The prevalence of novel influenza A (H1N1) and vaccination status in hemodialysis facilities were surveyed in the Tokyo Tama area. Using the network for disaster of the Santama Associations of Kidney Disease Physicians, novel influenza A (H1N1) infections among dialysis patients and staff of dialysis facilities were reported monthly between 1 October 2009 and 31 March 2010, and vaccinated subjects among dialysis patients and staff were also reported between 1 November 2009 and 31 March 2010. Seventy-six of 93 corresponding facilities participated in this survey. Prevalence of novel influenza A (H1N1) among dialysis patients and dialysis staff decreased gradually between October 2009 and March 2010. In 6 months, 70 dialysis patients and 25 dialysis staff were reported as having novel influenza A (H1N1) infection. The prevalence of influenza A (H1N1) among dialysis patients and dialysis staff was 1.58% and 2.59%, respectively. Only one dialysis patient required mechanical ventilation, but he eventually recovered. There were no deaths associated with novel influenza A (H1N1) among dialysis patients in this area. Dialysis patients aged 65 and over comprised 34.3% of infected cases. The positivity rates found using an influenza rapid diagnosis kit were 40% among dialysis patients and 60% among staff. Overall prevalence of novel influenza A (H1N1) in the general population was reported to be one-sixth in Japan. Our data on the prevalence in dialysis facilities were much lower than the estimates in the general population. This is mainly explained by the higher age composition of our subjects, especially among dialysis patients. In conclusion, the survey of novel influenza A (H1N1) and information sharing are useful for regional infection control at dialysis facilities.

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The characteristics of a newly developed bicarbonate dialysate acidified with citric acid were studied. Carbostar _® L (CL) (Ajinomoto Pharma, Tokyo) was compared with conventional bicarbonate dialysates acidified with acetic acid:Kindary^® AF2 (K2), AF3 (K3) (Fuso Pharma, Osaka). After dilution of CL, K2 and K3 at the regular mixing ratio, changes in the concentrations of total calcium (tCa) and ionized Ca (iCa), and also of the pH and pCO₂, were measured under a sealed condition after 0, 2, 4, 19, 24 and 48 hours. The size and number of Ca precipitates were measured simultaneously under a polarizing microscope. SUS316 steel and fluoro rubber were immersed in concentrate A solutions of CL and K2 for 4 months, then the Fe, Cr, Ni and Mn levels eluted into the solution were measured, along with tensile strength testing and surface scanning of fluoro rubber under an electron microscope. The levels of glucose degradation products (3-deoxyglucoson ; 3-DG, 5-hydroxymethylflufural ; 5-HMF and levulinic acid) were measured in CL, K3 following 6 months storage under high-temperature conditions (40℃ and 50℃). The tCa level was significantly higher in K3 than in CL or K2, and the iCa level was significantly lower in CL than in K2 or K3. There were significant differences in the ratio of iCa/tCa among CL (0.64±0.09), K2 (0.84±0.05) and K3 (0.91±0.06). The size of Ca precipitates was larger in CL than in K2 and K3, but there were no differences in the number of precipitates among CL, K2 and K3. There were no significant differences in the level of eluting metals, the tensile strength or surface scanning findings of fluoro rubber among CL, K2 and K3. The level of 3-DG was significantly higher in K3 than in CL. The level of 5-HMF was significantly higher in CL than in K3, suggesting accelerated degradation of glucose in CL. In conclusion, there may not be any problem of deterioration of machine materials associated with the clinical use of citrate dialysate. However, careful observation to detect a low iCa level and accelerated degradation of glucose may be necessary.

