Due to various metabolic disorders, especially dyslipidemia, in patients undergoing dialysis, the prevailing reference values of indices for determining obesity may differ from those used in the general population. To clarify visceral fat levels indicating obesity in dialysis patients, we analyzed indices for determining obesity and lipid profiles, and compared the data between dialysis patients and control subjects with normal renal function.
This study was conduced in 75 hemodialysis patients (HD group) aged 61.0 y on average and 58 control subjects (control group) aged 44.5 y on average. We calculated body mass index (BMI), waist circumference at the umbilical level (W), waist-height ratio (W/Ht) and evaluated visceral and subcutaneous fat areas using computed tomography (CT) at the level of the umbilicus. In addition, we measured postprandial total cholesterol (TC), triglyceride (TG), high density lipoprotein cholesterol (HDL-C) in the serum and calculated the ratios, (TC-HDL-C)/HDL-C and TG/TC.
Visceral fat area, (TC-HDL-C)/HDL-C and TG/TC in HD group were 58.1cm², 2.31 and 0.74, which were significantly higher than those in the control group (37.4cm², 1.95 and 0.52), respectively. A significant positive correlation was found between visceral fat area and BMI, W, and W/Ht in both groups. In control subjects, visceral fat area was highly correlated with (TC-HDL-C)/HDL-C (r=0.532, p less than 0.0001), and with TG/TC (r=0.286, p=0.0296). In contrast, visceral fat area in hemodialysis patients was highly correlated with (TC-HDL-C)/HDL-C (r=0.397, p=0.0004), and with TG/TC (r=0.568, p less than 0.0001).
Our study demonstrated that visceral fat accumulation in hemodialysis patients increased irrespective of BMI, and the standard criteria for obesity using BMI would be unsuitable. Furthermore, we identified a novel indicator, non-fasting TG/TC, which seems to indicate visceral fat obesity in hemodialysis patients.

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Diabetic nephropathy is the most frequent cause of endstage renal disease with severe complications and poor prognosis. Recent increases in diabetic endstage renal failure (DESRF) patients cause increased utilization of medical resources to provide dialysis therapy for such patients and might over tax the overall health-care resources of society. We tried to estimate future trends in the incidence of diabetic dialysis patients using data from the Patient Registry Committee of Japanese Society for Dialysis Therapy.
We calculated the incident DESRF per 100, 000 population by gender and age between 1995 and 2004, and identified linear increases. Then we extrapolated the projected incidences by gender and age to 2010. Future estimates of the general population by age and gender were obtained from the Ministry of Health and Labor. Future incidence of DESRF was calculated by multiplying the estimated populations by the estimated incidences by gender and age. DESRF in 2010 were estimated to be 12, 579 male patients and 5, 756 female patients (total: 18, 335, 30.6% increase compared with those data in 2004). Age group of 50-59-year-olds showed increases until 2004, then plateaued thereafter. The age group of 60-64-year-olds showed increases until 2010, then start to decrease thereafter.
These calculations could provide an estimate of the future diabetic dialysis population, though the estimates of patient number could not include factors related to scientific, economic, and socio-cultural changes.

