This study investigated carnitine metabolism and its relation to nutritional parameters in patients receiving peritoneal dialysis (PD).
We measured carnitine fractions in serum, dialysate and urine in 51 patients (28 male and 23 female) with PD. To evaluate the PD adequacy and nutritional status, we measured weekly creatinine clearance (W-Ccr), KT/V, indices f peritoneal equilibration test (PET), normalized protein catabolic rate (nPCR) and body composition (biolctricai impedance analysis).
Serum total carnitine (TC) and free carnitine (FC) levels (37.9±8.3μmol/L and 24.9±5.6μmol/L, resectively) were significantly reduced, although serum acyl carnitine (AC) levels (13.0±3.7μmol/L) remained in the normal range. The AC/FC ratio was five-fold higher in urine than in dialysate (2.10±1.13 and 0.42±0, 09, respectively). Peritoneal clearance of FC (5.3±1.3L/day) was significantly higher than that of AC (4.3±1.5 L/day, p<0.001), and the amount of peritoneal FC loss showed a linear correlation with dialysate volume. There was a negative correlation between residual renal function and serum AC and AC/FC ratio. There was no correlation found between serum carnitine levels and KT/V, and indices of PET.
There was a positive correlation was found between serum carnitine levels and body composition (total body mass, lean body mass, body mass index), serum creatinine and albumin. A positive correlation was found between the amount of carnitine elimination (dialysate and urine) and pralbumin, albumin, and nPCR. These results indicate that residual renal function plays an important role in urinary AC excretion and that dialysate volume influences peritoneal FC losses. Furthermore, serum carnitine levels and daily carnitine elimination correlate with various nutritional parameters.
We conclude that it is necessary to maintain residual renal function and to use oral carnitine supplements for carnitine deficiency in PD patients, so as to prevent aggravation of carnitine metabolism and nutritional status.

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Nutrition and hernodialysis status of twenty-two patients who had been on hemodialysis for 15 years or longer was examined in single center. These long-term survivors were compared to a control group of 50 hemodialysis patients matched for age, gender and causes of renal failure, who had been on hemodialysis for 2 to 10 years. Normalized protein catabolic rate was higher in the long-term survivors than in the control group, 1.10±0.16 and 0.99±0.17g/kg/day, respectively (p<0.05). Kt/V for urea was higher in long-term survivors, 1.63±0.22 vs. 1.39±0.25 (p<0.001), and Kt/V for β₂-microglobulin was higher, 1.21±0.41 vs. 0.86±0.44 (p<0.001).
Body mass index of the long-term survivors was 20.0, 95% confidence interval (CI) was 19.1 to 20.9. Energy intake was 37.9 kcal/kg/day, 95% CI 35.3 to 40.7. The actual dietary intake of protein, potassium and phosphorus of the long-term survivors was higher than those recomende by the Guidelines of the Japan Society of Nephrology, 1.45g/kg/day (95% CI 1.36 to 1.54, p<0.05), 1.73g/day (95% CI 1.57 to 1.90, p<0.01), 925mg/day (95% CI 840 to 1010, p<0.001), respectively. The actual intake of calcium was lower, 449mg/day (95% CI 373 to 525, p<0.001), while most patients used calcium carbonate as a phosphorus binder.
The characteristic dietary intake of the long-term survivors was higher in calories, higher in protein and lower in calcium with adequate dialysis and calcium-based phosphorus binder.

