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A survey has been made of 150 cases of acute renal failure (A.R.F.) seen between 1962 and 1981. The overall mortality was 43.3%. The patients ranged from 7 to 75 years old. The mean age of all the patients was 47.2 years old. The mean age of the patients seen between 1970 and 1981 was 58.1 years old, 20 years older than those seen between 1962 and 1969. Despite increasing expertise in management of the complications of surgical, medical, and obstetric disorders, and considerable technical advances in dialysis, there was no decrease in mortality over the 20-year period of survey. Many factors have been identified as having an adverse influence on prognosis, such as age of patient, surgical origin, and complications. Mortality rate was high in the patients over 71 years old, postsurgical group (55.6%), and hepatorenal syndrome group (92.3%). Five major complications had an adverse influence: septicemia (57.1%), respiratory infection (61.1%), cardiovascular disorder (46.3%), hemorrhage (59.6%), unconsciousness (62.2%), and hepatic dysfunction (56.8%). Between 1970 and 1981 the mortality in the patients dialyzed up to 3 times was 81.3%, compared with 26.5% in those dialyzed from 4 to 19 times (p less than 0.01). In the former group severity of the underlying disorder had an adverse influence on prognosis. Although the A.R.F. may be controlled in the earlier stages of illness, many of these patients die of overwhelming infection or other complications.

Twenty-five of 34 patients who underwent pyeloplasty operation for ureteropelvic junction obstruction were able to be followed up for three months or more after operation. Postoperative results were compared in twenty-six kidneys of these patients according to clinical conditions such as age, duration of indwelling nephrostomy tube and splint catheter, operative method (one-stage or two-stage operation), preoperative urinary tract infections, preoperative grade of hydronephrosis and the postoperative period evaluated. Postoperative results evaluated at three months after operation, revealed no case with excellent improvement. At 36 months after operation excellent improvement rate was 46.7% and there was a significant difference in excellent improvement rate between these times. At 3, 6, 12 and 36 months after operation, improvement rate was 35.7, 55.0, 52.9 and 86.7%, respectively. At 3 and 6 months or more, deterioration rate was 29 and 0%, respectively. It is concluded that evaluation of pyeloplasty should be done at least 6 months after operation and even if renal function is stable at this period, more improvement in renal function can be expected at one year or more after operation.

A statistic survey was carried out on the patients, diseases, and operations experienced at the urological ward of Kyoto University Hospital during the years of 1977 to 1982.

26例の手術対象の上部尿路閉塞性疾患に, 123I-orthohippurateによる経時的腎イメージ, レノグラム, 局所レノグラム, functional imageを作成し検討した.functional imageはレノグラムよりも鋭敏に腎機能の改善度を描出, 把握することが可能で, 腎機能を形態的情報とともに知ることができた, Renal scintigraphy and regional renography using I-123- orthoiodohippurate were performed in 26 cases of obstructive nephropathy. After 1 mCi of I-123- orthoiodohippurate was given intravenously, serial renal scintigrams were obtained for 25 minutes and regional renogram curves were derived from the whole kidney, the cortical and pelvic areas. At the same time, renal functional images with Tmax as the peak arrival time were processed. Tmax in normal cases ranged from 2 to 3 minutes in the cortex and from 4 to 5 minutes in the pelvis, while there was some delay in Tmax in the obstructive nephropathy. In the case of acute ureteral obstruction by stones, most of the regional renograms in the cortex and pelvis improved soon after the removal of the obstruction. On the contrary, in the case of chronic obstructive nephropathy obstructive patterns on renogram curves was usually observed postoperatively. However, in some cases, functional images in cortical and/or pelvic areas showed marked recovery before improvement of findings on renograms or IVP. I-123- orthoiodohippurate renoscintigraphy is a useful adjunct for assessing pre- and post-operative renal function in obstructive nephropathy. Particularly, the analysis of regional renogram curves enables early prediction of postoperative recovery, and the functional image enables early detection of the functional recovery of the hydronephrotic kidney.

A recent six year statistic survey was carried out on the patients in the Urological Outpatients Clinic of Kyoto University Hospital.

