The effects on erythropoiesis, iron metabolism, and oxidative stress of differences in iron preparation administration methods by intravenous injection were investigated for hemodialysis patients undergoing CERA treatment. The subjects comprised 20 hemodialysis patients undergoing CERA administration once in 4 weeks with sFtn below 100 mg/dL. The subjects were divided into 2 groups : those repeatedly administered Fesin^® at 40 mg 8 times, once a week, from the CERA administration date (repetitive group), and those administered it 2 times, once a week, from the CERA administration date and subsequently repeating 2-week drug withdrawal, totaling 8 administrations (non-repetitive group). Hb, Ret, sFe, TSAT, Hep-25, CHr, sFtn, sTfR, and 8-OHdG before and after administration were chronologically measured. Ret increased in both groups, peaking one week after CERA administration. The sFe, TSAT, Hep-25, and CHr values showed declining patterns 1 to 2 weeks thereafter, and then increased 3 to 4 weeks thereafter in both groups, with no significant difference between the groups. The sFtn value significantly increased following iron preparation administration compared with that before administration in the repetitive group, but not in the non-repetitive group. The value was high at weeks 3 to 9 in the repetitive group. The 8-OHdG value was significantly high but within the normal range before iron preparation administration, exhibiting no significant changes during follow-up or significant differences between the two groups. One period showed accelerated erythropoiesis following CERA administration, causing iron deficiency despite intravenous injection of the iron preparation. Such iron deficiency could not be prevented by repetitive or non-repetitive administration ; moreover, the dosage was insufficient in non-repetitive administration for supplementing stored iron. The development of an iron preparation administration method by intravenous injection conforming to CERA drug properties is required.

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【Background/Aims】Gastrointestinal bleeding (GIB) has been clarified to occur frequently in chronic renal failure patients, particularly in those undergoing maintenance hemodialysis (HD). In the present study, we aimed to examine the clinical features of HD patients who underwent emergent upper and/or lower gastrointestinal endoscopy (GIE) for the detection of GIB. 【Method】In total, the records of 44 HD patients who had undergone emergent GIE for GIB from January 2005 to December 2010 were retrospectively evaluated, including their symptoms, the diseases causing GIB, and recurrence. Furthermore, the patients were divided into 2 groups according to the hemoglobin (Hb) level at admission, including one group with Hb level <7.0 g/dL (n=22) and the other with Hb level ≥7.0 g/dL (n=22). The differences in the clinical parameters were examined between these 2 groups. 【Results】The GIB symptoms were melena in 26, hematemesis in 13, bloody stool in 4, and other in 1 patient. The diseases causing GIB were gastric ulcers in 13, angiodysplasia in 11, and primary gastrointestinal malignancy in 5 patients ; the disease associated with GIB could not be identified in 3 patients. The need for blood transfusion during admission and the frequency of taking a proton pump inhibitor or histamine H₂ receptor antagonist were significantly higher, and duration of hospitalization was also significantly longer in patients with Hb level <7.0 g/dL than in those with Hb ≥7.0 g/dL. However, no difference was noted in the frequency of the use of warfarin and/or anti-platelet therapy. Moreover, with regard to the disease causing GIB, a significant difference was noted between the 2 groups : angiodysplasia was more frequently noted as the disease causing GIB in patients with Hb level <7.0 g/dL, whereas primary gastrointestinal malignancy was more frequently noted as the disease causing GIB in those with Hb level ≥7.0 g/dL. 【Conclusion】 In HD patients undergoing emergent GIE for GIB, gastric and duodenal ulcers, angiodysplasia, and primary gastrointestinal malignancy would be frequently detected as the cause of GIB.

