Patients under hemodialysis treatment (HD patient) have an acquired immunodeficiency and are associated with susceptibility to infection and high mortality, although the precise mechanisms underlying the susceptibility of HD patients to infection remain unknown. Our recent studies support the concept that E-CR1 plays a role in susceptibility to infection in HD patients and we discuss the hypothesis in this review. E-CR1 is detected in erythrocytes and plays a role in host defenses as both a complement receptor and a complement suppressor. Immune complex (IC) reacts with complement in the blood, binds to E-CR1, and is transported to the liver and/or spleen where IC removal and degradation occurs. The production of erythropoietin (EPO) is suppressed in the HD patient, which causes anemia and decreases E-CR1. Recombinant EPO (rEPO) has been given to HD patients with anemia as a routine treatment that increases complement suppressors DAF and CD59. In contrast, the efficacy of rEPO treatment to correct low E-CR1 varies among patients. Host defenses might be compromised in HD patients whose E-CR1 expression remains low after rEPO treatment. E-CR1 expression is genetically regulated by two types of CRI allele (H and L), and E-CR1 expression in the HH type is higher than that in the LL type. In HD patients with anemia, decreased E-CR1 expression was demonstrated in both the HH and LL types. Patients with low E-CR1 develop severe complications with infection including arteriovenous fistula infection and HCV infection being the most frequent complication. In 95 randomly selected HD patients, the percent survival at 5 years was significantly lower for patients with low E-CR1, compared to that of patients with high E-CR1. These studies suggest that E-CR1 plays an important role in host defense in HD patients. Insight into the mechanisms underlying the susceptibility of HD patients to infection will provide a scientific basis for identifying novel treatments for these patients.

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Outbreak of a new type (swine) of influenza is a major threat to dialysis patients and the staff of dialysis facilities. The first fatal case of this influenza was an Okinawa dialysis patient in August 2009. With this news, we started a weekly survey of every new case of influenza in both patients and staff throughout the islands. Information was obtained by sending questionnaire through the dialysis network in Okinawa and by telephone interview, if necessary. All dialysis facilities (N=73) cooperated. Data suggested that the prevalence and incidence were lower among dialysis patients (2.5%) than among dialysis staff (6.2%). Preventive strategies, such as increased personal hygiene, although not specific, to this virus, are currently being practiced. At present, we give one tablet of Oseltamivir (Tamiful) to patients complaining of fever, suggesting influenza unless proven otherwise. General supportive care is of utmost importance, as malnutrition is the strongest predictor of poor survival among dialysis patients. Vaccine against swine influenza is still not available in Japan. Our survey efforts may provide some epidemiological basis for a better understanding of the “new type of influenza” in high risk populations.

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[Objective] To clarify the pharmacokinetic profile of prulifloxacin (PUFX) in patients undergoing hemodialysis (HD). [Methods] The plasma concentration of ulifloxacin (UFX), the active metabolite of PUFX, was measured in 8 HD patients after single or multiple once-daily oral administration of prulifloxacin (264.2mg). HD was performed with a blood flow of 180~290mL/min from 2 to 6h after dosing following a single administration and on alternate days for patients receiving successive administrations. [Results] In single administration, the biological half life in blood and the area under the curve for UFX were 15.4±4.5hr and 12.9±6.7μg•hr/mL, respectively. In daily administration, the plasma concentration of UFX on day3 was higher than that on day1 pre HD and post HD, but there was no significant difference (pre HD, p=0.2180 ; post HD, p=0.1635). There were no apparent side effects during the study period. [Conclusion] The pharmacokinetic profile of PUFX suggested that the appropriate dosage of PUFX was 132.1mg once a day and the HD procedure was performed from 4 to 6hr after administration of PUFX in HD patients.

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We report a new simple buttonhole (BH) method based on a combination of Twardowski's method with Toma's method. Our previous BH method can be performed by repeated cannulation with a standard sharp needle at the same site and in the same direction by the same medical staff. Thus, the limitation of this method is that it requires the medical staff to perform needling until the establishment of a fixed route, and it also carries a risk of expansion of the hole. Recently, we developed a new method using a dull needle for repeated cannulation after the primary single needling with sharp needle, and we simultaneously evaluated the usefulness and safety of this new method. We enrolled nine HD outpatients who were clinically stable and underwent dialysis three times a week, excluding those with an unfixed puncture route or has past history of blood access infection. After written informed consent was obtained, eight patients (male/female : 2/6, age : 64.3±8.5 years, primary disease : CGN 5, DM 2, NS 1) were enrolled. Seven patients felt less puncture pain and one patient had a shorter hemostatic time after withdrawal of needle. We used a sharp needle at the first cannulation and then tried to insert dull one into the same hole thereafter. Seven patients (87.5%) could undergo insertion of the dull needle after the initial puncture by a sharp needle, however, one patient could not. In the seven successful patients, there was neither blood access infection nor drop-out due to other complications. Dialysis could be performed using the BH for about three months. We compared the pain of cannulation with a sharp needle before making the BH with insertion by dull needle thirty days after making the BH. The pain on insertion became less in six cases (85.7%), while one patient did not feel any pain. The VAS score decreased from 46.7±22.5 (10～70) to 25±13.9 (0～40). However, there was no significant difference. Hemostatic time shortened from twenty to ten minutes in a patient in whom hemostatic time was observed after withdrawal of needle. We developed a new BH method using a dull needle after primary single puncture with a sharp needle. This method can resolve several issues associated with the conventional BH method ; expansion of BH, cost of BH creation and maintaining the same needling staff for each patient. We conclude that this method is more useful and safer than the conventional method, and recommend spreading the use of this technique among patients receiving dialysis.

