Intradialysis hypotension is encountered more frequently in diabetic patients than in nondiabetic patients. In this study, we evaluated the plasma refilling rate (PRR) and circulating blood volume change (ΔBV) during hemodialysis using CRIT-LINE™ (In-Line Diagnostics, UT, USA) in ten diabetic and ten nondiabetic hemodialysis patients. As a result, there were no significant differences in the averaged value of PRR between diabetic and nondiabetic patients. There was a correlation between ΔBV and PRR in nondiabetic patients (r=-0.64), but not in diabetic patients. At high ΔBV levels (less than 9%), PRR was significantly lower (0.71±0.10 vs. 0.90±0.15, p<0.01) and the rate of change in mean blood pressure tended to be lower (10.07±12.21% vs. 1.83±10.09%, p=0.11) in diabetic patients, compared with that in nondiabetic patients. In conclusion, an inadequate PRR to ΔBV observed in diabetic patients was one of the factors affecting intradialysis hypotension.

View full abstract

We report a female with amyloid arthropathy of the hip joints. She was a 67-year-old woman who had been treated by hemodialysis for 22 years. She had demonstrated a 5-month history of continuous low-grade fever and pain in her left hip and she was finally unable to walk by herself. Findings on X-ray films and MRI of the hip joints suggested avascular necrosis in both femur heads. To palliate symptoms, bipolar surgery on the left hip joint was performed. Pathological examination of bone tissue specimen demonstrated that there was some β₂-microglobulin (β₂-MG)-related amyloid accumulation in the femur head. Based on this clinical experience, we performed MRI screening for amyloid lesions of the hip joints in another 11 asymptomatic female patients undergoing hemodialysis for 20 years or more. Cystic lesions of the hip joints were observed in 8 patients, amyloid arthropathy in 2 patients, and fluid trapped in the joint in 1 patient. Patients with amyloidosis had significantly lower serum β₂-MG levels than patients without amyloidosis (28.6 mg/L versus 41.4 mg/L ; p=0.0339). Our findings show that dialysis-related amyloidosis of the hip joints is one of the potential and significant problems in female patients on long-term hemodialysis therapy. It may be important to screen for this pathological condition in long-term hemodialysis patients.

View full abstract

At the 50^th congress (in 2005), the patient registration committee of the Japanese Society for Dialysis Therapy (JSDT) formally accepted that there are regional differences in the outcome of dialysis in Japan. We investigated factors that influence the survival of dialysis patients in each prefecture. We analyzed the data reported for each prefecture by the Japan Statistics Bureau and JSDT using univariate and multivariate regression analysis. Univariate analysis showed that the density of dialysis centers (number in relation to the area of the prefecture), the percentage of new dialysis patients in the general population over 65 years old, the average age of new dialysis patients, the average annual temperature, the average lifespan, the mortality rate in the general population, and the mortality rate of persons with cerebrovascular disease and heart failure (excluding those with hypertension) correlated with the 5-year survival rate of new dialysis patients between 1995 and 1999. Multivariate regression analysis showed that the mortality rate in the general population with heart failure (excluding hypertension) (P=0.0483, F=4.1438, negative correlation), the average annual temperature (P=0.0013, F=11.9212, positive correlation), and the percentage of new dialysis patients over 65 years old (P=0.0081, F=7.7596, negative correlation), were extracted as determinants of the 5-year survival rate of new dialysis patients in each prefecture. The survival rate of new dialysis patients in each prefecture may be influenced by factors that cannot be controlled after the initiation of dialysis.

