The present study surveyed the status of nutritional management records using the problem-oriented system (POS) for nutrition management of patients on dialysis, and examined several aspects during trial use of a nutritional management record model that we had developed. It is meaningful to develop an ideal nutritional management chart that allows efficient entry of a huge volume of nutritional data of the patients and is applicable to present and future clinical practice.
The survey was conducted in 2002 inviting registered dietitians in selected facilities to trial use of the new nutritional management record model. The model adopts a checking format compatible with critical path (CP) and electronic medical record. The results were analyzed and the usability and points for improvement of this model were examined.
Twenty-six facilities responded and a total of 140 cases were recorded and analyzed. POS-based items were entered in 90% or more cases in both the dialysis and nondialysis groups. Dietary items were entered in 60-90% of the cases in both groups. These results together with suggestions from dietitians after trial use identified various aspects that need improvement, such as the format, recording items and ease of use. These data are useful for further development of an ideal nutritional management chart.
In the future, nutritional management charts using a simple recording method and a common language applicable to evidence-based medicine (EBM) and easily understandable by other health care staff will allow effective use of the information in clinical practice. Such charts will also be applicable to team care, critical path, and electronic medical record.

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We investigated the reliability of using HbA1c and glycoalbumin (GA) levels to estimate the blood glucose (BG) condition in 41 diabetic patients (31 males, 10 females; mean age, 65±9 years) undergoing hemodialysis (HD). All patients underwent HD during the daytime, with a mean start time 143 minutes after breakfast. BG levels were measured at 3 points; pre-dialysis, before lunch, and post-dialysis, while HbA1c and GA levels were simultaneously measured at the pre-dialysis point. Mean BG levels at the pre-dialysis point for the past 4 weeks (BG4W) or the past 2 weeks (BG2W) were obtained from the medical records of each patient. We found a correlation between HbA1c and GA levels (r=0.663, p<0.001). Further, GA levels were correlated to BG levels at the pre-dialysis point and before lunch, while HbA1c did not show any correlation to those values. There were also significant relationships among BG4W, HbA1c, and GA level, and among BG2W, HbA1c and GA level. Additionally, BG4W and BG2W each correlated with the ratio of GA to HbA1c (GA/HbA1c) (r=0.418, r=0, 431, respectively), while GA/HbA1c increased with deterioration of BG. In a comparison of 3 patient groups classified by BG4W levels (group A, <150mg/dL; group B, 150-199mg/dL; group C, ≥200mg/dL), HbA1c, GA, and GA/HbA1c levels were significantly higher in group C than in group A, though GA/HbA1c in group A was as high as 3.5. In diabetic patients undergoing HD, absolute levels of HbA1c were low even if BG conditions were good, though the levels maintained a relationship with BG levels. Further, the absolute levels became lower with deterioration of BG levels. Our findings support the hypothesis that GA measurement provides a better estimation of BG status than HbA1c measurement in diabetic patients undergoing HD.

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The most preferable method of blood access (BA) in maintenance hemodialysis is a native arteriovenous fistula (AVF).
Advanced age as well as the rapid increase in underlying diseases such as diabetic nephropathy and nephrosclerosis in chronic dialysis patients also means that the veins and arteries used to establish the AVF have sustained vascular damage, making construction of an AVF more difficult compared to that constructed earlier.
Although there are various conditions under which arterial superficialization or AV-graft must be chosen, it remains a rule that the first choice for BA should be AVF whenever possible. To improve postoperative results, it is necessary to reduce malfunctions immediately following surgery. We conducted a survey of 23 dialysis facilities throughout the country and analyzed data from the past 3 years regarding the functionality of the AVF at initial puncture following construction in 5, 007 cases of newly constructed AVFs.
Upon initial puncture, primary failure (PF) is defined as those cases in which thrombosis or inadequate blood flow occur. PF occurred in 7.6% of the cases in this series, but there was a wide distribution of PF, 0.8-23.6%, due to differences in quality among facilities. This difference in PF is probably affected by technical aspects, the main factor being the characteristics of the patient. Survey responses included: (1) vascular damage to the veins and arteries used in creating the AVF and (2) the suitability of the location chosen for construction.
In the data collected, many methods were used to repair those primary AVFs in which PF occurred. The salvage rate was 70%. Currently, the most preferable form of BA is AVF adhering to the principle that appropriate timing of the choice and construction of AVF should consider the maturation period. To accomplish this, it is vital that vascular mapping be performed preoperatively to construct the AVF. If PF does occur, the cause should be thoroughly investigated and repairs made effectively.

