The association of hemoglobin level variability in hemodialysis patients with an increased mortality rate has been shown previously. To examine the factors contributing to this variability, we calculated “weekly erythropoietin moving average”, which is the average of weekly erythropoietin doses administered between 14 weeks and one week previously (EPO-MA (-14w-1w)). It was then examined, whether there was a relationship between the erythropoietin moving averages and red blood cell values in 110 chronic hemodialysis patients. The curves of the clinical course of both EPO-MA (-14w-1w) and the hematocrit values revealed an extremely similar pattern. In 65 of 110 cases, a significant positive correlation was noted between EPO-MA (-14w-1w) and the hematocrit level. In 30 of 45 cases showing no significant positive correlation, the erythropoietin dose could be decreased after iron administration, and the changes in both EPO-MA (-14w-1w) and the hematocrit value showed similar clinical patterns, although no significant correlation could be found. We examined the appropriate period for calculating the moving average of weekly erythropoietin doses. Calculation in the period between 14 weeks and one week before blood sampling revealed the highest correlation coefficient. It was confermed that this period was appropriate for calculating the moving average deviation. The main cause of hematocrit variation may be the change of erythropoietin dosage. This variability could be reduced if the current dosage were changed with reference to the erythropoietin dosage 14 weeks previously.

View full abstract

We measured skin perfusion pressure (SPP) in the treatment of leg ulcer of diabetic dialysis patients. We analyzed whether the original wound site was healing properly. The subjects were 64 diabetic dialysis patients with a total of 128 legs whose SPP values were measured between August 2005 and October 2007. These subjects were divided into two groups with ulcer and without ulcer and comparisons were made. The mean SPP values were 38.9±18.7 mmHg and 51.7±19.8 mmHg (p=0.000336) for the ulcer and non-ulcer group, respectively. Leg ulcers in diabetic dialysis patients were difficult to treat. We found that healing occurred in only 7 patients during the term of observation and their mean SPP values were 49.2±20.4 mmHg. SPP is easy to measure and has low invasiveness and might be useful to judge the state of healing and prognosis in critically ischemic limbs. However, it is necessary to use this approach in combination with CT (MDCT) or angiography.

View full abstract

Pruritus is one of the most bothersome symptoms in chronic hemodialysis patients. Itchy skin may have significant negative effects on quality of life (QOL) in these patients. This study evaluated the efficacy of fexofenadine hydrochloride on pruritus in hemodialysis patients. In this prospective, open-label study, adult hemodialysis patients with pruritus (visual analogue scale (VAS) score ≥ 40) were treated with fexofenadine hydrochloride (60 mg bid) for 8 weeks. A total of 80 adult patients were enrolled. The intensity of pruritus was assessed by VAS and a specially adapted questionnaire scoring method. QOL was assessed by Skindex 29. In addition, sleep disturbance and daytime sleepiness were also assessed. After a 2-week treatment with fexofenadine hydrochloride, the intensity of pruritus including distribution of pruritus and frequency of itching was significantly improved (p<0.001) and continued to improve until the end of the study. All parameters of QOL, sleep disturbance and daytime sleepiness were also significantly improved by treatment with fexofenadine hydrochloride (p<0.001). There were no serious adverse effects during this study. In conclusion, pruritus, QOL, sleep disturbance and daytime sleepiness in hemodialysis patients were significantly improved after only 2 weeks of treatment with fexofenadine hydrochloride and continued to improve until the end of study. This study indicates that fexofenadine hydrochloride is effective for the treatment of pruritus in chronic hemodialysis patients.

View full abstract

We report three neonates treated with continuous hemodialysis. The first case was a 5-day-old infant who demonstrated hyperammonemia due to a urea cycle disorder. After treatment with continuous hemodialysis (CHD) for 48 hours, he recovered from hyperammonemia and was able to be removed from HD. The second case was a 3-day-old infant with transient hyperammonemia. He was treated with CHD for 40 hours and was then removed from HD. The third case involved severe neonatal asphyxia. Although he was effectively treated with CHD for 9 days, he was not able to survive. In the future, as the survival rate of neonates improves, it is expected that the number of infants treated with hemodialysis, as in our three cases, will increase. It is necessary that safer and more effective hemodialysis become an established therapy.

