【Purpose】 Hemodialysis patients with diabetic nephropathy often have functional dyspepsia (FD) due to gastrointestinal dysfunction. Recently, Rikkunshito, a kampo preparation, was reported to be useful for FD. In this study, we aimed to examine the clinical effects of Rikkunshito on hemodialysis patients with diabetic nephropathy who had FD. 【Methods】 A total of 15 hemodialysis patients with diabetic nephropathy, whose symptoms of FD could not be improved by the administration of omeprazole (20 mg/day) for more than 6 months, were studied. The Gastrointestinal Symptom Rating Scale (GSRS) with the questions for FD and WHOQOL26 were used to assess the patients' gastrointestinal symptoms and everyday quality of life (QOL) before and 4 weeks after the administration of Rikkunshito. 【Results and Conclusions】 Not only the symptoms of FD, but also abdominal pain, acid reflux, disturbed digestion, diarrhea, and constipation were significantly improved in the GSRS evaluation. The psychological and general life scores were significantly improved on WHOQOL26 evaluation. Labolatory data showed a significant increase in total protein, and the cardiothoracic ratio was markedly reduced. These results suggest that the nutritional condition could be improved by Rikkunshito. Rikkunshito can be selected as a safe and efficient treatment for such functional gastrointestinal diseases as FD in hemodialysis patients with diabetic nephropathy.

View full abstract

A retrospective observational study was conducted to determine the relationship between the hemodialysis (HD) prescription/dose and patient mortality using data from the Japanese Society for Dialysis Therapy Renal Data Registry (JRDR). The 1-year mortality (up to the end of 2003) and 5-year mortality (up to the end of 2007) risks of thrice-weekly HD patients as of the end of 2002 were assessed by performing a logistic regression analysis of HD prescription and dose data, using a cause of death other than accident or suicide as the endpoint. The standard HD prescription (determined by average values) at the end of 2002 was as follows : dialysis time (DT), 239 min ; blood flow rate (Qb), 192 mL/min ; dialyzer membrane area (DMA), 1.55 m² ; and dialysis fluid flow (Qd), 486 mL/min. On average, the standardized HD dose of urea (Kt/V urea) was 1.32, and the nonexponential HD dose (Kt urea) was 40.7 L. The results of the prognostic analysis showed that when a DT of ≥240 and<270 min was regarded as the reference, the mortality risk was higher in the group of patients with a DT shorter than this, and tended to be lower in the patients with a longer DT. When a Qb of ≥200 and<220 mL/min was regarded as the reference, the mortality risk was higher in patients with a lower Qb and tended to be lower in the group of patients with a higher Qb. The mortality risk was higher in the group of patients with a DMA of<1.2 m², but there was no clear relationship between the mortality risk and DMA values other than 1.2 m². When a Kt/V urea of ≥1.4 and<1.6 or a Kt urea of ≥38.8 and<42.7 L was used as the reference, the group of patients with an HD dose smaller than this showed an increased mortality risk, and patients with a larger HD dose exhibited a decreased mortality risk. These results were favorable in patients receiving HD for 5 years or more at the time of the present study, who were assumed to have no residual renal function. These results suggest that the prognosis of thrice-weekly HD patients may be improved by increasing the HD dose through a longer DT and increased Qb.

View full abstract

Problems of vascular access in hemodialysis have existed for years, and still remain unresolved. The numbers of diabetic patients with renal failure are increasing as the population ages and develop arteriosclerosis and, as a result, the number of difficult cases are increasing. Hemasite, which was developed and first sold by Renal Systems (USA) around 1980, was introduced to Japan around 1983. From 1984 to 2005, my hospital used Hemasite in 43 cases. We analyzed the various complications of these cases to identify the cause of the complications, and found that the blood flow through the shunt tended to increase more than necessary and adversely affected both the venous and arterial walls to cause an increased cardiac workload, inducing more symptoms. I planned, designed, and made a trial device to control the blood flow on using Hemasite to prevent various complications without decreasing the effective blood hemostatic function of Hemasite, which uses silicon gum as a divider. I believe that the development of this new type of vascular access, which can be installed with a single surgical procedure and can be used for a long period, will contribute greatly to the field of artificial dialysis.

