It is considered fully possible to perform clean preparation of dialysis fluid for hemodialysis therapy, provided that the user follows the manufacturer's instructions for cleaning and disinfecting the dialysis fluid delivery system (DDS). However, bacterial contamination in dialysis fluid would be observed in many hemodialysis facilities. To evaluate the origin of bacterial contamination in the system, we prospectively observed under daily regular use of DDS in a facility since August 2004 for three years. We measured bacterial endotoxin activity in dialysis fluid twice a week. We also recorded all of events on the system (daily preparation of dialysis fluid, cleaning and disinfecting, breakdown and preventive maintenances), and whether the procedures were performed with or without hand hygiene. During the observation period, the relation of endotoxin activity and events on the system was analyzed. Cleaning and disinfecting of the system itself reduced endotoxin activity. However, the manufacturer's instructions for reducing the bio-burden were insufficient to avoid contamination of the system. Twenty-four of 110 breakdown and preventive maintenance procedures were performed after hand washing and wearing gloves through out all hours of operation, and the other 86 without hand hygiene. Endotoxin activity remained constant with adequate hand hygiene, but significantly increased from 0.0177±0.0153 to 0.0206±0.0208 EU/mL without hand hygiene (p=0.016). We concluded that avoiding contamination by performing appropriate hand hygiene technique is essential to minimize the bio-burden during hospital preparation of dialysis fluid.

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Protein-binding uremic toxins such as indoxyl sulfate (IS) and pentosidine (PEN) cannot be removed efficiently by hemodialysis (HD) and therefore, these toxins accumulate in HD patients. In the present study, removability of protein-binding uremic toxins was compared between cellulose triacetate dialyzer (FB-UH) and polysulphone dialyzer (APS-MD) in 14 HD patients. Patients were treated with FB-UH and APS-MD in a crossover manner under the same condition for three months each, and plasma levels of IS and PEN were measured at the end of each treatment. Although the removal rate of small molecular materials did not differ between the two dialyzers, β₂-microglobulin was removed more efficiently with FB-UH than with APS-MD. The removal rates of IS and PEN were greater with FB-UH (54±3% and 20±5%, respectively) than with APS-MD (34±3% and 11±4%, respectively). The leakage of albumin into dialysate effluent was also greater with FB-UH compared with APS-MD (2.6±1.2 g vs 1.3±0.2 g, p<0.05). Using FB-UH but not APS-MD, the removal rate of PEN was correlated with the leakage of albumin into dialysate effluent (r=0.56). In conclusion, FB-UH was superior to APS-MD with regard to removing protein-binding uremic toxins via greater leakage of albumin into dialysate effluent.

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Metabolic acidosis has been independently associated with increased risk of hospitalization and decreased life-expectancy in dialysis patients. The use of sevelamer hydrochloride (SH) with acetate dialysate has reportedly reduced plasma bicarbonate (HCO₃) levels. To investigate whether metabolic acidosis can be improved when SH is used with citrate dialysate, cross sectional studies were performed. In study 1,183 patients on hemodialysis in our clinic were divided into four groups ; group C : calcium carbonate was used, group C+S : calcium carbonate was used with SH, group S : SH was used, group N : no phosphate binder (P-binder). Then the relationship between P-binders and each parameter of metabolic acidosis was examined. Study 2 examined the relationship between daily SH use and each parameter of metabolic acidosis. Study 1 showed that the plasma HCO₃ level in group C and N satisfied the K/DOQI guidelines (≥22 mmol/L), but the levels (mean±SE) in group C+S (20.6±2.9 : p=0.003) and S (21.2±3.2 : p=0.02) decreased and were below the guidelines. The plasma level of potassium (K), chloride (Cl) and the anion-gap (AG) were significantly increased in group C+S (p<0.0001) and group S (p<0.0001), group S (p=0.028) and group C+S (p=0.023), respectively. Study 2 showed that daily SH use negatively correlated with pH (p=0.0004), HCO₃ (p<0.0001) and base excess (p<0.0001), and positively correlated with K (p<0.0001), Cl (p=0.0003) and AG (p=0.01). Increased daily SH use worsened metabolic acidosis despite the use of citrate dialysate. It is cautiously suggested that SH treatment of hyperphosphatemia causes acid loading. We look forward to the development of other P-binders that do not have negative effects on plasma HCO₃ levels.

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A 50-year-old man was admitted to our hospital with pyrexia of 38°C and dyspnea. Chest X-ray film showed infiltration of the right lower field, and the serum creatinine was 4.01 mg/dL. We suspected atypical pneumonia, and cefozopran (CZOP) and minocycline (MINO) therapy was started. Although his general condition improved, renal function gradually deteriorated without an increase creatine phosphokinase level. On the 2nd hospital day, hemodialysis was started to treat acute renal failure. Renal function was improved after two hemodialysis sessions. On the 5th hospital day, a urinary Legionella antigen test proved positive ; consequently, the antibiotic therapy was switched to ciprofloxacin (CPFX) and MINO. Finally, on the 12th hospital day, the patient was discharged from our hospital without renal dysfunction. Rhabdomyolysis is often seen in certain cases of Legionella pneumonia associated with acute renal failure. However, in the present case, the patient's creatine phosphokinase level was normal ; therefore, rhabdomyolysis was not the cause of the observed acute renal failure. We consider that endotoxemia, direct microbial toxicity, inflammatory cytokines, or NSAIDS could have caused this patient's acute renal failure.

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The efficiency of plasmapheresis (PP) has been demonstrated in patients with ANCA-associated vasculitis and has been reported by many authors. However, plasma exchange (PEX) causes sometimes allergic reaction and double filtration plasmapheresis (DFPP) also removes fibrinogen and IgG from plasma, possibly resulting in worsening pulmonary hemorrhage and severe infection. Case 1 : A 75-yr-old male with MPO-ANCA-associated vasculitis complicated with rapidly progressive glomerulonephritis (RPGN) and diffuse pulmonary hemorrhage. We promptly initiated PEX with intravenous methylprednisolone therapy. Case 2 : A 43-yr-old female with MPO-ANCA-associated vasculitis showed very rapidly aggravated renal function and was treated with DFPP and intravenous methylprednisolone therapy. The MPO-ANCA titers of the two patients dramatically decreased, and their symptoms including diffuse pulmonary hemorrhage and/or the renal function, were remarkably improved without serious complications following PP, although levels of both IgG and fibrinogen were temporarily extremely lower after DFPP. Our case report indicates the efficiency of PP together with immunosuppressive therapy for pulmonary bleeding and RPGN in patients with MPO-ANCA-associated vasculitis. It is necessary to determine weather PEX or DFPP is more available to treat this disease according to hemorrhagic diathesis including pulmonary hemorrhage and general condition.

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