[Purpose] Assisted peritoneal dialysis (assisted PD) is a useful treatment for elderly patients with end-stage renal disease; however, in Japan, only visiting nurses are available to provide assisted PD. We conducted a one-year observational study of the assisted PD provided to users of a day care center for elderly patients. The purpose of this study was to investigate the effects of providing assisted PD at day care centers for elderly patients with end-stage renal disease. [Subjects and Methods] Eleven patients who used the day care center received assisted PD. Three patients stopped receiving assisted PD at the day care center, as they were transitioned to hemodialysis, admitted to a nursing home, or hospitalized due to a chronic subdural hematoma, respectively. The remaining 8 patients (4 males, 4 females; mean age: 78±78.52 years, mean body mass index: 22.3±3.2) who continued receiving assisted PD for one year were enrolled. The health status of the PD patients, their laboratory data, and the incidence rates of adverse events over one year were analyzed. Furthermore, we also calculated the cost of providing PD-related medical care at the day care center and the cost of providing standard PD care according to the Japan national health insurance system. In addition, the patients’ families were asked to complete a questionnaire about their satisfaction with the assisted PD. [Results] No adverse events were observed in any patient during the one-year study period. All of the subjects underwent stable dialysis, and the patients’ families exhibited high levels of satisfaction. However, the cost of providing PD-related medical care at the day care center was not satisfactory. [Conclusion] Assisted PD can be effectively provided to elderly PD patients in day care centers. However, further investigations of the economics of providing such care are required.

Cinacalcet hydrochloride (cinacalcet) is a useful treatment for secondary hyperparathyroidism, but it causes upper gastrointestinal symptoms at a relatively high frequency. Compared with cinacalcet, evocalcet exhibits an improved upper gastrointestinal symptom and drug interaction profile. In this study, we investigated the efficacy and safety of evocalcet in outpatients undergoing maintenance hemodialysis who developed secondary hyperparathyroidism at our hospital, including 57 patients who received ≤50 mg/day cinacalcet before switching to evocalcet. The observation period was 12 weeks from the initiation of evocalcet treatment between June 2018 and September 2018. The target intact parathyroid hormone (iPTH) level was 60-240 pg/mL, and the doses of evocalcet and a vitamin D (VitD) preparation were adjusted based on the corrected serum calcium level. The starting dose of evocalcet was 1 mg/day. The evocalcet dose was increased by 1 mg at intervals of at least 2 weeks. After 12 weeks, 42.1% of patients were receiving 1 mg evocalcet, and 49.1% of patients were receiving 2-4 mg evocalcet. A VitD preparation was added or the VitD preparation dose was increased in 5.3% of patients. iPTH levels of ≤240 pg/mL were seen in 71.9% of cases at the baseline, 49.1% after 1 week, and 64.9% after 12 weeks, and the iPTH levels of patients who switched from ≥37.5 mg/day cinacalcet decreased. Of 5 patients who experienced adverse upper gastrointestinal reactions while receiving oral cinacalcet, none of them exhibited symptoms while taking evocalcet. Only two patients developed novel symptoms while receiving oral evocalcet, and only one patient developed a corrected serum calcium level of ≤7.5 mg/dL. In this study, evocalcet was considered to be useful in terms of both its efficacy and safety, although the iPTH level increased after the medication switch in some patients who had been treated with 50 mg/day cinacalcet.

The protein responsible for dialysis-related amyloidosis (DRA) is irreversibly unfolded amyloid β₂ microglobulin (A-β₂M), but a partially unfolded conformer of β₂M (I-β₂M) has been detected during the amyloidization of native β₂M. In this study, we analyzed the serum I-β₂M of predialysis chronic kidney disease (CKD) patients, short-term hemodialysis patients, and long-term hemodialysis patients and tissue β₂M derived from amyloid tissue using liquid chromatography/mass spectrometry (LC/MS). Four ionized peaks at ＋7 to ＋10 were found in all samples. Since the ionized peak for native β₂M was located at＋7 and＋8, and that for A-β₂M was located at ＋9 and ＋10, we analyzed the ratio of (＋9 plus ＋10) to (＋7 plus ＋8) as the MS index (MS-I). The serum I-β₂M MS-I of the predialysis CKD patients, short-term hemodialysis patients, and long-term dialysis patients were 1.70±0.13, 1.90±0.13, and 1.79±0.25, respectively, and did not differ significantly among the 3 groups. On the other hand, the MS-I of the tissue β₂M derived from amyloid tissue were markedly higher (4.15 and 7.33). The main finding of this study; i.e., that A-β₂M, which causes the formation of amyloid, could not be detected in the sera of hemodialysis patients by LC/MS, was consistent with our hypothesis that some of the incompletely unfolded β₂M moves from the serum to the extravascular tissue, where it continues to unfold, and the accumulation of this substance leads to the onset of DRA.

We examined two diabetic patients during hemodiafiltration to clarify the kinetics of 28 amino acids (AA) in the presence or absence of the intradialytic administration of an AA formulation (IVAA) for kidney disease. In the absence of IVAA, the amount of AA excreted into the spent dialysate per session was 13 to 15 g, and the amount of AA that flowed out from the extravascular AA pool and into the blood was 12 to 13 g. IVAA suppressed the total AA outflow from the AA pool to 1 to 2 g per session; however, the outflow of non-essential AA continued at a high level (about 6 g per session). To prevent abnormalities in AA metabolism due to dialysis in diabetic patients with metabolic disorders, the development and application of an appropriately constituted AA formulation are highly desired.

Hemodialysis (HD) patients exhibit a high incidence of peripheral arterial disease (PAD), which can lead to critical limb ischemia (CLI) without an early diagnosis or appropriate intervention. The early diagnosis of PAD is extremely important for saving the lower limbs of HD patients; however, it is often difficult to accurately diagnose PAD on computed tomography angiography due to arterial calcification. We report two HD cases in which lower limb ultrasonography (LUS) was used to detect severe PAD before CLI developed by evaluating the Doppler waveform. Although the number of possible observation sites for LUS is often limited in HD patients due to arterial calcification, LUS is a non-invasive examination that is able to detect PAD early in HD patients, and should be actively performed.