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On two groups of subjects, the side effects of constipation as a result of the administration of sevelamer hydrochloride (SV), and its prevention by the co-administration of laxatives were investigated. Patients in group 1 (n=8) were instructed to take a solution of D-sorbitol (SOR) on the first day of SV administration, and then, to take additional SOR depending on the nature of the feces produced. Patients in group 2 (n=7) were basically instructed to not take any laxatives, but on the first day of the appearance of constipation, they were instructed to take picosulfate at bedtime, using a self-conrolled the amount. In both groups, the total score for constipation by questionnaires based on Rome II showed a tendency toward improvement, and the total scores 3 months after administration of SV were significantly decreased, compared to data obtained before the administration of SV in group 1.
Furthermore, the solidity of feces was quantified using a visual analogue scale (VAS) measurement. Although VAS for the solidity of feces from 11 to 20 days, from 61 to 70 days, and from 81 to 90 days were significantly higher than that before taking SV in group 2, there was no change in VAS for the solidity of feces in group 1. However, VAS indicated a tendency for solidity to be markedly increased in group 2 before the beginning of SV to 20 days after its administration, after which VAS scores were slightly decreased from 21 to 30 days, finally reaching a steady state from 31 to 90 days. As a result, co-administration of SOR at the initiation of SV administration, then, taking a self-controlled dose of SOR appears to be effective in preventing constipation induced by SV.

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Coronary artery bypass grafting (CABG) is increasingly being performed in chronic dialysis patients. Although postoperative short-term CABG outcomes have been reported, indicating stable results, the long-term outcomes of surgery have rarely been reported. Therefore, we investigated the long-term outcomes of CABG at this hospital. Seventy-seven patients receiving dialysis regularly between January 1983 and December 1999, who underwent CABG only were studied. The patients ranged in age from 40 to 76 years, and consisted of 61 males and 16 females. Among these, the mean preoperative dialysis period was 6 years. The underlying disease that made dialysis necessary was diabetes mellitus (DM) in 32 patients, chronic glomerulonephritis (CGN) in 27, nephrosclerosis (NS) in 10, and other in 8. Our guidelines for surgery were that it be performed under extracorporeal hypothermic cardiac arrest as a rule and performed under beating heart if the patient had central nervous system complications. Patients received dialysis for 2 days preoperatively, received dialysis while extracorporeal circulation was being used, and began postoperative dialysis on day 2. Eight patients died during their hospital stay, of whom 3 died of digestive-tract bleeding, 2 of sepsis, and 1 each of brain death, arrhythmia, and cardiogenic shock. Of these 8 patients, 5 had DM as the underlying disease. There were 24 deaths during long-term follow-up, of which 4 were due to acute myocardial infarction, 2 to cardiac failure, 9 to dialysis encephalopathy, 2 to cerebral hemorrhage, 1 each of malignant tumor, hyperkalemia, weakness, and purulent pleurisy, 2 to sudden death, and 8 due to unknown causes. The diseases requiring dialysis among patients who died during long-term follow-up were DM (10 cases), CGN (7), NS (4), and other diseases (3). The cumulative survival rate was 0.699 at 3 years, 0.577 at 5 years, and 0.425 at 7 years, when classified by diseases that made dialysis necessary, cumulative survival rates among patients with DM were 0.665 at 3 years, 0.332 at 5 years, and 0.166 at 7 years, while the rates among patients with CGN were 0.798 at 3 years, 0.798 at 5 years, 0.709 at 7 years, and 0, 709 at 10 years. The long-term outcome of CABG in chronic dialysis patients was unsatisfactory. Although the outcome of CABG was favorable in patients with CGN, it was unfavorable in patients with DM. Therefore, we recommend that CABG be indicated cautiously for DM patients.

