Measurement of bioactive parathyroid hormone (PTH) is essential for optimal management of bone abnormalities in dialysis patients. This can be accomplished by PTH measurements using third-generation PTH assays, which detect more or less of the first six amino acids of the PTH structure. Such assays do not detect non-(1-84) PTH fragments, such as human PTH (7-84), which are recognized by the second-generation PTH assays that use a detection antibody that recognizes an epitope within the 13-34 region of the PTH structure. Therefore, third-generation PTH results are expected to be lower than those that are obtained with second-generation PTH assays. Rare exceptions to this rule have been reported for patients with severe primary hyperparathyroidism or parathyroid cancer. Sera and gland extracts were analyzed from a dialysis patient with high bone turnover disease and with surprising higher PTH levels by a third-generation assay than by a second-generation assay. This finding normalized after the surgical removal of an enlarged gland with a single nodule, an advanced type of nodular hyperplasia. HPLC fractionation of sera and gland extracts revealed the overproduction and secretion of a PTH molecule with an intact amino-terminus structure distinct from (1-84) PTH. This form of PTH was readily detectable by third-generation PTH assays but was poorly reactive in second-generation PTH assays. Therefore, parathyroid glands with advanced uremic nodular hyperplasia may overproduce and secrete a novel, biologically active form of PTH with an intact 1-6 region but a presumably modified 12-18 region required for the detection in second-generation PTH assays.

As of the end of June 2005, 27 of 96 dialysis outpatients at our clinic had developed carpal tunnel syndrome (CTS). Of 19 patients who had undergone dialysis for 30 years or longer, 15 had CTS, whereas none of the 38 patients who had received dialysis for less than 10 years had CTS. These data reflect trends in CTS development: from 1983 the incidence of CTS increased for many years, but more recently there has been a decline in new cases of CTS. Comparison of the 27 CTS and 69 non-CTS dialysis patients at our clinic showed that those in the CTS group were older and had a longer duration of dialysis. Patients in the CTS group were found to have had a high plasma beta2-microglobulin (BMG) level in the distant past (15-21 years ago), but conversely had a much lower BMG level in recent years. Simple correlation analysis and multiple logistic regression analysis showed that the presence of CTS was correlated with high BMG levels in the distant past, in addition to age and duration of dialysis. These findings suggest that reduction of the plasma BMG level due to advances in dialysis therapy in recent years has contributed to the decreased incidence of CTS.

Sevelamer hydrochloride, a non-aluminum-and non-calciumcontaining hydrogel, is an effective phosphate binder in dialysis patients. The suppressive effect of the switching from calcium carbonate to sevelamer hydrochloride on the progression of vascular calcification was examined by measuring areas of calcification on routine chest X-rays using image-analyzing software. The data of 69 maintenance hemodialysis patients were analyzed retrospectively. Over a period of 18 months, 19 patients took only sevelamer hydrochloride as a phosphate binder, while the other 50 patients took only calcium carbonate. The area of calcification increased in the calcium carbonate group, but did not change significantly in the sevelamer group. While the usefulness of computed tomography in detecting vascular calcification in hemodialysis patients has been reported previously, the suppressive effects of switching from calcium carbonate to sevelamer hydrochloride on the progression of aortic calcification can be observed without computed tomography by using the plain chest X-ray films that are routinely performed in hemodialysis clinics.

Key words：pneumatosis cystoides intestinalis(PCI), a-glucosidase inhibitor(a-GI), hemodialysis 〈Abstract〉 We encountered an 88-year-old male hemodialysis patient taking an oral a-glucosidase inhibitor(a-GI)who developed pneumatosis cystoides intestinalis(PCI)accompanied by intra-abdominal free air. In July 2008, the patient was placed on dialysis due to chronic renal failure derived from diabetic nephropathy. During this time, the use of insulin was discontinued and the patient began taking a-GI orally. Around late November 2008, the patient began to notice a bloating sensation in his abdomen, and was admitted to hospital on November 30 after an abdominal CT scan demonstrated the presence of intra-abdominal free air. Since there were no peritoneal symptoms, the patient was only restricted from oral intake and placed under observation. However, this did not yield any improvement in the bloating sensation in the patientʼs abdomen. On December 4, exploratory laparotomy was performed but there was no perforation of the digestive tract dected. However, PCI was found on the side of the ileal mesentery approximately 70 cm to 150 cm from the terminal ileum. Although the cause of PCI in this patient has yet to be resolved, reports of PCI caused by a-GI have recently been encountered on occasion. It was concluded that a-GI may have contributed to PCI in this case as well.

Key words：obturator hernia, male, hemodialysis 〈Abstract〉 This medical case involves a 75-year-old male who had been on hemodialysis since April, 2007 due to chronic renal failure stemming from chronic nephritis. He began experiencing abdominal distension early in July, 2012 and came to the hospital the next day for hemodialysis. Prominent distention of the intestinal tract was detected by plain X-ray of the abdomen and a diagnosis of left obturator hernia was made by plain CT of the abdomen. Hernioplasty was carried out the same day through emergency surgery, and the patient made good post-operative progress. An obturator hernia is a rare disorder that makes up only 0.073％ of all hernias and 0.4％ of all ileus. In addition, the disorder appears most commonly in older, thin women, with men affected in only 5％ of cases. In some instances, the clinical manifestation is mild, and although it is difficult to suspect obturator hernia, early diagnosis and early treatment are important since the disorder has a high fatality rate.