Optimal maintenance levels of intact PTH between 130 and 200pg/mL are recommended for the treatment of secondary hyperparathyroidism in patients undergoing hemodialysis therapy. It is known that the intact PTH level is affected by changes in serum Ca concentration. In this study, we investigated whether the intact PTH level was influenced by either serum Ca level or Vitamin D pulse injection therapy.
We simultaneously measured intact PTH and C-PTH levels using the same blood samples from 123 patients with chronic renal failure who were being treated at our hospital. Relationship between intact PTH and C-PTH was analyzed separately under several conditions, such as 1) difference in serum Ca level, 2) presence or absence of diabetes, and 3) with or without Vitamin D pulse injection therapy.
The slope of the C-PTH to intact PTH ratio differed in the high Ca group (more than 10.6mg/dL) being treated with conventional Vitamin D treatment, normal Ca group and low Ca group. Influence on intact PTH level due to changes in serum Ca was much higher on conventional Vitamin D therapy than on pulse therapy. The ratio of intact PTH to C-PTH was lower in the Vitamin D pulse therapy group than in the conventional treatment group. When patients were treated with Vitamin D pulse injection therapy, C-PTH remained high and the slope of the correlation line was shifted even if intact PTH levels decreased to 130-200pg/mL.
We conclude that the intact PTH level was affected by the concentration of Ca and Vitamin D pulse injection therapy. These findings indicate that data of serum Ca and C-PTH might provide useful information in the treatment of secondary hyperparathyroidism, especially measurement of C-PTH is useful when Vitamin D pulse injection therapy is being administered.

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Teicoplanin (TEIC) is an anti-MRSA antibiotic that is predominantly excreted in urine in an unaltered form; thus, dosage adjustments are necessary in patients with renal insufficiency and those undergoing hemodialysis. Several reports have indicated that the trough concentration of TEIC should be maintained at more than 10μg/mL. The present study attempted to establish a TEIC dose regimen for renal failure patients undergoing hemodialysis so that a trough drug serum level above 10μg/mL is maintained.
Eight patients with renal failure who were receiving hemodialysis were included in this study. The mean age was 67.0 years, and the mean body weight was 54.1kg. Patients received hemodialysis three times a week, and the durations of hemodialysis treatments ranged between 3 and 4 hours. TEIC concentrations were determined using a fluorescence polarization immunoassay.
When the patients received two doses of 400mg of TEIC on the first day and 400mg on the second and third days, the trough levels of TEIC on the third and fourth days were 13.3±1.4μg/mL (n=5) and 11.5±1.1μg/mL (n=3), respectively. In six of the eight patients, the TEIC levels exceeded 10μg/mL. To maintain the trough levels of TEIC above 10μg/mL, approximately two doses of 400mg were needed weekly. Software that simulated the TEIC concentration was effective for determining the appropriate intervals for administration. Overall, 5.7±2.5% of the TEIC was eliminated by hemodialysis treatment using a cellulose triacetate membrane dialyzer.
The recommended dosage regimen in patients undergoing hemodialysis is two doses of 400mg of TEIC on the first day and 400mg on the second and third days, followed by twice weekly doses. This regimen enables the trough serum concentrations of TEIC to be maintained above 10μg/mL.

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We report two hemodialysis patients with central nervous system side effects, such as hallucination and pseudopsia due to lafutidine administration.
Case 1, a 64-year-old man, developed cholestatic hepatic injury followed by hallucination and pseudopsia ten days after lafutidine administration at a dose of 20mg/day. Case 2, a 55-year-old man, complained of hallucination after six months of lafutidine administration at a dose of 20mg/day. The symptoms disappeared after drug cessation in both cases. The plasma lafutidine level in case 2 before hemodialysis was 918ng/mL, which was approximately 4.5 times higher than the normal value. These findings indicate that the symptoms were derived by lafutidine intoxication.
Although the urinary excretion rate of lafutidine is known to be 10.9%, its bioavailability is still not fully understood. Therefore, it may not be easy to establish the optimal individual dosage based on renal function data. However, we should be prudent when prescribing lafutidine for hemodialysis patients, as it is recommended for H₂-blockers of the renal excretion type.

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We present the case of a young child with end-stage renal disease (ESRD) treated by sevelamer hydrochloride (Renagel^®) as a phosphate binder. The patient was a 20-month-old female with ESRD secondary to right agenetic and left hypoplastic kidneys, who had been undergoing peritoneal dialysis (PD) therapy since 9 months old. While renal rickets was found in this patient before the induction of PD therapy, the use of activated vitamin D₃ and calcium-containing phosphate binders was restricted because of the coexistence of hyperphosphataemia and hypercalcemia. After the introduction of PD therapy, hypercalcemia and hyperphosphataemia persisted together with significant elevation of calcium-phosphate ion (Ca×P) products and she was given aluminum-gel phosphate binder. To avoid aluminium retention, the patient was then switched to sevelamer hydrochloride, a non-absorbed aluminium- and calcium-free phospate binder. Under sevelamer treatment, her serum phosphate level was adequately controlled without an increase in serum calcium levels, maintaining optimal levels of Ca×P products. Serum total cholesterol and blood HCO₃^- levels decreased after the start of sevelamer therapy. Sevelamer can lower serum phosphate levels without increasing serum calcium levels. Other difficult issues included necessity to grind sevelamer tablets into powder, an obstruction of her feeding tube, and defecation discomfort, but all of these issues were resolved. Although sevelamer is widely used in adult patients with ESRD, reports on pediatric use of this agent have been very limited, and there has not been any report describing use in children younger than 2 years of age. Our report suggests that sevelamer therapy can be well tolerated.

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The patient was a 50-year-old man with a long history of maintenance hemodialysis since 1975. On October 31, 2001, he lost consciousness while having lunch at his work place and sustained a mild contusion to the forehead. He recovered consciousness shortly, however, he felt excruciating pain on both arms. He consulted the hemodialysis facility where he underwent maintenance hemodialysis therapy and was diagnosed as having complete A-V block. Therefore, he was transferred to our hospital. Central cervical cord injury was detected by magnetic resonance imaging (MRI), and this lesion was considered to be the cause of arm pain. Immediately after MRI, we performed implantation of a permanent transvenous pacemaker under general anesthesia. Arm pain was improved by high dose therapy with methylprednisolone.
Though pathological examination was not performed in this case, we consider that hemodialysis-associated amyloidosis might have affected the development of central cervical cord injury. We must take cervical cord injury into consideration in patients undergoing long-term hemodialysis even when the neck injury is mild.

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In this paper, we present an elderly bedridden inpatient whose treatment included one peritoneal dialysis-free day (PD holiday) each week for approximately 3.5 years. The patient, a 71-year-old male, had been bedridden in a local hospital due to chronic renal failure. He came to our hospital in September 2000, and hemodialysis (HD) was performed. As the internal shunt did not work well, the treatment was switched to continuous ambulatory peritoneal dialysis (CAPD) in December. Even though the volume of urine was low (100mL/day), CAPD was effective. In January 2001, after explaining the dialysis dose and prognosis and obtaining consent, we switched the treatment to IAPD (six days a week). The treatment was then switched to APDi in February 2001. Although the dialysis dose was not adequate, there was no change in symptoms and regular dialysis could be continued. Although his food intake had decreased since admission, and hypokalemia and exacerbation of edema were observed during the treatment, appropriate therapies improved these conditions. Currently, the patient's treatment still includes one PD holiday per week.
If the patient is informed and consent is obtained, including a “PD holiday” in dialytic treatment is considered an option for patients with a low activity level in daily life.

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