A statistical survey at the end of 1999 by the Japanese Society for Dialysis Therapy resulted in responses from 3, 220 (99.66%) of 3, 231 institutions providing dialysis. The survey found 197, 213 chronic dialysis patients in Japan, an increase of 6.4% (11, 891 patients) from the 1998 survey. The 1999 survey found a slight decrease in the gross annual mortality percentage compared to 1998 (9.7%). The mean age of patients newly introduced to dialysis increased to 63.4±13.9 (±SD) years in 1999. The mean age of the dialysis population at the end of 1999 was 60.6±13.3 years. The primary diseases leading to dialysis were diabetic nephropathy (36.2%) and chronic glomerulonephritis (33.6%). New survey items for 1999 survey included the following: 1) with/without reverse osmosis, 2) with/without dialysate endotoxin measurement and endotoxin concentration, 3) itchiness, 4) HBs and HBe antigen/antibody, 5) earlier hepatitis B vaccine inoculation, 6) HCV antibody/HCV-RNA, 7) serum glutamic pyruvic acid transaminase (GPT) activity, 8) hepatocellular carcinoma or cirrhosis, 9) previous limb amputation, 10) history of cerebral infarction, cerebral hemorrhage, or myocardial infarction, 11) loss of eyesight due to diabetic retinopathy or retinal circulatory disturbance, 12) serum cholesterol level, 13) number of cigarettes smoked, 14) platelet and leukocyte counts, 15) C-reactive protein levels, 16) height and body mass index (BMI), 17) tuberculosis within the previous year and 18) both the fluid substitution method in hemodiafiltration and the amount of substitution fluid. The survey findings for 1999 included 1) 93.0% of the patients were dialyzed using reverse osmosis 2) endotoxin concentrations tended to be lower in institutions with more patients, and 3) 56.7% of the patients experienced no itchiness and received no treatment for itchiness. Other survey findings were that 84.7% of the patients were HBs antigen (-) antibody (-), 1.9% were HBs antigen (+) antibody (-), and 13.0% were HBs antigen (-) antibody (+). The survey also found that 2.3% of patients were inoculated with Hepatitis B vaccine, 16.1% were HCV antibody (+), and 8.2% were HCV-RNA (+). The survey found that 2.1% of the patients had cirrhotic complications and 0.6% had hepatocellular carcinoma. The mean serum total cholesterol level was 162.84mg/dl, and the mean BMI was 20.61kg/m2. Using the Cox's proportional hazards model, a Kt/V of 1.4, a normalized protein catabolic rate of less than 0.9g/kg/day or more than 1.5g/kg/day, and a low creatinine generation rate were risk factors in the 6-year mid-term prognosis for hemodialysis patients.
In order to elucidate brain oxygen metabolism in uremic patients, the regional cerebral blood flow (rCBF), oxygen extraction (rOEF) and oxygen metabolism (rCMRO2) were measured by positron emission tomography (PET) in both 10 hemodialysis patients (HD: male [m]/female [f]=2/8, age of 49±3 [SEM] years old, HD duration of 113±26 months) and 13 pre-dialysis renal failure patients (CRF: m/f=10/3, age of 61±2 years old, serum creatinine (SCr) of 6.3±1.0mg/dl). Data were compared with 20 non-uremic subjects (Control: m/f=7/13, age of 62±2 years old, SCr of 0.9±0.1mg/dl). They had no neurological abnormalities, congestive heart failure, history of cerebrovascular accident, diabetes mellitus, or symptomatic brain lesion on magnetic resonance imaging. The age of HD was significantly younger than the other groups (p<0.02) and the hemoglobin (Hb) levels in both HD (10.5±0.5g/dl) and CRF (9.8±0.9) were significantly lower than that in Control (13.3±0.3) (p<0.02). In the hemisphere, rCMRO2 in both HD (1.82±0.10ml/min/100g) and CRF (1.95±0.09) showed significantly lower values as compared to Control (2.23±0.05) (p<0.01, respectively). Hemispheric rCBF in HD (35.6±2.1ml/100g/min) and in CRF (36.1±2.1) were not different from that in Control (31.8±1.4). Hemispheric rOEF in CRF (45.7±1.6%) was significantly higher than that in Control (40.5±1.2%) (p<0.02), but that in HD (43.7±1.9%) did not increase significantly. These tendencies were similar in all regions of interest, especially in the cerebral cortices, but not in the cerebellum. All PET parameters in the frontal cortices tended to show the lowest value in renal failure patients. For all HD patients, rCBF in both the frontal cortex and the white matter correlated inversely with HD duration (frontal cortex: r=-0.649, p<0.05; white matter: r=-0.706, p<0.02). Based on these data, it is concluded that brain oxygen metabolism is depressed in renal failure patients on or before hemodialysis treatment. The cause for the depressed brain oxygen metabolism is considered to be due either to the dysregulation of cerebral circulation or to lower brain cell activity.