Adrenocortical function was studied on 25 cases of acute renal failure. 1) Plasma cortisol level before hemodialysis or peritoneal lavage was 38.35±4.48 pg/dl (normal value: 14.33±2.36µg/dl, p

Clinical study was made on 65 cases of acute renal insufficiency experienced at the Department of Urology, Kyoto University from 1962 to 1969. 1) Causes and clinical manifestations of acute renal insuffiCiency were varied, but they were classified into the prerenal origin (32 cases), the renal origin (23 cases) and postrenal origin (10 cases). 2) Main treatment for these cases was dialysis. Forty-four (67.7 %) received hemodialysis with either Kolff's twin coil artificial kidney or Kiil two layers dialyzer. Twenty (30.8 %) were treated by peritoneal dialysis. 3) As to prognosis, over-all mortality was 44.6 % (29/65). Although the mortality rate was quite high (60 %) for the first few years, it has decreased to 40 % for the recent two years probably because of adoption of the early and preventive hemodialysis which has been technologically improving. Mortality rate of each causative origin was as follows: prerenal 53.1 % (17/32), renal 39.1% (9/23) and postrenal 30% (3/10). Prognosis of the group of prerenal origin was therefore poor, in which mortality rate of hepatorenal syndrome was 100 %, postoperative 50 % and posttraumatic 40 %. Adult age groups, 31 to 60 years, showed relatively high mortality. 4) Complications observed were cardiovascular disorder, pulmonary edema, and hemorrhage. This order is that of frequency as well as that of cause of death. 5) Pathophysiological aspect of the development of acute renal insufficiency was discussed with emphasis on intrarenal circulation at the time of acute renal failure. Mechanism of oliguria and anuria was also discussed from both of glomerular and tubular function.

1) Case report : A male 29, complained of hematuria an d pyuria. Pyelogram revealed a right ureteral stone with incomplete duplication of the ureter, and lateral displacement of the left kidney compressed by fist sized tumor mass. Left pyelogram was apparently normal (no reduction of any calyces). Seminal vesiculogram (thro u gh vasoseminal route) showed dilated ureter end terminating in the left seminal vesicle. Both ureteral orifices were essentially normal cystoscopically. This patient had 2 children and did not notice any ejaculatory distress. Supernumerary ectopic ureter opening into seminal vesicle with a nonfunctioning upper renal segment was diagnosed preoperatively. Operative exploration conf i rmed these findings i. e. hydroureteronephrosis of superior pole of duplicated kidney and ureter drained by corresponding kidney. Heminephrectomy and total resection of the ectopic ureter were performed. (Ureterolithotomy for the right ureteral stone had been performed 2 weeks before.) Post-operative course was uneventful. 2) A total of 228 cases of ectopic ureter (including male and female) found i n Japanese literatures were statistically analyzed chiefly concerning age, type (Thom), opening site, complication, and treatment. Concerning type , the most frequent is type III and then type II in Europe and U. S. A., but type I (70.6 %) and secondly type III (20.6 %) in Japan. Concerning opening site in female, the most frequen t is urethra or vestibule of vagina and thin vagina in Europe and U. S. A., but in Japan firstly vagina (66.6, °0) and secondly vestibule of vagina (14.4 %). In Japanese male, 5 cases open into seminal vesicle, 1 case into vas deference, and 1 case into ejaculatory duct. 3) Only 7 cases of male ectopic ureter w ere reported in Japanese literatures, and the above reported case was the 6 th one. In Japan the number of male patients was about 1/33 of that of female patients v. s. 1/2 to 1/3 in Europe and U. S. A.. This difference of male and female ratio between Japan and Western countries may b partly attributed to the considerable number of autopsy cases reported in the latter. Male cases are difficult to diagnose because clinical signs are not suggestive as in female (i. e. urinary incontinence), so that it is necessary to suspect ectopic ureter and perform detailed examination in male cases of unexplained pyuria, reccurent or persistent epididymitis, and when duplication is suspected urographically where a segment of renal parenchyma has no apparent calyceal drainage. 4) A total of 10 cases of ectopic u r eter experienced in our clinic were shown briefly in the table 11.

Twenty-six patients were treated by intermittent hemodialysis with Kiil dialyser for past two years, April, 1968 to March 1970. All the patients were equipped with the arteriovenous shunt of Quinton-Scribner type, 16 in the forearm and 10 in the leg. Average shunt survival in the patients dialyzed more than three months was 11 to 12 months on the arterial side and 8 to 9 months on the venous side both in the forearm and leg shunts. If the cases dialyzed more than one year were taken, the shunt survival was 14 to 17 months on the arterial side and 10 to 12 months on the venous side with a little longer survival in the leg shunt. These results are never inferior to those in the western countries. Complications associated with shunt consisted of clotting (48.3 %), mechanical imperfection (26.7 %), infection (15 %) and bleeding (10 %). These were predominantly seen on the venous side, therefore, recannulation required was mostly that of the venous cannula. Frequency of the complications was a little higher in the forearm shunts, but that of recannulation was almost same in both groups. Angiography is important for diagnosis of the complications. It is often helpful for recannulation to know about the state of the vessel where the vessel tip is inserted as well as about the collateral circulation.

