A statistical survey conducted at the end of 2005 covered 3,985 medical facilities across Japan, and 3,940 facilities (98.87%) responded. The dialysis population in Japan at the end of 2005 was 257,765, which showed an increase of 9,599 patients (3.87%) from the end of the previous year. The number of patients per million was 2,017.6. The crude death rate for one year (from the end of 2004 to the end of 2005) was 9.5%. The mean age of the patients who began dialysis (in 2005) was 66.2, and the mean age of the entire dialysis population was 63.9. The primary diseases of the patients who began dialysis were diabetic renal disease (42.0%) and chronic glomerulonephritis (27.3%). The mean (±S.D.) serum ferritin concentration of all the dialysis patients was 191 (±329) ng/mL. The percentages of antihypertensive agents administered to the hemodialysis patients were as follows: calcium antagonist, 50.3%; angiotension-converting enzyme inhibitor, 11.5%; and angiotensin II-receptor antagonist, 33.9%. Of the peritoneal dialysis patients, 33.4% used automatic peritoneal perfusion devices. Moreover, 7.3% of the peritoneal dialysis patients received dialysis treatment only in the daytime, and 15% received the treatment only at night. Icodextrin solution was used by 37.2% of the peritoneal dialysis patients. The average amount of dialysis solution used by the peritoneal dialysis patients was 7.43 (±2.52) L/day and the average amount of the removal fluid was 0.81 (±0.60) L/day. A peritoneal equilibration test was conducted on 67% of the patients, and the mean dialysate to plasma (D/P) ratio was 0.65 (±0.13). The annual incidence of peritonitis in the peritoneal dialysis patients was 19.7%. Of the 126,040 patients who responded to the inquiry of the therapeutic situation of peritoneal dialysis, 676 (0.7%) had a history of encapsulated peritoneal sclerosis and 66 (0.1%) were treated for encapsulated peritoneal sclerosis. The mean life expectancy of the dialysis population in 2003 was calculated according to sex and age. Results showed that the mean life expectancy of the dialysis population was approximately 40-60% of that of the general population of the same sex and age.

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Pharmacokinetics of a glycopeptide antibiotic, teicoplanin, was examined in patients undergoing continuous hemodialysis (CHD). During CHD treatment, 400 mg of teicoplanin was intravenously administered twice on the first day. Then 400 mg of teicoplanin on the 2nd and 3^rd day, then 100 mg was administered once daily on subsequent days. Prescription for CHD was dialysis solution flow ; 500 mL/hr and blood flow ; 80 mL/min using a APF-06S hemofilter. The average level of teicoplanin an hour after administration was 39.6±18.1 μg/mL, and the average trough levels were 12.5±0.9 μg/mL, 13.2±0.8 μg/mL, 12.2±1.0 μg/mL on the 3rd, 5th, and 7^th days, respectively. Curative effects were obtained in 7 of 10 patients, and there were no apparent side effects during the study period. It was suggested that our protocol would be useful for teicoplanin administration to patients undergoing CHD.

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We examined the effect of erythropoietin (EPO) treatment on glycohemoglobin (HbA1c, A1c) values based on the relationship between A1c and glycated albumin (GA) in diabetic hemodialysis (DM-HD) patients. We measured A1c and GA values every two months during 10- to 36-month periods in 24 DM-HD patients and examined the ratio of GA to A1c (GA/A1c) on each occasion. We examined the correlation between GA/A1c values and EPO dose on 170 occasions and tried to estimate A1c and GA values based on the EPO dose. The maximum and minimum GA/A1c values were 4.36±0.66 and 3.44±0.50, respectively in all patients. In 9 patients whose EPO doses remained unchanged for 12 months or longer, these values were 3.91±0.66 and 3.41±0.53, respectively. There was a significant correlation between GA/A1c values and EPO dose (r=0.74, p<0.0001, GA/A1c=3.16+0.008×EPO dose (U/kg/week)). The estimated A1c values corresponding to 20% of the GA values were 6.3, 5.6, 5.1, and 4.6% at EPO doses of 0, 50, 100, and 150 U/kg/week, respectively. The differences between the estimated GA values and measured values were greater than±2% on 40% of all occasions. In conclusion, GA/A1c values tend to be higher and A1c values tend to be lower as EPO doses increase in DM-HD patients. It is possible to estimate A1c and GA values based on the EPO dose, but it is necessary to consider that GA/A1c values often change independently of EPO treatment.

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Rhabdomyolysis, which is caused by various factors, may induce acute renal failure or even death, if not treated properly.
We encountered four cases of rhabdomyolysis with ARF from September 2001 to March 2004. All patients had been prescribed neuroleptics for long periods. Case 1 developed malignant syndrome. Forced diuresis and hemodialysis (HD) were performed simultaneously. The patient recovered and was discharged 45 days later. Case 2 was suspected of having malignant syndrome. Forced diuresis and HD were performed similarly, but the body temperature rose to over 40°C and the patient died on the fifth day after onset. Case 3 was caused by trauma. The patient was treated by forced diuresis and hemodiafiltration (HDF), and discharged after 45 days. Case 4 was caused by infection and dehydration. Only forced diuresis was applied to the patient, and he was discharged on the 81st day of hospitalization.
Based on our experiences with these 4 cases of rhabdomyolysis-induced ARF, forced diuresis should be applied immediately. For those of oliguria, blood purification therapy should be added simultaneously. Some reports recommend, as a blood purification therapy, HDF or plasma adsorption should be applied instead of HD for the purpose of myoglobin elimination. However, there is no solid evidence.

