【Background】Intradialytic hypotension is associated with a risk of mortality in patients undergoing hemodialysis. The second-order derivative of plethysmogram (SDPTG) is a sensing tool that monitors cardiac functions such as cardiac output and peripheral vascular resistance. In the present study, the relationship between hypotension and the SDPTG waveform during dialysis was investigated.【Method】Eighty-one patients undergoing hemodialysis were investigated in this study. Blood pressure (BP), SDPTG, and the changing rate of blood volume (⊿BV) were measured in pre-, intra-, and post-hemodialysis sessions. Hypotension was defined as a >40 mmHg decrease in systolic BP. The waveform of SDPTG consists of the a, b, c, and d waves in systole and the e wave in diastole. We categorized the waveform by the height of the waves : the c wave was higher than the d wave (typeⅠ), the c wave was lower than the d wave (typeⅡ-a), and the c wave disappeared from the waveform (typeⅡ-b). Logistic regression analysis was used to assess the effect on hypotension of the SDPTG waveform during hemodialysis.【Result】Hypotension occurred 33 times among the 360 BP measurements in intra-hemodialysis. The BPs of the typeⅡ-a and Ⅱ-b groups were significantly lower than that of the typeⅠ group. The typeⅡ-b group showed significantly lower BP than the typeⅡ-a group. The occurrence rates of IDH were 4.7% (reference), 15.8% (odds ratio (OR) 3.03 ; 95% confidence interval (CI) 1.1 to 7.9), and 40.7% (OR 9.5 ; 95% CI 3.3 to 27.1) in the typeⅠ, Ⅱ-a, and Ⅱ-b groups, respectively. 【Conclusion】The changes in waveform on SDPTG were associated with BP variations during a dialysis session. These results suggest that SDPTG is useful as an indicator of intradialytic hypotension.

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We evaluated the validity of calf circumference (CC) measurement for nutritional assessment in 59 maintenance hemodialysis (HD) patients (male 38, female 21 ; age 71±11 years ; dialysis duration 63±43 months). The correlations with other nutritional parameters were examined. Receiver operating characteristic (ROC) curve analysis was performed to identify the cut-off levels of anthropometric parameters for predicting a Geriatric Nutritional Risk Index (GNRI) of less than 91.2. The changes in the nutritional parameters including CC during 6 months were examined in 50 patients. CC was 30.6±3.5 cm, and significantly correlated with age, body mass index, arm circumference (AC), triceps skinfold (TSF), prealbumin, albumin, and GNRI. Multivariate stepwise regression analysis showed that age, body mass index, and prealbumin were significant determinants of CC (β=−0.27, 0.71, 0.21, p=0.002, <0.001, 0.01, R²=0.71). The cut-off value of CC for predicting GNRI of less than 91.2 was 29.9 cm (sensitivity 77.4%, specificity 60.7%), and the area under the ROC curve was almost the same as that of AC (CC : 0.74 (95% confidence interval : 0.61～0.87), AC : 0.73 (0.60～0.86)). The change in CC during 6 months was−2.3±2.6%. Significant correlations were found between the changes in dry weight, AC, and GNRI, and the change in CC. Multivariate stepwise regression analysis showed that gender, and the changes in dry weight and GNRI were significant determinants of the change in CC (β=−0.29, 0.35, 0.33, p=0.03, 0.02, 0.02, R²=0.38). These results suggest that CC measurement could be a tool for nutritional assessment in HD patients.

