Malnutrition is prevalent in chronic hemodialysis (HD) patients and is related to multiple factors; HD procedure itself has been suggested to be a catabolic factor. To examine the possible effect of HD on energy metabolism, resting energy expenditure (REE) and respiratory quotient (RQ) in twenty-three chronic HD patients were measured by using indirect calorimetry before, during and after HD of 4 hours duration. Age-, sex-, and body mass index-matched healthy volunteers were used as control subjects. There were no significant differences in REE and RQ between 2 measurement-days. REE at the start of HD was significantly lower in HD patients. REE did not change significantly during HD. RQ at the start of HD was significantly higher than that in the control. RQ decreased during HD. Then, patients were divided into 2 groups according to the changes in the dry weight (DW), being the patients who had gained DW (group A) and those who had lost DW (group B). REE at the start of HD in group A was significantly higher than that in group B, and RQ in group A at the start of HD was significantly lower. The rate of RQ showed a marked decrease during the dialysis in group B. REE has been become a useful marker for assessing the state of nutrition in HD patients. Moreover, it has the potential to become an index of energy prescriptions (IDPN; Intradialytic parenteral nutrition), facilitating effective nutrition guidance based on monitoring REE and RQ values.

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Increasing number of hemodialysis (HD) patients with end stage renal disease (ESRD) are complicated with ischemic heart disease (IHD) of variable severity by the time of dialysis induction. Understanding the prevalence, the severity and the type of treatment in this population is important for both the dialysis staff and patients in order to start safe and satisfactory dialysis regimen. There were one hundred ten (110) patients with a history of medication, percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) at or prior to dialysis initiation among the 1, 060 patients who started dialysis therapy in our institution during the last 20 years. Because of the small number of with IHD, patients this series was divided into 4 groups according to the year of HD induction, Group I (1983-1987, 10 patients), Group II (1988-1992, 21 patients), Group III (1993-1997, 38 patients) and Group IV (1998-2002, 41 patients). Diabetes mellitus (DM) represents the major background disease among these groups being 5/10 (50%), 10/21 (48%), 21/38 (55%), and 22/41 (54%), respectively. Types of treatment for IHD were medication in 6/10 (60%), 4/21 (19%), 17/38 (45%) and 12/41 (29%); PCI in 3/10 (30%), 12/21 (57%), 15/38 (39%) and 18/41 (44%); CABG in 1/10 (10%), 5/21 (24%), 6/38 (16%) and 11/41 (27%) of patients, respectively. These data show that severe IHD with multiple vessel involvement have increased recently partly because of the high prevalence of DM and the number of older patients. It is, therefore, important to treat or prevent IHD during the maintenance phase of chronic kidney disease to improve the prognosis of HD patients.

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Adiponectin is adipocyte-derived protein with insulin-sensitizing and antiatherogenic properties. Plasma adiponectin is associated with a decrease in cardiovasucular risk in both non-renal and renal patient, and is reduced in obesity and insulin-resistant states. Recently, adiponectin has been shown to inhibit hypertrophic signaling in the myocardium through activation of AMP-activated protein kinase. We used echocardiography to investigate the influence of plasma adiponectin concentrations changes in left ventricular (LV) mass over a two-year period in 40 hemodialysis patients. Plasma adiponectin concentrations were 15.8±5.3μg/mL in male diabetic nephropathy, 14.1±6.4μg/mL in female diabetic nephropathy, 16.6±5.2μg/mL in male nondiabetic nephropathy, and 16.1±6.5μg/mL in female non-diabetic nephropathy, respectively. Regression in LV mass index (LVMI, 136.6±37.2 to 106.4±32.0g/m²) was detected in 20 patients (R group), while progression in LVMI (120.9±39.2 to 174.6±60.5g/m²) was detected in 20 patients (P group) over two years. Plasma adiponectin concentrations were 18.3±5.8μg/mL in the R group and 13.1±4.6μg/mL in P group. Multiple logistic regression analysis showed that the factors influencing the progression of LV hypertrophy (LVH) were plasma adiponectin concentrations (odds ratio (OR): 0.815, confidence interval (CI): 0.669-0.993) and systolic blood pressure (OR: 1.886, CI: 1.019-3.493). These findings suggest that adiponectin prevents left ventricular hypertrophy even in hemodialysis patients.

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The prevalence of sleep apnea syndrome (SAS) in hemodialysis patients is extremely high as compared to the general population, and it has recently been suggested that SAS is a risk factor for cardiovascular complication. We report a case of obstructive SAS, who presented nighttime hypertension in a diabetic hemodialysis patient. A 33-year-old woman undergoing hemodialysis for three years due to diabetic end stage renal disease was admitted to our hospital for nighttime esquinancea, insomnia and severe hypertension. Ambulatory blood pressure monitoring showed reverse-dipper status. We administered antihypertensive drugs and tried to control her dry weight to reduce volume overload, but failed to improve clinical symptoms and hypertension. Polysomnography was performed and she was diagnosed as having obstructive SAS with an apnea-hypopnea index (AHI) of 30.1. After nasal continuous positive airway pressure (CPAP) treatment, symptoms were improved and AHI was reduced to 14.7. Daytime and nighttime blood pressure decreased and the circadian pattern was restored to dipper pattern. Moreover, plasma glucose at the start of dialysis session and HbA1c level were reduced after CPAP treatment. We speculate that increased activity of the sympathetic nervous system along with SAS might have played an important role in hypertension presenting reverse-dipper status and insulin resistance. The restoration of a circadian blood pressure pattern and improvement in insulin sensitivity induced by nasal CPAP treatment may lead to an improvement in the prognosis of hemodialysis patients.

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This is the first case of renal transplantation with Fabry disease after introduction of enzyme replacement therapy (ERT). A 32-year-old man, who was diagnosed Fabry disease at the age of 13, was referred to our hospital because of chronic renal failure. To prevent the further progression of renal dysfunction, ERT of α-galactosidase A was introduced. Although plasma and urinary concentration of globotriaosylceramide (GL-3) were reduced significantly, renal function deteriorated gradually and reached the level of end stage renal disease. Two weeks after initiating hemodialysis, he underwent living renal transplantation with his father as a donor. Graft kidney functioned well, and ERT was continued. ERT of α-galactosidase A after renal transplantation is considerable for patients with Fabry disease to prevent not only accumulation of GL-3 in graft kidney but also cardiovascular disease as a fatal complication of Fabry disease. In renal transplant patients, the indicator for ERT should not be urinary GL-3 but plasma GL-3.

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