To evaluate the biocompatibility of a peritoneal dialysis fluid with neutral pH and low levels of glucose degradation products (GDP), Stay-safe^® Balance (NPDF) was compared with a conventional acidic PD fluid (APDF). In this study, 128 patients from 49 centers were divided into two groups : 40 patients were started on PD with NPDF (group I) and 88 patients were switched from APDF to NPDF (group II). The 49 non-diabetic patients in group II were divided into two subgroups according to the PD duration : less than 3 years : 28 patients ; more than 3 years : 21 patients. Effluent procollagen I peptide and hyaluronic acid levels were measured as markers of fibrosis, effluent and plasma 3-deoxyglucosone (3-DG) level as markers of the GDP level, effluent cancer antigen 125 (CA125) level and mesothelial cell area as markers of mesothelial cells, and effluent and plasma free- and total-pentosidine levels as markers of advanced glycation end products 0, 3, 9, 15, 21 and 27 months after the use starting to NPDF. There were no differences in the markers of fibrosis between groups I and II. CA125 increased in group II, while they remained unchanged in groupI. The mesothelial cell area decreased in group II, but not in group I. Effluent and plasma 3-DG were decreased in group II, but remained unchanged in group I. Effluent free- and total-pentosidine were unchanged in groups I and II. Plasma free- and total-pentosidine were decreased in group II, but remained unchanged in group I. Analysis of subgroups demonstrated a positive correlation between the plasma free- and total-pentosidine and PD duration. Decrease in plasma total-pentosidine was noted at 15 months in the group with a PD duration of more than 3 years. In conclusion, NPDF improves the mesothelial cell markers and decreases the circulating pentosidine levels. At least 15 months seem to be required for the washout of accumulated pentosidine, therefore, APDF should be switched to NPDF as early as possible.

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A recent study has shown that the accumulation of visceral fat is increased in dialysis patients irrespective of BMI. We reported a negative relationship between the visceral fat area (VFA) and the log-transformed values of the ratio of high molecular weight adiponectin to leptin (h-Adipo/Lep ratio) in dialysis patients. In this study, to clarify the association between all-cause mortality and visceral obesity, we investigated whether or not VFA and the h-Adipo/Lep ratio were predictors of survival. The study included 120 dialysis patients during a 53-month follow-up period. We measured serum high molecular weight adiponectin and leptin concentrations, and visceral fat area by abdominal CT. Log-transformed h-Adipo/Lep ratio was inversely related to the visceral fat area for all subjects (r=-0.624, p<0.0001). As the criteria for obesity, we used VFA=75cm² or its equivalent of h-Adipo/Lep ratio=0.65. We divided all subjects into two groups according to these criteria, and compared the survival rates by the Kaplan-Meier method and Logrank test. During the 53-month follow-up period, 28 patients died. In the deceased group, the proportions of elderly, males, and those with diabetes mellitus were higher. The median h-Adipo/Lep ratio in the deceased group was 2.00 (range 0.04-29.7) and in the survivor group was 1.12 (0.03-83.5) and the former was higher than the latter. The survival rate was not significantly different between the two groups with VFA<75cm² or VFA>75cm². The survival rate in the h-Adipo/Lep ratio>0.65 group was 65.1%, which was significantly lower than that in the h-Adipo/Lep ratio<0.65 group ; 94.3% (p=0.002). Additionally, among subjects with h-Adipo/Lep ratio>0.65, the survival rate in the VFA>75cm² group was significantly lower than that in the VFA<75cm² group (p=0.001). These findings demonstrated that VFA was not significantly associated with 53-month survival, although the h-Adipo/Lep ratio was an independent predictor of all-cause mortality in dialysis patients.

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The conventional therapy for secondary hyperparathyroidism (SHPT) consists of serum phosphate reduction using a phosphate binder and suppressing parathyroid hormone (PTH) with vitamin D sterols. Excess vitamin D may promote intestinal calcium absorption, which leads to hypercalcemia and increased risk of cardiac and vascular calcifications. We prospectively endeavored to reduce the amount of vitamin D during therapy with cinacalcet for SHPT. Adult patients undergoing hemodialysis who had difficulty achieving the target of biomarkers recommended by the National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF-K/DOQI) with conventional therapy for SHPT were enrolled. The patients received combined therapy, i.e. a calcimimetic and a low dose of vitamin D, and the primary assessments included plasma wPTH, serum ionized calcium, calcium, phosphorus and calcium-phosphorus products every 2 weeks for 28 weeks. In total, 30 patients were enrolled in the study and 27 completed the 28-week course. The primary endpoint was defined as a mean plasma wPTH concentration≤160pg/mL and was achieved in 67% of patients. Moreover, 96% had a Ca×P≤55mg²/dL² (At baseline, the proportions were 11% and 26%, respectively). At the end of the study, 85% of patients received vitamin D and the mean±SD dose was 0.42±0.22μg/day. Our findings suggest that combination therapy with a low dose of vitamin D and cinacalcet is effective for the treatment of SHPT in patients on chronic hemodialysis.

