 1 (HTLV-1), the etiologic agent for adult T-cell leukemia (ATL) and probable causative agent for tropical spastic paraparesis and its Japanese version, HTLV-1-associated myelopathy (HAM). Hemodialysis (HD) patients seem to be at high risk for HTLV-1 infection even in other regions of Japan because they sometimes receive multiple blood transfusions. We examined antibody against ATL-associated antigen (ATLA-Ab) in 1,132 HD patients, including 1,066 patients in nonendemic areas (Chubu and Tokyo) and 66 in a highly endemic area (Okinawa). The HD patients in Okinawa showed the highest prevalence, 21.2% (14/66), while those in the Chubu area showed the lowest, 1.1% (10/846), and those in the Tokyo area an intermediate value, 2.7% (6/220). The prevalence of HD patients in each area was significantly higher than that of local blood donors, reflecting an increased prevalence roughly corresponding to the respective endemic rate. The average prevalence of ATLA-Ab among the HD patients was 2.7% (30/1,132), which was similar to that of HBs antigen (3.2%). In the nonendemic areas, 15 of 16 patients with ATLA-Ab had a history of blood transfusions, showing a significant correlation to the presence of ATLA-Ab (P less than 0.01), although four had family histories related to the endemic area. The relative risk of the presence of ATLA-Ab for HD patients with a history of blood transfusions was calculated as 10.3. In the endemic area of Okinawa, the relationship to blood transfusion was not so close, probably masked by the high background prevalence.

Eosinophilic Pneumonia Caused by Aspergillus niger : Is Oral Cleansing with Amphotericin B Efficacious in Preventing Relapse of Allergic Pneumonitis ?

Eosinophilic pneumonia was confirmed by bronchoalveolar lavage fluid examination and transbronchial lung biopsy. Aspergillus niger was cultured from the patients pharyngeal swab and bronchoalveolar lavage fluid. Inhalation bronchoprovocation test with A. niger antigen was positive. Although the patients condition improved promptly with 10 mg/day prednisolone administration, dry cough recurred approximately 2 months after completion of this therapy. Severe coughing disappeared on oral cleansing with 300 mg/day amphotericin B, and he recovered completely on 100 mg/day amphotericin B administration. Oral cleansing with amphotericin B may be efficacious in preventing relapses of eosinophilic pneumonia caused by allergic reaction to fungal antigen.

A rare type of alternating bundle branch block in a patient with cardiac sarcoidosis--a case report.

The authors report a rare type of alternating bundle branch block observed in a patient with cardiac sarcoidosis. Not only alternation of complete right and left bundle branch block but also narrow QRS complexes were observed on electrocardiogram. The mechanism of these unusual findings is briefly discussed.