Background : Reports about long-term maxacalcitol (OCT) therapy for secondary hyperparathyroidism (SHPT) are rare. Material and Methods : Seventy hemodialysis (HD) patients with a serum intact parathyroid hormone (iPTH) level>200pg/mL and serum albumin corrected calcium (cCa) level<11.5mg/dL were enrolled. OCT was given three times weekly for 24 weeks. Doses were adjusted according to iPTH and cCa levels on the first day of every other week. After evaluation at 24 weeks, the patients were continued with OCT or intervention therapy for SHPT. The condition of each patient was studied using questionnaires sent to each attending physician about 5 years later. Results : At 24 weeks, 31 patients (44.3%) showed an iPTH level<200pg/mL, and 27 patients (38.6%) showed an iPTH decrease>50%. Eleven patients (15.7%) showed hypercalcemia, which was related to the initial cCa level (p=0.0003). In the follow-up study, 27 patients died, two patients underwent kidney transplantation and two patients were lost to follow-up after changing hospitals. Five HD patients underwent parathyroidectomy. At the end of December 2006, compared with the data at 24 weeks', iPTH had significantly decreased, cCa had significantly increased and serum P had not changed. In the last six months, 21 HD patients were maintained with OCT therapy against 8 HD patients who had stopped it. Between the two groups, iPTH showed a significant difference. Conclusions : These findings suggest that long-term OCT therapy is useful for SHPT in some patients.

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Recently, we have reported that bioelectrical impedance analysis (BIA) using a body composition analyzer (InBody S20) is useful for assessing the body fluid components of hemodialysis patients. The ratio of extracellular water (ECW) to total body water (TBW) appears to be a useful marker for estimating clinical dry weight (Cl-DW). The present study investigated the optimal ECW/TBW ratio for setting DW under various clinical conditions such as diabetes, heart failure, hypoalbuminemia, dialysis-related hypotension, obesity, long-term dialysis, and non-oliguric HD patients. The subjects comprised 57 patients who were undergoing maintenance dialysis. In addition to routine blood test, various body fluid components using an InBody S20 were measured before and after dialysis. Furthermore, we measured the cardiothoracic ratio (CTR) on chest Xp, and human atrial natriuretic peptide (hANP), brain natriuretic peptide (BNP), the inferior vena cava (IVC) diameter and the left ventricular ejection fraction (EF) on cardiac ultrasonography after dialysis. The ECW/TBW ratio significantly decreased after dialysis under all clinical conditions (p<0.0001). The post-dialysis ECW/TBW ratio was negatively correlated with the serum albumin concentration (r=-0.720, p<0.0001), and it was higher in diabetic patients than in non-diabetic patients (p<0.0001). Thus, we divided the patients into 4 groups based on the presence or absence of diabetes (DM) and hypoalbuminemia (hypo Alb). The post-dialysis ECW/TBW ratio was significantly higher in GroupII (DM (-), hypo Alb (+) ; 0.397±0.013, p<0.001) and GroupIII (DM (+), hypo Alb (-) ; 0.398±0.011, p<0.001), compared to that in GroupI (DM (-), hypo Alb (-) ; 0.384±0.005). The highest value was obtained from GroupIV (DM(+), hypo Alb(+) ; 0.404±0.012, p<0.0001 vs. GroupI). There was a strong positive correlation between BIA-DW, which is equal to the BW when the ECW/TBW ratio is 0.380, and Cl-DW (r=0.996, p<0.0001). These values were almost identical in GroupI. On the contrary, Cl-DW was approximately 0.5～0.8kg greater than BIA-DW in GroupII and GroupIII, and approximately 1kg greater in GroupIV. The post-dialysis ECW/TBW ratio did not correlate with blood pressure, heart function, duration of dialysis or urinary volume. In conclusion, the post-dialysis ECW/TBW ratio determined by BIA may be a useful marker for predicting DW in hemodialysis patients with various clinical backgrounds.

