Background : To study the serum parathyroid hormone and bone mineral density (BMD) as risk factors of fractures in hemodialysis patients, we reviewed the incidence of fractures in our hospital. Method : Three hundred and twelve patients were treated between 2003 and 2005 ; twenty-five fractures (8.0%) were documented during this period. We investigated the background and laboratory values for intact PTH, ALP and BMD of subjects. Results : In females, there was a significant gender-associated risk of fracture (p<0.01). The values for intact PTH and BMD (YAM%) were significantly lower (p<0.01) in patients with fractures. When patients were divided into three groups based on K/DOQI clinical practice guidelines (2003), patients with serum intact PTH levels in the lowest tertile (<150 pg/mL) had a greater risk of fracture than those in the normal (150∼300 pg/mL) and highest (>300 pg/mL) tertile (p<0.05). Moreover if the criteria for the lowest tertile of intact PTH was increased to 200 pg/mL, patients with in the lowest tertile had a significantly greater risk than the other groups (p<0.05). Then we investigated the relationship with intact PTH and BMD as a risk factor for fracture. There was significantly higher risk at YAM% in the lowest tertile (<150 pg/mL) of intact PTH compared to that in the other groups (p<0.05). Conclusion : In the lowest tertile of intact PTH, the frequency of fractures was significantly higher and BMD (YAM%) was well maintained. To prevent fracture in hemodialysis patients, the target lower limit of intact PTH should be estimated slightly higher. And even if the patients showed a high value of BMD (YAM%), careful evaluation remains important because these patients might have a low bone turnover rate.

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We performed a cohort study evaluating the incidence and the risk factors for encapsulating peritoneal sclerosis (EPS) and pre-EPS findings in 240 patients who received peritoneal lavage after peritoneal dialysis (PD) withdrawal. EPS or bowel obstruction was assessed as the primary outcome, and ascites or an elevated CRP (pre-EPS findings) was assessed as a secondary outcome. The duration of PD, D/P-Cr, mesothelial cell area just before PD withdrawal (PD area), mesothelial cell area just before lavage withdrawal (lavage area) and the PD solution used for peritoneal lavage were investigated as possible risk factors for outcomes. The primary outcome was observed in 13 patients (5.4%), while a secondary outcome was observed in 42 patients (17.5%). Significant risk factors were PD duration and PD and lavage areas. Cutoff values, determined based on the sensitivity and specificity of the measures, were a PD area of 350 μm² for the primary and secondary outcomes, a lavage area of 320 μm² for the primary outcome, a lavage area of 300 μm² for the secondary outcome, a PD duration of 120 months for the primary outcome, and a PD duration of 96 months for the secondary outcome. The cumulative incidence rate for the primary outcome was 4.2% after 1 and 2 years in the good prognosis group (lavage area <320 μm² and a PD duration<120 months) and 39.7% after 1 and 2 years in the poor prognosis group (lavage area≥320 μm² and a PD duration≥120 months) (p=0.0138). The cumulative incidence rate for the secondary outcome was 5.3% after 1 and 2 years in the good prognosis group (lavage area<300 μm² and a PD duration<96 months) and 55.5% after 1 year and 70.3% after 2 years in the poor prognosis group (lavage area≥300 μm² and a PD duration≥96 months) (p=0.0013). The lavage area decreased significantly after 3 months in the primary group and 9 to 15 months in the secondary group. The lavage area also decreased after 3 to 21 months in non-outcome patients with more than 350 μm² of PD area, while in non-outcome patients with under 350 μm² of PD area, the lavage area did not changed during 27 months post withdrawal observation. After the withdrawal of peritoneal lavage, EPS occurred in 3 of 104 patients and ascites occurred in 4. We concluded that risk factors for EPS and pre-EPS findings were the PD duration and the PD and lavage areas. EPS and pre-EPS findings developed during peritoneal lavage. However, effective prevention can be achieved by considering risk factors when performing peritoneal lavage after PD withdrawal.

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Objectives : The effects of benidipine hydrochloride (benidipine), a long-acting calcium channel blocker, on bone mineral density in haemodialysis patients were investigated. Methods : A randomized parallel trial was carried out in 30 haemodialysis patients receiving anti-hypertensive drug treatment, who had bone mineral density measurement 1 year earlier. The enrolled patients were undergone treated with benidipine (benidipine group, n=16) or other anti-hypertensive drugs (control group, n=14) for 1 year, and bone mineral density was again measured. Results : Blood pressure decreased to the same level in both groups during the trial period. Bone mineral density was decreased significantly (2.42 to 2.35 mmAl, p<0.05) in the control group, but there were no significant change (2.37 to 2.39 mmAl, p=0.642) in the benidipine group. Conclusion : This preliminary study suggests that benidipine may have an inhibitory effect on the decrease in bone mineral density in addition to an antihypertensive effect in haemodialysis patients. In the future, it will be necessary to perform a detailed examination of the effects of benidipine on bone metabolism including the parameter of bone metabolism as a multi-center research trial.

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In fourteen hemodialysis (HD) patients, blood viscosity and its determinants including oxidative stress were examined before and one year after the usage of vitamin E-coated cellulose membrane hemodialyzer (CL-EE). Before CL-EE, blood viscosity, hematocrit, plasma viscosity, plasma fibrinogen and oxidative LDL (a marker for oxidative stress) increased following HD. One year after HD with CL-EE, blood viscosity remained unchanged at the start of HD. However, the increment of blood viscosity following HD was significantly suppressed (3.1±0.3 to 3.8±0.9 mPa · s before CL-EE ; 3.1±0.3 to 3.4±0.5 mPa · s after CL-EE ; hemodialysis × dialyzer interaction, p<0.05). In contrast, oxidative LDL decreased at the start of HD and HD-induced increase was attenuated after CL-EE (3.3±1.0 to 4.2±2.0 ng/μg LDL protein before CL-EE ; 1.9±0.7 to 2.1±0.60 ng/μg LDL protein after CL-EE ; hemodialysis × dialyzer interaction, p<0.05). The HD-induced increase in blood viscosity was positively correlated with that in oxidative LDL (r²=0.17), plasma viscosity (r²=0.62), hematocrit (r²=0.60) and plasma fibrinogen (r²=0.42). In conclusion, the long-term use of CL-EE could suppress the increase in blood viscosity induced by HD, at least in part, via decrease in on oxidative stress.

