During acute blood purification, it is very important to estimate the severity and prognosis precisely in order to select the appropriate treatment and manage medical resources efficiently. Such a precise estimate can be also useful for explaining the situation to a patient and family during the informed. Twenty-eight patients who needed acute dialysis in our hospital between December 2005 and May 2006 were divided into two groups. The first group of 14 patients died after treatment and the second group of 14 patients survived. The prognosis was assessed by 4 scales : APACHEII, SOFA, MODS, and the Japanese organ severity score, and the appropriateness of the treatment and uses of medical resources were also evaluated. APACHEII score did not show any significant difference between the two groups. However, when scores were under 9 points by SOFA, under 5 by MODS, and under 6 by Japanese organ severity score, the patient survival rate was 100%. Especially, the Japanese organ severity score was the most reliable of the four scales in estimating the prognosis precisely. Blood purification treatment is an effective treatment, but its medical cost is extremely high. Therefore, we have to select the treatment and patient appropriately.

View full abstract

Sevelamer hydrochloride has been administered to control hyperphosphatemia without calcium load. In this study, we investigated the effects of attenuation of calcium load by sevelamer hydrochloride on bone metabolic markers in 46 hemodialysis patients with serum intact parathyroid hormone (iPTH) levels<150 pg/mL. After replacement of calcium carbonate with sevelamer, their serum calcium levels decreased. The iPTH levels increased after 4 weeks and the magnitude of the increase was highly correlated with the extent of decrease in serum calcium concentration. Whole PTH, bone alkaline phosphatase (BAP), and bone-specific tartrate-resistant acid phosphatase (TRAP5b) levels were also increased after 12 weeks. However, the relationship between iPTH and BAP or TRAP5b that was observed before the sevelamer replacement therapy was preserved only in patients with serum iPTH levels<60 pg/mL at enrollment. Thus, in patients with pretreatment iPTH levels ≥ 60 and<150 pg/mL, the increase in iPTH level might not always result in the improvement of bone metabolism. In the patients administered vitamin D at enrollment, the frequency of overshooting iPTH, BAP, or TRAP5b levels was lower than that in the patients without vitamin D administration. In conclusion, replacing calcium carbonate with sevelamer could be a therapeutic option to improve bone metabolism in patients with hypoparathyroidism (iPTH<60 pg/mL) and vitamin D might be useful to avoid the excess enhancement of bone turnover by sevelamer therapy.

View full abstract

We report a relapse of microscopic polyangitis with alveolar hemorrhaging and scleritis in a patient with a high MPO-ANCA titer that had persisted for 18 years after the introduction of hemodialysis. A 60-year-old woman was admitted to our hospital because of coughing and progressive anemia. Proteinuria and hematuria had been previously detected in 1986. Renal biopsy had shown focal segmental necrotizing glomerulonephritis with cresents. In February 1990, she was admitted to our hospital because of rapidly progressive glomerulonephritis with alveolar hemorrhaging, and was diagnosed as having microscopic polyangitis. ANCA titer at that time was 260EU. Although steroid pulse therapy improved her pulmonary hemorrhaging, renal failure progressed and she was started on maintenance hemodialysis. Even in the remission stage, a high MPO-ANCA titer had persisted for 18 years during maintenance hemodialysis. In January 2008, she was admitted with coughing and progressive anemia. Chest Xp showed a diffuse reticular shadow on both lungs. Lung biopsy demonstrated old and new alveolar hemorrhaging. Although, she had not shown signs of vasculitis, a review of her chest Xp suggested that mild alveolar hemorrhaging had occurred repeatedly since 2005. Physicians should pay attention to the occurrence of chronic alveolar hemorrhaging in maintenance hemodialysis patients with a high MPO-ANCA titer during the remission phase.

View full abstract

Sudden onset of back pain is well known as a typical symptom of acute aortic dissection. In the clinical setting, it is not difficult to make a precise diagnosis of acute aortic dissection based on imaging findings along with this typical symptom. A 70-year-old man with chronic kidney disease stage 5 consulted our hospital for a scheduled appointment. He had no symptoms and no clinical signs on physical examination ; however, his serum C-reactive protein (CRP) was extremely high (19.0 mg/dL). Even on further examination, there were no significant abnormal findings except for a small collection of left pleural effusion on chest X-ray. Since the pleural effusion was independent of the decrease in body weight by dialysis, we performed chest computed tomography to investigate the cause of pleural effusion. Surprisingly, chest CT scan clearly showed dissection of the thoracic aorta, resulting in a diagnosis of Stanford type B aortic dissection. High serum CRP was the only sign indicating onset of aortic dissection in this case.

View full abstract

A 67-year old woman with chronic renal failure due to IgA nephropathy was admitted to our hospital because of a rapid 10 kg weight gain and anasarca for one month. She was soon started on hemodialysis. The dialysis was performed with out complication, but remarkable cardiac dilatation was not improved despite volume reduction. Echocardiography demonstrated cardiac tamponade with massive pericardial effusion and collapse of right atrium. We diagnosed her as having uremic pericarditis based on the clinical course and findings, and the serological data. We performed intensive daily hemodialysis and aggressive volume reduction of 16 kg. However, there was only a mild improvement in chest X-ray and echocardiography findings. Therefore, we carried out pericardiocentesis and drained non-bloody viscid exudate of about 500 mL. Continuous drainage was not performed, but cardiac dilatation continued to decrease and pericardial effusion did not recur. Uremia pericarditis has become rare in recent years, but physicians should recognize it as a potentially fatal disorder. In this case, because the circulatory dynamics were stable, we initially performed intensive daily dialysis. Thereafter, a single pericardiocentesis procedure induced remarkable amelioration. This case seems to suggest the appropriate management of such cases.

View full abstract

Vascular access failure is the main cause of hospital admission for patients undergoing hemodialysis, and it has a close relationship to prognosis. Endovascular balloon angioplasty is now generally used to maintain access patency. To improve chronic total occlusion of median basilic vein easily and safely, we inserted a 4 Fr hook-type angiographic catheter (Approach VII) by retrograde approach from the distal basilic vein. We consider that this approach is an important technique to treat chronic total occlusion of hemodialysis access.

View full abstract