[Introduction] DFPP is useful therapy to remove pathological IgG in patients who have undergone transplantation and in those with autoimmune disease. However, excess DFPP may reduce essential proteins such as albumin and fibrinogen (Fbg) since the removal rate of Fbg is greater than that of IgG. Especially in patients scheduled for transplantation, lack of Fbg may lead to serious complications including massive bleeding. It is important to predict the levels of IgG and Fbg after DFPP prior to treatment in order to decide appropriate treatment. To investigate the efficacy and safety of DFPP, a formula to predict changes in these proteins was established. [Methods] A patient with acute myeloblastic leukemia who had undergone plasma exchange gave written informed consent to the examination of effluent during plasma exchange. The plasma effluent was processed using plasma fractionators with a closed circuit in vitro, and plasma parameters were serially determined at 10-minute intervals during the processing. A prediction formula for these parameters was established based on a 1-compartment model. The prediction formula was prepared using the parameters before DFPP, circulating plasma volume (VP), flow rate of plasma (QF) and drainage (QS), sieving coefficient of plasma separation and fractionator (Sc_I,_II). Using this formula, estimated data were compared with measured data in vitro. Likewise in vitro, estimated data of clinical DFPP (18 treatments) ex vivo were compared with measured data ex vivo. [Results] The prediction formula ; Concentration at t time=concentration at 0 time*exp (-Sc_I*(QF-Sc_II*(QF-QS))*t/VP). The estimated data from the formula were consistent with measured data both in vitro and ex vivo (R²>0.950). [Discussion] The formula for DFPP is available to predict the levels of albumin, IgG, and Fbg after DFPP prior to treatment, and to remove IgG without causing a deficiency of Fbg. Using the prediction formula, suitable DFPP for individual patients could be performed effectively and safely.

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[Objective] The status of glycemic control in maintenance hemodialytic patients with diabetes mellitus was assessed by glycated albumin (GA), and the impact on the prognosis was reviewed. [Method] We reviewed eighty-seven patients with diabetes mellitus who received maintenance hemodialysis in Yamanashi-Kosei Hospital from January 1, 2004 to December 31, 2009 (age 65.9±10.9 years old, 60 males and 27 females). GA was measured every month throughout the observation period and the mean value was obtained (mean GA). We examined the influence of mean GA on survival using multivariate Cox proportional-hazard model. The subjects were divided into four groups according to their mean GA, and survival was analyzed by the Kaplan-Meier method. [Result] The observation period was 3.1±2.0 years, and 30 subjects died. The mean GA was 21.9±4.1%. The mean GA and patient age each had a significant impact on death (mean GA : proportional hazard : 1.108 ; 95% confidence interval : 1.013 to 1.213 ; p=0.026, age : proportional hazard : 1.035 ; 95% confidence interval : 1.001 to 1.070 ; p=0.046). The group with a mean GA≥24.23% had significantly poorer survival than the group with a mean GA of 19.05% to 24.02% (p=0.496, log-rank test). [Conclusion] Poor glycemic control in maintenance hemodialytic patients with diabetes mellitus is a risk factor for death. This finding indicates that the careful management of glycemic control in these patients is important.

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MBD-5D (mineral and bone disorders outcomes study for Japanese chronic kidney disease stage 5D patients) was a prospective multicenter observational study in hemodialysis patients with secondary hyperparathyroidism (SHPT) conducted between January 2008 and January 2011 with the participation of large dialysis facilities in Japan. Investigation of the impact of practice patterns at these facilities on the outcomes of SHPT patients is one of the aims of the study and the practice patterns at the start and the end of the study were investigated. Eighty-five facilities (98.8%) responded to the survey on practice patterns at the start of the study. We report here the survey results focusing on compliance with the “Guidelines for the management of secondary hyperparathyroidism in chronic dialysis patients” published in 2006 by the Japanese Society for Dialysis Therapy (JSDT) and patterns of drug administration for MBD. At 95.3% of the facilities, serum phosphorus (P) and calcium (Ca) levels were measured at the frequency recommended by the Guidelines (at least once to twice a month) and 64.7% of the facilities measured parathyroid hormone (PTH) at the recommended frequency (once every 3 months). Management target values (lower limit to upper limit) for corrected serum Ca level, serum P level and serum intact PTH level were within the target ranges of the Guidelines in 60.0%, 71.8% and 54.1% of the facilities, respectively. The survey demonstrated the patterns of drug administration to treat MBD, including calcium carbonate, sevelamer hydrochloride and active vitamin D as proposed by the Guidelines, as well as cinacalcet hydrochloride, which was launched after establishment of the Guidelines. This survey documented current practice patterns including advances in MBD management that have developed after the Guidelines were published. These current practice patterns are expected to be considered during future revision of the Guidelines.

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The conventional method of treating phosphorus deficiency by dipotassium phosphate injection as a phosphorus supplement may induce hyperkalemia. To address this challenge, Otsuka Pharmaceutical Factory, Inc. has developed an electrolyte solution (sodium phosphate injection [OPF-102]) that substitutes sodium phosphates for their potassium counterparts in the formulation. This solution can be used when there is a risk of high serum potassium concentrations. In this study, we evaluated the effectiveness and safety of OPF-102 for correction of serum phosphorus levels when administered to patients with renal failure who were undergoing hemodialysis and required phosphorus repletion. We administered OPF-102 intravenously to 10 subjects. In all subjects, the serum phosphorus concentrations normalized after administration of OPF-102. The patients' serum potassium concentrations, which fluctuated before administration of OPF-102, were not affected. In addition, there were no adverse events requiring clinical intervention during administration of OPF-102. OPF-102 is expected to be useful as a phosphorus supplement in clinical situations with a potential risk of inducing a high serum potassium concentrations.

