Objectives: Hemodialysis patients are at risk of malnutrition, inflammation, and atherosclerosis, which make up MIA syndrome. Here, we assessed the geriatric nutritional risk indexes (GNRI) of patients undergoing maintenance dialysis, then measured various parameters such as serum CPR, plasma IL-6, Fetuin-A, and 8-OHdG to investigate the nutritional status, and investigated correlations between these. Subjects: One hundred and thirty-eight patients were undergoing stable maintenance hemodialysis at this institution. Of these, 95 were men and 43 women. The mean age was 69±11 years (38 to 88 years), and the mean dialysis time was 58±60 months (3 to 390 months). Methods: GNRI was that proposed by Bouillanne et al., calculated using a formula revised by Yamada et al. Plasma IL-6, Fetuin-A, and 8-OHdG were assessed with enzyme-linked immunosorbent assay (ELISA) methods. Results: GNRI slowly decreased with advancing age, and a significant negative correlation with age was shown. Moreover, significantly lower values were shown for women compared to men, while significant differences with or without diabetic nephropathy as an underlying disease were not noted. In terms of the biochemical parameters, positive correlations were shown for serum albumin (p<0.0001) and Fetuin-A (p<0.01), while negative correlations were shown for CRP (p<0.0005), IL-6 (p<0.0001), and 8-OHdG (p<0.0001). Results: We believe the GNRI to be an easily measureable guide reflecting the nutritional status of dialysis patients. Moreover, it was suggested that there are close relationships between the GNRI and nutrition, inflammation, atherosclerosis, and oxidative stress.

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It has been reported that glycoalbumin (GA) is more suitable than the hemoglobin A1c (HbA1c) level as an indicator of diabetes control in hemodialysis (HD) patients with diabetes. Because of the use of Erythropoiesis Stimulating Agent (ESA), HbA1c has been underestimated by about 30% in HD patients. We measured casual plasma glucose (PG), HbA1c, and GA of 58 diabetes HD patients, and evaluated the current diabetes control situation in HbA1c and GA. Sixteen of 30 patients (53.3%) with HbA1c<5.8% showed a GA level of more than 20%, and 25 of 40 patients (62.5%) with HbA1c<6.5% showed a GA level of more than 20%. We have come to be able to use Alogliptin, Dipeptidyl-peptidase IV inhibitor, in HD patients with diabetes. After Alogliptin at 6.25 mg/day was administered to the 13 HD patients with GA>20%, the mean PG level decreased significantly one month later, and HbA1c and GA levels decreased significantly two months later (p<0.05). The mean PG, HbA1c, and GA levels were 178.8±39.5 mg/dL, 6.05±1.16%, and 26.1±5.95% before dosage, 150.9±30.6 mg/dL, 5.35±0.83%, and 21.2±1.74% three months later, and 151.8±29.8 mg/dL, 5.18±0.72%, and 20.3±2.41% five months later. Although the HbA1c<6.5% achievement rate before dosage was 53.8%, the HbA1c<6.5% achievement rate had significantly increased to 84.6% three months later, and to 100% five months later (p<0.05). The GA<20% achievement rate was 0% before dosage and 23.1% three months later, but increased significantly to 38.4% four months later, and to 46.2% five months later (p<0.05). Therefore, GA is useful in diabetes management of HD patients. Alogliptin is beneficial in the treatment of HD patients with diabetes.

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The aim of this study was to evaluate the effects of levocarnitine chloride (L-cartine^®, LC) on maintenance hemodialysis patients who received DA at 40 μg/week or rHuEPO at 9,000 U/week by examining the changes in serum carnitine levels during hemodialysis (study 1), and the treatment effects of LC on ESA-resistant anemia (study 2) and dialysis-associated muscle symptoms (study 3). In study 1, we monitored 100 patients. The average levels of total carnitine (TC) and free carnitine (FC) within one year after the introduction of dialysis were 57.9±18.2 and 38.8±13.6 μmol/L, respectively. At one year, however, these levels significantly decreased to 39.3±18.6 (TC) and 25.0±12.5 (FC) μmol/L (p<0.01), respectively, and continued to decrease in accordance with the duration of hemodialysis. In study 2, 32 patients (treated group) who wanted to receive LC orally at a dose of 2×300 mg daily were compared with 43 patients without treatment (non-treated group). The TC and FC levels after 12 weeks in the treated group were 175.0±95.5 and 122.3±64.6 μmol/L, respectively. The erythropoietin resistance index (ERI：ESA dose (units/week)/hemoglobin (g/dL)) significantly decreased in the treated group from 1,041 to 737 (24 weeks)(p<0.01), while it did not decrease in the non-treated group. In study 3, 32 patients (treated group) were scored using a questionnaire by nurses regarding the four symptoms (asthenia, muscular cramping, intradialysis hypotension, and dyspnea after exertion) before and after treatment with LC (at 12 and 24 weeks), and the effects of LC on symptom scores were evaluated. Asthenia and muscular cramping exhibited noticeable changes after treatment (p<0.001). Our studies revealed the beneficial effects of LC treatment on ESA-resistant anemia and dialysis-associated muscle symptoms, with no significant adverse events.

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In critical limb ischemia (CLI) of a maintenance hemodialysis patient, leg amputation of the foot region, lower leg, or thigh not only severely debilitates the patient, but is also known to have a serious negative effect on the prognosis. For these reasons, a major challenge when administering treatment of CLI is to avoid leg amputation and preserve the walking function to the greatest extent possible. Here, we describe the use of a latissimus dorsi myocutaneous flap together with a vein bypass graft to treat an intractable heel ulcer arising from a tissue deficit in a maintenance hemodialysis patient, thereby providing comfort to the leg region. The case was a 49-year-old male patient who came to this hospital in April 2010 for hemodialysis due to chronic kidney failure brought on by diabetic kidney disease. Pain and skin ulcer occurred in the patient's right heel from around May 2011. The patient was hospitalized after signs of infection were found in the same region. Antibiotics were administered and debridement was conducted for the infected region, but there was no improvement. The skin ulcer further aggravated, leading to a tissue deficit. Therefore, in August 2011, we used a latissimus dorsi myocutaneous flap together with a vein bypass graft, which enabled us to reduce the pain in the patient's leg and preserve the walking function. This suggested that the combined use of a vein bypass graft and free flap can be an effective CLI treatment option for hemodialysis patients.

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A 73-year-old female was admitted to our hospital for high fever, malaise, anorexia, anuria, and systemic edema. Following several examinations, we started antimicrobial therapy and hemodialysis for acute kidney injury due to suspected bacteremia on the first day. However, her condition did not improve, and laboratory data revealed normocytic-normochromic anemia and thrombocytopenia on the sixth day. On the eighth day, these abnormalities progressively worsened. Increased serum LDH, decreased serum haptoglobin, negative results for both direct and indirect Coombs tests, and schistocytes in the peripheral smear suggested intravascular hemolysis due to thrombotic microangiopathy. We started plasma exchange (PE) using FFP. On the twelfth day, anti-glomerular basement membrane (GBM) antibody in her serum at admission was found to be positive. We diagnosed her with acute kidney injury associated with anti-GBM antibody disease and TMA. We added steroid pulse therapy and continued PE and hemodialysis. Although we could induce TMA remission following twenty-five sessions of PE, her renal function did not improve. To our knowledge, there are only eleven reported cases of anti-GBM antibody disease associated with TMA. Only four of these eleven cases were successfully treated, and five cases died. We consider that this case is quite rare.

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