Nowadays, patients who undergo dialysis are older and the duration of dialysis is longer. It is important for patients on dialysis to maintain their activities of daily living (ADL). We designed an intra-dialytic resistance exercise program by self-training, and accumulated and analyzed the clinical information of patients who underwent our exercise program over six months. Nine patients at NTT Medical Center Tokyo, whose intra-dialytic hemodynamics was stable, were included in our study. The strengths of pectoralis major and quadriceps femoris were significantly increased. In addition, the results of some physical function tests, such as natural walking speed, maximum walking speed, 30-second sit-and-stand test and 5-time sit-and-stand test, were also significantly improved. We designed an intra-dialytic resistance exercise program by self-training, which was effective to strengthen muscles and improve physical function.

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【Objectives】This study aimed to clarify the incidence and risk factors for catheter-related bloodstream infection (CRBSI) in hemodialysis patients. 【Methods】Hemodialysis patients using catheters for a short term were analyzed by a prospective cohort study from November 2009 to the end of March 2012. The subjects were divided into three groups by incidence : confirmed CRBSI group, suspected CRBSI group, and non-CRBSI group. We analyzed patient-related factors, relative risk (RR), and prognosis. 【Results】Sixty-one subjects were analyzed, with 4 subjects in the confirmed CRBSI group, 12 in the suspected CRBSI group, and 45 in the non-CRBSI group. After analyzing the patient-related factors, significant differences were observed in terms of gender, diabetes mellitus, and the duration of catheter placement (p<0.05), as well as hemoglobin (Hb) and albumin (Alb) values (p<0.01). RR was determined for five items and the values are shown as RR[95% confidence interval (CI) ] : duration of placement (≥5 days) : 0.495 (0.259-0.946), male gender : 1.406 (1.104-1.792), diabetes mellitus : 1.377 (1.036-1.832), Hb values of less than 7.3 g/dL : 2.812 (1.608-4.918), and Alb values of less than 2.4 g/dL : 3.375 (1.780-6.398). There was significantly poor prognosis in the CRBSI group at 1 year after catheter removal (p<0.05). 【Conclusion】It can be concluded that the patient risk factors are gender (male), diabetes mellitus, malnutrition, and anemia, which resulted in the incidence of CRBSI having an impact on life prognosis. The risk for CRBSI was rather small upon a longer duration of placement (5 days or more), so strict adherence to infection prophylaxis, particularly at the time of catheter placement, is required.

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With the rise in the numbers of patients with diabetes and long-term dialysis patients, an increasing number of patients are experiencing hypotension or unstable circulatory dynamics during maintenance hemodialysis treatment. Because dialysis patients show marked fluctuations in their body fluid levels, monitoring circulatory dynamics is important in carrying out hemodialysis safely. This study evaluated circulatory dynamics during hemodialysis using a body composition analyzer and a noninvasive cardiac output monitor. We measured body composition values and stroke volume before, at the initiation of, every hour during, and after 5-hour dialysis in seven patients (one man and six women ; mean age, 61 years) with chronic kidney disease undergoing thrice-weekly maintenance hemodialysis. Human atrial natriuretic peptide levels, serum dopamine levels, and blood pressure were also measured, and their relationships with the body composition values and stroke volume were examined. The extracellular fluid and edema rates as well as stroke volume were significantly lower at the three-hour mark during hemodialysis than before the initiation and each showed a positive correlation with the rate of change of circulating blood volume. Blood pressure showed no correlation with either body composition values or stroke volume. The pulse rate showed a negative correlation with the circulating blood volume change rate and a positive correlation with the serum dopamine concentration. This study reveals that a body composition analyzer and a noninvasive cardiac output monitor offer effective techniques to monitor the rate of change of blood volume and hemodynamics during hemodialysis. It also suggests that these tools could be useful in setting dry weight in dialysis patients. Moreover, it shows that, during dialysis, blood pressure does not fluctuate immediately with changes in body composition values and stroke volume, and that the pulse rate possibly fluctuates more immediately than blood pressure with changes in the circulating blood volume rate.

