A nationwide statistical survey of 4,124 dialysis facilities was conducted at the end of 2008, and 4,081 facilities (99.0%) responded. The number of patients undergoing dialysis at the end of 2008 was determined to be 283,421, an increase of 8,179 patients (3.0%) compared with that at the end of 2007. The number of dialysis patients per million at the end of 2008 was 2,220. The crude death rate of dialysis patients from the end of 2007 to the end of 2008 was 9.8%. The mean age of the new patients introduced into dialysis was 67.2 years and the mean age of the entire dialysis patient population was 65.3 years. For the primary diseases of the new patients introduced into dialysis, the percentages of patients with diabetic nephropathy and chronic glomerulonephritis were 43.3% and 22.8%, respectively. Among the facilities that measured bacterial count in the dialysate solution in 2008, 52.0% of facilities ensured 10 mL or larger amount of dialysate solution sample for the measurement. Among the patients treated by facility dialysis, 95.4% of patients were treated three times a week, and the average time required for one treatment was 3.92 (±0.53 s. d., omitted hereafter) h. The average amounts of blood flow and dialysate solution flow were 197 (±31) and 487 (±33) mL/min, respectively. The number of patients using a polysulfone (PS) membrane dialyser was the largest (50.7%) and the average membrane area was 1.63 (±0.35) m². According to the classification of dialyzers by function, the number of patients using a typeIV dializer was the largest (80.3%). The average concentrations of each electrolyte before treatment in patients treated by blood purification by extracorporeal circulation were 138.8 (±3.3) mEq/L for serum sodium, 4.96 (±0.81) mEq/L for serum potassium, 102.1 (±3.1) mEq/L for serum chloride, and 20.7 (±3.0) mEq/L for HCO₃^-, and the average serum pH was 7.35 (±0.05). Regarding the type of vascular access in the patients treated by facility dialysis, 89.7% of patients used anteriovenous fistule and 7.1% used anteriovenous graft. The percentage of hepatitis C virus (HCV) -positive patients who were HCV-negative in 2007 was 1.04% ; the percentage is particularly high in patients with a period of dialysis of 20 years or longer. The risk of becoming HCV-positive was high in patients with low serum creatinine, serum albumin, and serum total cholesterol levels, and/or low body mass index before treatment.

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The concentrations of hepatitis C virus (HCV) are reported to be lower in dialysis patients than in HCV-positive non-dialysis patients. We investigated the elimination dynamics of HCV antigens (core proteins) levels pre- and post-dialysis using a regenerated cellulose membrane (CU ; AM-FP1.3), cellulose triacetate membrane (CTA ; FB-150E), polymethylmethacrylate membrane (PMMA ; BK-1.6P), or polysulfone membrane (PS ; F-70S). The rates of HCV antigen decrease by a single dialysis session were as follows 32.7±10.5% with the F-70S, 19.0±2.2% with the BK-1.6P, 10.4±1.7% with the FB-150E, and 8.8±2.2% with the AM-FP1.3. Furthermore, we compared the HCV antigen elimination ability of each dialysis membrane material in an in vitro experiment. We perfused albumin (Alb) containing HCV in the blood circuit connected to AM-FP1.3, FB-130U, BK-1.3P, and F-60S, and measured quantities of HCV antigen and Alb over time. The quantity of HCV antigen decreased 25.8% with the F-60S, 20.5% with the BK-1.3P, 16.0% with the FB-130U, and 10.5% with the AM-FP1.3. Furthermore, to confirm HCV adsorption to the dialysis membrane, we perfused washing solution containing non-ionic surfactant in the blood circuit used in the above investigation, and measured quantities of HCV antigen in the washing solution. The quantities of HCV antigen eluted in the washing solution were nearly equivalent to the decreases in HCV observed in the in vitro experiment. In conclusion, HCV in blood is adsorbed and eliminated by dialysis membranes.

