Carnitine is often prescribed to patients under dialysis therapy, with the expectation of improving aspects such as the cardiac activity, anemia and muscle symptoms in the patients; both cases in which it is effective and not effective are encountered in clinical practice. In relation to improvement of the cardiac activity or muscle symptoms, in the process of transport of fatty acids into the mitochondria, carnitine is involved only until acyl coenzyme A. Therefore, different results are obtained in relation to the subsequent process of ATP production. Water-soluble vitamins which are easily removed by hemodialysis therapy are required for beta-oxidation and the TCA cycle. Thereafter, coenzyme Q10 is also required for the electron transport chain (respiratory chain system), however, coenzyme Q10 generation is inhibited if a statin is used. In relation to anemia improvement, many elements, including carnitine, are involved. It is necessary to adjust all these elements in the hematopoietic process. Muscle contraction is associated with alkalosis. Furthermore, in the case of cramps occurring during the latter half of hemodialysis therapy, there is the additional component of contraction alkalosis. In general, alkalosis induces the binding of calcium ions to serum albumin and consequently, alkalosis produces hypocalcemia. In order to maintain the serum calcium ion concentration, calcium ions are released from the sarcoplasmic reticulum of the muscle cells, resulting in muscle spasms. When the sarcoplasmic reticulum reabsorbs the released calcium ions via ATP, the muscle contractions cease. However, in the case of carnitine deficiency, the muscle spasms persist due to ATP deficiency. We may be able to use carnitine more effectively by knowing precisely what roles carnitine participates in.

In collaboration with the Okinawa Dialysis Physicians Association, we studied diabetic dialysis patients who were started on dialysis at the age of <60 years in Okinawa. A questionnaire was sent to 56 units, and responses were obtained from 33 of them. Of a total of 2,235 patients, 167 (7.5%) patients were considered to be targets. We analyzed 103 of them with full information. The subjects’ mean (SD) ages at the diagnosis of diabetes mellitus (DM) and the start of dialysis were 32.3 (9.5) and 47.7 (6.8) years, respectively, and their maximum body mass index before the diagnosis of DM was 31.4 (6.5) kg/m². Fifty-four percent of the subjects had a history of treatment withdrawal for at least 1 year. In particular, treatment withdrawal was common among those who were diagnosed with DM during mass screening, and about half of them had received no treatment for >10 years. In conclusion, to prevent end-stage renal disease in young people that have been diagnosed with obesity and DM, health education and continuous follow-up are necessary together with effective measures involving clinicians, policymakers, and the community.

We investigated the influence of exercise intensity during hemodialysis on the removal of small, medium, and large solute molecules. Out of 285 hemodialysis patients who were enrolled in our hospital, 17 were eligible for the study. Each patient completed two trial arms (the routine hemodialysis arm and the exercise during hemodialysis arm) in a randomized order. Dialysate and blood samples were collected at hourly intervals on the first hemodialysis day of the week and used to measure potassium (K), phosphate (P), blood urea nitrogen (BUN), β₂-microglobulin (β₂MG), α₁-microglobulin (α₁MG), and albumin (Alb) levels. A cardiopulmonary exercise test was used to obtain anaerobic threshold (AT) measurements for each subject. The patients were classified into two groups, the below AT group, whose exercise intensity was below the AT, and the AT group, whose exercise intensity was at or above the AT level. In comparison with routine hemodialysis, the amounts of K, P, and BUN removed increased during exercise in the below AT group, while the amounts of P and BUN removed decreased after exercise in the AT group (p<0.05). The amount of α₁MG removed increased in both exercise intensity groups (p<0.01), while those of β₂MG and Alb remained unchanged throughout the study period. These findings suggest that low-intensity exercise during hemodialysis might enhance K, P, BUN, and α₁MG removal during hemodialysis without causing Alb loss.

The patient was a 67-year-old male, who had been on hemodialysis due to diabetic nephropathy for 3 years. He was admitted with a 3-day history of weakness and disturbance of consciousness. After admission, his general condition gradually improved, but laboratory tests demonstrated sustained elevated C-reactive protein levels. Transthoracic echocardiography revealed vegetation on the mitral valve, but the patient’s blood cultures remained negative. Further investigation determined that he had been in contact with a cat prior to admission; therefore, we investigated his Bartonella henselae antibody titer. An immunofluorescence-based assay confirmed that the patient was suffering from a Bartonella infection. He was treated with intravenous cefotaxime and recovered. Hemodialysis patients are at high risk of infectious disease, and in some cases it is difficult to identify the causative microorganisms. This case showed that if a hemodialysis patient exhibits chronic inflammation despite being well and afebrile, there is a possibility of infection. In such cases, a Bartonella infection should be considered when blood culture-negative endocarditis is suspected.

We report the cases of 5 patients (1 male, 4 females; mean age: 76 years old), who developed various types of cytopenia due to copper deficiency. The mean duration of the dialysis period was 5.2 years. The patients’ concomitant diseases included aspiration pneumonia (n=3), cranial nerve disorders (n=2), dialysis access infections (n=2), malnutrition after colon cancer surgery (n=1), and pyogenic spondylitis (n=1). Enteral alimentation was employed in 1 patient, and zinc preparations were administered to 4 patients. The mean concentrations of blood copper and ceruloplasmin at the time of diagnosis were 26.6 μg/dL (7 to 46) and 12.6 mg/dL (6 to 17), respectively. As for the patients’ cytopenic patterns, 2 patients had pancytopenia, 2 patients had anemia and platelet depletion, and one patient had anemia alone. Three patients received oral copper sulfate, one patient took pure cocoa, and one patient received copper supplements. The patients’ blood cell counts improved as their copper concentrations increased in all cases. As they are subjected to phosphorus restriction, dialysis patients often have to eat foods that contain large amounts of copper. Furthermore, the absorption of copper in the intestinal tract might be inhibited by zinc supplementation. Therefore, it is suggested that dialysis patients are more prone to copper deficiency than healthy individuals. Furthermore, copper deficiency is associated with erythropoietin-stimulating agent-resistant anemia combined with leukopenia or thrombocytopenia in hemodialysis patients.