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The prevalence of human immunodeficiency virus (HIV) infection among people affected by end-stage renal disease has already been reported in Western countries. However, little is known about the prevalence of HIV infection in chronic dialysis patients in Japan. We performed a cross-sectional nationwide study from October to December 2012, using a questionnaire to inquire about the current number of patients undergoing maintenance dialysis therapy. The response rate was 50.7% (1,951/3,845 facilities). The prevalence of HIV infection among Japanese chronic dialysis patients was estimated to be 0.024% (42/176,839 patients), including 4 patients on continuous ambulatory peritoneal dialysis. A total of 96 dialysis facilities (4.9%) had accepted HIV-positive dialysis patients, and the majority were in the Kanto region. Among these facilities, 78.1% were ready to accept new HIV-positive dialysis patients. In contrast, among the 1,851 dialysis facilities with no past experience of accepting HIV-positive dialysis patients, 55.3% were reluctant to accept them. The main reason to refuse the medical request with referral for follow-up was a lack of knowledge on how to manage HIV-infected individuals undergoing chronic dialysis therapy.

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Little data are available regarding the course of residual renal function (RRF) and the predictors of RRF loss in hemodialysis (HD) patients. We evaluated the decline of RRF after the initiation of HD and the related clinical variables in 25 maintenance HD patients (male 17, female 8 ; age, 68±12 years ; observational period, 41±19 months). The incidences of RRF loss defined by urinary volume (UV) of less than 200 mL/day were 12.9% at 2 years, 40.7% at 3 years, and 88.6% at 5 years. A multivariate regression model showed that the rate of change in dry weight during 24 months after the initiation of HD was significantly associated with changes in UV (β=0.54, p=0.005, R²=0.70) and changes in estimated glomerular filtration rate defined by the average values of creatinine clearance and urea clearance (β=0.54, p=0.06, R²=0.39), respectively. Cox proportional hazard model showed that urinary protein excretion, the rate of change in dry weight during 24 months after the initiation of HD, and the initial UV were factors independently associated with RRF loss (hazard ratio, 3.30 (95%CI, 1.46-7.46), 0.84 (0.71-0.99), 0.995 (0.991-0.999), p=0.004, 0.04, 0.007). In conclusion, proteinuria, the change in dry weight, and initial urinary volume were significantly associated with RRF loss in maintenance HD patients. Additional studies regarding the influence of volume status and nutritional status on RRF loss in maintenance HD patients are necessary.

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【Objectives】To characterize uremic xerosis (dry skin) and pruritus, which are common complications in hemodialysis patients, and to evaluate the possible relationship between them. 【Methods】The prevalence and intensity of pruritus were assessed by a questionnaire survey including a visual analog scale in 450 chronic hemodialysis patients. The skin water contents at the forearm inside part and the lower back were also measured. We analyzed the relationship between pruritus and skin water content in conjunction with blood chemistry data.【Results】The overall prevalence of pruritus was 65.6% in all hemodialysis patients. The median value of arm water content was 30.9% and positively correlated with the back water content (31.2%). In contrast, the arm and back water contents did not show any relationship with gender, age, hemodialysis duration, presence of diabetes, presence of pruritus, frequency of pruritus, intensity of pruritus, presence of sleep disturbance, medication for pruritus, presence of topical cream usage nor satisfaction rating for medication. Multiple regression analysis showed that male gender, presence of diabetes, and post-dialysis serum uncorrected Ca levels were significantly and positively correlated with the presence of pruritus. Another multiple regression analysis showed that post-dialysis serum Na levels and pre-dialysis serum corrected Ca levels were selected as variables that significantly correlate with water content. 【Conclusion】Skin water content does not correlate with the presence or intensity of pruritus in chronic hemodialysis patients.

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Anemia is a common complication associated with hemodialysis and is usually managed by treatment with erythropoiesis-stimulating agent (ESA). However, some patients remain hyporesponsive to a high dose of ESA despite adequate iron therapy. Reduced free carnitine and elevated acylcarnitine have been implicated as factors potentially contributing to ESA hyporesponsiveness in some cases. Decrease in free carnitine (27.2 μmol/L) and increase in acylcarnitine/free carnitine ratio (0.42) were observed in a 77-year-old male maintenance hemodialysis patient. Supplementation of L-carnitine at 600 mg/day remarkably improved the hyporesponsiveness to ESA. The patient's hemoglobin level increased gradually after six months of L-carnitine supplementation (8.5±0.73 to 9.7±0.43 g/dL). The patient's hemoglobin level remained stable (11.52±0.51 g/dL) for up to eighteen months of L-carnitine therapy. Weekly ESA (Darbepoetin alfa) dose administration decreased considerably, from 1.1 μg/kg/week to 0.52 μg/kg/week.

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