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It has been reported that serum bicarbonate levels decrease in chronic hemodialysis patients treated with sevelamer hydrochloride, whereas these levels increase with calcium-containing phosphate binders. We investigated the effect of calcium carbonate administration on serum bicarbonate levels and metabolic acidosis in chronic hemodialysis patients treated with sevelamer hydrochloride.
Sixteen chronic hemodialysis patients were studied (M/F; 8/8, age; 51.0±9.6y, hemodialysis duration; 58.0±56.0m). All subjects were treated with sevelamer hydrochloride at 2.25g/day for 2 weeks, then increased to 2.95±1.4g/day for 2 weeks. After discontinuing sevelamer hydrochloride followed by wash out for 8 weeks, they were again treated with sevelamer hydrochloride at 2.25g/day for 2 weeks, then increased to 2.95±1.4g/day for 2 weeks with calcium carbonate at 1.5g/day. Serum bicarbonate levels were measured before hemodialysis.
Serum bicarbonate levels with sevelamer hydrochloride significantly decreased from 23.2±1.86 to 20.3±1.40 after 2 weeks (p<0.0001) and 19.9±2.07mmol/L after 4 weeks (p<0.000001). Serum bicarbonate levels with sevelamer hydrochloride and calcium carbonate also significantly decreased from 23.0±1.68 to 21.5±2.23 after 2 weeks (p<0.05) and 20.9±2.37mmol/L after 4 weeks (p<0.01) respectively. Metabolic acidosis induced by sevelamer hydrochloride was significantly mitigated by calcium carbonate (after 4 weeks with sevelamer hydrochloride vs after 4 weeks with sevelamer hydrochloride and calcium carbonate; p<0.01).
Administering calcium carbonate improves metabolic acidosis induced by sevelamer hydrochloride in hemodialysis patients.

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We report here a rare case of crural pyomyositis in a hemodialysis patient receiving corticosteroid therapy. The patient was a 70-year-old man who had been on hemodialysis since December, 1997 due to diabetic nephropathy. On May, 2004, he was admitted to our hospital because of fever, right chest pain, and right pleural effusion. After admission, pleuritis due to autoimmune reaction was suspected because of positive antinuclear antibody, LE cells, and exudative pleural effusion. Oral administration of prednisolone (40mg/day) was initiated, and pleuritis was gradually improved. Two weeks after starting steroid therapy, the patient suddenly developed right leg pain and fell into shock. Group G streptococcus was positive on cultures of soleus, blister effusion and blood. MRI showed diffuse soleus enlargement and increased signal intensity on T2-weighted image. We diagnosed to be crural pyomyositis. Treatment with ampicillin 2g/day was initiated and 2 weeks later pyomyositis was improved. We assumed that toxic shock-like syndrome was complicated by pyomyositis with group G streptococcus during steroid therapy. When hemodialysis patients develop leg pain, pyomyositis should be considered.

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We report the clinical effects of acupuncture treatment on intermittent claudication in a diabetic hemodialysis patient. A 59-year-old man had experienced intermittent claudication since 1998. The patient started maintenance dialysis for diabetic neuropathy in 2000, but he did not receive treatment for claudication. Based on the medical history, findings on physical examination, and Magnetic Resonance Imaging (MRI), claudication was suspected to be due to arteriosclerosis obliterans (ASO). Acupuncture treatment was performed on acupoints located on the low back and leg, once a week, for twenty sessions. To examine the effects of this treatment, MOS Short Form 36 Health Survey (SF-36v2^TM), plethysmography of both halluxes, and walking distance were adopted as outcome measures. Scores increased for five of the eight SF-36 criteria. In particular, Mental Health (MH) score increased from 54.5 to 65.1, and Role-Physical (RP) score increased from 27.0 to 34.0. Height of the pulse waves in plethysmography increased following acupuncture treatment, and walking distance increased from 168m to 378m. These findings suggest that acupuncture treatment might be effective for intermittent claudication in diabetic dialysis patients.

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A 28-year-old male patient undergoing hemodialysis was admitted to our hospital due to severe pain and swelling of the left forearm. An aneurysm of the arteriovenous shunt located in the left forearm had been bitten by a cat earlier the same day. We diagnosed as phlegmon cellulitis around the aneurysm. Blood flow in the arteriovenous shunt had already stopped on arrival. Although amikacin, piperacillin and clindamycin were immediately administered, the inflammatory reaction increased and high fever persisted. Since Pasteurella multocida was isolated from the wound discharge, we changed the antibiotics to panipenem/betamipron and minocycline. Although inflammation improved, the aneurysm suddenly ruptured on the 22 hospital day. We urgently performed aneurysmectomy. The wall of the aneurysm was weakened probably due to the infection.
The incidence of Pasteurella multocida infection after cat bite has recently increased. This case is the first report of vascular access infection by Pasteurella multocida.

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