【Objectives】This study investigated the distribution of serum zinc levels and the factors related to hypozincemia in hemodialysis (HD) patients.【Methods】Serum zinc levels were measured in 518 HD patients. The relationships between serum zinc levels and patient background factors, serum biochemical factors, or drug usage were analyzed. In addition, we compared 2 groups with serum zinc levels of <60 μg/dL and ≧60 μg/dL based on the diagnostic criteria for zinc deficiency.【Results】The median serum zinc level was 59 (52-67) μg/dL. The serum zinc level was not related to age, sex, body mass index, diabetes mellitus, or the dialysis time slot (morning/afternoon/evening), but it was positively correlated with the dialysis vintage. In addition, the patients on hemodiafiltration (HDF) had lower serum zinc levels than those on HD. Multiple regression analysis showed that dialysis vintage and the serum levels of creatinine, Na, triglycerides, albumin (Alb), alkaline phosphatase (ALP), and hematocrit were significant independent predictors of the serum zinc level. Fifty-one percent of patients had serum zinc levels of <60 μg/dL. Binomial logistic regression analysis showed that HDF and the serum levels of phosphorus (P), Alb, and ALP were significant independent predictors of hypozincemia. On the other hand, serum zinc levels were not correlated with the erythropoiesis-stimulating agent (ESA) dosage, ESA resistance index, or the use of other drugs.【Conclusion】Approximately half of dialysis patients have serum zinc levels of <60 μg/dL. The dialysis vintage; HDF; and nutritional factors, such as serum P and Alb levels, were identified as independent predictors of hypozincemia.

A 30-year-old female visited a local hospital with complaints of pain upon right eye movement, anorthopia, and visual field contraction in her right eye, which had lasted for 4 days. Her right visual acuity subsequently rapidly worsened. Anti-aquaporin-4 (AQP4) antibodies were detected in her serum, and high-intensity lesions were found in the right optic nerve on T1-weighted magnetic resonance imaging. On the basis of these findings, she was diagnosed with anti-AQP4 antibody-positive optic neuritis. Although she was treated with 2 courses of steroid pulse therapy followed by 40 mg/day of prednisolone, it had no beneficial effects. So, she was referred to our hospital, where she underwent double-filtration plasmapheresis (DFPP). After a total of 7 sessions of DFPP, the anti-AQP4 antibodies disappeared, and the patient’s visual function gradually recovered. In conclusion, DFPP seems to be a useful therapeutic option for steroid-resistant anti-AQP4 antibody-positive optic neuritis.

A 50-year-old male with diabetes and end-stage kidney disease, who had been undergoing hemodialysis (HD) for more than 10 years, underwent hemithyroidectomy for thyroid goiter and was diagnosed with follicular adenoma. Eight months after the surgery, multiple bone metastases were detected on computed tomography and bone scintigraphy, and the patient’s condition was finally diagnosed as follicular adenocarcinoma. For the metastatic lesions in the right femur, external radiation therapy and intramedullary rod insertion were performed to prevent bone fractures. Furthermore, external radiation therapy and posterior decompression and fusion were conducted for severe spinal cord compression associated with metastasis to the 11th thoracic vertebra. During radioactive iodine-131(I-131) internal radiation therapy, the patient was required to stay in an isolation room for at least a week due to the risk of third parties being exposed to radiation from the patient himself, his excrement, and his dialysis solution. Therefore, his renal replacement therapy was switched from HD to peritoneal dialysis (PD). There have not been any reports about the use of I-131 internal radiation therapy in patients with thyroid cancer that are undergoing dialysis. The present case suggests that a change from HD to PD should be considered in HD patients treated with I-131 internal radiation therapy.

