[in Japanese]

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[in Japanese]

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The protein intake standard for hemodialysis patients receiving hemodialysis, 1.0-1.2 g/kg/day, is higher than that recommended for healthy individuals because of protein and amino acid leakage and nutrition disorder due to hemodialysis. Meanwhile, high protein intake increases phosphorus and potassium intake to cause hyperphosphatemia or hyperpotassemia. Optimal protein intake for hemodialysis patients was studied from the viewpoint of physical and mental health sciences. Thus, the authors studied the possibility of protein intake of less than 1.0 g/kg/day for controlling serum phosphorus and serum potassium and maintaining nutrition status, and the mental stress of the patients caused by decreased protein intake. For one year from July 2000, 77 hemodialysis patients were studied by dividing by their normalized protein catabolic rate (nPCR in g/kg/day), calculated from their annual blood data to represent their protein intake, into the groups of nPCR from 0.6 to less than 0.8, from 0.8 to less than 1.0, and 1.0 or higher. The patients in the groups were compared in terms of their physical background and mental state. No significant difference was found in the age, dialysis history, BMI, energy intake and serum albumin between the groups, while the serum phosphorus, urea nitrogen and serum potassium decreased with decreasing nPCR. No significant difference was found in their mental state represented by the State-Trait Anxiety Inventory and the Sense of Coherence; thus, mental stress due to restricted protein intake was not observed. The Kidney Disease Quality of Life instrument showed better scores in social functioning, mental health, effect of kidney disease and burden of kidney disease in the group with low nPCR. Protein intake of less than 1.0 g/kg/day was estimated to be appropriate both physically and mentally for hemodialysis patients.

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Infection is known to account for 20～30% of the causes of death in hemodialysis (HD) patients in Japan. Peripheral blood mononuclear cells (PBMC) obtained from HD patients were reported to decrease interferon (IFN)-γ mRNA expression stimulated with phytohemagglutinin (PHA). As zinc is involved in the control of immunity through intracellular signal transduction, zinc administration could be expected to promote IFN-γ production from PBMC in HD patients. We administrated zinc (34 mg/day) orally for 16 weeks to 14 HD participants with serum zinc of less than 65 μg/dL, and investigated the changes of IFN-γ production from PBMC stimulated with PHA by measuring the number and mean gray value of spots, which reflect the status of IFN-γ-producing cells, using the images obtained from the positive control in T-SPOT^®.TB kit (Oxford Immunotec, Inc.). Serum zinc increased significantly at 5 weeks (p<0.01 vs. baseline) and remained unchanged. Although we found no changes in the number of spots at 4 weeks, a significant decrease was shown at 12 weeks (p<0.05 vs. baseline, 4 weeks). Although we found a significant decrease in the mean gray value of spots at 4 weeks (p<0.05 vs. baseline), we found significant increases at 8 weeks (p<0.05 vs. 4 weeks) and 12 weeks (p<0.01 vs. baseline, 4 weeks, 8 weeks). In 20 HD patients without zinc administration, a decrease of the number and an increase of the mean gray value were observed. Therefore, zinc administration in HD patients for 4 weeks would be expected to promote innate immunity by the increase of IFN-γ production from PBMC, although longer administration might have a risk of decreasing IFN-γ production.

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Although ultrasound is useful as an adjunctive method for diagnosing peritoneal dialysis catheter tunnel infection, precise ultrasound images of catheters have not been published. In order to obtain precise ultrasound images and clarify scanning techniques, a simulation study was performed. To simulate a catheter without infection, a catheter was placed horizontally in a gelatin simulator and observed using an ultrasound machine with a linear probe. The tube of the catheter was visualized as four dots or arches with a short-axis view, and four parallel lines with a long-axis view. The cuff of the catheter was visualized as a hyper-echoic crescent with a short-axis view, and a bold line with a long-axis view with a prominent acoustic shadow beneath it. To simulate tunnel infection, a layer of water was added around the catheter, creating a surrounding hypo-echoic area. When the probe was angled at approximately 12 degrees, the hypo-echoic area became almost unidentifiable. The area, however, became visible again by adjusting the ultrasound beam to be perpendicular to the catheter with a short-axis view. Similar findings were observed in patients with or without tunnel infection. As detecting any hypo-echoic area around the catheter is crucial for the sonographic diagnosis of tunnel infection, it is necessary to adjust the angle of the ultrasound probe with a short-axis view. Although further reports should be accumulated to determine the sonographic criteria for tunnel infection, the simulation was useful for clarifying basic ultrasound images of the peritoneal dialysis catheter.