View full abstract

A 62-year-old woman on hemodialysis with more than 30 years was admitted to our hospital with complaints of high fever, general malaise, pleural effusion and infected decubitus of the buttocks. She had a history of pyelonephritis (24 years of age) and inflammation of the hip and knee joints (40 years of age). One year prior to the admission, she developed renal cell carcinoma (RCC) on the right side. The right kidney was surgically extracted, but 1 year later the dissemination of RCC to the lung and bones was found. For the last decade, she had shown a good response to erythropoietin stimulating agent (ESA), maintaining Hb levels around 11-12 g/dL. However, about one year prior to the admission, she developed ESA-resistant anemia, which required frequent red blood cell transfusions. The diagnosis of lymphoproliferative disorder of granulocytes (LPDG) was based upon the diagnostic criteria for LPDG. The characteristic finding is the presence of increased numbers of lympho-granulocytes, which were rarely identified in the peripheral blood smear in our present case because of leucopenia. On bone marrow biopsy, scattered lymphoid aggregates with CD3-positive cells were determined by immune-histochemistry. Flow cytometric analysis of the bone marrow displayed clonally expanded lymphocytes with a CD3+, CD8+, CD16+, CD56- phenotype. The analysis of T-cell receptor gene rearrangement showed beta and/or gamma chain gene rearrangement using PCR techniques. According to these findings, the diagnosis of T-cell type LPDG based on the WHO classification was reconfirmed. Despite treatment with cyclosporine for LPDG, antibiotics for the infection and pleural drainage and snitinib for RCC, the patients developed septicemia and died a few months after the admission. This case suggests that despite its rarity LPDG and concurrent disorders might be found in patients on long-term dialysis, and that an early awareness of this clinical entity is crucial not only for hematologists but for also for nephrologists and general practitioners specialized in renal replacement therapy in order to help patients on dialysis live longer.

View full abstract

A 63-year-old woman demonstrated subclavian steal syndrome. She had been diagnosed with radio-cephalic AVF (RCAVF) 13 years earlier. MRA and cerebral angiogram demonstrated retro-grade filling of the left vertebral artery. SPECT demonstrated lowered blood supply of the left cereberal area that disappeared following administration of Diamox. Doppler examination demonstrated retrograde flow of the left vertebral artery. With simple manual compression of the AVF anastomosis of the left wrist, Doppler wave form changed from a retrograde to a normal antegrade form. Estimation of the left brachial arterial flow by Doppler examination was 3.5 L/min. We concluded that SSS of this case caused by lowered subclavian arterial pressure and high blood flow speed derived from high flow RCAVF. Vertibrobasilar insufficiency symptoms disappeared after closure of RCAVF.

View full abstract

Fournier's gangrene is a fulminant necrotizing fasciitis of the perineal area, known to have a poor prognosis without early diagnosis and treatment. We report our experience with two maintenance hemodialysis patients who survived Fournier's gangrene. Case 1 was a 73-year-old man. He had an 8-year history of dialysis with chronic glomerulonephritis as the underlying disease. In April 2007, he sought medical atlention when perianal abscess led to fever and enlarged scrotum. Bad odor and partial dermal gangrene accompanied enlarged scrotum and severe inflammatory reaction, and abdominal CT indicated abscess with subcutaneous air in the scrotum/buttocks area. Fournier's gangrene was diagnosed. On the day of presentation, the affected part was incised and drained, and systemic administration of MEPM was begun. The anaerobe Bacteroides fragilis was detected on bacterial culture. Extensive debridement including removal of the right testicle was conducted, and the injured area cleaned daily. He was discharged 60 days post operatively. Case 2 was a 75-year-old man. He had a 5-month history of dialysis with diabetic nephropathy as the underlying disease. In August 2007, urethral injury from the urethral catheter led to fever and enlarged scrotum. There was severe inflammatory reaction, abdominal CT demonstrated abscess with air in the penis and scrotum, and Fournier's gangrene was diagnosed. On the day of presentation, extensive debridement including removal of the left testicle and cystostomy were performed, and systemic administration of MEPM was initiated. The anaerobe Bacteroides fragilis was detected in bacterial culture of the affected part. Both cases were hemodialysis patients, and their underlying condition probably weakened their resistance (host factors : reduced defense against infection, reduced nutritional state, advanced age, diabetes). When fever and sudden redness and swelling in the perineal area occur in such patients, this disorder must be included in the differential diagnosis and an immediate response must be made.

View full abstract

A 69-year-old female developed fever following each hemodialysis session after admission for esophageal cancer surgery. We determined that both the original and generic versions of nafamostat mesilate (NM) was the cause of these reactions. On a detailed examination of her symptoms, the allergic response to NM apparently differed between the original and generic NM. In the case of generic NM, the appearance of fever occurred sooner after the start of hemodialysis using NM and finally hypotension developed. When original NM was administered instead of the generic form, fever appeared several hours after the hemodialysis session and there was no anaphylactic reaction. We studied the mechanisms of response, which apparently differed between the original and generic NM. DLST was positive for generic NM examined 116 days after the start of administration while it was negative for the original NM at 128 days and negative for both at later dates. IgE antibody against NM was negative for original NM but IgG antibody was positive. Due to technical problems with generic NM, IgE and IgG antibodies could not be measured. In conclusion, NM turned out to be the cause of adverse reaction in hemodialysis in this case and IgG antibody was apparently involved in the reaction to the original NM. However, it was not clarified whether the anaphylaxic reaction seen with generic NM was mediated by IgE. This case was the first report in which both of original and generic version of NM caused allergic reaction with differing responses. We would also postulate that it might be important to set up the system to detect IgE and IgG antibodies to the generic version to understand differences in adverse reactions between the original and generic NM.

View full abstract