In Japan, there were 2, 961 dialysis facilities with 167, 192 patients on dialysis at the end of 1996. Continuous ambulatory peritoneal dialysis (CAPD) therapy was provided in 1, 035 facilities (35%) with 8, 715 patients (5.2%). Hemodialysis (HD) was much more frequently used than CAPD in the treatment of end stage renal disease (ESRD). Possible reasons for this include a larger number of facilities with more established treatment protocols for HD as compared to those for CAPD, A high incidence of infections specific to this modality, and a decreased peritoneal membrane function were frequently observed in long-term CAPD patients. We carried out a survey of 1, 308 prevalent patients, which was equivalent to 15% of CAPD patients in Japan, from 23 dialysis facilities, over a 2-year period from October 1, 1994 to the end of September, 1996. Data collected included cause of peritonitis, etiologic microorganism, treatment method, and prognosis of CAPD related-peritonitis. The incidence of peritonitis was one episode in 53.3 (20.4-272.6) patient months, that is 0.23 episodes/patient year, showing a remarkable decrease as compared to the result of a comparable survey conducted in 1986. Although there was significant center variability in the incidence of peritonitis, improved device and improved patient education by in-center staff were reported as presumably important factors contributing to the reduction in the incidence of peritonitis. The first line of antibiotics therapy for treatment was vancomycin in accordance with the 1993 Ad Hoc Committee recommendations.
There have been a few reports of a persistently abnormal “doughnut” pattern on technetium-99m-pyrophosphate (99mTc-PYP) myocardial scintigraphy in maintenance hemodialysis patients with severe ischemic heart disease. The present patient was a 65-year-old woman who had suffered from diabetes mellitus since the age of 46 years and had been on chronic hemodialysis because of diabetic nephropathy since the age of 62 years. She had no definite history of angina. Despite repeated episodes of congestive heart failure, she had been maintained on intensive hemodialysis and extracorporeal ultrafiltration method for two years. She complained of the sudden onset of chest pain on March 31, 1998. The electrocardiogram showed sinus tachycardia and there was 1-3mm of ST depression in leads V3-V6. Creatine phosphokinase (CPK) was 528IU/l and CRP was 4.1mg/dl. Echocardiography revealed anteroseptal hypokinesis. Myocardial scintigraphy using technetium-99m tetrofosmin (99mTc-tetrofosmin) showed defects in the anterior and posterolateral walls, and 99mTc-PYP showed a “doughnut” pattern of cardiac uptake. Coronary arteriography demonstrated 99% stenosis of seg. 1, 75% stenosis of seg. 7, 99% stenosis of seg. 9, and total obstruction of seg. 11 (AHA classification). Five months later, 99mTc-PYP myocardial scintigraphy showed persistence of the abnormal “doughnut” pattern of cardiac uptake. The endocardial biopsy specimen from the right ventricle revealed ischemic cardiomyopathy. Six months later, she died of congestive heart failure. 99mTc-PYP myocardial scintigraphy may be a practical and noninvasive means of diagnosing severe ischemic heart disease in patients with chronic renal failure secondary to diabetic nephropathy.