View full abstract

In patients on chronic hemodialysis, incidences of opportunistic infections and cancers are very high. Therefore, early detection of these diseases is very important for maintaining the quality of life. In this regard, it is imperative to have standard distribution ranges (SDRs) for the major laboratory tests specific for hemodialysis patients in a steady state. We derived RIs, from routine test results of 1,392 patients belonging to 16 hemodialysis centers, for 25 common biochemical analytes and for 14 measurements regarding peripheral blood cells just before regular hemodialysis. We adopted the latent abnormal value exclusion method for the derivation, which features iterative exclusion of individuals with abnormal results on other analytes. After the selection process, the SDRs were computed parametrically as 95 confidence intervals using the Box-Cox power transformation method. Changes typical of chronic renal failure were observed in the majority of the analytes. The widths of pre-dialysis RIs were two or more times those of healthy individuals for creatinine (CRE), urea nitrogen (UN), inorganic phosphate (IP), Mg, amylase, and eosinophil, 1.5 times more for urate, K, MCV and reticulocyte. Peculiar low-sided shifts of RIs were noted for total bilirubin, AST, ALT, and pseudo-cholinesterase. Post-dialysis RIs for Na, K, Ca, IP, CRE, urate, and UN were reduced to narrow ranges, that are regarded as targets for optimal hemodialysis. In conclusion, setting of SDRs specific for hemodialysis patients maintained in a steady state seems to be of great clinical relevance for early detection of emerging complications and for planning an optimal hemodialysis regimen.

View full abstract

In ischemic heart disease (IHD) of hemodialysis patients, silent myocardial ischemia (SMI) may occur without subjective symptoms. Early diagnosis of type 1 SMI is important, because acute myocardial infarction may develop suddenly without angina pectoris. We reviewed pulse wave velocity (PWV) of 10 hemodialysis patients diagnosed as type 1 SMI by coronary angiography. The extent and severity of IHD were assessed by the coronary severity index (CSI). As a result, CSI correlated significantly with PWV. Our findings indicate that PWV may predict type 1 SMI in hemodialysis patients.

View full abstract

A 68-year-old man underwent total cystectomy and ileal conduit construction for bladder cancer. Subsequently, his left kidney lost function, following hydronephrosis associated with ureteral obstruction. When he was admitted due to acute pyelonephritis, serum creatinine levels were elevated to 1.9 mg/dL. On the eleventh day after discharge, he developed severe renal insufficiency, showing creatinine levels of 7.09 mg/dL. Since conservative therapy was not effective and renal dysfunction was progressive, hemodialysis was started. Serum anti-GBM antibody was positive and renal biopsy showed crescentic glomerulonephritis associated with linear deposition of IgG along the GBM, thus he was diagnosed as having anti-GBM antibody nephritis. Although he received plasmapheresis and corticosteroid therapy, his renal function did not improve and he had to be treated by regular hemodialysis. Although anti-GBM antibody nephritis is a rare disease, it should be considered in a patient with acute renal dysfunction under any situation.

View full abstract

The patient was a 73-year-old man undergoing hemodialysis due to nephrosclerosis since April 2002. To control hyperphosphatemia, he was treated with sevelamer hydrochloride 3 g/day as a phosphate binder. One month later, serum protein level began to decrease rapidly. Three months later, the amount of sevelamer hydrochloride was reduced to half. Six months later, sevelamer hydrochloride was discontinued due to severe hypoproteinemia (TP 3.7, ALB 2.1 g/dL). It took about six months to restore the original serum protein level. The patient maintained good self-control with little change in dietary intake, weight or anemia. Malnutrition caused by deficiency of protein intake did not seem to be the primary cause of hypoproteinemia, and there were no apparent symptoms of protein loss. Hypoproteinemia was considered a side effect of sevelamer hydrochloride. As for the mechanism, suppression of protein synthesis in the liver was supposed to be the cause of hypoproteinemia, when the coincidence of changes in the level of serum protein and cholinesterase was observed. However, AST and ALT were within the normal range. The underlying mechanism of hypoproteinemia was an unknown. Cases treated with sevelamer hydrochloride as a phosphate binder have recently increased. This case is the first report of hypoproteinemia caused by sevelamer hydrochloride.

View full abstract

Mitochondrial disease patients develop lactic acidosis due to the accumulation of lactate and pyruvate. Here, we report a diabetic hemodialysis patient with mitochondrial disease accompanied by deafness, hypertrophic cardiomyopathy, congestive heart failure and lactic acidosis, that occurred frequently during maintenance hemodialysis. Hypotension and severe fatigue on dialysis treatment caused a decrease in the quality of life (QOL), and were not improved by hemodiafiltration (HDF). However, these symptoms were moderately improved after changing the dialysis method to acetate-free biofiltration (AFB). The lactate/pyruvate ratio (i.e, lactic acidosis index) decreased to nearly the normal range after AFB.

View full abstract