Vitamin D pulse therapy effectively reduced PTH production and corrected high turnover bone condition due to secondary hyperparathyroidism (2°HPT). However, it was not clear whether this therapy could improve clinical symptoms of the patients and bone mineral density, or reduce the size of enlarged parathyroid glands. We thus prospectively evaluated the effects of maxacalcitol, a lower calcemic vitamin D analogue, on these issue using dual energy x-ray absorptiometry (DEXA) and echosonography up to 1 year after initiating treatment. The patients consisted of 10 males and 12 females, aged from 37 to 79 years, who had undergone hemodialysis for 13.5±7.3 years. The patients received maxacalcitol intravenously at every hemodialysis session. The dose was adjusted to 2.5 to 15 μg/session according to PTH and serum calcium levels. The mean intact-PTH level was 865±392 pg/mL before treatment, which was reduced to 406±253 pg/mL after 1 year of treatment (p<0.01). Alp level was also reduced from 593±817 IU/L to 252±135 IU/L (p<0.01). Age-matched bone mineral density in L_2-4 was increased from 87.8±14.2% to 91.0±16.0% (p=0.033). Clinical symptoms, such as osteoarticular pain, were also reduced. In contrast, total parathyroid volume, measured by echosonography, was increased from 0.40±0.68 cm³ to 0.49±0.76 cm³ (p=0.023). These results indicate that maxacalcitol therapy can improve bone mineral density but cannot reduce the swelling of the parathyroid glands in any case. In the subgroup patients with an intact-PTH increase of less than 200 pg/mL, total parathyroid volume showed a tendency of decrease. For patients resistant to maxacalcitol therapy, such radical treatment as parathyroidectomy or percutaneous ethanol injection therapy is recommended.

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Bioelectrical impedance analysis (BIA) is a method that can accurately measure total body water (TBW), intracellular water (ICW), extracellular water (ECW), soft lean mass (SLM) and body fat mass (BFM). It is considered to be a preferable technique for determining dry weight (DW) in hemodialysis (HD) patients. InBody S20, a body composition analyzer, consists of a multifrequency and eight-polar tactile-electrode impedance method, and both its precision and reproducibility have been well established. Recently, the clinical application of this method for HD patients has been reported.
The present study investigated whether or not bioelectrical impedance is a useful method for estimating DW. The subjects comprised 41 chronic HD patients. In addition to routine blood tests, plasma human atrial natriuretic peptide (hANP) was measured. Body fluid components were measured by InBody S20 before and after HD. In addition, the cardiothoracic ratio (CTR) on chest Xp and dilatation of the inferior vena cava (IVC) on ultrasonography were measured after HD. The excess fluid volume (Edema score) was then estimated based on the ratio of ECW to TBW.
As a result, 1) The levels of hANP significantly correlated with the CTR and IVC during expiration (IVCe) (p<0.01 and p<0.05, respectively). 2) TBW, ECW and ICW all significantly decreased after HD (p<0.001) and correlated with IVCe (p<0.001). 3) The percentage change in TBW before and after HD (%TBW) significantly correlated with that of blood volume (%BV) and circulating plasma volume (%CPV) (p<0.001). 4) The ECW/TBW ratio significantly decreased after HD (p<0.001) and correlated with the levels of hANP (p<0.001). 5) DW determined by BIA (BIA-DW) after HD, which is equal to the BW when the ECW/TBW ratio is 0.38, significantly correlated with clinical DW (cDW) (r=0.99, p<0.001).
In conclusion, InBody S20, immediately, and non-invasively provides the information regarding body fluid components and body composition in HD patients. Especially, the ECW/TBW ratio and BIA-DW after HD are considered useful markers for estimating DW.

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Skin lightness was quantitatively determined in 100 patients with chronic renal failure (55 chronic nephritis and 45 diabetic nephropathy) on maintenance hemodialysis and 137 non-dialytic patients, using a spectrophotometer, CR-400^® (Konica Minolta). Skin lightness decreased significantly in hemodialytic patients (p<0.01), and the decrease correlated with the duration of maintenance hemodialytic treatment (p<0.01), while there was no significant correlation with patient age. Skin lightness in patients with diabetic nephropathy was significantly higher than that in patients with chronic nephritis (p=0.0005). The skin pigmentation was significantly more prominent in patients with chronic nephritis than in patients with diabetic nephropathy remains obscure, however a possible stimulatory effect of insulin on the metabolism of MSH was considered.

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Adiponectin and leptin, adipose-specific secretory proteins, are associated with obesity. It has been reported that the plasma adiponectin and leptin concentrations were both higher in women than in men, and were markedly increased among hemodialysis patients in comparison with healthy controls.
This study was conduced in 104 hemodialysis patients and 35 healthy controls. To obtein a novel indicator for the visceral fat area in hemodialysis patients, we measured total adiponectin (t-Adipo), high molecular weight adiponectin (h-Adipo) and leptin (Lep) in serum and evaluated visceral and subcutaneous fat areas using computed tomography. In addition, we calculated the percentage of the high molecular weight form per total adiponectin (h-Adipo/t-Adipo) and the ratio of adiponectin to leptin (Adipo/Lep ratio). Hemodialysis patients were divided into four groups based on their visceral fat area level (under 40 cm² ; group I, 40-70 cm² ; group II, 70-100 cm² ; group III, 100 cm² or more ; group IV). T-Adipo, h-Adipo, leptin and h-Adipo/t-Adipo were significantly higher in women than in men. T-Adipo, h-Adipo and h-Adipo/t-Adipo were lower in group IV than in group I. Leptin were higher in group III and IV than in group I. The T-Adipo/Lep ratio and h-Adipo/Lep ratio were lower in group III and IV than in group I. Especially, the h-Adipo/Lep ratio in group IV was significantly decreased compared with that in group III. By simple regression analysis of the correlation between visceral fat area and each parameter of adipocytokine, the highest correlation coefficients were seen with the log transformed h-Adipo/Lep ratio. Log transformed h-Adipo/Lep ratio were inversely related to visceral fat area for men (y=-36.16x+75.8, r=-0.558, p<0.001) and for women (y=-36.07x+68.2, r=-0.725, p<0.001). The two regression lines between-gender difference were equivalent in slope. We conclude that h-Adipo/Lep ratio may be a marker for evaluating visceral fat area in hemodialysis patients.