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Nutritional assessment and active intervention for malnutrition in patients with hemodialysis are recommended because malnutrition makes the clinical outcome worse. We examined the association between mini nutritional assessment short form (MNA-SF) and mortality in elderly patients with hemodialysis, by comparisons of malnutrition-inflammation score (MIS) and geriatric nutrition risk index (GNRI). Eighty-two patients aged ≥65 who had received hemodialysis for ≥6 months were rated with MNA-SF, MIS, and GNRI by dietitians. Cases with MNA-SF <12, MIS ≥6, and GNRI <91.2 were defined as at risk of malnutrition. All cause death was prospectively examined for 2 years. The score of MNA-SF was significantly correlated with MIS (ρ=−0.660, p<0.001) and GNRI (ρ=0.482, p<0.001). According to MNA-SF, MIS, and GNRI, 55%, 59%, and 35% of the patients were classified as at risk of malnutrition, respectively. During the follow-up period, 14 patients (17%) died. Relative mortality risks of each group were 10.7 (p=0.002), 2.6 (p=0.137), and 4.6 (p=0.004), respectively. Although the score by each method significantly predicted death in receiver operating characteristic analysis, area under the curve of MNA-SF was the largest (0.829, 95% confidence interval 0.723-0.935). Logistic analysis revealed that food intake (p=0.048) and neuropsychology (p=0.005) in MNA-SF and food intake (p=0.033) and functional capacity (0.035) in MIS were significantly associated with survival. Our study showed that MNA-SF was a significant predictor of mortality and was better than MIS or GNRI. MNA-SF should be a useful screening tool for malnutrition in elderly patients with hemodialysis.

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【Background and Aim】Carnitine deficiency may contribute to erythropoietin-resistant anemia and malnutrition, which could lead to impaired quality of life in patients with hemodialysis (HD). We examined here the effects of oral L-carnitine supplementation on renal anemia and malnutrition in HD patients. We also investigated whether switching from oral administration of L-carnitine to intravenous injection could affect serum carnitine levels in these patients.【Methods】One hundred and two HD patients (total carnitine levels<50μmol/L) were enrolled and randomized to either oral administration of L-carnitine (900 mg/day) (N=51) or control (N=51). After 6 months, anemia and clinical variables, including serum levels of carnitine, were measured. Three months after administration, serum carnitine levels were examined just before and after the HD session. Furthermore, oral L-carnitine administration was switched to intravenous injection (500 or 1,000 mg), and serum carnitine levels were examined.【Results】Oral L-carnitine supplementation for 6 months (n=23) significantly increased hematocrit, LDL-cholesterol, triglycerides, and all carnitine levels, while AST and ALT levels, and acyl/free carnitine ratio were decreased. Switching to intravenous injection therapy (1,000 mg) for 1 week dramatically increased all serum carnitine levels just before and after and 10 min after the injection. There was no change of carnitine levels by switching to 500 mg intravenous injection.【Conclusion】The present study demonstrated that oral L-carnitine supplementation might improve renal anemia and malnutrition in HD patients. Switching to intravenous injection may be beneficial as a result of increase in carnitine levels, improvement of adherence, cost-benefit, and reducing the production of trimethylamine-N oxide (TMAO).

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Elution of polyvinylpyrrolidone (PVP) from polysulfone (PS) dialysis membrane is one of the most important problems in dialysis therapy. When dialysis treatment is started, rapid measurement of PVP eluted from the PS membrane is desirable. In this study, real-time measurement of PVP using ultraviolet spectroscopy (UV-s method) was compared with the conventional iodine coloration method (Müller method). As a result, there was a significant correlation between the UV-s and Müller methods for measuring PVP concentrations of less than 10 mg/L (r=0.970, p<0.001) and also for concentrations from 10 to 100 mg/L (r=0.993, p<0.001). The PVP concentration in PS-1.6UW dialyzer washings obtained by rinsing with 0.5 L was 2.8±2.9 mg/L by the Müller method and 3.6±2.1 mg/L by the UV-s method, while the PVP concentrations after rinsing with 1.0 L were 2.0±2.1 mg/L and 3.1±0.9 mg/L, respectively. There were no significant differences between the two methods. However, as the PVP concentration accounted for most of the dialyzer washings, the UV-s value for the PVP eluted from a dialyzer is thought to be close to the real value. It is possible to perform real-time measurement of PVP by the UV-s method and PVP eluted from a PS-1.6UW dialyzer can be measured by the UV-s method.

