International Kidney Evaluation Association Japan (IKEAJ) aims early detection and treatment of CKD. Early detection of CKD is important, but actually it's hard for us to detect earlier. Many issues are pointed out. Firstly, who to choose for examination ; to cover all Japanese it is impossible in terms of cost. Then, what examination would be appropriate? The examination should be simple and easy in order to be conducted nationwide. Furthermore, efficiency is also important. Also, global criteria should be applied for diagnostic criteria. IKEAJ developed KEEP JAPAN Program based on KEEP by US National Kidney Foundation (NKF). KEEP JAPAN is conducted for those who would pose some risks of diabetes, hypertension or have family members with the diseases including kidney disease, and provides CKD reviews CKD incidence and risk factors in our country. CKD incidence (stage 1-4) is 26.7% by albumin and creatinine ratio and eGFR. CKD incidence among participants with diabetes is 35.0%, which is 1.7 time higher than non-diabetes participants. CKD incidence among hypertension participants is 34.8%, which is 3.4 times higher than non-hypertension participants. Prevalence of CVD among participants with CKD is 28.9%, which is 1.9 time higher than non-CKD participants. Also, prevalence of CVD among of participants with history of diabetes and hypertension is 38.3%. CKD incidence is higher than we expected. KEEP JAPAN identifies high-risk population with CKD based on the definition of this program, and compares the figures with the data from other countries. WHO places NCD management as one of the strategies and focuses on CVD, cancer, diabetes and chronic respiratory disease. It is evident that these diseases are closely related to risks from negative lifestyle habits such as smoking, unhealthy diet, lack of exercise, and alcohol. Although diabetes, CVD and CKD are closely related to developing complication, CKD itself is not so recognized in the society as the above mentioned life-style related diseases. I would say that CKD is the new major disease in Japan. Raising awareness of CKD globally can be a CKD management.

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Recently, there have been several reports that hemoglobin variability is associated with adverse outcomes such as increases in morbidity and mortality. The cause of hemoglobin variability is not yet clear, and the difference between rHuEPO and long-acting ESA, Darbepoetin alfa, has not yet been clarified. To examine the difference between rHuEPO and long-acting ESA for hemoglobin variability, we analysed hemodialysis patient data. The data used for analysis were obtained from a double blind randomized study in which efficacy and safety of Epoetin alfa compared with those of Darbepoetin alfa. We evaluated hemoglobin variability using six methods that have already been reported. As a result, there was no difference between the efficacy and safety of Epoetin alfa and Darbepoetin alfa for hemoglobin variability. Therefore, it is suggested that hemoglobin variability is not influenced by the type of ESA.

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The concept of hemoglobin cycling (Hb cycling) in the treatment of renal anemia with erythropoiesis-stimulating agent (ESA) has recerved considerable attention. Hb cycling is a non-physiological periodic variability in Hb levels, which may be associated with hospitalization and cardiovascular complications, determining the survival prognosis of hemodialysis patients. In this context, inhibition of Hb variability appears to be important to improving patient prognosis. We analyzed the Hb variability induced by the conventional rHuEPO prescription regimen in 230 stable hemodialysis patients at our hospital (140 males and 90 females) and showed that the mean Hb level was low, and that variability comprised a high-risk pattern affecting a high percentage of patients (9.68±0.97 g/dL, Low : 33.5%, LAL : 51.7%). We, therefore, changed these patients to a new regimen and followed the patients for 1 year. The mean Hb level rose to the target range recommended by the JSDT guidelines, and the rate of patients showing a decrease in the high-risk Hb variability pattern (add the numbers equivalent to the pretreatment value of 10.35±1.05 g/dL, Low : 11.8%, LAL : 56.5%). These findings suggest that the newly-employed rHuEPO regimen in our hospital may be a better administration method of rHuEPO than that of the conventional one, and that this new method can be applicable to patients with clinically overt Hb variability.

