A questionnaire survey was conducted to clarify awareness and eating behavior in relation to salt restriction among 96 patients receiving peritoneal dialysis in the Tohoku region. Among 83 patients who responded, 84.3% of patients recognized that they had previously been advised to restrict salt, and 64.4% regarded themselves as complying with the salt restriction. However, 54.2% were able to indicate their prescribed salt intake. Fifty-two percent of patients described salt restriction as mentally painful. The most frequent reason for difficulty in salt restriction was “appetite disturbance due to tastelessness”. Dining-out, pickles, instant-food and processed salt-rich foodstuff were generally avoided. However, miso-soup was still consumed daily in not a few (30.5%) cases, especially among the elderly (41.9%). Soy sauce was used without restriction by 25.9% of patients. These findings suggest that there is a clear discrepancy between awareness of salt restriction and actual eating behavior. We consider that concrete guidance based on patient backgrounds and appropriate mental assistance is needed to promote actual compliance with salt restriction.

View full abstract

Daily polished rice was changed into BG pre-washed rice as dietary therapy for hemodialysis (HD) patients. Fifteen Japanese HD patients (8 men, 7 women, age: 54.1 years old, dialysis duration: 10.1 years), a polished rice was changed to BG prewashed rice for 1 month, and the change in serum phosphorus (Pi) value was examined decreased. The serum Pi decreased significantly from 7.2±0.2mg/dL to 6.3±0.4mg/dL (p=0.0014). This reduction was observed in 12 (80%) of 15 patients, and 10% or more reduction was seen in 9 (60%) of these 12. During the trial, there were no remarkable problems including decreased flavor. Moreover, there was no correlation between the degree of reduction in the serum Pi before trial and either the dialysis duration or the baseline serum Pi. Since the economic burden was not large, controlling the amount of phosphate intake by changing to BG prewashed rice was considered to be useful for both dialysis patients and their families.

View full abstract

The patient was a 57-year-old man on maintenance dialysis since 1979. To control secondary hyperparathyroidism, he underwent total parathyroidectomy with autotransplantation to his left arm in 1994. He underwent a second parathyroidectomy for the remaining parathyroid tissue in 1999. In June 2003, he started to complain of gait disturbance with a pain in the right hip. On examination at our hospital in December 2003, the serum calcium level was 13.2mg/dL, phosphate level 6.1mg/dL, albumin level 4.4g/dL and the intact parathyroid hormone (i-PTH) level 360pg/mL. X-ray film showed a fist-sized tumoral calcification extending from the right hip to the thigh. After we discontinued vitamin D derivatives, bisphosphonate and aluminium-containing phosphate binder, sevelamer hydrochloride was administered. Serum calcium and phosphate were normalized. In contrast, the i-PTH level increased to 2, 022pg/mL, in December 2004, therefore the patient underwent surgical removal of autotransplanted parathyroid tissue. The tumoral calcification reduced dramatically after several months. Administration of sevelamer hydrochloride and surgical removal of autotransplanted parathyroid tissue have been thought to treat the tumoral calcification related to vitamine D overdose and secondary hyperparathyroidism.

View full abstract

A 52-year-old male had been diagnosed with alcoholic liver cirrhosis. He began haemodialysis due to chronic renal failure on 2003. Because of occulusion of the arteriovenous access, he consulted a doctor on June 30, 2004, then he was admitted to our hospital on July 7, 2004, for surgical fistula revision. There was no bleeding tendency observed on preoperative examination. After hospitalization, the catheter for dialysis was inserted into the right internal jugular vein. Thereafter, there was persistent bleeding from the catheter insertion site, and enlargement of the right cervical vein was observed. Because dyspnea became advanced, we began respirator management with endotracheal intubation. At the time of onset, the platelet count was unchanged, but the elongation of the APTT and PT, and the reduction of TTO and HPT were observed. There was no acceleration of the fibrinolysis system, Since Vit K deficiency was suspected, Vit K was administered intravenously. Thereafter, bleeding improved during catheter implantation and serologic data also improved promptly. By a careful examination of his history, it was found that he had been taking chitin-chitosan preparation (one day 30 tablets, with a recommended daily dose of 10 tablets) after preoperative examination. It is considered that the chitin-chitosan preparation affected the absorption of fat-soluble vitamins. Moreover, he had liver cirrhosis, which might result in poor excretion of bile. Since the chitin-chitosan preparation was ingested while bile excretion was declining, it caused a further decrease in bile excretion, then Vit K absorption became poor, leading to acute Vit K deficiency. Since this is the first report of a bleeding tendency caused by chitin-chitosan preparation, we emphasize the need for particular attention to non prescribed health food administration.

View full abstract

We experienced 2 chronic dialysis patients in whom large thrombus formed in the right atrium at the tip of an indwelling dialysis catheter. In both patients, the catheters and thrombus were successfully removed by the open heart surgery. Case 1 was a 66-year old woman. She started hemodialysis at age 64 because of chronic glomerulonephritis. Due to frequent vascular access problems, an indwelling catheter (Perm Cath^®) was used for further dialysis treatment. The catheter was inserted from the right subclavian vein and the catheter tip was located at the right atrium level. One month later, the patient developed cellulitis in the left leg followed by MRSA bacteremia. Occasionally blood drawing through the dialysis catheter became totally impossible, trans-esophageal echogram demonstrated the formation of a large thrombus in the right atrium. Chest CT showed multiple pulmonary embolisms. Open heart surgery was explored for removal of the catheter and thrombus. The post surgical course was uneventful and CAPD was started. Case 2 was a 58-year old woman who started hemodialysis at age 55 due to chronic glomerulonephritis. Indwelling dialysis catheter (Perm Oath^®) was inserted to the right atrium through the left jugular vein. However, blood flow through the catheter soon became impossible and a central venous line was used for total parenteral nutrition treatment for anorexia nervosa. Ten months later, she developed hypotension with dehydration and a trans thoracic wall echocardiogram obtained at that time demonstrated a large thrombus formation in the right atrium. The thrombosis moved back and forth through the tricuspid valve into the right ventricle. Catheter and thrombus were removed by open heart surgery. Several risk factors might have promoted thrombus formation in these two patients. In case 1, the patient was complicated by malignant lymphoma, deep venous thrombosis and adrenal deficiency. In case 2, the patient had prolonged chronic anorexia nervosa and was chronically dehydrated. We diagnosed atrial thrombus by echocardiography and after open heart surgery, the patients each had a good clinical course. Thrombosis related to long-term dialysis catheter is a rare complication, but catheter tip thrombosis should be considered if catheter malfunction is encountered.

View full abstract