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【Background】 Pertussis (whooping cough), caused by Bordetella pertussis, has been recognized as a common infectious disease in the general population, not restricted to children. Maintenance hemodialysis (HD) patients are supposed to be vulnerable to such infectious diseases, because they are immunocompromised hosts and receive dialysis therapy along with other patients in a closed unit. However, reports of Bordetella pertussis infection among maintenance hemodialysis patients have been limited, and there are no surveillance reports describing antibody levels against Bordetella pertussis in dialysis patients. 【Methods】 All 141 ambulatory patients receiving dialysis therapies at Toride Kyodo General Hospital were enrolled in this study after informed consent was obtained from each patient. The patients comprised 109 of hemodialysis (M/F : 56/53, 63.9±11.4 years old) and 32 of peritoneal dialysis (M/F : 20/12, 65.3±9.9 years old). Two antibodies against Bodetella pertussis (Touhama and Yamaguchi) were applied to detecting the level of antibodies in the serum obtained from patients using the established agglutinin method. 【Results】 Positive levels (≥×10) of antibodies were identified in 78 patients (61 of HD and 17 of PD). Within two groups, there were no significant differences in patient characteristics about age and sex. The incidence of positive levels of antibodies was not related to dialysis modalities or the past history of vaccination against pertussis, but rather related to the position of the bed in which patients received hemodialysis therapy during each dialysis session. 【Conclusion】 Since pertussis may spread from one patient to another during hemodialysis sessions in a closed dialysis unit, appropriate prophylaxis, diagnosis, and treatment of pertussis should be established in maintenance dialysis units.

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We retrospectively analyzed the effect of extracorporeal ultrafiltration method via peripheral veins (venovenous ECUM) in peritoneal dialysis (PD) patients with excessive body fluid retention. Since 2004, a total of 4 PD patients (1 male and 3 female) were treated with VVECUM. Two veins either at the forearm or upper arm were punctured by 16 G needles and the blood flow was kept at 60-100 mL/min. Heparin was used as an anticoagulant in all cases and the treatment time was around 2 hours per day. Based on the hydration status, the number of individual treatments was adjusted. Although residual renal function (RRF) was relatively low in all cases, PD therapy was possible for a limited (4 to 6 months) period after normalization of body fluid by VVECUM. Furthermore, long-term (over 42 months) PD therapy was successfully continued in a case that showed sufficient ultrafiltration volume and good control of fluid intake. Without this VVECUM treatment, all cases would have been immediately transferred to standard hemodialysis or required complementary hemodialysis due to refractory fluid retention. These findings suggest that VVECUM treatment made the patients more aware of hemodialysis and motivated them to continue PD, which was the patient's own choice, and to maintain strict restriction in fluid intake.

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A 55-year-old male with diabetic nephropathy received hemodialysis treatment 3 times a week over a 9-year period. In February 2008, he was hospitalized with acute respiratory failure. Steroid pulse therapy was performed under a diagnosis of interstitial pneumonia with acute progression. However, he developed respiratory failure and consequently required mechanical ventilation. There was no improvement in the interstitial pneumonia and persistent infection was observed despite intensive care. Rhizopus sp. belonging to the order Mucorales was microbiologically detected in the sputum aspirated during bronchoscopy. Therefore, liposomal amphotericin B (L-AMB) was administered for pulmonary mucormycosis (zygomycosis). However, the patient died due to respiratory failure approximately 3 weeks after the admission. Microscopic examination of autopsy samples confirmed that numerous fungal thrombi had occluded the pulmonary vessels. Generally, it is difficult to diagnose and treat mucormycosis due to the low detection rate of the fungus and the rapidly progressive nature of the condition. Physicians should consider mucormycosis as a differential diagnosis in patients with end-stage renal disease associated with conditions such as antibiotic-refractory infection, negative β-D-glucan, and invasive fungal infection.

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Calciphylaxis is a rare but fatal disorder characterized by systemic medial calcification of the small arteries and ischemia of the subcutaneous tissues, often leading to necrosis of the subcutaneous fat and skin. This condition most commonly affects patients with end-stage renal disease (ESRD) and the pathogenesis is poorly understood. At present, there is no established treatment. We recently encountered three cases of calciphylaxis. The first case involved a 66-year-old man with ESRD who had been maintained on peritoneal dialysis(PD) for 7 years. The patient was admitted with painful ulcers on his thighs, hip, waist and wrists. Skin biopsies demonstrated calciphylaxis. Treatment with bisphosphonate and sodium thiosulfate hydrate had no effect and he died of peritonitis and DIC soon after admission. The second case involved a 53-year-old woman with ESRD who had been maintained on hemodialysis for 2 years. The patient was admitted with painful purpura on the lower legs and diagnosed with calciphylaxis based on skin biopsies. Hyperbaric oxygen therapy was initiated, and showed prominent results with symptom resolution and subsequent discharge. The third case involved a 72-year-old man with ESRD maintained on PD for 2 years, who was admitted for treatment of pneumonia. He displayed painful purpura on the lower legs and glans, and skin biopsies demonstrated calciphylaxis. He died of peritonitis and DIC before treatment could be started. All three patients were receiving warfarin for atrial fibrillation and vitamin D for secondary hyperparathyroidism, while levels of serum calcium levels were normal. We postulated that warfarin use may play an important role in the pathogenesis of calciphylaxis.

