Parathyroidectomy is necessary in treatment-resistant cases of renal hyperparathyroidism. Although the number of patients undergoing parathyroidectomy has decreased since the approval of cinacalcet, parathyroidectomy is still necessary in some cases. However, some patients do not undergo parathyroidectomy as recommended by the guidelines because of prognostic, cost, or surgical issues. In this study, we examined the predictors of parathyroidectomy by comparing cases that led to parathyroidectomy with cases in which conservative treatment continued to be employed. As a result, it was suggested that a serum intact parathyroid hormone value of 308.05 pg/mL at one year after cinacalcet use might be a useful cut-off value for determining the necessity of parathyroidectomy.

【Background/Aim】Both total renal volume and the grade of renal dysfunction might influence the exacerbation of renal cyst infections associated with autosomal dominant polycystic kidney disease (ADPKD). However, the pathophysiological interaction between these two factors remains obscure. In this study, we compared the roles of the two factors on the resistance of renal cyst infections to antimicrobial therapy in ADPKD. 【Method】Of the 44 patients with ADPKD that were hospitalized at our institution between 2006 and 2011, the cases of patients with renal cyst infections were investigated retrospectively. On the basis of the guidelines for chronic kidney disease (CKD), we evaluated the stage of renal dysfunction and analyzed whether differences in renal volume affected treatment resistance within the same stage of renal dysfunction. 【Results】Of the 44 patients with ADPKD, we treated 14 patients for renal cyst infections, who were admitted a total of 24 times. In all of the patients with stage 3 or 4 CKD, antimicrobial therapy was effective against their renal cyst infections. In contrast, antimicrobial therapy was not effective (due to treatment resistance) in 7 of the 12 patients with stage 5 or 5D CKD, and two of them eventually died. In the 12 cases of stage 5/5D CKD, the mean expected renal volume of the 7 patients that exhibited treatment resistance was 3,550 cm³ , whereas that of the other 5 patients was significantly smaller (1,985 cm³, p=0.03). 【Conclusion】Regarding the effects of treatment on renal cyst infections associated with ADPKD, renal volume and the grade of renal dysfunction might have independent effects on prognosis.

【Objectives】 To examine the influence of the prescribed phosphate binder pill burden on medication adherence and serum phosphorus levels in Japanese hemodialysis patients. 【Methods】Adherence to phosphate binders was assessed using a questionnaire in 229 chronic hemodialysis patients that were being treated with phosphate binders. We analyzed the relationships between the number of monthly prescribed phosphate binder pills and adherence according to the questionnaire or other patient characteristics including the serum calcium, phosphorus, or intact parathyroid hormone level. 【Results】The median monthly pill burden was 210 pills, and 50% of the patients were receiving monotherapy. The higher pill burden group exhibited a younger age, a longer hemodialysis vintage, and higher serum phosphorus levels. A positive linear relationship was also observed between the number of phosphate binder pills and the serum phosphorus level. Approximately 30-40% of the patients were non-adherent. The patients that forgot to take the pills, had pills remaining, or wanted to reduce the number of pills they were taking exhibited a higher pill burden and higher serum phosphorus levels. In addition, the proportions of patients that had pills remaining or felt that they were taking many/too many pills rose as the number of prescribed pills increased. Furthermore, more non-adherent patients felt that they were taking many/too many pills compared with the adherent patients. 【Conclusion】The prescription of a higher number of phosphate binder pills is associated with lower medication adherence and worse serum phosphorus control.

【Background】 Acetate intolerance (AI) and symptomatic hypotension (SH) during hemodialysis have become problems among patients undergoing dialysis using a bicarbonate dialysate containing low levels of acetate (8 or 10 mEq/L). 【Methods】 We analyzed the data of 391 patients who underwent 4-hour dialysis sessions 3 times a week to determine the incidence rates of AI and SH. SH was defined as dialysis-associated hypotension that required intervention, and AI was defined as a serum acetate level of ≥2 mmol/L. The subjects’ serum acetate levels were measured at 2 and 4 hrs after the start of dialysis, and the acetate load rate and acetate clearance were calculated. Factors associated with SH and those associated with the serum acetate level and acetate clearance were identified using multivariate regression analysis. 【Results】 SH was observed in 71 patients (18.2%), and AI was seen in 1 patient (0.3%). SH was associated with diabetes (odds ratio [OR], 1.92 ; 95% confidence interval [CI], 1.09-3.38 ; p=0.024) and the weight loss ratio (OR, 1.29 ; 95%CI, 1.07-1.55 ; p=0.008), but not with the serum acetate level. The subjects’ serum acetate levels reached a steady state after 2 hrs (1.000±0.325 mmol/L at 2 hrs and 1.062±0.348 mmol/L at 4 hrs). The acetate load rate was 1.51±0.48 mmol/hr/kg, which was within the acetate metabolic rate of dialysis patients. The acetate clearance rate was 1.30±0.42 L/min, which was 57% of the value seen in normal subjects. The serum acetate level and acetate clearance were associated with sex, age, and the body mass index. 【Conclusion】 Low levels of acetate in dialysate do not appear to be associated with the development of AI or SH. However, it might be necessary to reconsider the definition of AI.

