The shunt blood flow rate (eSF) of arteriovenous fistulas (AVF) and grafts was estimated using a new method based on the flow volume (FV), the resistance index (RI), and systemic blood pressure. The shunt flow index (SFI), which was created by removing systemic blood pressure parameters from the eSF formula, was compared with the FV and the RI in 79 chronic renal failure patients who underwent more than two rounds of vascular access intervention therapy (VAIVT) to allow hemodialysis (HD) to continue within three years. The sensitivity of the SFI for detecting critical blood flow reductions in AVF was evaluated just before VAIVT. The SFI was more sensitive than the FV and RI at a specificity of 90%, which was measured soon after VAIVT. The eSF was compared with the maximum quantity of blood flow (Qb) during HD in 47 patients, who were selected from the 79 patients because their eSF seemed to be similar to the maximum Qb just before VAIVT. The difference between the eSF and the maximum Qb was 15±22% of the maximum Qb. The rates of reduction in the SFI between two VAIVT procedures changed in an irregular manner in about 72% of the 79 cases. The SFI and eSF are valuable methods for evaluating shunt blood flow through AVF, but are poor at forecasting the optimal dates for subsequent VAIVT procedures.

Denosumab treatment was administered to hemodialysis outpatients who were complicated with osteoporosis (young adult mean [YAM]: <70%). Thirty-eight consecutive patients (13 males, 25 females; mean age: 70.8 years; range: 23-94 years, mean YAM: 52.1%) were recruited. Sixty mg of denosumab was administered subcutaneously every 6 months. After the start of denosumab treatment, the patients’ bone mineral density (BMD) at the 1/3 distal radius increased≧3 point over 3 years. Furthermore, their levels of tartrate-resistant acid phosphatase 5b (TRACP-5b, a bone absorption marker) and total procollagen 1 intact N-terminal (P1NP, a bone formation maker) significantly reduced over 3 years. The hemodialysis-induced change in the albumin-adjusted Ca level was significantly lower at the end of the study than at the administration of the first dose of denosumab, but the hemodialysis-induced change in the inorganic phosphate level did not change significantly during the study period. The dosage of an intravenous vitamin D preparation administered increased significantly due to the correction of hypocalcemia achieved by denosumab. Denosumab treatment improved BMD at the 1/3 distal radius in hemodialysis patients with osteoporosis. However, it is necessary to carefully observe the hemodialysis-induced changes in albumin-adjusted Ca levels in such cases.

[Objectives] This real-world study aimed to investigate the effects of switching from cinacalcet hydrochloride (cinacalcet) to evocalcet on serum parameters, concomitant medication usage, and upper gastrointestinal tract (GI) symptoms. [Methods] One hundred and forty-seven chronic hemodialysis patients that were taking cinacalcet were simultaneously switched to 1 mg evocalcet and followed for 8 months. A questionnaire on GI symptoms and medication adherence was carried out. [Results] After the switch, serum intact parathyroid hormone (PTH) levels increased for several months, while serum corrected calcium (Ca) levels transiently increased, but soon returned to the original levels. The cinacalcet dose just before the switch was positively correlated with change in the amplitudes of PTH and Ca. In addition, the change in the amplitude of PTH was positively correlated with the change in the amplitude of Ca, suggesting that the transient elevation of the Ca level was derived from the bone. There were no significant changes in concomitant medication usage; however, some patients stopped taking drugs that stimulate GI motility. The questionnaire indicated that the proportion of patients with GI symptoms decreased and medication adherence increased after the switch. [Conclusion] This real-world study indicates that evocalcet is a useful alternative calcimimetic drug to cinacalcet.

This case involved a 75-year-old male with a 17-year history of dialysis. We have been performing online hemodiafiltration (HDF) with γ-sterilized polysulfone (PS) membranes for 2 years. The patient’s treatment followed a stable course, but at some point his systolic blood pressure dropped to 70 mmHg just after the onset of HDF, resulting in dysdialysis with dysphoria. First of all, incompatibility with the PS membrane was suspected so the membrane material was changed to cellulose triacetate or ethylene vinyl alcohol copolymers (both γ-ray sterilized membranes), but no improvement was achieved. We also changed the anticoagulant, but this did not ameliorate the dysdialysis. Furthermore, an ultrafiltration rate of 0 mL/hr and extracorporeal ultrafiltration methods were also tested at the start of treatment, but it was not possible to prevent reductions in blood pressure. The blood volume (BV) waveform was monitored during dialysis with a BV meter, and an abnormal waveform, which rose just after the start of treatment, was detected, and it was judged that the patient’s vascular permeability had increased due to incompatibility with the membrane. When the membrane was changed to a high-pressure steam-sterilized PS instead of a γ-ray sterilized membrane, the reduction in blood pressure and dysphoria disappeared, and the BV waveform also normalized. In this case, the dialyzer sterilization method was important, as changing the membrane to the same type of material, but using a different sterilization method, was effective. In addition, monitoring the BV waveform was useful for judging the effects of changing the treatment conditions.

Caffeine is a readily available drug that is used to prevent sleepiness in Japan. However, severe caffeine intoxication can be fatal. Only a few cases of severe caffeine intoxication have been reported in Japan. We report a case involving a 32-year-old female with active suicidal thoughts, who visited our hospital after consuming 240 caffeine tablets, each of which contained 24 g of caffeine. The day after she took the pills, she visited our hospital complaining of sustained nausea and tremors. She was suffering from excessive perspiration and eyelid spasms, hypertonia, and tremors on arrival. Her electrocardiogram revealed sinus tachycardia and premature ventricular contractions. Hypokalemia and an acid-base balance disorder were detected during a blood test performed on arrival. She was immediately treated with hemodialysis for 4 hours, which resulted in the rapid disappearance of the premature ventricular contractions, tachycardia, and other symptoms of caffeine poisoning. After one hemodialysis session, the patient’s blood caffeine concentration had decreased to 13.9 mg/L from 49.4 mg/L, and her blood caffeine level became undetectable within 24 hours after her arrival. Caffeine is the most commonly used drug that stimulates the sympathetic nerve system worldwide. The number of caffeine poisonings resulting from overdoses has recently increased in Japan. Many treatments have been employed for caffeine poisoning, but no effective treatment has been found. The volume distribution of caffeine ranges from 0.6-0.8 L/kg, its plasma protein binding value is 36%, and its molecular weight is 194, so hemoadsorption and hemodialysis should theoretically be effective. In our case, hemodialysis caused the rapid disappearance of the patient’s caffeine-poisoning symptoms. We present a case of acute caffeine poisoning, in which hemodialysis produced good outcomes. This case report suggests that hemodialysis is an effective treatment for acute lethal-dose caffeine poisoning.