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Maintenance of an appropriate body fluid volume in hemodialysis patients is important for reduction of the risk of CVD events and improvement of prognosis. We evaluated overhydration (OH) in healthy controls and hemodialysis (HD) patients using a bioimpedance spectroscopy device cross-sectionally. In the present study, 219 healthy controls (mean age 68.8±8.4 years, 69 men) and 64 HD patients (61.7±12.8 years, 37 men) were enrolled. The average OH of healthy controls was 0.70±0.78 L, and 76.3% of them were within the healthy reference range (−1.1-1.1 L). Before and after HD, OH was 2.9±1.5 L and 0.6±1.7 L, respectively. The amount of ultrafiltration was significantly correlated with the absolute change of OH before and after HD (r=0.61, p<0.05). Before and after HD, OH was not significantly associated with blood pressure or cardiothoracic ratio before HD. After HD, OH was significantly associated with ANP level after HD (r=0.48, p<0.05). Patients with HD were divided into 3 groups based on ANP level after HD (higher>60 pg/mL, median 40-60 pg/mL, lower<40 pg/mL) ; mean OH after HD was significantly different (p<0.05). In conclusion, these data suggest that a bioimpedance spectroscopy device could be useful to evaluate fluid status in patients with HD. We need to perform further studies to assess the relationship between OH and cardiac function. We also need to investigate the usefulness of OH in terms of evaluating over-volume regardless of cardiac function and predicted survival.

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A 77-year-old woman was admitted to our hospital because of exacerbation of cardio-renal failure, hyperkalemia, and third-degree atrioventricular block. The patient had been suffering from chronic heart failure due to ischemic cardiomyopathy, nephrosclerosis, and chronic pulmonary abscess, and was started on chronic hemodialysis therapy twice a week. However, her urine volume decreased to less than 300 mL per day, a year after starting hemodialysis. We subsequently administered tolvaptan at 15 mg in addition to furosemide and indapamide. This resulted in a remarkable increase in urine volume to more than 1 L per day. The increase of body weight between hemodialysis treatments was less than 1 kg, and her blood pressure and performance status were improved. This effect on water diuresis has been continuing for more than 2 years. The combined therapy of sodium diuretics and tolvaptan may be effective in patients with CKDG5A3-associated chronic heart failure, resulting in the production of sufficient amounts of urine, and in patients continuing hemodialysis therapy twice a week.

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We report a case of a type 2 diabetic patient with end-stage renal disease (ESRD) who experienced repeated pyrexia after each hemodialysis session due to acetate intolerance. A 62-year-old man with type 2 diabetic kidney disease was admitted to our hospital for dialysis initiation. Since the first dialysis session, he had experienced general malaise and fever with temperatures of 37～39℃ after dialysis. On the basis of intensive laboratory examinations, no evidence suggestive of the presence of infection, cancer or collagen diseases was demonstrated. The endotoxin concentration in the dialysate was within the acceptable range. Changes of the dialyzer membrane and anticoagulant agent were unsuccessful. Finally, we changed from bicarbonate dialysate containing a small amount of acetate to completely acetate-free dialysate, which effectively led to disappearance of the pyrexia. Given the clinical course, the cause of the pyrexia was considered to be acetate intolerance. We need to add acetate intolerance to the list of differential diagnoses of pyrexia associated with hemodialysis.

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Case 1 : A 54-year-old woman on maintenance hemodialysis for chronic interstitial nephritis developed cystitis and received oral levofloxacin (LVFX). Four days later, she developed severe pain in her bilateral Achilles tendon and bilateral extensor and flexor tendons of the thumb. We diagnosed LVFX-induced tendinopathy. Two months after the discontinuation of LVFX, pain of the upper limbs improved, and all symptoms had disappeared completely four months later. Case 2 : A 79-year-old man on maintenance peritoneal dialysis for chronic glomerulonephritis had taken oral steroid for eosinophilic peritonitis. He received oral LVFX due to peritoneal dialysis-associated peritonitis. Four days later, he developed severe pain in his right Achilles tendon. Magnetic resonance imaging revealed Achilles tendon rupture, so achillorrhaphy was performed. Unfortunately, two months after surgery, Achilles tendon rupture relapsed. Case 3 : An 82-year-old man on maintenance hemodialysis for hypertensive nephrosclerosis developed sepsis and received oral LVFX. The next day, bilateral Achilles tendon pain appeared and persisted for two weeks under LVFX therapy. This pain disappeared one week after the withdrawal of LVFX. Fluoroquinolone-induced tendinopathy is less well known and has risk factors such as old age, steroid use, and chronic renal failure.

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