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Estimating Total Body Water (TBW) in dialysis patients is vital to infer dialysis efficacy, medicinal distribution in the body, and the amount of body water. To date, a wide variety of formulas have been used to estimate TBW, including the well-known formula proposed by Watson, Hume-Weyers, Chertow, et al. In this study, we compared the TBW estimate derived from the above formula with that measured by the Bioelectrical Impedance Analysis (BIA). As a result, all the TBW estimates calculated by the formula took high values relative to those estimated by the BIA with a significant difference (p<0.05). This difference was considered due to the difference between samples: data for the BIA was taken from Japanese dialysis patients; while data for the formula was obtained from healthy persons in the U.S. and Europe. Kichul Cha, et al. reported that the impedance index obtained through the multi-frequency BIA has an outstandingly high correlation coefficient (r=0.974) with the TBW estimate measured using deuterium oxide (D₂O) also has a high correlation coefficient (r=0.886) with the estimate of the Extra-Cellular Water (ECW) measured using sodium bromide (NaBr). The study by Glenn M. Chertow, et al. Indicates that TBW values estimated by the BIA correlate with those measured by deuterium oxide (D₂O). From these studies, it was affirmed that the BIA is a useful method of measuring TBW. Through the above discussion, we suggest that we could measure the TBW of individual patients with a high degree of precision and accuracy relative to the conditional calculation by the formula. In addition, error in this TBW estimation did not induce any detectable error in the estimate of dialysis efficacy: Kt/V Daugirdas. Such errors should be considered when estimating items such as dialysis efficacy using TBW estimates.

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Measurement of aortic pulse wave velocity (PWV) is one of the useful and reliable tools for estimating atherosclerosis. PWV has been applied to hemodialyzed (HD) chronic renal failure (CRF) patients in whom atherogenic disorder frequently induced critical complications. In this study, we initially measured PWV in 112 HD patients compared with conventional parameters related to atherosclerosis, such as blood pressure (BP), serum chemical data and aortic calcification index (ACI). Secondly, to investigate the effect of each HD maneuver on PWV, especially, how the PWV changes in response to decreases in BP after dialysis, related factors and autonomic function were analyzed. Using the oscillometric method, hbPWV (heart-brachial) and baPWV (brachial-ankle) were measured. Twenty patients were compared by PWV response after dialysis, and autonomic function were evaluated by analysis of the heart rate interval (RR interval SDNN). Ten patients were also evaluated by spectral analysis, on which the high frequency (HF) component is thought to correlate with parasympathetic nervous system activity, and the low frequency (LF) component with sympathetic nervous system activity. These tests were performed to assess change in autonomic nervous system activity during the dialysis session. The PWV significantly correlated with age and blood pressure on logistic regression analysis, while baPWV significantly correlated with ACI. In the patients with an absence of any decrease in PWV in response to BP decrease, baPWV correlated with age, BP and ACI with a reduced RR interval suggesting autonomic dysfunction. PWV is a useful functional test for atherosclerosis and changes in PWV before and after dialysis may be implicated in the pathophysiology of atherosclerosis and autonomic nervous system disorders.

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We encountered a continuous ambulatory peritoneal dialysis (CAPD) patient complicated by hemophagocytosis syndrome. A 68-year-old woman underwent radical left nephrectomy for left renal tumor in 1997. At that time, intraoperative contralateral biopsy led to a diagnosis of secondary amyloidosis. Subsequently, her renal function deteriorated until May 1998, when she underwent hemodialysis. However, a hypotensive state persisted during dialysis, which became difficult to perform. Thus, the patient received CAPD in December 1999.
Thereafter, her course was favorable until the end of February 2000, when she developed fevers between 38°C and 39°C. The source of the fevers could not be determined, and there was little or no response to antibiotics. Finally, we considered the possibility of reinfection with EB virus, and administered an immunosuppressant (cyclosporin), which had an antipyretic effect. However, the patient died 1 week later. Postmortem histopathological examination of the lungs, liver, kidneys, and bone marrow showed amyloid deposition in the lungs, and features of hemophagocytosis in the liver and bone marrow, leading to a diagnosis of hemophagocytosis syndrome (HPS). This was a valuable case in that HPS developing in a dialysis patient is extremely rare.

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