A nationwide statistical survey of 4,255 dialysis facilities was conducted at the end of 2011. Responses were submitted by 4,213 facilities (99.0%). The number of new patients started on dialysis was 38,613 in 2011. Although the number of new patients decreased in 2009 and 2010, it increased in 2011. The number of patients who died each year has been increasing; it was 30,743 in 2011, which exceeded 30,000 for the first time. The number of patients undergoing dialysis has also been increasing every year; it was 304,856 at the end of 2011, which exceeded 300,000 for the first time. The number of dialysis patients per million at the end of 2011 was 2,385.4. The crude death rate of dialysis patients in 2011 was 10.2%, which exceeded 10% for the first time in the last 20 years. The mean age of new dialysis patients was 67.84 years and the mean age of the entire dialysis patient population was 66.55 years. The most common primary cause of renal failure among new dialysis patients was diabetic nephropathy (44.3%). Diabetic nephropathy was also the most common primary disease among the entire dialysis patient population (36.7%), exceeding chronic glomerulonephritis (34.8%) which had been the highest until last year. The survey included questions related to the Great East Japan Earthquake, which occurred on 11 March 2011. The number of dialysis facilities that were affected by the earthquake with a seismic intensity of at least 6 was high in the Tohoku region. The number of facilities affected by a seismic intensity between 5 and 6 was high in the Kanto region. The number of dialysis facilities that could not continue providing medical services owing to the earthquake was 315. As a result, a total of 10,906 patients were transferred to other dialysis facilities after the earthquake. The mean uric acid levels of the male and female patients were 7.30 and 7.19 mg/dL, respectively. Certain drugs for hyperuricemia were prescribed for approximately 17% of patients. From the results of the facility survey, the number of patients who underwent peritoneal dialysis (PD) was 9,642 and the number of patients who did not undergo PD despite having a peritoneal dialysis catheter was 369.

View full abstract

[Background and objectives] Since the dipeptidyl peptidase-4 (DPP-4) inhibitor, a therapeutic agent for diabetes mellitus involving incretin, emerged, it has brought about a paradigm shift in the treatment of diabetes mellitus. Among DPP-4 inhibitors, vildagliptin is available not only for patients with renal insufficiency, but also for hemodialysis patients. The purpose of this study was to assess the efficacy and safety of vildagliptin (50 mg once daily), and observe the effect on glucose fluctuations using continuous glucose monitoring (CGM) in hemodialysis patients with type 2 diabetes mellitus (T2DM). [Design, setting, participants, & measurements] The study included 42 hemodialysis patients (26 men: mean age±SD, 68.0±11.2 years) with T2DM who had inadequate glycemic control. We divided them into two groups. Fifty mg/day of vildagliptin was administered to one group (V group) in addition to the original treatment. The other group (C group) continued the original treatment. We assessed HbA1c, glycated albumin (GA), and blood glucose values in the two groups before and 1 month after the treatment. Additionally, we evaluated the averaged glucose value (AGV) and blood glucose fluctuation (SD) for 24 hours using continuous glucose monitoring (CGM). [Results] In the V group, HbA1c and the blood glucose value decreased significantly 1 month after the administration of vildagliptin (6.5±1.1 to 5.6±1.1% and 184±79 to 135±50 mg/dL, p<0.05, respectively). GA also showed improvement in the V group (25.1±5.3 to 22.9±4.4%, p=0.16). CGM showed that AGV and SD improved both one day and one month after vildagliptin administration. [Conclusion] Our data showed that vildagliptin improved blood glucose control rapidly as well as glycemic fluctuations without any adverse effects.

View full abstract

We investigated the present situation of dialysis facilities accepting HIV-infected endstage renal disease patients. We sent questionnaires to 3,802 Japanese dialysis facilities, and obtained 1,552 responses (40.82% recovery rate). Those which had experience of accepting HIV-infected dialysis patients were 94 facilites (6.2%), and 1,434 (93.8%) had no such experience. Eighty-nine HIV-infected patients were dialyzed in November, 2011 in Japan (60 facilities, range: 1～7 patients, 1.48±1.12 persons (mean±S. D.)). Sixty-nine of these (74.2%) answered yes to the question of whether they would continue to accept HIV-infected dialysis patients. In facilities with no experience of HIV-infected dialysis patient acceptance, 227 facilities (15.7%) would accept them if referred, and 445 facilities (30.7%) are preparing for acceptance from now on. A total of 776 facilities (53.6%) refused the future acceptance of HIV-infected dialysis patients. The reasons for being “hard to accept” were “the difficulties to prepare the dedicated bed and dialysis machines”, “the procedures for HIV-infected dialysis patients are not clearly organized”, and “back-up facilities for sudden changes in patients' conditions are not available”. We conclude that there are many difficulties for private sector facilities to accept HIV-infected dialysis patients due to the lack of public assistance.

