The Committee on Diabetic Nephropathy revised the classification of diabetic nephropathy in view of the current status of eGFR and CKD in Japan. To make revisions for the classification of diabetic nephropathy 2014, the Committee carefully evaluated the report of the Research Group on Diabetic Nephropathy, Ministry of Health, Labour, and Welfare of Japan. The major revisions made were as follows : 1. eGFR can be used for the evaluation of GFR ; 2. In stage 3 (overt nephropathy), A and B were combined; 3. Stage 4 (renal failure) was defined as GFR less than 30 mL/min/1.73 m², regardless of albuminuria ; and 4. The importance of differential diagnosis was stressed in all stages.

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【Purpose】 The aims of this study were to clarify the determinant factors of daily physical activity, the relationship between the method of ambulation and physical activity, and mobile function in patients with hemodialysis therapy. 【Methods】We studied 53 patients (34 males and 19 females, mean age 62±3 years) who underwent ambulant hemodialysis therapy. We assessed Comorbidity Index, Geriatric Nutrition Risk Index (GNRI), Mobile Function Scale, and Life Space Assessment (LSA) as indicators of daily physical activity. We analyzed the determinant factors of daily physical activity by multivariate regression analysis, using receiver operating characteristic curve to evaluate the cut-off points of daily physical activity and mobile function. 【Results】LSA points had negative relationships with age (r=−0.41, p<0.05) and Comorbidity Index (r=−0.30, p<0.05), and positive relationships with GNRI (r=0.48, p<0.05), vintage of hemodialysis (r=0.30, p<0.05), and Mobile Function Scale (r=0.76, p<0.05). From the results of multivariate regression analysis, Mobile Function Scale and age were positively associated with LSA points (R²=0.54, p<0.01). Additionally, the cut-off values for independent ambulation were LSA 63 points (ACU 0.861, p<0.01, 95%CI 0.760-0.962) and mobile function scale 44 points (ACU 0.912, p<0.01, 95%CI 0.835-0.990). 【Conclusion】 The determinant factors of daily physical activity were identified as age and mobile function. We recommend using the LSA and mobile function scale as screening tools to determine whether ambulation support is necessary.

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【Aim】Previous studies reported that zinc deficiency leads to various diseases. Therefore, the relationship between the serum zinc concentration and diet was assessed among patients receiving hemodialysis in our hospital. 【Methods】A cross-sectional study was performed on 39 chronic hemodialysis patients using a dietary assessment with the Food Frequency Questionnaire Based on Food Groups (FFQg) to assess its relationship with the serum zinc concentration. 【Results】 A simple regression analysis indicated that the serum concentration of zinc was strongly correlated with that of albumin (R=0.55, p<0.01), while it was weakly correlated with the total cholesterol level (R=0.32, p=0.05). A multivariate regression analysis (R=0.45) demonstrated that dietary potassium (t=3.0, p<0.01) and phosphate (t=−2.3, p<0.05) were associated with the serum zinc level. A stepwise analysis showed that, among the various components of nutritional intake, vitamin C was a major determinant of the serum zinc level (t=3.9, p<0.0001). Among the various food groups analyzed, the serum zinc level was found to be related to the intake of vegetables, potatoes, and especially fruit (t=3.2, p<0.01). 【Conclusion】The present data raise the possibility that consuming vitamin C and/or avoiding excess dietary phosphate can prevent zinc deficiency, thus providing a new strategy for improving the nutritional control of zinc.

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【Background】 The mortality of HIV-infected patients has been dramatically improved since the highly active anti-retroviral therapy (HAART) era. However, an increase in chronic dialysis patients with HIV has emerged as a new social problem, along with the increasing number of long-term survivors with HIV-infection. The mortality and clinical course of those who have undergone chronic hemodialysis (HD) are not fully understood. 【Subjects and Methods】Clinical characteristics including the status of HIV control, frequency of admission after HD initiation, mean number of days of hospitalization after HD initiation, incidences of cardiac disease, pneumonia, and cancer, and all-cause mortality were retrospectively studied in 9 HIV-infected patients. Cumulative mortality over time following the chronic HD initiation was analyzed by the Kaplan-Meier method. The Kaplan-Meier estimates were compared between HIV patients and 19 age-, gender-, and diabetes comorbidity rate-matched non-HIV CKD patients who initiated chronic HD during the study period. 【Results】Mean patient age was 53.0±8.8 years. Median follow-up period was 4.6 years (range 3.5-8.9 years). All HIV-infected patients had received HAART before the HD initiation. The 5-year cumulative survival rate over time after the HD initiation of the HIV-infected patients was 88.9%, whereas that of the control patients was 79.9% (p=0.4505). Laboratory data of HIV control parameters were well controlled during the maintenance dialysis period. Five cardiac diseases, three bacterial pneumonias, and one oropharynx cancer occurred after the HD initiation. Mean frequency of hospitalization was 2.2±1.4 times and mean number of days of hospitalization was 58.0±51.8. HIV-contaminated needle-stick injury, HIV transmission to medical staff and patients, and trouble due to harmful rumors in dialysis facilities were not reported during the follow-up period. 【Conclusions】The mortality and clinical course of HIV-infected patients after the initiation of chronic HD were better than expected.