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Blood leakage alarm is a critical incident, which means blood has directly contacted dialysis fluid without the barrier of the dialyzer membrane. Recently, even though the technology of sterilization of dialysate has been widely distributed and the level of sterilization of the dialysate has been guaranteed in many dialysis centers, the critical incident of blood leakage in dialysis centers where the sterility of dialysate is insufficiently high still occurs, which may cause endotoxin and/or bacterial contamination of blood. Here, we report a case in which, although blood leakage could be observed on the output side of the dialyzer during sounding of the blood leakage alarm, the alarm could not be canceled by changing the dialyzer, so the cause of this alarm might have been pseudo-blood leakage. A 77-year-old female had been undergoing hemodialysis (HD) due to renal dysfunction accompanied by heart failure. The mode of dialysis was 3 hours of HD and 1 hour of ECUM, for a total of 4 hours. On the day of treatment, after changing the dialysis mode from HD to ECUM, the blood leakage alarm sounded. After changing the dialyzer to another of the same type, the dialysis was resumed, but the blood leakage alarm again sounded and could not be canceled. There was no damage observed on the dialyzer membrane, and there was also no problem in terms of the condition of the sensor of blood leakage. As the blood haptoglobin was lower than 10 mg/dL, there should have been hemolysis. Therefore, this hemolysis could not have been due to hemodialysis, but would rather have been pseudo-blood leakage due to mechanical hemolysis by prosthetic heart valves. When the blood leakage alarm sounds in hemodialysis patients undergoing heart valve replacement, we may consider the possibility that this alarm has been caused by pseudo-blood leakage due to mechanical hemolysis by prosthetic heart valves.

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A 73-year-old woman, who had been receiving continuous ambulatory peritoneal dialysis (CAPD) for chronic renal failure due to nephrosclerosis since 2007, was admitted to our hospital for CAPD peritonitis. Treatment was started with intravenous cefazolin and ceftazidime, which was later administered intraperitoneally for 2 weeks. After hospital discharge, she had chronic non-bloody watery diarrhea. Clostridium difficile antigen, as detected in her watery stool, was treated with metronidazole for 2 weeks. However, her diarrhea symptoms did not improve, appetite loss occurred, and the inflammatory reaction became positive. She was admitted again for further examination to determine the cause of the diarrhea. On colon fiberscopy, her colon appeared normal. Histopathological examination, however, revealed a thickened sub-epithelial collagen band in the chronic mucosa, and a definitive diagnosis of collagenous colitis (CC) was made. CC is characterized by chronic watery diarrhea without bleeding. Recently, the number of patients with CC has been increasing in Japan. CC has often been linked to the use of non-steroidal anti-inflammatory drugs (NSAIDs), lansoprazole, simvastatin, and other drugs. In this case, lansoprazole was started 3 months before the onset of diarrhea symptoms. As lansoprazole could be a cause, it was discontinued, and then her diarrhea symptoms disappeared. Many patients on dialysis use proton pump inhibitors to prevent and treat peptic ulcers. CC, however, has seldom been reported in patients on CAPD. In conclusion, CC should be suspected if chronic watery diarrhea of unknown origin is encountered in CAPD patients, such as in the present case.

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A 49-year-old man on maintenance hemodialysis for focal glomerulosclerosis developed the symptoms of a common cold. A week later, he presented with swelling of the neck. Measurement of the thyroid hormone levels revealed increased serum levels of free T3 (5.3 pg/mL) and free T4 (1.62 ng/mL), and a decreased serum TSH level (0.021μIU/mL) ; a test for thyroid autoantibodies was negative. Thyroid gland ultrasonography revealed slight swelling and a low-echoic region in the thyroid. On the basis of these findings, we diagnosed the patient as having subacute thyroiditis, and started him on treatment with oral prednisolone (20 mg/day). One week later, the patient's general condition improved, the thyroid hormone levels normalized, and the inflammatory reaction subsided. We were able to control the subacute thyroiditis with an oral steroid on an outpatient basis, without any complications.

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