Residual kidney function (RKF) is important to determining the prognosis and optimal dialysis in peritoneal dialysis (PD) patients. Cystatin C is a low-molecular-weight protein used as a glomerular filtration rate marker (GFR), because its production rate appears to be constant and its elimination route is predominantly renal. The present study investigated the relative contribution of RKF to serum cystatin C and serum β₂-microglobulin in adult PD patients. Cystatin C and β₂MG were measured in 96 serum samples from 68 patients. Serum cystatin C concentrations were inversely correlated to weekly kidney Kt/V_urea (Spearman rank correlation coefficient r=-0.39, p<0.0001), weekly kidney creatinine clearance (CCr) (r=-0.38, p<0.0001), GFR (r=-0.38, p<0.0001), urine volume of 24 hours (r=-0.19, p=0.024). Serum β₂MG concentrations were inversely correlated to weekly kidney Kt/V_urea (r=-0.69, p<0.0001), weekly kidney CCr (r=-0.66, p<0.0001), GFR (r=-0.66, p<0.0001), urine volume of 24 hours (r=-0.60, p<0.0001). Correlation coefficients between Serum β₂MG and RKF were stronger than those of serum cystatin C to RKF. It was suggested that β₂MG provides a better measure than cystatin C for estimation of RKF in PD patients.

View full abstract

[Purpose] Pyogenic spondylitis often develops in elderly and compromised hosts and the number of cases has increased. In recent years, there have been many reports of pyogenic spondylitis especially in dialysis patients. To clarify the incidence and features of pyogenic spondylitis in dialysis patients, we mainly studied dialysis patients in the general population who were diagnosed with pyogenic spondylitis in our hospital. [Methods] A retrospective study was performed in 27 patients (22 males and 5 females, mean age±SD 66±12 years (49~89)) who were diagnosed with pyogenic spondylitis and treated in our orthopedic department between October 2003 and October 2008. We analyzed age, underlying disease, disease background, affected site, causative microorganism, presence or absence of abscess, therapy, and other factors. By comparing these survey items between dialysis patients and general patients, we demonstrated specific features in dialysis patients and analyzed the ratio of underlying disease. [Results] Of the 27 patients, 5 (18.5%) were receiving hemodialysis. Pyogenic spondylitis developed due to puncture site infection, catheter infection, or bacteremia after vascular graft surgery in 3 of the 5 patients and due to local infection after lumbar spine surgery in the other 2. While the average age at onset was 68±11 (mean±SD) years in non-dialysis patients, it was 56±7 (mean±SD) years old in dialysis patients, showing a younger onset (p value: 0.020). The causative microorganism could be identified in 15 patients, and Staphylococci including MRSA were the most frequently observed pathogen (10 patients, 67%). [Conclusions] The percentage of patients on hemodialysis as an underlying disease was higher than expected, and showed a younger onset in diaysis patients than in non-dialysis patients. We showed the importance of the disease statistically in the differential diagnosis of fever in dialysis patients presenting with back pain.

View full abstract

The patient was a 76-year-old woman, who had been receiving on maintenance hemodialysis therapy since May 1992 due to stage5 chronic kidney disease caused by chronic glomerulonephritis. In June 2008, she was diagnosed as having multiple myeloma (IgA-λ type). In August 2009, she was started on MP therapy (melphalan and prednisolone). MP therapy effectively induced a decrease in serum IgA, and there were no adverse reactions. A second cycle of MP therapy was started 5 weeks after the first cycle, and thalidomide was introduced at 100mg/day. In October 2009, the patient was referred to our hospital for determination of the cause of hypotension during hemodialysis. On admission, physical examination demonstrated dyspnea, marked edema of the right lower leg, and hematologic examination demonstrated abnormally high plasma FDP and D-dimer levels. Contrast-enhanced CT of the chest and pulmonary arteriography demonstrated contrast defects suggestive of embolism of the left main pulmonary artery, and a diagnosis of deep vein thrombosis of the leg with pulmonary embolism was made. Heparin infusion was started, along with placement of an inferior vena cava filter, which resulted in improvement of both the deep vein thrombosis of the leg and the pulmonary embolism. Thalidomide, which shows efficacy against multiple myeloma, has been reported to cause pulmonary embolism as an adverse reaction. The usual dosage of thalidomide is 100 to 400mg/day, and our patient developed pulmonary embolism despite receiving the lowest recommended dose level of 100mg/day. We consider this case not able as it suggests that thalidomide, given for the treatment of multiple myeloma, may trigger the development of pulmonary embolism even when administered at low doses in patients under maintenance hemodialysis therapy.