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We developed a new optical device (Nikkiso Co., Ltd.) to assess changes through blood volume monitoring (BVM) during hemodialysis and were able to determine the ideal levels when changes in blood volume (BV%) occur in hemodialysis patients. We evaluated the significance of BVM for setting the post-dialytic body weight in a multicenter group. Previously, we obtained the ideal level of BV% in patients whose dry weight was suitable. Upper limit line : BV%/BW%end=-0.437t-0.005. Lower limit line : BV%/BW%end=-0.245ln(t)-0.645t-0.810. When BV% is within this range, we can consider the dry weight suitable. BV was monitored three times in each patient. Of 430 measurements obtained from 144 hemodialysis patients from nine hemodialysis centers, 94 measurements were excluded because they were outside the protocol. A total of 230 of 336 measurements were obtained from patients whose dry weights were considered suitable under the criteria established by each center. For 167 measurements (72.6%), post-dialytic body weight was also considered suitable by BVM. The causes of inconsistencies between findings on BVM and clinical evaluation were blood access recirculation, positional changes during monitoring, and body weight gain of less than 1.0kg. There was a consistent ratio of 71.6% between the evaluation by BVM and that by PWI (plasma weight index : index of the ratio of circulating plasma volume change per body weight change). There was a consistent ratio of 68.8% between the evaluation by BVM and that by hANP (25≤ANP≤75 (pg/mL). We conclude that BVM is a useful index for setting post-dialytic body weight in clinical practice, and the greatest benefit is that BVM facilitates the visualization of blood volume changes in real time.

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It would be clinically useful to be able to estimate bicarbonate concentration (BC) from standard blood biochemical values in hemodialysis patients, because at present bicarbonate concentration is usually measured by blood gas analysis. The formula for estimating bicarbonate concentration was determined from blood gas analyses and blood biochemical values using samples obtained from 83 hemodialysis patients. Because anion gap (AG) is well correlated with serum inorganic phosphorus concentration (IP), we were able to estimate anion gap with the formula IP (AG=7.33+IP×0.99). We transformed the formula of anion gap (AG=Na-Cl-BC) and were able to derive the formula of estimated bicarbonate concentration (BC=Na-Cl-IP×0.99-7.33). We further simplified the formula to ‘estimated BC=Na-Cl-P-7’ for ease of use at the bedside. Results from this ‘estimated BC’ formula correlated well with bicarbonate concentration values determined by gas analysis (r=0.76). The present study indicates that hyperphosphatemia is an important factor in metabolic acidosis related to increased anion gap and is associated with other unmeasured fixed acids in hemodialysis patients.

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Purposes : To clarify longitudinal mobility-associated ADL changes essential for chronic dialysis patients to continue life at home, based on interim assessment scores in surveys for long-term care need certification, and identify services necessary for continuing life at home. Methods : In this study, subjects consisted of 234 dialysis patients (dialysis group) and 765 non-dialysis patients (non-dialysis group), all of whom were certificated as patients needing long-term care in Niigata City between April 2003 and the end of March 2009. Those using long-term care insurance for at least 4 years were selected. For each subject, results of the most recent certification survey were designated as the fourth results, and those from previous annual surveys were retrospectively designated as third, second, and first results. Then, two-way analysis of variance (ANOVA) was performed using the mean score for each survey in Groups 2 to 5 of the interim assessment items as dependent variables, and the number of times the survey was performed and presence/absence of dialysis as independent variables. Results : There were 24 subjects aged≤69, 44 in their 70s, and 53 aged≥80 in the dialysis group, and 15 aged≤69, 86 in their 70s, and 234 aged≥80 in the non-dialysis group. ANOVA indicated that there was no interaction between the number of times the survey was performed and the presence/absence of dialysis. The dialysis arm showed significantly lower interim assessment scores among women aged≤69 in Group2 (p<0.05), and significantly higher scores among women aged≥80 in Group4 (p<0.01), women in their 70s in Group5 (p<0.05), and men (p<0.05) and women (p<0.001) aged≥80 in Group5. Discussion : The necessity of providing assistance for hospital visits and preventing the development of a conditions requiring care were suggested in order to counteract declining ADL associated with mobility problems.

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The dialysate calcium concentration in hemodialysis has varied with the era of treatment. Recently, Vitamin D and a Ca-containing phosphorus absorbent have frequently been used, and a dialysate calcium concentration of 2.5mEq/L is common. In our hospital, we has used a dialysate calcium concentration of 3.0mEq/L starting in August 2003, and then changed to 2.5mEq/L in September 2008. We analyzed the short-term effects of the change in the dialysate calcium concentration on calcium-phosphorus metabolism in hemodialysis patients. As of September 2008, 81 patients were receiving hemodialysis at our hospital. Those who had undergone hemodialysis for less than 6 months, those whose dialysate calcium concentration was unchanged and those for whom drugs related to calcium-phosphorus metabolism had been changed were excluded. Finally, 52 cases were included in this analysis. We analyzed shifts in serum calcium concentration, serum phosphorus concentration, calcium-phosphorus product and intact PTH after changing the dialysate. Additionally, the change in the rate of achievement of the target levels of serum calcium and phosphorus concentrations in the guideline of the Japanese Society for Dialysis Therapy was analyzed. Eight or more weeks after changing the dialysate, we allowed changes in drugs related to calcium-phosphorus metabolism. After changing the dialysate, serum calcium was decreased, and intact PTH, serum phosphorus and calcium-phosphorus products were significanly increased. As a result, the rate of achieving the target levels of serum calcium and phosphorus concentrations was decreased. However, with changes in drugs, these parameters significantly improved and the achievement rate also improved. Though the dialysate calcium concentration was changed, we could approach target levels of serum calcium and phosphorus by prescribing various agents to manage calcium-phosphorus metabolism.