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【Objectives】This presentation describes approaches physicians use to promote active patient participation in decision-making with regard to medical care, and the provision of supportive suggestions about that care. The presentation will also focus on the autonomy preferences of chronic hemodialysis patients (i. e. decision-making and information-seeking preferences) and the factors involved in shared decision-making. 【Patients】The sample consists of 107 chronic hemodialysis patients treated as outpatients at S-Hospital and S-Clinic. 【Methods】The study was conducted using a self-administered questionnaire. Decision-making and information-seeking preferences were measured using the Autonomy Preference Index (API). A scale of the shared decision-making approach used by physicians was developed by the researchers. 【Results】Responses from the patients (n=63) were analyzed. In this series, the decision-making score was 33.3±13.2 (full score was 100), and information-seeking score was 87.8±8.2 (full score was 100). Decision-making was associated with age, occupation, and some categories of the shared decision-making approach by physicians. 【Conclusions】These findings suggest that most chronic hemodialysis patients have a high desire for information, but a low desire for decision-making. These findings also suggest, however, that a shared decision-making approach may increase patients' decision-making desire. The presentation concludes, therefore, that it might be important for the autonomy preferences of the patient for physicians to use a shared decision-making approach. The strategies used by physicians to increase patient decision-making involvement thus call for further discussion within the medical profession.

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A 62-year-old woman was diagnosed as having glycogen storage disease Type I at 55 years of age, and then developed end-stage kidney disease (ESKD). Since she had abdominal enlargement due to hepatic tumor, we considered that she was contraindicated for peritoneal dialysis. Hemodialysis (HD) was initiated as the primary therapeutic modality. Hypoglycemia was completely prevented through a glucose supply from frequent feedings during HD, and maintenance HD was successfully performed. It appears that HD treatment is effective for ESKD patients with glycogen storage disease Type I with frequent feedings during the HD.

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Percutaneous transluminal angioplasty (PTA) is being performed more frequently for the treatment of stenosis in order to increase the patency of arteriovenous fistulae. This report describes a 78-year-old female who was diagnosed as having heparin-induced thrombocytopenia (HIT) just after the initiation of renal replacement therapy due to end stage diabetic nephropathy. An arteriovenous fistula was surgically created to provide permanent access for hemodialysis ; however, it failed to mature. Therefore, she underwent PTA by proximal catheterization of the fistula with the insertion of introductory sheaths and 5 mg bolus injection of argatroban. A balloon was inflated for at least 2 minutes, and this was repeated until no residual waist remained in the balloon. A final fistulogram performed 30 minutes after the initiation of PTA demonstrated complete resolution of stenosis. These observations suggest that argatroban could play a role as an alternative agent for anti-coagulation replacing heparin during PTA for hemodialysis vascular access in patients with HIT.

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A 35-year-old man had undergone maintenance hemodialysis therapy since 1998, which however was switched to peritoneal dialysis because of blood access problems in 2000. He developed huge ectopic calcifications in the right shoulder and left buttock in December 2003 due to hyperphosphatemia and calcium-phosphate product above 90 (mg/dL)². To improve hyperphosphatemia and ectopic calcifications, the dialysis modality was converted to hemodialysis in October 2004. However, the ectopic calcifications progressively worsened. He was referred to our hospital for kidney transplantation in February 2005. However, 67Ga scintigraphy showed uptake in the right shoulder and left buttock. Furthermore, methicillin-resistant Staphylococcus aureus was detected from the left buttock incision, which necessitated the delay for renal transplantation. Because antibiotic therapy had no effect and the calcification had worsened further, he was treated by weekly 22-hour long hemodialysis sessions. After conversion to prolonged hemodialysis, calcium-phosphate product was controlled and ectopic calcifications were reduced. Finally, he received a renal transplant from his mother on 14 January 2009. This is the first case of kidney transplantation after conversion to prolonged hemodialysis for huge ectopic calcification. The huge ectopic calcifications were difficult to treat, however, prolonged hemodialysis sessions were useful in the management of this case.

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