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A 34-year-old male was started on peritoneal dialysis (PD) for end-stage renal disease due to non-IgA mesangial proliferative glomerulonephritis in March 2006. Idiopathic anemia had previously been diagnosed in 1990. Because severe anemia required frequent red blood cell transfusions, he was hospitalized for further examination in August 2006. Based on bone marrow findings, he was diagnosed as having myelodysplastic syndrome classified as refractory anemia (RA). Administration of anabolic steroids was started and we switched him from PD alone to combined therapy with PD and hemodialysis (HD) in order to achieve more adequate clearance with a higher dosage of ESA at HD sessions. However his hemoglobin concentration did not rise, so we changed the ESA from epoetin beta to darbepoetin alfa, the dosage of which was gradually increased to 180μg administered intravenously weekly. This resulted in reducing the frequency of transfusions and improving anemia. High-dose darbepoetin treatment may be effective for management of low- risk MDS. We expect that ESA will be widely available not only for chronic kidney disease (CKD) patients but also for MDS patients in the future.

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We describe a case of collagenous colitis on maintenance hemodialysis. An 83-year-old Japanese woman suddenly developed watery diarrhea five to six times per day. She had been receiving hemodialysis three times a week for 3 months. The cause of chronic renal failure was unknown. She had been taking lansoprazole for 3 months. By repeated testing for other causes of diarrhea, e.g., infectious diarrhea including Clostridium difficile colitis were excluded. Colonoscopic examination of the transverse colon showed normal findings, but histological examination demonstrated subepithelial collagen bands, which is a characteristic feature of collagenous colitis. Lansoprazole was changed to ranitidine hydrochloride, but diarrhea persisted. After ranitidine hydrochloride was discontinued, diarrhea abruptly disappeared. Hypoalbuminemia and peripheral edema slowly improved thereafter. There has not been any previous report of hemodialysis patients with collagenous colitis. Since collagenous colitis was first described in 1976 and only recently recognized as a common cause of diarrhea, many physicians may not yet be aware of this entity. Physicians should consider collagenous colitis as a possible cause in patients with chronic diarrhea.

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We report a case of acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise (ALPE) in a patient with hypouricemia and mutation in the gene encoding uric acid transporter 1 (URAT1). The patient was a 23-year-old man who experienced general malaise, severe nausea and vomiting on July 23, 2008, several hours after participating in a 200-m dash at a neighborhood athletic meeting. He consulted a local doctor, and a drip infusion was administered, but his symptoms did not improve. He was admitted to our hospital the next day, with nausea, vomiting, and renal failure. The patient's serum urea nitrogen and creatinine levels were 23.2mg/dL and 2.4mg/dL, respectively. However, his serum uric acid level was 5.2mg/dL, that is within the normal range. His renal function rapidly deteriorated and hemodialysis was performed. Whole-body bone scintigrams with 99m technetium methylene diphosphonate (^99mTc-MDP) demonstrated multiple patchy increased accumulations of the isotope in the kidney. The patient completely recoverd 20 days after admission. Subsequently, his serum uric acid level decreased to a very low level of 1.1mg/dL. In contrast, the fractional excretion of uric acid (FEUA) was 56%. Therefore, we made a diagnosis of ALPE in a patient with hypouricemia. Genetic testing was performed for mutations in URAT1, and the results demonstrated that the patient was a compound heterozygote for W258X/R90H. A previous study reported that 10% of patients with mutation in the gene encoding URAT1 had a history of ALPE or urolithiasis ; moreover, hemodialysis was required in 21% of the patients with ALPE in that series. This is a rare case where hemodialysis was performed for a patient with mutation in the gene encoding URAT1. Whole-body bone scintigrams with ^99mTc-MDP may be useful in providing theoretical evidence suggesting ALPE.

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