View full abstract

Epoetin beta pegol is a novel agent that corrects anemia and raises hemoglobin (Hb) levels when administered at monthly intervals. However, patients undergoing therapy with epoetin beta pegol demonstrate a monthly variability of Hb levels; Hb levels increase and reach a peak 2 weeks after the injection, and decrease and reach a trough 4 weeks after administration. Studies suggest that rapid variability of Hb, especially a rapid fall in the Hb level, contributes to a risk of cardiovascular events. It is, therefore, important to understand the characteristics of patients showing marked monthly variability of Hb levels associated with epoetin beta pegol therapy. We defined the “high-variability group” as patients in whom the Hb difference from the peak-to-trough levels was more than 0.7 g/dL two times, and the rest of the patients fell into the “low-variability group.” Fifty-eight dialysis patients who received therapy with epoetin beta pegol once every 4 weeks were evaluated. Sixteen patients were in the high-variability group, and 39 patients were in the low-variability group. The low-variability group showed maintained Hb levels, but the high-variability group showed decreased Hb levels (low-variability group: Hb, 11.43±1.90 g/dL; high-variability group: Hb, 10.19±1.45 g/dL; p=0.002). The high-variability group showed significantly higher levels of transferring saturation (TSAT) than the low-variability group (p=0.042). Moreover, patients with elevated Hb levels in the low-variability group were defined as an “Hb-elevated group.” The high-variability group showed significantly higher levels of Fe (p=0.025) and TSAT (p=0.043) and significantly lower levels of serum ferritin (p=0.009) than the Hb-elevated group. Dialysis patients who have adequate functional iron and poor iron storage are likely to exhibit marked monthly variability on treatment with epoetin beta pegol. In order to suppress the monthly variability of Hb, patients who have low levels of serum ferritin may be administered iron.

View full abstract

Some severely intoxicated patients require extracorporeal drug removal by blood purification. We report a case involving an intentional overdose of quetiapine (QTP), promethazine (PMZ) and valproate (VPA), with successful removal by direct hemoperfusion (DHP). A man in his 30's with a history of schizophrenia and suicide attempts was admitted to our hospital 9 hours after taking 450 mg of QTP, 900 mg of PMZ, and 7,600 mg of VPA. On arrival, he was comatose, with a Japan coma scale score of III-200. His temperature was 37℃, and the blood pressure was 90/60 mmHg. DHP was initiated with activated charcoal (Hemosorba, Asahi Medical Co.). Sixty min after initiation, he became irritable, and 75 min after initiation, DHP treatment was discontinued. After DHP, serum QTP, PMZ, and VPA levels decreased from 169 to 139 ng/mL, 55.2 to 42.5 ng/mL, and 95 to 73 μg/mL, respectively. The clearance of QTP, PMZ, and VPA was 117.5, 126.7, and 96.8 mL/min, respectively. Within 4 hrs after DHP, the patient became alert, and was discharged on day 2. Our case indicated that the effective removal of QTP, PMZ, and VPA by DHP was associated with clinical improvement.

View full abstract

We evaluated three chronic hemodialysis patients who were treated with percutaneous coronary intervention (PCI) or coronary surgery in a 3-month exercise-based cardiopulmonary rehabilitation program. A 57-year-old and a 58-year-old female underwent PCI, and a 63-year-old-male received a coronary bypass graft (CABG). Cardiopulmonary exercise testing (CPX) was performed using breath-by-breath gas sampling on two occasions：before and 3 months after rehabilitation. The anaerobic threshold (AT), exercise time, oxygen uptake (VO₂), Barthel index, and vitality index were measured. The AT, exercise time, peak VO₂, and vitality index increased in 3 patients. The Barthel index did not change from the baseline. Cardiovascular exercise with CPX should be considered in chronic hemodialysis patients undergoing coronary intervention. Further research is needed to develop appropriate methods for cardiovascular rehabilitation and evaluate the long-term effects of cardiovascular exercise on the aerobic capacity, physical functioning, and quality of life.

View full abstract