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A retrospective study was conducted to determine the incidence of central venous catheter (CVC)-related infections in patients on hemodialysis between 2003 and 2004. There were 533 CVC occurring in 439 patients and the median duration of catheterization was 14 days. The incidence of fever associated with CVC was 14% and 11 episodes of CVC-related infections were identified. The incidence of CVC-related infections was calculated to be 1.63 episodes per 1000 catheter days, 0.83 for the internal jugular vein and 8.16 for the femoral vein on subgroup analysis. In cases in which the CVC was placed in the femoral vein, the incidence of fever was significantly higher, compared to that in placement in the internal jugular vein (7.4% vs. 1.1%, respectively). Multiple logistic regression analysis demonstrated that CVC insertion in the femoral vein was a significant risk factor for CVC-related infection (Odds ratio, 4.98 ; 95% confidence interval, 1.34 to 18.54 ; p=0.017) and fever (Odds ratio, 2.87 ; 95% confidence interval, 1.55 to 5.30 ; p<0.001). Gram-positive organisms were isolated in all cases of infection, and gram-negative organisms and fungi were less frequent. It is necessary to carry out a prospective study, to establish a superior system for the management of CVCs and to clarify risk factors that are associated with CVC-related infections in dialysis patients.

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A 39-year-old man with advanced diabetic nephropathy was admitted to our hospital because of worsening of renal dysfunction and anasarca. He was diagnosed as having diabetes mellitus at the age of 36, and then required repeated hospitalization because of poorly controlled nephrotic syndrome due to diabetic nephropathy. After an episode of severe diarrhea, he experienced oliguria, dyspnea on exertion and marked leg edema. The levels of serum creatinine and blood urea nitrogen were significantly elevated and he was admitted for the initiation of emergent hemodialysis therapy. Chest X-ray and echocardiographic findings showed cardiomegaly with moderate pericardial effusion. Despite aggressive volume reduction, the cardiothoracic index gradually increased on chest X-ray. Blood pressure then gradually decreased, and he went into shock on the tenth hospital day. Echocardiography demonstrated cardiac tamponade with massive pericardial effusion and collapse of the right ventricle. Pericardiocentesis and pericardial drainage were performed, which demonstrated massive bloody pericardial effusion. We diagnosed the patient as having uremic pericarditis based on the clinical course, serological data and puncture fluid analysis, and performed intensive daily hemodiafiltration. After treatment, the amount of pericardial effusion decreased gradually and clinical symptoms improved.
When pericardial effusion with tamponade is detected in patients with acute renal failure, those with chronic renal failure around the initiation of dialysis, or those with insufficient dialysis efficacy, uremic pericarditis should be considered along with volume overload, infectious disease, collagen disease or malignancy.

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An 69-year-old woman with a 13-year history of hemodialysis had received an arteriovenous graft in the left upper arm. She consulted our outpatient department because of a 2-week history of painless swelling and redness of the left forearm. We performed Doppler ultrasonography (US) and three-dimensional computed tomography (3DCT) because of pulsations on the medial side of her forearm. US and 3DCT showed an aneurysm measuring 2.5×2.5×1.5 cm along the left radial artery beneath the bifurcation of the brachial artery. Resection of the aneurysm was performed, and swelling of her forearm improved. Histopathology showed pseudoaneurysm. Culture of the aneurysm was negative. There was no history of trauma or puncture to the left radial artery. The aneurysm was thought to be due to atherosclerosis.
To date, she has not developed another aneurysm. This is a rare case of non-iatrogenic solitary aneurysm occurring in a hemodialysis patient.

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We report here on a pediatric case of preemptive kidney transplantation in type IV Bartter's syndrome with end-stage renal failure. The patient was a 15-year-old boy. Oral intake and weight gain in infancy were poor and, at 10 months old, polyposia and polyuria were evident. Laboratory data documented hypokalemia, a high level of plasma renin activity, and moderate renal insufficiency at 1 year 9 months old, which established the diagnosis of Bartter's syndrome with sensorineural deafness (type IV Bartter's syndrome). He was treated with indomethacin, spironolactone and potassium chloride orally thereafter. Renal function had been deteriorating since puberty, and he was referred to our hospital for kidney transplantation in April 2004. Although we intended to perform living-related kidney transplantation for him in November 2004, blood urea nitrogen (156 mg/dL) and serum creatinine (17.2 mg/dL) levels became elevated in October. Therefore, we began hemodialysis before kidney transplantation to improve his general condition. Kidney transplantation from his mother, who was forty years old, was successfully performed. We administered enalapril maleate and losartan potassium preoperatively, although the levels of hormones involved in the renin-angiotensin-aldosterone system were normal preoperatively. After transplantation, renal function improved and there were no abnormalities in the renin-angiotensin-aldosterone system. Chronic renal failure rarely develops in Bartter's syndrome. Theadministration of NSAIDs, which is often recommended to treat Bartter's syndrome, may promote renal dysfunction, as does the disease itself. Moreover, we consider kidney transplantation a useful treatment for Bartter's syndrome patients with chronic renal failure because not only renal function but also endocrine abnormalities caused by Bartter's syndrome improve after transplantation.

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