View full abstract

A 60-year-old woman developed chronic renal failure as a result of lupus nephritis secondary to systemic lupus erythematosus (SLE) and peritoneal dialysis was initiated in May 2001. In December 2008, the patient developed acute aortic dissection and underwent replacement of the ascending aorta followed by anticoagulant therapy with warfarin. In August 2010, hemorrhage in the left iliopsoas muscle was observed following admission for CAPD peritonitis. The bleeding was controlled with conservative therapy involving transfusion and rest. These various vascular lesions were thought to have been caused by a number of factors, including autoimmune abnormalities due to SLE, vasculitis, the effects of steroid treatment on arteriosclerosis and abnormalities in phosphorus and calcium metabolism caused by peritoneal dialysis. The long-term prognosis of SLE has improved greatly with advances in its treatment. However, the incidence of arteriosclerosis and other vascular lesions in patients with SLE is expected to increase in the future, and methods of preventing these complications must be investigated in a large number of patients.

View full abstract

We present a 78-year-old woman receiving outpatient treatment for chronic renal failure. She was admitted to the hospital with general malaise and loss of appetite in April 2009 and hemodialysis was initiated because of uremic symptom. Eleven days after the start of hemodialysis with heparin treatment, blood coagulation in the dialysis circuit, temporary vascular catheter obstruction, and significant reduction of platelet counts were observed. Since we identified the HIT antibody, we diagnosed HIT type II, and switched from heparin to argatroban treatment. Seventeen days after stopping the administration of heparin, we created left upper-arm arteriovenous fistula by transposition of the basilic vein. Heparin-induced thrombocytopenia (HIT) is an important adverse effect of heparin characterized by a significant reduction in platelet counts. In addition, HIT carries the risk of causing thrombosis. We need to take every precaution to avoid such an event in the case of heparin treatment for hemodialysis. However, there is no medical consensus on vascular access management for patients with HIT. Once activated, HIT antibody titers generally decline within 50-85 days after withdrawal of heparin. Additionally, the condition is known to be associated with a high incidence of thromboembolism due to the presence of HIT antibody. Therefore, we must ensure that HIT antibody titers revert to negative, if possible. However, as described, there are situations where vascular access must be created in the early phase of HIT. In 1996, Warkentin et al. reported that the subsequent 30-day risk of thrombosis was 52.8% after withdrawal of heparin and most such thromboses occurred within 10 days. As a result, we consider that it is better to create the vascular access at least 10 days after the withdrawal of heparin.

View full abstract

Neuromyelitis optica (NMO) is an inflammatory demyelinating disease of the central nervous system that causes severe optic neuritis and myelitis attacks. The association of NMO with serum autoantibody marker NMO-IgG was reported in 2004. The effectiveness of immunoabsorption plasma pheresis (IAPP) therapy for treating acute exacerbations of NMO has not been well evaluated; thus, accumulation of therapeutic experience for this disease is important. We report 2 patients with acute exacerbations of NMO spectrum disorders, although neither patient has demonstrated optic neuritis to date. Both patients were unresponsive to intravenous methylprednisolone therapy, but showed significant improvement after IAPP therapy, which allowed us to reduce the immunosuppressive medications. In conclusion, IAPP therapy may be one of therapeutic options for patients demonstrating a fulminant attack of NMO.

View full abstract