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A 34-year-old male was admitted for fatigue and appetite loss in June 2004. In 1994, he was diagnosed to have Cushing's disease and underwent surgery to remove pituitary adenoma. In 2001, kidney biopsy was performed, since proteinuria and monoclonal serum protein had been detected. Nearly 60% of glomeruli showed global sclerosis, but there was no vasculitis. At the same time, recurrence of the pituitary tumor was note. In 2003, he underwent surgery again, but the tumor was not completely resected. In February 2004, he was involved in a car accident. After the accident, renal insufficiency worsened gradually. After admission, hemodialysis therapy was started. Fever, leukocytosis and increase in C-reactive protein (CRP) were observed. Initially, the symptoms seemed to arise from the hematoma that occurred when the blood access catheter was pulled out. Thereafter, anti-bacterial therapy was initiated since catheter infection was suspected. However, fever, leukocytosis and increased CRP persisted. Tuberculosis was suspected and he was treated accordingly, but there was no improvement. He complained of hypoesthesia of the extremity in July and weakness of the right foot in August. Since neuropathy worsened gradually, he was diagnosed with motor dominant polyneuropathy and treated with high-dose immunoglobulin therapy, because he may have developed chronic inflammatory demyelinated polyneuropathy. Although neuropathy was not relieved, fever, leukocytosis, increased CRP and the general condition did improve. However, the improvement was temporary and the general condition worsened gradually. The patient died at the beginning of November. Autopsy showed the arteritis of small and medium-sized arteries of the kidney, heart, median nerve, testis, stomach, peritoneum and pancreas, indicating polyarteritis nodosa (PAN). A case of PAN accompanied by Cushing's disease is very rare. It was very difficult to diagnose PAN in this case because the patient showed a very intricate clinical course. A disease with poor prognosis such as PAN should always be considered in the differential diagnosis in order to provide adequate treatment.

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We report a 51-year old man with idiopathic portal hypertension (IPH) receiving long-term hemodialysis treatment, who developed pancytopenia that had mildly progressed over a five-year period before the current admission. Abdominal ultrasound showed splenomegaly, and abdominal computed tomography showed dilatation of the portal and paraumbilical veins. Neither hematological nor collagen disease was suggested. We concluded that the patient had idiopathic portal hypertension, and splenectomy was performed. Liver biopsy was simultaneously performed and histological analysis demonstrated normal liver tissue ; there was no evidence of any excess inflammation and no features to suggest cirrhosis or drug-induced liver disease, consistent with IPH. Post operatively, recovery was uneventful and rapid improvement of pancytopenia was observed.

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In recent years, many choices for arteriosclerosis obliterans (ASO) treatment have been reported. Double-filtration plasmapheresis thermo-mode called “DF thermo” is reported to be effective for ASO. To our knowledge however, only one severe ASO patient has been reported. We performed “DF thermo” treatment for two hemodialysis patients with severe ASO. Case 1 was a 76-year-old woman. Hemodialysis was indicated for end-stage renal disease due to diabetic nephropathy in November 2000. She demonstrated ulcer on the right first toe that had progressed from a shoe sore in January 2005. Because the ulcer was not improved by medical and interventional treatment, “DF thermo” was performed from September 2005 and the ulcer was improved thereafter. Case 2 was 71-year-old man. He had been treated for diabetes for 30 years at an other hospital. He was also being treated for poor color of the right foot from July 2005, but the color did not improve. Since diarrhea, loss of appetite and dehydration appeared and renal dysfunction subsequently worsened, he was hospitalized. After hospitalization, hemodialysis was indicated and “DF thermo” was initiated from October 2005. Because the ulcer was worsening and aggravation of the infection appeared after the fifth treatment, right knee amputation was performed by emergency surgery. Daily observation, care and various treatments may avoid the need for amputation. As for “DF thermo”, the potential for this method to become one of the treatments of choice is suggested. Herein we present two cases and discuss some consideration based on the literature.

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A 20-year-old man came to a local hospital with complaining of headache and general malaise and he was referred to our hospital for the treatment of renal dysfunction, anemia, thrombocytopenia and severe hypertension. The diagnosis of thrombotic microangiopathy (TMA) was made because of thrombocytopenia, hemolytic anemia in accompanied with fragmentation of erythrocytes and progressive renal failure. After hospitalization, antihypertensive therapy by calcium channel blockers, plasmapheresis and administration of glucocorticoid hormone were performed. Because the activity of plasma von Willebrand factor cleaving protease (vWF-CP)/ADAMTS13 was normal, he was diagnosed as having TMA associated with malignant hypertension. Thrombocytopenia and hemolytic anemia were immediately improved by the beginning of these treatments, however renal insufficiency and proteinuria were deteriorated and congestive heart failure developed. Following continuous hemodiafiltration (CHDF) and administration of angiotensin converting enzyme inhibitor and angiotensin receptor II antagonist, overall general condition and renal function improved. Blood purification therapy such as CHDF was no longer required, and the patient was discharged from our hospital. Renal biopsy performed during convalescence showed endothelial edematous thickening of arteriole, indicating malignant nephrosclerosis. As causes of TMA comprise a divergent range of factors, it is often difficult to establish the differential diagnosis based on clinical manifestations only. Here, we report it because the measurement of the activity of plasma vWF-CP/ADAMTS13 was useful for diagnosing TMA with malignant hypertension.

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