View full abstract

The PD catheter is usually inserted into the abdominal cavity using a stylet. The stylet is a stainless rod which is placed in the catheter lumen. The aim of using a stylet is to convey the catheter deep within the pelvic area, but there may be intra-operative complications such as visceral perforation, although the incidence is low. In Oji hospital, from November 2006 to March 2010, 119 consecutive operations to implant a PD catheter were carried out without a stylet. In 115 of the 119 operations, catheters were inserted to an appropriate position in the abdominal cavity. It took only a few seconds to complete catheter insertion. Four catheters could not be inserted to an appropriate position without a stylet, and these patients were obese with a thick abdominal wall. The insertion of a catheter without a stylet is known as non-stylet catheter insertion. Non-stylet insertion has some advantages in that it avoids visceral perforation. In recent years, the long PD catheter has gradually become popular, and intra-operative touch contamination of the long catheter using a long stylet must be reduced by non-stylet insertion. Since non-stylet insertion is an easy and safe skill, it could become a standard procedure to insert the PD catheter into the abdominal cavity.

View full abstract

[Objective] To examine factors associated with the development of vascular calcification of the thoracic aorta determined by three-dimensional computed tomography. [Methods] Computed tomography (Light Speed 16^® from General Electric Company) using contrast medium was performed in 46 hemodialysis patients (29 males and 17 females). The volume of the thoracic aorta, 10 cm caudal part from the bifurcation of the trachea, and the volume of the vascular calcification were determined using the software, Advantage Workstation 4.2^®. Calcification index (CS) was defined as the ratio of the volume of the vascular calcification to the volume of the thoracic aorta. The association of annual changes in CS (ΔCS) with multiple factors was examined. [Results] ΔCS showed positive correlation with the product of average corrected serum calcium (Ca) and phosphorus (P) for one year, Whole PTH, maximal thickness of the intima-media complex of the carotid artery (Max IMT), pulse-wave velocity, and age. Stepwise multiple regression analysis disclosed that ΔCS was predictable from Whole PTH, Max IMT, and Ca • P product. ΔCS did not correlate with average serum Ca, P, undercarboxylated osteocalcin (ucOC), osteocalcin (OC), ucOC/OC, pentosidine, LDL cholesterol, average systolic blood pressure for one year, radial cortical bone density, or dialysis duration. ΔCS was not significantly different between males and females, diabetics and non-diabetics, smokers and non-smokers, patients with and without vitamin D injection, or patients with and without cinacalcet hydrochloride. [Conclusion] Our data suggest that the important factors associated with development of vascular calcification are Ca • P product, PTH, and Max IMT.

View full abstract

As highly active antiretroviral therapy (HAART) has improved the longevity of human immunodeficiency virus (HIV) -infected patients, chronic kidney disease (CKD) and end-stage renal disease (ESRD) have emerged as significant comorbidities in such patients. This study investigated the clinical characteristics of HIV-infected patients who developed CKD, resulting in ESRD. Using electronic medical records, we retrospectively studied 10 ESRD patients with HIV-infection at Tokyo Metropolitan Komagome Hospital, in August 2009. Clinical characteristics, duration from HAART initiation to dialysis, parameters for HIV infection control, comorbidities and exposure to nephrotoxic drugs including antiretroviral drugs were studied. All individuals were Japanese males receiving HAART, and the mean patient age was 50.7±9.1 years. CD4⁺ T cell count and HIV RNA level at the initiation of dialysis were 340±185 cells/μL and less than 50 copies/mL, respectively. The serum creatinine level was 6.6±1.6 mg/dL and estimated glomerular filtration rate was 8.7±2.6 mL/min/1.73 m². Mean period from the HAART initiation to ESRD was 8.1±2.9 years in overall patients. Patients who had preexisting CKD at the time of HAART initiation reached ESRD 4 years earlier than those who did not have preexisting CKD. Two patients died a few months and about 3 years after the initiation of dialysis, respectively. Before HAART initiation, the prevalence of diabetes, hypertension and hyperlipidemia was 50%, 30% and 10% among ESRD patients, respectively. Number of patients with hypertension and hyperlipidemia were 2-fold or more increased after HAART initiation. None of the patients showed exposure to tenofovir disoproxil fumarate, and 2 patients had exposure to indinavir. Exposure to other nephrotoxic drugs such as trimethoprim-sulfamethoxazole and nonsteroidal anti-inflammatory drugs were found in 4 and 3 patients, respectively. Half of the ESRD patients with HIV infection had diabetes before HAART initiation. The mean time to reach ESRD after HAART initiation was approximately 8 years. None of the ESRD patients had any exposure to Tenofovir disoproxil fumarate (TDF). Preexisting hypertension and metabolic diseases, and further deterioration of such comorbidities after the HAART initiation could be involved.