The aim of this study was to clarify the incidence of protein-energy wasting (PEW) and its associations with clinical characteristics and daily nutritional intake in Japanese chronic hemodialysis (HD) patients. A total of 409 patients who had been receiving stable HD therapy for >6 months (mean age : 64±11 years, duration of HD : 8 (3-14) years, frequency of hypertension : 74.6%, body mass index : 21.1±3.4, % arm muscle area : 103±22%, serum albumin : 3.7±0.3 g/dL, energy intake : 30±6 kcal/kg ideal body weight (IBW), protein intake : 1.01±0.22 g/kg IBW) were enrolled. In total, 17.1% of the patients met ≥3 of the four diagnostic criteria for PEW determined by the International Society of Renal Nutritional Metabolism (ISRNM). Multivariate logistic analysis demonstrated that age, HD duration, and hypertension were independently associated with PEW (≥3 ISRNM criteria). Furthermore, after adjusting for these variables, meat intake of <46.7 g/day, fish intake of <41.7 g/day, and sugar intake of <9.0 g/day were determined as cut-off values associated with PEW based on receiver-operating characteristics curves [odds ratio (OR) : 2.74, 95% confidence interval (CI) : 1.55-4.85, p=0.001 ; OR : 2.04, 95%CI : 1.16-3.61, p=0.014 ; OR : 1.88, 95%CI : 1.05-3.37, p=0.033, respectively]. Poor protein or energy intake might be associated with PEW in chronic HD patients.

This prospective 12-week study aimed to evaluate the changes in the levels of inflammatory and oxidative stress markers after the administration of ferric citrate hydrate (FCH) and to determine whether the serum hepcidin-25 level could serve as a prognostic indicator during the treatment of anemia with FCH. The serum levels of inorganic phosphorus, hemoglobin (Hb), iron, erythropoiesis-stimulating agents (ESA), inflammatory and oxidative stress markers, and serum hepcidin-25 together with the erythropoietin resistance index (ERI) were studied in both the FCH treatment group (1,500 mg/day FCH) and control group (who were administered a phosphate binder other than FCH). The patients that exhibited changes of <10% in their serum hepcidin-25 levels were designated the “invariant group”, whereas those that exhibited changes of >10% in their serum hepcidin-25 levels were designated the “gain group”. In the FCH group, significant increases in the serum ferritin level and significant reductions in the ERI and the serum ESA level were observed after the administration of FCH. There were no significant changes in inflammatory or oxidative stress markers in either group. The invariant group exhibited significantly higher Hb levels than the gain group (2.2±0.4 vs. −0.6±1.4 g/dL, respectively ; p=0.0105). Therefore, the serum hepcidin-25 level could be a novel prognostic marker of the increase in the Hb level induced by the administration of FCH.

The patient was a 50-year-old female who had been receiving dialysis for 21 months. She had hepatitis C virus-related liver cirrhosis (Child-Pugh B-C) and was on maintenance dialysis for hepatic glomerulosclerosis-associated end-stage renal disease. Respiratory failure occurred due to massive right-sided pleural effusion and left-sided pneumonia, and she was admitted to our department. Oxygen and antimicrobial agents were administered, a right chest drain was installed, and the pleural effusion was drained. The left-sided pneumonia improved, and the amount of the pleural effusion passing through the drain decreased on the 14th hospital day. The chest drain was removed on the 20th hospital day, but the massive right-sided pleural effusion reappeared after 3 days and so the chest drain was re-inserted. Leaking pleural effusion was noted during pleural effusion testing, a bacterial culture was negative, cytology was negative, and no left cardiac dysfunction or abnormal wall movement was detected during echocardiography. Based on these findings and the patient’s clinical course, she was diagnosed with hepatic hydrothorax. The patient’s pleural effusion remained intractable and so pleurodesis was selected. The pleurodesis succeeded after it was applied twice using 4 g of talc and once using OK432 5KE, and no further accumulation of pleural effusion around the right lung was seen. Hepatic hydrothorax is often treatment-resistant in dialysis patients, and pleurodesis might be a useful option in such cases.