Utility of venography in shunt surgery on hemodialyzed patients

Fifty-eight examples of upper extremity venography in 40 patients undergoing or about to undergo hemodialysis and 18 normal subjects were evaluated. In the normal subjects, tools and conditions of venography were investigated. It was considered necessary to maintain 30 degrees flexion of the cubital joint and supination of the antebrachium and use a 35 x 43 cm film to facilitate upper extremity venous system interpretation. In the patient group, standard venography was compared with shunt-delineating venography (called shuntgraphy) as to advantages and drawbacks. Venography proved to be of excellent use in shunt constructive and reconstructive surgeries in that it provided information supplementary to that obtained in shuntgraphy, or even more valuable information.

Side effects and pharmacokinetics of nonionic iodinated contrast medium in hemodialyzed patients

We conducted contrast CT scanning on 22 dialysis patients using the same method as usually applied to cases with normal renal function and studied the incidences and types of side effects and the pharmacological kinetics of non-ionic iodine contrast medium (Iopamiron 370, 100 ml). During the followup period (five days at most), we found localized urtication as a side effect in only one case (4.5%). Therefore we speculate that non-ionic contrast medium is a safe agent in dialysis patients, as long as it is cautiously used. After contrast medium injection, we conducted dialysis twice, which definitely decreased total blood iodine content. The extraction ratio at first dialysis was particularly high (73% on average). We recognized a statistically positive correlation between this extraction ratio and dialyzer size. Although two cases studied proved the notable acceleration of vicarious excretion in dialysis patients, this acceleration appeared only with high total blood iodine content. This phenomenon was considered mainly due to excretion from the hepatobiliary tract. Vicarious excretion appeared relatively soon after contrast medium injection (within a few hours), but showed a slower decreasing tendency.

Combined hepatitis B immune globulin and vaccine for postexposure prophylaxis of accidental hepatitis B virus infection in hemodialysis staff members: comparison with immune globulin without vaccine in historical controls

Twenty-three staff members serving in a hemodialysis unit were exposed accidentally to needlestick contaminated with blood containing hepatitis B surface antigen and hepatitis B e antigen, as well as high levels of DNA polymerase activity (greater than 100 cpm). They received hepatitis B vaccine (20 micrograms) simultaneously with hepatitis B immune globulin (5 ml, 200 IU per ml) within 48 hr after the exposure, and the vaccination was repeated at 1 and 3 months. The protective efficacy was compared with that in a past study in the same unit in which 33 members were given hepatitis B immune globulin alone within 48 hr after the exposure to blood with similarly high levels of DNA polymerase activity. No differences were noted in age or sex between the staff members who were vaccinated and those who were not, nor were there any differences between their inocula in the titers of hepatitis B virus markers. During 12 months after the accident, only one (4%) of the 23 vaccinated members contracted hepatitis B virus infection, at a frequency significantly lower than 11 (33%) of the 33 members who did not receive vaccine (p less than 0.02). These results indicate that hepatitis B vaccine, when given in combination with hepatitis B immune globulin, is efficacious for postexposure immunoprophylaxis of accidental infection.

[Cardiothoracic ratio and roentgenologic heart size as the indices of body fluid retention in uremics under hemodialysis]

We evaluated the cardiothoracic ratio (CTR) and the roentgenologic heart size (RHS) as the indices of body fluid retention in 31 of uremic patients under hemodialysis. The maximum changes of the roentgenologic thoracic diameter, measured monthly for one year in 31 patients, varied from 10 to 68 mm. The average differences of RHS and CTR between maximum inspiration and forced inspiration in 18 healthy people were 1 mm (RHS) and 2.5% (CTR), respectively, and the change of roentgenologic thoracic diameter was 12 mm. The error of repeated CTR measurements in a period of one year could be estimated more than 2%. In 22 patients the body weight reduction of 1 kg corresponded to a 4 mm decrease of RHS (p less than 0.005) and 1.5% of CTR (p less than 0.05), respectively. In relation to the change of body fluid balance assessed by the change of body weight, RHS showed a higher correlation than CTR. These results could be attributed that RHS was hardly influenced by the respiration, whereas CTR was surprisingly affected. It is concluded that the measurement of RHS is more useful as an index of control of body fluid balance than CTR.

Factors influencing postexposure immunoprophylaxis of hepatitis B virus infection with hepatitis B immune globulin. High deoxyribonucleic acid polymerase activity in the inocula of unsuccessful cases

Hepatitis B immune globulin was given intramuscularly to 102 staff members of a dialysis unit within 48 h after the accidental needlestick exposure to blood containing hepatitis B surface antigen (HBsAg). Hepatitis B virus (HBV) infection developed in 11 of 56 persons (20%) who had been exposed to blood containing hepatitis B e antigen (HBeAg). Among 56 HBeAg-positive inocula, HBsAg-associated deoxyribonucleic acid polymerase activity in the 11 inocula that transmitted HBV infection was significantly higher than that in the remaining 45 inocula that did not (log counts per minute 3.27 +/- 0.57 vs. 2.09 +/- 1.19, p less than 0.001). These 11 HBeAg-positive inocula revealed higher hemagglutination titers of HBsAg (geometric mean 13.5 +/- 1.4 vs. 11.2 +/- 3.2, p less than 0.001). The receptor for polymerized human serum albumin was detected significantly more often in the inocula that transmitted HBV infection than those that did not (10/11 vs. 24/45, p less than 0.05). Based on the results obtained, the failure in protecting all of those exposed to HBeAg-positive blood would be attributable to a high concentration of HBV in some HBeAg-positive inocula and the inability of intramuscular injection to raise a protective level of antibody in the circulation immediately.

Two siblings with hypophosphatasia

Two siblings with hypophosphatasia, one of whom was autopsied, were reported. The first case which was a product of a 26-year-old mother complicated by hydroamnios represented poor mineralization of the entire bones on X-ray examination and died shortly after birth. The second case weighing 1850 g delivered from the same mother had a rhizomelic micromelia and poor visualization of the skull, long bones and vertebral bones on X-ray at postmortem. The autopsy on the second case showed small thoracic cage with rachitic rosaries of ribs, membranous skull and poorly ossified vertebral and long bones. Microscopically, there was a marked disturbance of both enchondral and membranous ossifications similar to the histology of rachitis. A biochemical examination showed low alkaline phosphatase, high calcium and normal PTH in the serum. Further examination of their family revealed relatively low level of alkaline phosphatase of the parents and one of their brothers which suggsted they were carriers of hypophosphastasia. Previous reports on hypophosphatasia were reviewed and differential diagnosis of hypophosphatasia from the other congenital dwarfisms was discussed.