The number of diabetic patients is increasing in Japan. Metformin is an antidiabetic agent, which suppresses gluconeogenesis. Unlike other antidiabetic agents, metformin reduces insulin resistance and is not strongly associated with hypoglycemia or weight gain. Furthermore, clinical studies have demonstrated that it is effective against cardiovascular disease. Given its effects and affordability, metformin is a commonly used oral hypoglycemic drug. However, its use is associated with lactic acidosis in extremely rare cases. While lactic acidosis is rare in metformin-treated patients, it requires immediate attention since it can be lethal. We report a case of severe lactic acidosis (pH: 7.0; lactate: >20 mmol/L, potassium [K]: 6.1 mEq/L, creatinine: 2.4 mg/dL, estimated glomerular filtration rate: 23.8 mL/min/1.7 m²) in a 53-year-old male diabetic patient who was taking metformin. On admission, his white blood cell count, C-reactive protein level, and procalcitonin level were elevated, and he was diagnosed with metformin-associated lactic acidosis (MALA) caused by an infection. Since his symptoms did not improve despite supportive care, he was switched to 2-hour hemodialysis using a blood pump (200 mL/min), dialysate pump (500 mL/min), and an APS18MD membrane (polysulfone; Asahikasei Kuraray Medical, Tokyo). After the hemodialysis, his condition improved markedly (pH: 7.4; lactate: 5.2 mmol/L, K: 4.7 mEq/L). Supportive care and extracorporeal circulation are the only treatment options for MALA. Extracorporeal circulation effectively removes metformin from the body. Furthermore, it rapidly controls acidosis, hyperlactatemia, and electrolyte imbalances and compensates for impaired kidney function. Patients with lactate levels of >20 mmol/L and pH values of <7.0 are indicated for extracorporeal circulation, until they achieve a lactate level of <3.0 mmol/L and a pH value of >7.35. In Japan, where dialysis is commonly employed, extracorporeal circulation is a highly safe treatment. Since MALA is a life-threatening disease, extracorporeal circulation should be used to treat high-risk patients with the condition whenever possible.

A 77-year-old female with dementia and depression was housed in a nursing home. When a member of staff visited her room in the early morning, no abnormalities were observed. An hour later, a member of staff found that she had partially fallen from her bed, and her head was touching the floor, her lower abdomen was pressed against the bed rails (which had overturned), while her lower body remained on the bed. After being rescued, she could not move her lower limbs, and renal dysfunction and hyperkalemia were observed the next day. So, she was admitted to our hospital. Based on the circumstances of the incident and various findings, we diagnosed her with acute kidney failure and disseminated intravascular coagulation (DIC) due to crush syndrome. We performed hemodialysis on the same day because anuria persisted despite massive fluid replacement. After three dialysis sessions, the patient’s renal function was restored. Then, dialysis was discontinued, and her DIC symptoms and lower limb motor function subsequently also improved. Crush syndrome is often seen after a disaster or traffic accident, when part of the body has been under pressure for a long period of time. However, it can occur in daily life, and it has also been observed in cases of emaciated or elderly people, in whom it can develop after short periods of pressure exposure. Crush syndrome is a serious condition, which often becomes life-threatening if it is not diagnosed. Knowledge of the patient’s history of recent injuries is important for diagnosing crush syndrome.

We describe the case of a 61-year-old female, who had been receiving treatment for diabetes and chronic kidney disease. Seven months earlier, she had decided (of her own accord) to discontinue her outpatient treatment, which eventually resulted in her emergency admission to our hospital because of dyspnea on effort and marked weight loss. Despite severe anemia (hemoglobin: 6.0 g/dL) accompanying her end-stage renal failure on admission, she refused a blood transfusion for religious reasons. After providing a careful explanation and obtaining informed consent, she and her husband agreed for her to undergo an alternative non-transfusion-based treatment during the initiation of hemodialysis. Her anemia was effectively managed by increasing the doses of erythropoiesis-stimulating agents (ESA) and initiating iron replacement therapy. Although there are many factors that contribute to ESA resistance during the hemodialysis initiation period, it is suggested that non-emergent severe anemia can be managed without transfusions.