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A 68-year-old male with a history of arterial hypertension, aneurysm of the aortic arch and heavy smoking was referred to our hospital because of acute renal failure (serum creatinine 7.5 mg/dL, serum urea nitrogen 78 mg/dL). The patient had complained of severe deterioration of his general status with appetite loss and a weight loss of 5 kg over the previous 1 month. Physical examination demonstrated livedo reticularis of the lower legs and cyanosis in the toes (blue toes). Laboratory data showed eosinophilia 1,526/μL. The diagnosis of cholesterol crystal embolism (CCE) was confirmed by biopsy of the skin lesion which demonstrated cholesterol crystals in small arteries. His renal function did not recover during the following days and hemodialysis (HD) was initiated. Twenty-one days after the initiation of HD, the patient was discharged and followed in the outpatient clinic for maintenance HD. However 13 days later, the patient was readmitted because of worsening blue toes with severe pain. His clinical condition worsened progressively and he died of multiple organ failure 27 days after readmission. At autopsy, diffuse erosive atherosclerosis of the aorta was observed and cholesterol crystal emboli were found in the kidneys, lungs, cerebellum, spleen, esophagus, stomach, small intestine and large intestine. CCE in the lung might have been caused by the dialysis arteriovenous fistula (radiocephalic), because there was no atherosclerotic change in the pulmonary and bronchial arteries, and no left-to-right shunting in circulation except for the dialysis arteriovenous fistula. This case suggests that HD requiring systemic anticoagulation deteriorates spontaneous CCE.

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Liver cirrhosis is an advanced stage of chronic liver disease, sometimes complicated with refractory ascites and/or spontaneous bacterial peritonitis(SBP). Continuous ambulatory peritoneal dialysis(CAPD)has been reported to be effective for end-stage renal disease(ESRD) patients with liver cirrhosis and ascites. However, there is insufficient information on the long-term outcome of CAPD therapy for patients with liver cirrhosis. We encountered two Japanese patients in whom CAPD therapy was initiated due to liver cirrhosis with ascites. A 49 y.o. male patient started CAPD, because of uremia due to transplanted kidney failure and refractory ascites. Initially, he demonstrated hyponatremia and hypoalbuminemia, which were resolved by the increased intake of salt and protein using branched-chain amino acids. However, hypotension persisted because of decreased peripheral vascular resistance with a hyperdynamic circulatory state associated with liver cirrhosis. Finally, he died of circulatory failure due to peritonitis after 16 months of CAPD therapy. A 74 y.o. male with diabetic nephropathy and idiopathic liver cirrhosis accompanied by ascites developed recurrent peritonitis mainly caused by E. coli after sclerotherapy of esophageal varices after 40 months of CAPD therapy. We changed therapy from CAPD to hemodialysis(HD) in order to prevent peritoneum sclerosis because we diagnosed this patient as having SBP-associated liver cirrhosis. He died of the progression of hepatic failure after 7 months of HD therapy. In this report, we also summarized 15 Japanese ESRD cases showing liver cirrhosis treated by CAPD, and discuss the advantages and disadvantages of CAPD therapy for these cases.

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A 29-year-old male had experienced episodic pain in the upper extremities since childhood, but it was diagnosed to be of unexplained origin and had been left untreated. Proteinuria was noted during a routine examination in high school, and a renal biopsy was recommended. However, these two problems remained unsolved. In 2005, he demonstrated impaired renal function on medical examination. He was subsequently diagnosed with advanced renal failure (BUN 55.2 mg/dL, Cr 4.9 mg/dL) and the kidneys were both atrophic. Although he was treated with antihypertensive drugs and diet, renal function continued to significantly worsen. On March 29, 2007, he was transported to the hospital by ambulance because of disturbed consciousness. Since there was no indication of cerebral vascular disturbance, he was diagnosed with end-stage renal failure (BUN 256.5 mg/dL, Cr 26.4 mg/dL) and associated lungs congestion. Haemodialysis was initiated soon after hospitalization, and consciousness recovered. Thereafter, he developed severe pain in the extremities which rapidly progressed. This suggested the possibility of Fabry's disease. The absence of α galactosidase A activity confirmed that diagnosis. The administration of carbamazepine yielded some improvement in the pain, but it remained severe and affected his quality of life (QOL). Enzyme replacement therapy was initiated (ERT : 1 mg/kg of agalsidase beta once every two weeks) and his QOL thereafter improved. This report presents a case first diagnosed as Fabry's disease based on severe pain emerging after the initiation of hemodialysis. The pain was thereafter successfully controlled with ERT. Although Fabry's disease is a rare disorder it should be considered in the differential diagnosis of pain and proteinuria.

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