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A 76-year-old man was introduced to maintenance hemodialysis in February 2006 due to gradually progressed renal failure following right nephrectomy for kidney cancer in 1995. The patient was referred to our department in May 2008 because of a right adrenal tumor associated with erythropoietin-resistant anemia. The adrenal tumor was probably a metastasis from kidney cancer. On magnetic resonance imaging, the liver showed a markedly low intensity on T2-weighted images, suggesting hemochromatosis. In addition, a serum level of ferritin was markedly elevated at 2,314 ng/mL. Iron overload might have been due to excessive intravenous iron administration as well as frequent blood transfusion. Following extirpation of the adrenal tumor, bone marrow biopsy was performed. The patient was diagnosed as having myelodysplastic syndrome : ringed sideroblasts comprised 20% of sideroblasts. Considering the physical condition of the patient, periodic blood transfusion was performed to treat anemia. Simultaneously, iron overload was treated with an oral chelating agent, deferasirox, starting in June 2008. The dose of deferasirox was gradually increased from 500 mg daily to the maximum dose of 1,250 mg daily while monitoring serum ferritin levels. Then, the dose was reduced when the serum ferritin level became less than 1,000 ng/mL. The only adverse event of deferasirox was diarrhea, which was well controlled with oral medication. In February 2009, after 9 months of deferasirox administration, the serum ferritin level was 467 ng/mL. Subsequently, administration of deferasirox was ceased. This is the first report in Japan of deferasirox administration to a dialytic patient. This agent would be one of the treatment options for iron overload even in hemodialysis patients.

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〔Background〕The economic environment for dialysis becomes more severe each time the medical fees are revised. However, medical institutions are responsible for maintaining the quality of dialysis, and there has been a growing demand for labor saving and improved dialysis efficiency, resulting in the necessity of using dialysis support systems and fully automatic dialysis systems. 〔Materials and methods〕Possible economic benefits from labor saving, improved efficiency, and reduced personnel were investigated using a dialysis monitor (NCV-1i, Nipro Corporation) and a dialysis information management system (DiaCom2006, Nipro Corporation) in 78 patients receiving one cycle of dialysis at the same time. 〔Results〕 (1) It became unnecessary to have recording paper available one-day before dialysis. (2) Labor and time were saved dramatically by 10min of automatic priming with saline solution. (3) Calculations for ultra filtration and machine entry after measurement of body weight became unnecessary, the time until starting dialysis was shortened and human errors were reduced dramatically. (4) Labor required for reinfusion was dramatically reduced the by fully automatic reinfusion function. As a result, patient waiting time was shortened and the staff could feel more “comfortable” both mentally and in terms of time pressure. (5) The number of staff required for one cycle was decreased by approximately ten. Annual labor costs were reduced by approximately 16.6 million yen per cycle and by approximately 50 million yen per three-cycle treatment. 〔Conclusion〕The dialysis support system using NCV-1i and DiaCom2006 was not only very useful for saving labor and improving efficiency but also convenient for dialysis. Furthermore, it improved the medical economics of dialysis by reducing labor costs.

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【Background】Since the study group for medical care of chronic renal failure (CRF) of the Ministry of Health and Welfare (MHW) published guidelines for dialysis initiation in 1991, clinical practices for chronic kidney disease have remarkably changed. At present, it is not clear how dialysis physicians use the guideline. 【Objective】To elucidate how dialysis physicians use and evaluate the guideline published by the MHW CRF study group. 【Experimental design】A descriptive epidemiological study (cross-sectional study with questionnaires). 【Setting】Twenty-eight dialysis facilities that the authors belong to or have affiliation with. 【Subjects】Sixty-four dialysis physicians who agreed to take part in the study. 【Method】We asked the dialysis physicians to complete an anonymous questionnaire. Physicians were reminded of the questionnaire just once. 【Results】Fifty-three physicians in 24 facilities completed the questionnaire. Their careers as physicians spanned 13.2±8.2 years. Nineteen physicians (36%) were using the guidelines. Many physicians who were not using the guidelines expressed the opinion that scores in the guidelines were not weighed appropriately from a clinical perspective. Classifyins each criterion for dialysis initiation into four grades, physicians place greater importance on heart failure, deterioration in renal function, volume overload, loss of appetite, and electrolyte disturbance. 【Conclusion】Dialysis physicians evaluate dialysis initiation comprehensively, based on criteria that urgently need to be improved. Though the guidelines are thought to be appropriate in most respects, the relationship between dialysis outcome and these criteria must be evaluated more thoroughly to develop an outcome-based guideline for dialysis initiation.