View full abstract

Three ADPKD patients in our facility experienced complications due to elevation of the intra-abdominal pressure during peritoneal dialysis. One suffered from left hydrocele and acute right hydrothorax, another from peri-catheter leakage and acute right hydrothorax, and the third from umbilical hernia which caused peritonitis. All of them decided to discontinue the peritoneal dialysis. Peritoneal dialysis for ADPKD patients is controversial, but we introduced it to preserve their ADL, residual renal function, and avoid the need for a strict diet, and we expected their satisfaction with treatment. The result was the complications above, and so we searched for an index to determine the appropriateness of peritoneal dialysis, as no effective index is available. We thought that CT scan would be a favorable modality to select candidates for peritoneal dialysis in ADPKD patients. We calculated the volumes of the intra-abdominal space and kidneys in the three ADPKD patients and other patients who had undergone peritoneal dialysis for other reasons. These three cases had common characteristics : they had huge cystic kidneys, and the volumetric ratios of their kidneys to intra-abdominal spaces were markedly high compared with others. The above complications might have been predictable considering the potential fragility of the membrane or abdominal wall in ADPKD patients due to their abnormal collagen metabolism. We suggest that the volumetric ratio of the kidneys to the intra-abdominal space can be a good objective index when we consider peritoneal dialysis for ADPKD patients or think we should perform such dialysis. Unfortunately, we could report only a few cases, and so we should accumulate more cases and investigate them, facilitating a comparative study of ADPKD patients.

View full abstract

A 73-year-old man with end-stage renal disease undergoing hemodialysis treatment visited our emergency room because of fever and a sore throat. He had a history of encapsulating peritoneal sclerosis, for which he received corticosteroid treatment, and had cardiac disease. A rapid detection test for influenza virus showed a positive result for A antigen, and so acetoaminophen and oseltamivir were administered. The patient was admitted the next day because of dyspnea, persistant fever, and anorexia. He was febrile, with pulse oxygen saturation of 78% in room air. Computed tomography of the chest showed bilateral multifocal consolidation involving all lobes and bilateral pleural effusion. He was treated with zanamivir, prednisone, and emergent hemodialysis. Subsequently, respiratory failure improved and the abnormal lung shadows disappeared after 5 days. Novel A/H1N1 viral RNA was detected in the patient's sputum specimen using the real-time reverse transcriptase-polymerase chain reaction. Novel influenza infections in dialysis patients have included lower repiratory disease, resulting in respiratory failure. Clinicians should be aware that severe novel A/H1N1 influenza infection can occur in hemodialysis patients with high-risk factors.

View full abstract

A 47-year-old man consulted a general practitioner because of a 1-month history of general edema and shortness of breath. Following the diagnosis of renal dysfunction (serum creatinine, 3.33 mg/dL), he was admitted to our hospital, in September 2008. On admission, marked proteinuria with hematuria, associated with further deterioration of the renal function, was observed. A renal biopsy was performed under the diagnosis of rapid progressive glomerulonephritis with nephrotic syndrome. The renal biopsy specimen contained 25 glomeruli, of which 23 had cellular or fibrocellular crescents. An immunofluorescence study showed the linear deposition of IgG along the capillary walls. Anti-glomerular basement membrane (GBM) antibody was positive (57 EU), and both MPO- and PR3-ANCA were negative. Taken together, the patient was diagnosed with anti-GBM glomerulonephritis. In addition to steroid therapy, including methylprednisolone pulse therapy, plasma exchange was commenced on hospital day 15. Two days after the first plasma exchange (on hospital day 17), the patient experienced a sudden generalized seizure, and continued loss of consciousness. Magnetic resonance imaging (MRI) showed multiple lesions in the bilateral temporal lobes, occipital lobes, brainstem, thalamus, basal nuclei, and both cerebellar hemispheres, which were hypo- and hyperintense on T1- and T2-weighted images, respectively. These findings were considered to be associated with anti-GBM disease. In addition to steroid therapy and daily plasma exchange, an anticonvulsant was administered and one course of cyclophosphamide pulse therapy was performed. Seven days after the onset of the generalized seizure (on hospital day 24), the consciousness level of the patient improved, and no further seizures occurred. Follow-up MRI revealed resolution of the multiple lesions. Although hemodialysis was introduced for the patient, convulsions have not occurred thus far without the administration of an anticonvulsant. We diagnosed the present case with reversible posterior leukoencephalopathy syndrome (RPLS) judging from the findings of images and clinical course. However, we could not deny the possibility of central nervous system vasculitis directly associated with anti-GBM antibody. This is because several cases of ANCA-negative Goodpasture's syndrome have all been diagnosed with anti-GBM antibody-associated central nervous system vasculitis. This is a rare case report of ANCA-negative anti-GBM glomerulonephritis showing central nervous system involvement.

View full abstract