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Hemorrhagic diathesis develops in end-stage chronic renal disease, which is widely treated with antihypertensive agents, particularly calcium antagonists. The present study investigated whether antihypertensive agents affect bleeding time in end-stage chronic renal disease requiring hemodilysis. Patients with chronic renal failure without and with antihypertensive agents were enrolled (n=135), and bleeding time (Simplate II method) as well as blood parameters (BUN, creatinine, platelet counts, and hemoglobin) were compared in patients with normal and prolonged bleeding time. Only 13 patients had not received antihypertensive agents and showed bleeding times within the normal range. Abnormal bleeding times were observed in 28 of 122 patients receiving antihypertensive agents. Positive, albeit weak, correlations were observed between bleeding time and PUN (r=0.19), serum creatinine (r=0.19), platelet counts (r=-0.16), or diastolic blood pressure (r=0.26). In patients treated with calcium antagonists (n=111), prolonged bleeding time was observed in 23.4% (n=26), whereas only 8.3% (n=2) manifested abnormal bleeding time in patients not taking calcium antagonists (n=24). In contrast, α-adrenoceptor blockers did not affect bleeding time. The percentage of patients with prolonged bleeding time was greater in the αβ blocker-treated group than in the untreated group, although the concomitant use of calcium antagonists was more frequent in the former than the latter group. In nine calcium antagonist-treated patients with prolonged bleeding time, the withdrawal of calcium antagonists markedly shortened bleeding time (from 11.4±1.0 to 5.9±1.0min, p<0.05). In contrast, in the additional group (n=7), continued treatment with calcium antagonists had no effect on bleeding time (from 12.2±1.1 to 10.3±1.3min). Despite the inhibitory effect of calcium antagonists on bleeding time, no clinically serious events associated with hemorrhagic diathesis developed. In conclusion, antihyprtensive agents, particularly calcium antagonists, prolong bleeding time in patients with end-stage chronic renal failure. The subclinical (laboratory) effect of calcium antagonists however is not necessarily associated with hemorrhagic events of clinical significance.

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To compare the effect of intravenous maxacalcitol on secondary hyperparathyroidism with that of oral calcitriol pulse therapy, we have conducted a 12-week prospective trial for 35 hemodialysis patients. Ten μg of maxacalcitol was administered intravenously to 20 patients three times per week after each dialysis session to patients with parathyroid hormone-intact (i-PTH) higher than 500pg/mL or 5μg to patients with i-PTH less than 500pg/mL. Two micrograms of calcitriol was given twice week to 15 patients. Dosage was then changed according to i-PTH and calcium. The PTH-suppressing effect of maxacalcitol was equal to that of calcitriol pulse therapy. Elevation of calcium was also noted in both groups. Although statistically significant difference was not found, serum phosphorus increased in some patients. However, maxacalcitol induced more rapid decrease of carboxyterminal telopeptide of type I collagen and bone specific alkaline phosphatase than oral pulse therapy, suggesting a direct action of maxacalcitol on bone to ameliorate high-turnover disease.

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In recent years, removal of β₂microglobulin (β₂MG) by the hemoadsorption method has been advocated as a newer promising therapy for dialysis-related amyloidosis. In this article we report maintenance-hemodialyzed female patient with hemodialysis-related amyloidosis who repeatedly showed worsening of renal anemia after application of β₂MG adsorbent column. Although cardiovascular complications and exacerbations of anemia have previously been noted in an unpublished manufacturer's report, details of the mechanism responsible have not yet been elucidated. Concerning anemia, some possible candidates such as deficiency of vitamin B₁₂, folic acid or carnitine have been raised as a causative factor in previous reports. However, we denied these as determinant in our case. Rather, we considered hemolysis as the most likely cause, because changes in haptoglobin level and reticulocyte count most clearly paralleled worsening of renal anemia. It is obvious that further studies are necessary for safe and effective application of the β₂MG adsorbent column to hemodialysisrelated amyloidosis treatment.

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The patient was 75-year-old man with chronic renal failure secondary to renal amyloiosis with rheumatoid arthritis, who had been on maintenance hemodialysis for 8 years, and who had PSA levels (11.3ng/mL) higher than the normal range (4.0ng/mL or less). Systematic prostate biopsy demonstrated well differentiated adenocarcinoma. The stage was determined as T2N0M0 (Stage B), and leuprorelin acetate (LH-RH analogue) was started. His family history indicated that his older and younger brothers also had prostate cancer, and to our knowledge this is the first report of prostate cancer in three brothers in which the proband was a hemodialysis patient in Japan.
It was previously reported that the morbidity of prostate cancer in hemodialysis patients was much lower than in healthy males. However, we have reported that the morbidity of prostate cancer in hemodialysis patients was markedly higher than in healthy males. Therefore, we emphasize that in hemodialysis patients it is very important to investigate for prostate cancer using PSA screening and to investigate the patient's family history in detail since it can also indicate one of the risk factors for prostate cancer.

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