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A 47-year-old woman, with a past history of renal transplantation about 7 years previously, returned to hemodialysis due to failed renal function in January 2012. The patient was referred to our hospital from a clinic. Her complaints included a 38-degree fever and vomiting. The symptoms were temporarily improved with antibiotics, but immediately returned upon stopping antibiotic treatment. After a diagnosis of pyonephritis in the grafted kidney, a graftectomy was performed. Pathological examination showed chronic rejection and pyonephrosis. This can be difficult to explain during hemodialysis due to deteriorated renal function following renal transplantation. Graft nephrectomy was ultimately performed in this case because pyonephrosis in the grafted kidney was the origin of the fever and was resistant to conservative therapy with antibiotics.

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Between December 2012 and November 2013, five hemodialysis patients with BPH received HoLEP. The mean age at the time of operation was 71.2 years (68-75 years), the mean urine volume was 420 mL/day (100-700 mL/day), the mean hemodialysis duration was 57.4 months (18-99 months), and the mean estimated prostatic volume was 36.8 mL (20.2-48.9 mL). Chief complaints of three cases were urinary retention, and those in the other 2 cases were nocturia and residual feeling. HoLEP was successfully performed under the condition of continuous oral anticoagulation. The mean enucleation time was 50 minutes (22-104 minutes) and the mean enucleated tissue weight was 11.8 grams (1-27 g). The mean hemoglobin loss after HoLEP was 1.8 g/dL (0-5.1 g/dL) and no patient needed blood transfusion. International Prostate Symptom Score and quality-of-life score were significantly improved 1 month after HoLEP. HoLEP has excellent hemostatic properties, and is a safe and effective procedure for hemodialysis patients with BPH.

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A 57-year-old woman was admitted to our hospital because of asthma, fever, and purpura. Sixteen years before admission, she had been diagnosed with asthma. Six years before admission, symptoms of EGPA (eosinophilic granulomatosis with polyangiitis) occurred with peripheral neuropathy and rapid progressive glomerulonephritis. Renal biopsy showed necrotizing crescentic glomerulonephritis. Immunosuppressive therapy improved her extra-renal symptoms, and resulted in normalization of her MPO-ANCA titer. However, her renal function did not recover and hemodialysis was initiated. She was treated with maintenance hemodialysis with low-dose prednisolone (PSL) without relapse for 5 years. After reducing the PSL dose from 5 mg per day to 3 mg per day because of infection, her asthma worsened and she exhibited hypereosinophilia, purpura, and fever, with an increased MPO-ANCA titer. On the basis of a diagnosis of EGPA relapse, immunosuppressive therapy, including steroid pulse therapy, was started and led to the remission of vasculitis. Although, it is very rare for patients with EGPA to be treated with maintenance hemodialysis, it is known that ANCA-associated vasculitis can occur during hemodialysis treatment. Physicians should consider the risk of a flare-up of EGPA at the time of asthma exacerbation with marked eosinophilia during maintenance hemodialysis in patients with EGPA, and then should check MPO-ANCA.

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Case 1 : A male in his 50s who had started hemodialysis for chronic renal failure with an unknown underlying disease in 1981 was taken off dialysis for renal transplantation in 1995. Hemodialysis had been reinitiated due to decreased function of the transplanted kidney in approximately August 2004. In August 2008, exertional dyspnea and epigastric pain were noted, and he was hospitalized for detailed examination. Computed tomography (CT) showed portal venous gas suggestive of intestinal ischemia. He died before surgical treatment could be performed. Case 2 : A male in his 70s had been started on peritoneal dialysis for chronic renal failure due to chronic glomerulonephritis in 1988, and was then switched to hemodialysis in 1992. In 2002, he underwent aortic valve replacement with a bioprosthetic valve. In 2008, he was hospitalized for exertional dyspnea and difficulty with fluid removal due to decreased blood pressure during hemodialysis. Severe aortic valve stenosis was noted, and acute exacerbation of cardiac failure due to worsening valvular disease was diagnosed. After hospitalization, administration of carvedilol was started. While the exertional dyspnea showed improvement, cardiac function did not. He experienced sudden abdominal pain during dialysis, and CT showed portal venous gas suggestive of intestinal ischemia. He underwent emergency surgery to remove the necrotic intestine but died 4 days later. Portal venous gas is a relatively rare condition. Hemodialysis for 20 years and significant left cardiac function failure were noted in both of our cases. We report these cases with discussion of the relevant literature.

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A 71-year-old man undergoing chronic hemodialysis due to hypertensive nephrosclerosis was admitted to our hospital because of high fever. After treatment for pneumonia, swelling of cervical lymph nodes was found. Upon examination of sputum culture, TB-PCR was negative. Biopsy specimen of the cervical lymph node demonstrated epithelioid granulomas with caseous necrosis and biopsy material revealed a positive TB-PCR result. The patient was diagnosed with tuberculous lymphadenitis. Intrahepatic nodular lesions and swelling of lymph nodes along the common hepatic artery were observed on computed tomography. Antituberculous treatment was started and continued for 6 months. All lesions improved after treatment. Latent tuberculosis infection should be considered when patients undergoing dialysis have continuous fever and high serum CRP level after the treatment of pneumonia.

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