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We report a 72-year-old female with 11 episodes of recurrent gram-negative bacteremia during a 5-year period since initiating hemodialysis due to autosomal dominant polycystic kidney disease (ADPKD). Even after bilatered nephrectomy, the patient demonstrated recurrent bacteremia due to Escherichia coli. The patient never showed any symptoms other than sudden onset of high fever due to bacteremia. When patients on hemodialysis develop a high temperature, physicians should always to perform a blood culture. Moreover, ADPKD patients should undergo magnetic resonance imaging or scintigraphy for the differential diagnosis of infection in the cysts. This case suggests that physicians need to pay attention to recurrent bacteremia in ADPKD patients receiving hemodialysis.

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A 72-year-old woman with a history of left nephrectomy due to renal cell carcinoma, was administered antibiotics to treat a Staphylococcus aureus infection of a prosthetic knee. Rapid-progressive renal failure developed with oligouria during the antibiotic regimen and a laboratory examination demonstrated hematoproteinuria and increased levels of serum myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA). Gallium scintigraphy demonstrated increased uptake in the right kidney and in the right knee joint. MPO-ANCA-associated vasculitis and interstitial nephritis were suspected. Prednisolone therapy was administered with a reduced dose (0.4mg/kg/day) considering that the infection had already started, but this did not improve renal function and both sensorineural hearing loss and encephalopathy subsequently occurred. Plasma exchange by transfusion with fresh-frozen plasma (40 units) was performed and steroid pulse therapy (methyl prednisolone 500mg/day for three days) was followed by prednisolone 0.5mg/kg/day that was tapered every two weeks. This strategy improved the neurological symptoms and renal function. Plasma exchange combined with a lower dose of steroid was effective without aggravating a complicating infection in a patient with MPO-ANCA-associated vasculitis.

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Recessive dystrophic epidermolysis bullosa hereditaria is characterized by generalized blistering of the skin and mucous membrane in response to slight mechanical stimulation. Although renal complications such as renal amyloidosis, IgA nephropathy and hydroureteronephrosis lead to chronic renal failure, which progresses to end stage kidney disease (ESKD), it is difficult to select either hemodialysis or peritoneal dialysis as renal replacement therapy. A 34-year-old male was diagnosed with recessive dystrophic epidermolysis bullosa hereditaria and had been treated by dermatologist. He required blood purification because of congestive heart failure derived from ESKD. We considered it difficult to introduce peritoneal dialysis due to low proteinemia as well as difficult to keep his skin clean for frequent needle puncture. Therefore, we selected maintenance hemodialysis with a permanent vascular catheter. Currently, he has been continuing this therapy and is in good clinical condition.

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As Crohn's disease (CD) is sometimes difficult to treat with standard medication alone, alternative therapies are needed. We describe a 69-year-old man with CD complicated by chronic renal failure successfully treated with infliximab after mesalazine and prednisolone treatment failed. However, there has been limited experience with CD patients undergoing hemodialysis while being treated with TNF-α inhibitors. Although he was complicated by pneumocystis jivorecii pneumonia (PCP) during the course of the second infusion of infliximab, we successfully managed the physical symptoms and fiberscopic findings using two intravenous doses of infliximab. A 69-year-old patient with chronic renal failure started hemodialysis in September 2005. He had a past history of CD 40 years earlier. He was admitted to our hospital to establish control of hypertention in July 2008. Four days after his wife's sudden death, he complained of the abrupt onset of melena and diarrhea. He was initially treated with mesalazine and nutrition treatment. About one month later, he relapsed again. Then prednisolone per 30mg/day was started. Twenty days later, he required 1,600mL blood transfusion in total due to frequent melena. Since he had already undergone excision of segments of the large intestine several times in the past, we selected treatment with intravenous infusion of infliximab. He was complicated by PCP two weeks after the second infusion of infliximab, but was successfully treated with both ST drugs and 1,000mg of pulse methyl-prednisolone treatment. After 6 months, there have not been any clinical or laboratory side effects and he remains in clinical remission. Tumor necrosis factor-α (TNF-α) is pivotal cytokine in the pathogenesis of CD that emerged as a promising therapeutic target based on experimental studies employing specific biological inhibitors. Infliximab is a chimeric mouse/human anti-TNF-α monoclonal antibody that has been shown to be effective for CD. This case study suggests that infliximab treatment might be well tolerated and effective therapy for CD patients undergoing hemodialysis despite the special attention required for complicated infection.

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