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【Background】Acute kidney injury (AKI) is usually determined by the elevation of serum creatinine level, but this is not suitable for therapeutic decision-making and the early diagnosis of AKI. It has been reported that urinary NGAL is useful in the early diagnosis of AKI and it is likely to be a predictor of continuous hemodiafiltration (CHDF) enforcement, but its usefulness is not clear. 【Purpose】To assess the usefulness of urinary NGAL as a marker to predict the enforcement of acute blood purification therapy. 【Methods】Case-control study. A total of 111 patients who were admitted to the ICU of our hospital from August 2011 to June 2012 and whose urinary NGAL was available were enrolled in this study. We compared the urinary NGAL values in the CHDF group (n=34) and the non-CHDF group (n=77). 【Results】Urinary NGAL at admission to the ICU was markedly higher in the CHDF group, 2,880±802 ng/mL, than in the non-CHDF group, 239±124 ng/mL. When the urinary NGAL value was available at admission, the cut-off value was 76 ng/mL. Its sensitivity for CHDF enforcement was 97.1％, but its specificity was 77.9％. When the maximal urinary NGAL value from admission to the 5th hospital day was available, the cut-off value was 500 ng/mL. It showed a strong association with CHDF enforcement. Its sensitivity was 89.6％ and its specificity was 97.1％. 【Conclusion】Urinary NGAL has the potential to help us determine whether to start CHDF or not, as an early diagnostic marker for AKI onset.

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Even among CKD-MBD (chronic kidney disease-mineral and bone disorder) cases, secondary hyperparathyroidism is one of the serious complications in hemodialysis patients. In recent years, its medical treatment has progressed. Calcium carbonate, vitamin D receptor activator, sevelamer hydrochloride, lanthanum carbonate, and cinacalcet hydrochloride are usually acceptable. However, in some patients, advanced secondary hyperparathyroidism is refractory to medical treatment, so surgical treatment is indicated. We experienced a hemodialysis patient who required parathyroidectomy (PTx) for advanced secondary hyperparathyroidism and for whom we performed PTx with intraoperative PTH monitoring. This patient was a 62-year-old woman for whom hemodialysis had been introduced in 1986 due to chronic nephritis. She then underwent a kidney transplant in 1987 and hemodialysis was restarted in April 1997. Thereafter, from 2012, a gradual increase of intact PTH level was observed, reaching a high value of 1,137 pg/mL in March 2013. PTx was performed with intraoperative PTH monitoring during surgery. From a preoperative value of 1,010 pg/mL, intact PTH level decreased to 103 pg/mL 10 minutes after the whole parathyroid glands had been removed. We conclude that intraoperative PTH monitoring can be useful to recognize whether the whole glands can be removed.

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Helicobacter cinaedi is a bacterium in the family Helicobacteraceae that causes mainly enteric and bloodstream infections. A relatively large proportion of patients with chronic kidney disease have H. cinaedi bacteremia, as they are immunocompromised. However, there are a few reports of cyst infection and bacteremia by H. cinaedi in patients with polycystic kidney disease (PKD). A male patient in his 50s with PKD who was receiving hemodialysis developed a high fever and abdominal pain. He had experienced a similar episode 2 years before the current admission, and levofloxacin had effectively improved his symptoms. This time, fluoroquinolone antibiotics did not improve his symptoms, and H. cinaedi was detected in his venous blood after 14 days of culture. Meropenem controlled his infection until neutropenia was induced by it. After other antibiotics failed to show a clear effect, the patient was examined by CT, diffusion-weighted MRI, and Ga-67 scintigraphy; however, no infected cysts could be identified as targets for injection with antibiotics. After drainage, minocycline was percutaneously injected to 3 randomly selected cysts for 1 week, and the symptoms remitted. The characteristics of H. cinaedi include its poor culturability, the need for more than 10 days for its detection, and its tolerance to antibiotics. Primary treatment by fluoroquinolones in accordance with the guidelines of the Japanese Society of Nephrology may not necessarily lead to a favorable response. In the case of refractory cyst infections, H. cinaedi should be considered as a causative pathogen, and a long observation period should be expected for its detection. Furthermore, not only antibiotic therapy but also interventional treatment should be considered in the early phase of its clinical course.

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