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【Introduction】Percutaneous transluminal angioplasty (PTA) is necessary to maintain vascular access but is also a painful procedure for hemodialysis patients. Therefore, we decided to use midazolam for pain relief during the procedure, and assessed its safety and effectiveness.【Objective & Method】We used midazolam during PTA for 44 cases (22 outpatients) from August 2013 to May 2014 at Tosei General Hospital. Patients and physicians evaluated the pain assessed by Visual Analog Scale (VAS). We investigated complications, appropriate dosage for dialysis patients, and medication interaction.【Results】Midazolam provided significant pain relief (82±18 mm vs. 11±32 mm ; p<0.001). All patients except one wanted further midazolam administration. Physicians assessed the pain as being more severe than the patients did (38±38 mm vs. 15±25 mm ; p<0.01) The average dosage of midazolam was 0.06±0.02 mg/kg, and patients using sleep medication required a significantly larger dosage (p<0.05). Complications were glossoptosis or reduction in SpO₂ (9 cases) and restlessness (2 cases), but no serious complications occurred.【Conclusion】Midazolam is safe for dialysis patients, and it is effective for pain relief during PTA.

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Consumption of Amanita virosa is a medical emergency requiring hospitalization. No definitive antidote for it is available. A man in his 50s with fulminant hepatitis was transferred to our hospital. He had hepatic encephalopathy grade 3, highly raised liver enzymes and hemoconcentration. It was suspected that the liver dysfunction was due to mushroom poisoning, since he had consumed Amanita virosa 2 days previously. In order to absorb Amanita toxin, which is highly toxic, repeated doses of activated carbon were applied, while treating the dehydration resulting from fluid loss. In addition, acute blood purification therapy that included plasma exchange (PEX) and high-flow-high-volume hemodiafiltration (hf-hv HDF) was performed for the toxin and high polymer removal with liver failure treatment. Two days after starting the PEX, % prothrombin improved. The hepatic encephalopathy improved five days after trarting the hf-hv HDF. The liver atrophy was slight as determined by computed tomography, and liver enzymes were normalized. He left the hospital 9 days after hospitalization. Blood purification therapy in cases of Amanita virosa poisoning is still controversial. However, the present study showed that it was effective against fulminant hepatitis due to Amanita virosa poisoning. The reason why it was effective was that the blood purification therapy was started within 48 hours of poisoning onset. This outcome suggested that immediate blood purification therapy is more likely to be effective when Amanita virosa poisoning is suspected.

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A 71-year-old woman had been on hemodialysis with heparin for end-stage renal failure due to chronic glomerulonephritis since 1996. She was found to have necrosis of her left toe on the day of hemodialysis in May 2013. The platelet count was 49,000/μL (the prior month' s count, 189,000/μL) and the CK value was 1,074 U/L. Contrast-enhanced CT showed the maintenance of blood flow up to the popliteal artery. The posterior tibial and dorsalis pedis arteries were identified on Doppler ultrasonography. We therefore considered the occlusion to be localized at the level of the toe. A test for heparin-induced thrombocytopenia (HIT) antibody was strongly positive. On the basis of these findings, typeⅡ HIT complicated by acute arterial occlusion of the lower extremity was diagnosed. After admission, heparin was discontinued, and the patient was treated with continuous infusion of argatroban. On hospital day 4, she underwent amputation of the left lower extremity. Although her platelet count gradually increased, HIT antibody remained positive during the course of treatment. The patient underwent regular hemodialysis with the administration of argatroban. The patient was discharged on hospital day 70. The incidence of typeⅡ HIT in the introduction phase of hemodialysis is reportedly 3-4%. However, since typeⅡ HIT is a rare occurrence in the maintenance phase, we report this case with a review of the relevant literature.

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