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Among patients undergoing chronic maintenance hemodialysis, some complain of pruritus despite oral treatment with histamine H₁ receptor antagonists ; these patients are called pruritus hemodialysis patients resistant to existing treatment. The intensity of pruritus was evaluated in 64 hemodialysis patients at our hospital using the Hearing Analogue Scale (HAS) devised at our hospital, as well as by measuring the serum levels of thymus and activation-regulated chemokine (TARC ; a type of chemokine). The HAS score, which may reflect the intensity of generalized pruritus, correlated well with the serum TARC level, suggesting that the serum TARC level can be used as a substitute for the HAS score. Subsequently, nalfurafine hydrochloride (nalfurafine) was orally administered at a dose of 2.5μg to 2 pruritus hemodialysis patients. Both the HAS score and the serum TARC level decreased after treatment, and the severity of pruritus also decreased. Thus, both parameters are useful indicators of the severity of pruritus in hemodialysis patients.

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Peritoneal dialysis or hemofiltration (HF) is recommended for acute-phase intracranial hypertension in the acute phase in the Guidelines for Stroke Treatment 2009. However, standard intermittent HF or daily short hemodialysis (DSHD) has also been performed. In our hospital, frequent and low efficient HF has been performed to minimize changes in osmotic pressure and bicarbonate (HCO₃^-). Therefore, we evaluated the safety and examined the effectiveness of frequent, low-efficient and short hemodialysis (FLESHD) supplemented with hypertonic glycerol in hemodialysis patients with acute-phase intracranial hypertension. Six maintenance HD patients with intracranial hypertension treated with low efficient HF (blood flow rate : 200mL/min, filtration rate : 2.5L/hour, filtration solution : AK Solita BW^®, filtration membrane : APS-15SA^®, 4 hour treatment) were shifted to low efficient HD (blood flow rate:100mL/min, dialysate flow rate : 500mL/min, dialysate solution : AK Solita DL^®, dialysis membrane : APS-11SA^®, 2 hour treatment) and then several parameters are measured. Two maintenance HD patients with intracranial hypertension in the acute phase underwent FLESHD at a lower dialysis flow rate of 300mL/min for three continuous days with administration of 400mL of glycerol during the session. The HD condition was shifted gradually to that without glycerol administration after the fourth FLESHD, and several parameters were measured. Osmotic pressure was significantly lowered low-efficient HF (289.5±10.4 to 285.8±9.3mOsm/kg, p<0.01) and low-efficient HD (294.5±16.3 to 290.2±12.7mOsm/kg, p<0.05), without significant changes in HCO₃^-. There were no significant differences in osmotic pressure or HCO₃^- between pre-HF and pre-HD values or between post-HF and post-HD values. Two patients showed improved consciousness levels after continuous FLESHD for 3 days. After six FLESHD sessions were performed, the osmotic pressure increased significantly post-HD (293.5±3.9 to 297.7±3.9mOsm/kg, p<0.05) but HCO₃^-did not. In patient 2, the % change in the osmotic pressure and HCO₃^- between pre-HD and post-HD just before changing hospitals (blood flow rate : 150mL/min, dialysate flow rate : 500mL/min, 2.5 hour treatment) were -3.4% and -3.9%, respectively. FLESHD supplemented with hypertonic glycerol seems to be a safe and effective strategy for maintenance HD patients with intracranial hypertension in the acute phase.

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A 61-year-old male patient began to receive hemodialysis due to end-stage renal disease in diabetic nephropathy and an arteriovenous fistula (AVF) was established in the left forearm in March 2005. The patient received hemodialysis at another hospital and then swelling of the left upper limb appeared around July 2007. The patient was diagnosed as having venous hypertension and underwent ligation of the AVF because of worsening symptoms and an AVF was simultaneously established in the right forearm in January 2008. Thereafter swelling in the face and right upper extremity edema progressed, the patient was referred to our hospital in March 2010. After the patient was transferred, significant facial edema and swelling of the upper extremity were noted along with the appearance of collateral circulation in the anterior chest and neck. The patient complained of heaviness in the head and nasal obstruction. Angiography was performed due to suspicion of venous hypertension in the right AVF and tight stenosis for a length of 30mm was demonstrated in the right brachiocephalic vein. Therefore, percutaneous transluminal angioplasty (PTA) with balloon angioplasty and stent placement was performed. Left central vein stenosis or occlusion was also considered as one of the causes of facial edema. Angiography demonstrated 99% stenosis for a length of 50mm in the left brachiocephalic vein. Therefore, we performed PTA by balloon angioplasty and stent placement on the left side as well. Thereafter, facial edema and upper extremity edema improved, and clinical symptoms such as the heaviness of the head and nasal obstruction disappeared. This paper is the first report of PTA for bilateral brachiocephalic vein stenoses, and PTA by balloon angioplasty and stent placement was considered a useful treatment in this case.

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