Peritoneal lavage was performed to a total of 16 patients consisted of 9 cases of chronic nephritis, 1 subacute nephritis, 1 bilateral hydronephrosis, 4 acute tubular necrosis and 1 acute "Brovarin" intoxication. The report deals with the results of dialysis and discussions on clearance of various substances through the peritoneum during the lavage. Literatures were also reviewed. Isolated intestinal loop for dialysis was carried out in 4 cases as the first performance in Japan, so that the results were reported as well as general review of the technique on vividialysis. Clearance of various substances through the isolated intestinal loop was found to be about a half of that by peritoneal lavage, but it has advantages on availabilities for prolonged and repeated performance. It is supposed that the technique is to be tried for treatment of chronic renal insufficiency more widely.

Two-hundreds and fourty-seven patients showed non-functioning kidney, either unilateral or bilateral, on IVP for 3.5 years of 1964 to 1967. They were statistically investigated regarding sex, affected side, age, chief complaints, renal diseases, examinations further performed, treatments, etc. The hospitalized cases were precisely studied besides. Recently, non-visualizing kidney after surgery for carcinoma of the cervix has been remarkably increasing in number. Delayed excretory pyelograms taken after injection of double dosage of contrast dye seemed to be the best diagnostic method for non-visualizing kidney. Renal function studies of the patients with non-visualization on routine IVP showed that majority of them had RPF below 100 cc/min and creatinine clearance below 10 cc/min. As to treatment, nephrectomy was the operation most frequently performed on such kidney.

1. 1, 265 operations were performed at our department fo r past five years (1964-68), and 85 (6.6 %) of them were obliged to have the second surgical intervention which were essentially undesired. 2. The second operations consisted of resuture of the wound 51, hemostasis 10, closure of the urinary fistula 6, removal of the organ 4, laparotomy 4, urinary diversion 4 and incision of the abscess 3. 3. Discussio n s were made on the causes which necessitated reoperations as well as on the relation with the original operations.

1. Twenty-six patients under chronic hemodialysis for p a s t two years, 4.1968 to 3.1970, . were divided into the outpatient and inpatient groups and further subdivided into the complete and incomplete groups based on the clinical findings and social adaptability. Findings such as blood pressure, cardiothoracic ratio, urine volume, creatinine clearance were all better in the outpatient group than in the inpatient. 2. For hemodialysis on the o u tpatient basis or on rehabilitation to be possible, the clinical indices should be as follows : mean blood pressure below 100 mmHg, cardiothoracic ratio below50 %, urine volume over 1000 ml per day and creatinine clearance over 4.0 ml/min. Social rehabilitation would be greatly depending on how much is the r e maining function, of the patients' impaired kidneys. In most of the western counteries, chronic hemodialysis is carried out on the outpatient basis. Hemodialysis under hospitalization is, of course, not what we willingly do. If a patient could not be discharged after two months, he should rather have renal transplantation than continuing hemodialysis. 3. Seven patients whose urine vo l ume is over 1000 m l/day were chosen for study of renal function. Changes of renal function were checked for three days among which 8 hours hemodialysis was inserted. After dialysis, GFR and free water clearance dropped, and all of the urnie volume, solute excretion, urinary sodium and potassium decreased. Values per each nephron also decreased. Specific gravity and osmolality showed no change due to hemodialysis and stayed fixed at the low values. So it was conjectured that function of the patients' own kidneys dropped during hemodialysis. After dialysis, GFR, urine volume, solute excretion, urinary sodium and potassium all increased gradually recovering to the predialysis values except for free water clearance which increased rapidly. 4. Discussions were made on the concentrating and diluting power of the kidneys, with emphasis on intact nephron hypothesis of Bricker et al. Their theory is not always applicable for dialysis patients, and there seem to be a certain balance among kidney function, dialysis frequency and uremic symptoms. We should not neglect the remaining function of the patients' own kidneys. If dialysis is continued based only on the uremic symptoms, urine volume might decrease. The renal function seems to be autoregulated by the physical demand of the patients. As to solute excretion, dialysis entirely takes place of the kidney ; therefore, it is natural that the excretion by the own kidney may decrease. This might be understood as regulatory adaptive phenomena by Bricker. Increased free water excretion from the remaining nephrons in the immediate postdialysis period is a good evidence of sufficient diluting power as well as of dominant of tubular diluting function over glomerular function. In this postdialysis condition, no glomerulo-tubular balance may exist. 5. If we regard, however, above changes of re n al function during and after hemodialysis as a series of homeostasis occurring in the patients, dialysis is a substitute of glomerular function although it is an unphysiologic, artificial and physical way of filtration and excretion of solutes. Tubular function which ceased during dialysis becomes dominant after that. Thus, glomerulo-tubular balance may be well maintained after all.