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Gastrointestinal disorder occurs frequently in hemodialysis patients. These symptoms are caused in some part by delayed gastric emptying. Mosapride citrate, a selective serotonin 5-hydroxytryptamine type4 (5-HT4) agonist is usually used for the treatment of dyspeptic symptoms. The objective of this study is to perform an open-label study of mosapride citrate for the evaluation of beneficial effects on abdominal symptoms in hemodialysis patients. After written informed consent was obtained, patients were evaluated by questions on abdominal symptoms, SF-36, gastrointestinal symptom rating scale (GSRS) during the pretreatment period. Then 15mg/day of mosapride citrate was orally administered. Four and 8 weeks after the initiation of the therapy, patients were reevaluated using the same questions as during pretreatment period. Thirty patients were enrolled in this study and 28 patients completed the 9-week study period. Two patients were withdrawn from the study because of abdominal pain. Clinical symptoms and SF-36 were improved 4 to 8 weeks after the initiation. However, these effects were not significant. GSRS improved significantly after therapy (2.09±0.75 pretreatment periods, 1.69±0.48 after 4 weeks, 1.68±0.75 after 8 weeks, p=0.021, multiple ANOVA). In fifteen GSRS parameters, two parameters, acid reflux (1.96±1.20 pretreatment periods, 1.42±0.67 after 4 weeks, 1.48±0.87 after 8 weeks, p=0.030) and constipation (2.96±0.84 pretreatment periods, 2.19±1.02 after 4 weeks, 2.08±0.99 after 8 weeks, p=0.001) responded significantly to mosapride citrate therapy. In this study, mosapride citrate was shown to be effective for improving abdominal symptoms in hemodialysis patients, especially constipation and acid reflux.

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A 66-year-old woman on maintenance hemodialysis (HD) was diagnosed as having idiopathic normal pressure hydrocephalus (iNPH). During the recent 6 months, motivation and walking disturbance appeared and then worsened. Evaluation of mental state scales also showed a decrease. Lumbo-peritoneal (LP) shunt ameliorated her symptoms and improved brain CT findings. It appears that minimally invasive LP shunt is effective for maintenance HD patients with idiopathic normal pressure hydrocephalus.

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Recently multiple infections of enteropathogenic E. coli O-157 (O-157) have sometimes occurred in all parts of Japan. We encountered a case of O-157 infection in a uremic patient who became deeply comatose. A 70-year-old man was referred to our hospital because of hemorrhagic enterocolitis in July 13, 2002. Five years earlier he had developed end-stage renal failure because of diabetic nephropathy and had received hemodialysis (HD). After hospitalization, he rapidly developed a markedly impaired consciousness. O-157 was detected by stool culture. He was treated conservatively and consciousness was completely restored. He did not develop thrombocytopenia, and did not meet the criteria for hemolytic uremic syndrome (HUS). However the cause of impaired consciousness was suspected to have been O-157 infection. Finally, it was thought that when an HD patient develops O-157 infection, attentive treatment is needed because there is a possibility that impaired consciousness will become reversible.

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We report a case of continuous ambulatory peritoneal dialysis (CAPD) with incisional flank hernia after open radical nephrectomy. On January 2008, a 60-year-old female consulted our hospital with a complaint of pain in the left flank, nausea, vomiting. CAPD was started in 2000 for end-stage renal disease due to nephrosclerosis. Open left radical nephrectomy was performed for renal cell carcinoma in 2006. After nephrectomy, CAPD was continued. Abdominal CT scan demonstrated left flank hernia and ileus. Bowel rest, support with phleboclysis, and nasogastric tube placement were performed. CAPD was stopped and hemodialysis was started. After conservative therapy, she recovered from ileus. Open sutural closure technique was performed for flank hernia repair. CAPD with hernia (umbilical hernia, inguinal hernia, surgical site hernia, etc) occurs in 10~28% of cases. Incisional flank hernia after renal surgery is uncommon. Our case is the first case of CAPD with incisional flank hernia in the Japanese literature.

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