2017 Volume 50 Issue 8 Pages 519-526
The patient was an 81-year-old female who had been receiving hemodialysis (HD) for 21 months. The patient was obese (body mass index [BMI]: 25.1±0.1); malnourished (serum albumin level: 3.3±0.03 g/dL, percentage creatinine generation rate [%CGR]: 56.0±1.8); and exhibited reductions in her muscle strength, walking speed, and ability to perform activities of daily living (which was considered to be due to frailty rather than sarcopenia). As the patient suffered frequent cramps and intradialytic hypotension, she was forced to stop receiving HD. HD removes not only uremic toxins, but also various nutrients, including water-soluble vitamins and amino acids. Therefore, there is a possibility that the amounts of nutrients removed by HD exceed those consumed via dietary intake, even after 4 hours HD (blood flow rate [QB]=200 mL/min, dialysis fluid flow rate [QD]=500 mL/min). Human energy levels are maintained by gluconeogenesis, which involves amino acid catabolism. Most amino acid catabolism involves glutamate as a reaction intermediate. In this study, the patient’s blood glutamate concentration increased after HD; nevertheless, HD removes plenty of glutamate. However, low-efficiency HD (QD: 200 mL/min, QB: 95 mL/min from 0-30 minutes, 170 mL/min from 30 to 90 minutes, 230 mL/min from 90 to 240 minutes) suppressed the increase in the patient’s blood glutamate concentration seen after HD. In other words, it suppressed gluconeogenesis. Eventually, low-efficiency HD significantly improved the patient’s nutritional status (serum albumin level: 3.6±0.1 g/dL, p=0.020; %CGR: 81.7±11.9, p=0.0024), BMI (27.1±0.22), and catabolic status. Furthermore, the number of rounds of treatment required for cramp combined with intradialytic hypotension dramatically decreased after the introduction of low-efficiency HD.