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We encountered an 88-year-old male hemodialysis patient taking an oral α-glucosidase inhibitor (α-GI) who developed pneumatosis cystoides intestinalis (PCI) accompanied by intra-abdominal free air. In July 2008, the patient was placed on dialysis due to chronic renal failure derived from diabetic nephropathy. During this time, the use of insulin was discontinued and the patient began taking α-GI orally. Around late November 2008, the patient began to notice a bloating sensation in his abdomen, and was admitted to hospital on November 30 after an abdominal CT scan demonstrated the presence of intra-abdominal free air. Since there were no peritoneal symptoms, the patient was only restricted from oral intake and placed under observation. However, this did not yield any improvement in the bloating sensation in the patient's abdomen. On December 4, exploratory laparotomy was performed but there was no perforation of the digestive tract dected. However, PCI was found on the side of the ileal mesentery approximately 70cm to 150cm from the terminal ileum. Although the cause of PCI in this patient has yet to be resolved, reports of PCI caused by α-GI have recently been encountered on occasion. It was concluded that α-GI may have contributed to PCI in this case as well.

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Fabry disease is an X-linked inherited lysosomal storage disease caused by deficiency of α-galactosidase A (AGA). Enzyme-replacement therapy (ERT) has been used to treat Fabry disease. Two preparations of α-galactosidase A, agalsidase α (Replagal^®) and agalsidase β (Fabrazyme^®), are available. Agalsidase β can be administered during hemodialysis without any decrease in efficacy, but there are no data on the efficacy of agalsidase α administration during hemodialysis. We investigated the pharmacokinetics of an agalsidase α preparation by assessing the AGA activity in the plasma. [Case] The patient was a 46-year-old man who showed cerebral infarction and was diagnosed with Fabry disease at the age of 26 years. His renal function diminished, and hemodialysis was started in August 2006. In November 2006, ERT with agalsidase β was initiated ; however, because of an infusion reaction, the therapeutic agent was changed to agalsidase α in April 2007. We measured AGA activity in plasma when the patient was receiving agalsidase α intravenously ; these assessments were serially performed during hemodialysis and again during the interval between dialysis sessions. There was no difference between AGA activity during hemodialysis and that during the interval between sessions. [Discussion] There was no reduction in the agalsidase α activity in the patient's plasma during hemodialysis. The 2 preparations showed equal efficacy as ERT for hemodialysis patients with Fabry disease. The clinical course of our case demonstrated the importance of continuing ERT in patients undergoing hemodialysis.

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A 54-year-old woman with IgA nephropathy underwent peritoneal dialysis (PD) from 1991. She then received PD and hemodialysis (HD) concomitantly from 2000 to 2006. PD catheter removal was performed in June 2007. Since ascites was found after catheter removal, we suspected encapsulating peritoneal sclerosis (EPS) and administered steroids. However, there was no response. In February 2008, she was referred to our hospital because of acute abdominal pain and hypotension. Massive abdominal ascites was observed on abdominal CT and gelatinous material was aspirated. Since multilocular cysts in the left ovary were observed on abdominal MRI, we suspected ruptured mucinous ovarian tumor. At surgery, multilocular cyst in left ovary, gelatinous ascites filling the abdominal cavity and multiple diverticulum with abscess in the ascending colon were found. According to pathological diagnosis, the patient was diagnosed as having mucinous adenoma with borderline malignancy in the left ovary with pseudomyxoma peritonei. Therefore, ascites after PD catheter removal should be examined as peritoneal effluent to determine the cause, such as overhydration, EPS or peritonitis including pseudomyxoma peritonei, which is a rare complication in female patients.

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