Regarding restless legs syndrome (RLS), a clearly high prevalence has been reported of 4.8-32.2% in hemodialysis patients but it is reportedly only 5-10% in Europe and America and 2-5% in Japan in the general population. However, only a few epidemiological investigations of RLS involving hemodialysis patients in Japan have been reported. Pramipexole hydrochloride hydrate (Pramipexole) was authorized as an idiopathic RLS therapeutic drug in January 2010. We investigated the prevalence using the RLS diagnostic criteria in 103 hemodialysis patients (56 males and 47 females). Moreover, Pramipexole was administered to patients diagnosed with RLS, and the clinical effectiveness was examined. The International Restless Legs Syndrome Rating Scale (IRLS) and Visual Analogue Scale (VAS) were used for the judgment of effectiveness. Eighteen patients fulfilled all four diagnostic criteria for RLS among the 103 hemodialysis patients (prevalence: 17.5%). Those patients agreeing to take Pramipexole among these 18 patients numbered 9. The average IRLS score before and after Pramipexole initiation was 25±6.9 points before dosage, 18.3±9.1 points one week later, and 14.7±7.7 points one month later, and the average IRLS score after one month had decreased significantly compared with before Pramipexole initiation. The average VAS score was 68.8±12.2mm before dosage, 36±19.7mm one week later, and 28.3±24.5mm one month later, and the average VAS score showed a significant difference at one week after the start and then decreased. Improvements of IRLS and VAS scores occurred on taking Pramipexole time-dependently. Therefore, a high prevalence of RLS was shown in hemodialysis patients. It was suggested that Pramipexole is useful for RLS treatment in hemodialysis patients because symptomatic improvement of RLS was verified on administering Pramipexole.

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A male dialysis patient, who was in his sixties, showed no liver dysfunction or gastrointestinal disease, with which lanthanum carbonate must be used carefully. The patient developed marked hypoalbuminemia with a decrease in weight after taking lanthanum carbonate. A ^99mTc-HSA protein-losing test revealed the leakage of HSA from the ileum and abdominal computed tomography showed ileal wall thickening. No evidence of parasitic disease was noted on stool examination. After lanthanum carbonate was discontinued, hypoalbuminemia abruptly improved. So, we believe that lanthanum carbonate was responsible for this protein-losing enteropathy. Although no histological studies of the affected ileum were conducted, it is suggested that the cause of protein-losing enteropathy in this case was eosinophilic-enteritis induced by lanthanum carbonate. The thickened ileum wall observed by computed tomography is a characteristic feature of eosinophilic-enteritis, and marked eosinophilia was demonstrated after using lanthanum carbonate in this case, which is one of the diagnostic criteria for eosinophilic-enteritis. There are biological studies providing suggestive evidence for the contribution of lanthanum carbonate to developing eosinophilic-enteritis. A toxicology study (animal experiments on rats) showed that long-term lanthanum carbonate exposure leads to the infiltration of eosinophils into the submucosa of the stomach with eosinophilia. Usually, lanthanum is used as a tracer in electron microscopic studies of the tight junction, and it was reported that ionic lanthanum penetrated through the tight junction of the rabbit ileum. Lanthanum may be absorbed through the epithelium of the ileum and induce an allergic reaction, leading to the development of eosinophilic enteritis. There has been no previous report of eosinophilic-enteritis induced by lanthanum carbonate. It should be kept in mind that lanthanum carbonate may be one of the causes of eosinophilic-enteritis.

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Hemodialysis (HD) patients are at risk of Zinc (Zn) deficiency because of augmented fecal Zn excretion due to a decrease in intestinal Zn absorption. Here, we report an HD patient, a 55-year-old woman, who presented with erythropoiesis-stimulating agent (ESA) hyporesponsive anemia and a poor appetite. In September 2006, a differential diagnosis was made because of severe anemia (Hb 6.6g/dL) and a poor appetite, and it became clear that the serum Zn concentration was low at 52μg/dL. She was diagnosed with Zn deficiency-associated anemia and malnutrition, and so Zn supplementation with polaprezinc was immediately initiated. After the start of Zn supplementation, the anemia markedly improved and also, the normalized protein catabolic rate (nPCR), which indicates dietary protein intake, was markedly increased. Furthermore, it was possible to decrease the dose of ESA administration, and management of the anemia and nutritional status has facilitated the maintenance of a stable condition for over 4 years on Zn supplementation.

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Among elderly patients with seronegative polyarthritis, McCarty et al. proposed the disease entity of “Remitting Seronegative Symmetrical Synovitis with Pitting Edema(RS3PE) syndrome” in 1985; however, few cases have been reported involving hemodialysis patients. Here, we report a patient with suspected RS3PE syndrome who underwent hemodialysis. The patient was a 71-year-old woman who had been on maintenance dialysis since 2004. She fractured the metatarsal of the fifth left toe in January 2009, and underwent hospitalization for surgery. The surgery went well; however, she had an attack of fever in the middle of February. Following a workup, she was suspected of having RS3PE syndrome. On starting steroid treatment, her limb edema and arthritic pain improved. In the subsequent course of treatment, it was doubtful whether this syndrome could involve a type of paraneoplastic edema and polyarthritis. When elderly hemodialysis patients develop symmetrical limb pitting edema with a relatively acute onset, RS3PE syndrome should be considered as a part of the differential diagnosis.

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After complaining of general fatigue, an 81-year-old woman with hypertension and chronic kidney disease who was being treated by her family physician was admitted to another hospital; she was then transferred to our hospital because of oliguria on day6. The serum creatinine level was 3.61mg/dL and blood urea nitrogen level was 94.2mg/dL. Physical examination on admission revealed cyanosis of the toes. We started renal replacement therapy to control acute kidney injury and heart failure. Skin biopsy of the acrocyanotic toes led to a diagnosis of cholesterol crystal embolism. In addition to the administration of prostaglandin and statins, we performed 10 sessions of low-density lipoprotein apheresis (LDL-A). Following LDL-A, the blue acrocyanotic toes and pain from improved markedly, but the renal function did not improve. Oral glucocorticoids (prednisolone 20mg/day) were started on day48. With these therapies, the renal function improved. Final hemodialysis (HD) was performed on day97, and then HD was discontinued. In this report, we also describe laboratory findings and outcomes of 14 patients diagnosed with cholesterol crystal embolism in our hospital.

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BK virus-associated nephropathy (BKN) has emerged as an important cause of allograft loss in renal transplant recipients. However, effective anti-viral treatment strategies are poorly defined. The control of viral infection is tentatively obtained by means of a reduction in immunosuppression. We report a case of successful avoidance of renal allograft loss by the intensive monitoring of immunosuppression after BKN. BK viruria is the first sign of active virus replication and progression to BK viremia appears to be a prerequisite for the development of BKN. Periodical urine cytology, ultrasonography and intensive monitoring of immunosuppression are very important for early diagnosis and the proper control of renal transplant recipients against BK virus infection.

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