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It is a problem that the QOL (quality of life) of maintenance hemodialysis patients has been lowered, however, study of the complaints regarding low QOL of the patients has not been sufficient. In this study, we conducted a questionnaire survey to investigate these complaints as well as opinions about acupuncture treatment to improve QOL in these patients. As a result, it was shown that most patients (92.7%) had multiple complaints (3.3), and there was no significant relationship between the number of complaints and patient age or duration of dialysis. There was no apparent relationship between complaints and the underlying disease of the patients. About 30% of patients previously had experienced acupuncture, but the understanding of acupuncture among these patients was apparently not sufficient based on the result of the investigation. However, a number of patients expressed a desire for acupuncture treatment. Because many patients complained of pain and numbness, which are commonly treated by acupuncture, it was suggested that acupuncture treatment might contribute to the QOL of hemodialysis patients.

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Background : In an increasing number of patients, vascular access is difficult to cannulate. We report an access cannulation method using a portable ultrasonographic (US) device. Methods : After disinfecting both the skin around the puncture site and the probe surface with povidone iodine, we placed the probe 1-2 cm from the presumed puncture site in a position perpendicular to the vessels. Then we cannulated the needle from the presumed site. We stop pushing the needle and then thrust only the outer sheath when the needle echo appeared in the lumen of the target vessel on the monitor. The needle direction should be modified according to the images on the monitor if cannulation fails. Finally, we confirm that the needle has not gone through the far wall of the vessel on longitudinal view. Discussion : We adopted an axial view (perpendicular to the vessel) instead of a longitudinal view (parallel to the vessel) for the following reasons. First, we only slightly miss the needle echo. Second, we are allowed more space than that in the longitudinal view in order to cannulate the needles more easily and freely. Finally, adjusting the monitor to the right and left of the actual position facilitates modification of the needle direction. However, the present method may be less useful for either highly convoluted vessels or native veins without AV fistula. The proposed method is so effective that we must maintain the standard of access cannulation technique without excessive reliance on US devices. Conclusion : We reported the advantages and disadvantages of an access cannulation method using ultrasonographic guidance.

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Objective : Adequate salt intake is essential for well-controlled fluid status in PD patients. To achieve it, education on adequate salt intake and patients' follow-up are mandatory, however, those profiles remain unclear.
Subjects and method : One hundred and thirty-nine medical institutions which run PD patients in the North-East region (Tohoku) of Japan were recruited, and those who are in charge of dietary counseling for PD patients were studied. Among them, permissions were obtained from 44 institutions to send a multiple-choice questionnaire regarding education about salt intake and follow-up system for PD patients. The questionnaire was sent by mail to each institution on February 2006.
Result : Responses were obtained from 40 institutions. It was answered by physicians in 19, dieticians in 11, nurses in 9, and other in one case. Physicians were responsible for delivering the dietary prescription at 32 institutions. In 55.0% of cases, it was prescribed according to the need to control blood pressure or the fluid state, however, there were no standards for quantification. In the rest, the prescribed dose was fixed as follows ; 5∼7 g/day in 8 and 7∼10 g/day in 6 cases. Compliance was assessed on a regular basis in 12.5%, or when needed in 45.0%, whereas there was no follow-up in 42.5%. By self-assessment on education about salt intake, 16 institutions (40.0%) recognized programs work more efficiently with systematic education including family members and consideration of patient life style, based on the dietary standards in each institution. Whereas 22 institutions (55.0%) recognized that the programs functioned poorly, mainly due to factors such as patient noncompliance and inadequate systems for education and follow-up.
Conclusion : Prescription regarding salt intake and education for PD patients, in general, remains unfocused. Standardization of education and rational systematic approach to patients are needed.

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We report a 55-year-old female with myasthenia gravis (MG) positive for muscle-specific tyrosine kinase (MuSK) antibody. Her disease was remarkably improved by double filtration plasmapheresis (DFPP). Thymectomy and a variety of immunosuppressive medications have been provided since she was diagnosed as having MG in 2000. On June 3, 2005, she was admitted to our hospital due to MG crisis with acute respiratory failure and soon required a mechanical ventilator. Although the conventional immune-suppressive treatments including steroid pulse therapy and a high-dose intravenous immunoglobulin were given, the clinical condition worsened. When DFPP therapy was added to immne-suppressive drugs, she showed a rapid recovery of respiration and bulbar symptoms accompanied by a reduction of anti MuSK antibody titers. Her general condition was quite improved regardless of reduced doses of immune-suppressive drugs and she was discharged on the 81st hospital day after she received surgery for vascular access construction for anticipated DFPP. At present, the patient is successfully being treated with a combination of periodic DFPP and oral immunosuppressant therapy, 30 mg of prednisolone (alternatively) and 3 mg of tacrolimus (daily). Anti MuSK antibody-positive myasthenia gravis is thought to be a rare disease that tends to induce respiratory crisis and is often refractory toward conventional drug therapy. This case report suggests that DFPP may be an alternative arm against anti MuSK antibody-positive MG.

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