Hypoxia-inducible factor (HIF) stabilizers, which are novel agents, stimulate endogenous erythropoietin by inhibiting HIF and the prolyl hydroxylase domain to mimic hypoxia. Phase 2 and 3 clinical studies have shown that HIF stabilizers are as effective as erythrocyte-stimulating agents (ESA) at ameliorating renal anemia. Long-term clinical experience has demonstrated that ESA improve patients’ quality of life and ameliorate cardiovascular-renal-anemia (CRA) syndrome, and malnutrition-inflammation-atherosclerosis (MIA) syndrome complicated by abnormal iron metabolism. Whether the same holds true in patients given HIF stabilizers is still unclear. In addition, given that HIF stabilizers act on multiple target genes, their use might result in unknown adverse events. The introduction of HIF stabilizers as a treatment for renal anemia provokes concern about how this alternative treatment will be employed in daily clinical practice. However, no clinical guidelines on how HIF stabilizers should be used are available at present due to the lack of clinical information. Nevertheless, this opinion-based review provides a future perspective on the management of renal anemia with HIF stabilizers. These novel agents could be indicated for CRA syndrome at the pre-dialysis stage; ESA-resistant anemia; and perhaps abnormal iron metabolism, such as that seen in MIA syndrome, in dialysis patients.
[Background] In dialysis patients, the implantation of devices on the same side as the arteriovenous fistula (AV fistula) is contraindicated; thus, they are implanted on the opposite side. If a device infection occurs, it is recommended that the system should be completely removed and re-implanted. However, the optimal re-implantation site in cases involving dialysis patients is unclear. [Case] The patient was a 72-year-old male dialysis patient. He had a left-sided AV fistula. After a pacemaker was implanted in the right precordial region, he developed sepsis from a gastrointestinal tract infection, which led to a device infection. [Progress] After the removal of the entire system, the main body of the system was placed in the right axillary pocket and direct puncture of the right axillary vein was performed. [Results] In a dialysis patient with a device infection, performing axillary pacemaker generator re-implantation and direct puncture of the axillary vein on the infected side was considered useful, as it ensured that the pacemaker generator was placed as far as possible from the infected pocket and the leads did not overlap with the locations of the removed leads.
We report two cases of peritoneal dialysis (PD)-related peritonitis caused by Micrococcus species. [Patient 1] A 61-year-old male had been on PD due to diabetic kidney disease since November 2017. Eleven months after the initiation of PD, he was diagnosed with PD-related peritonitis and was treated with antibiotics. Since Micrococcus species were cultured from the dialysis effluent, we changed the antibiotics based on drug sensitivity considerations. The patient recovered and was discharged on the 22nd hospital day. Twelve days later, he exhibited signs of PD-related peritonitis again, and was treated with vancomycin. However, his symptoms did not improve, and the PD catheter was removed on the 56th day. He did not present with any further symptoms. [Patient 2] A 64-year-old male had been on PD due to diabetic kidney disease since July 2018. Eight months after the initiation of PD, he developed PD-related peritonitis and was treated with antibiotics. Micrococcus species were cultured from the dialysis effluent. His condition improved, and he was discharged on the 16th hospital day. He did not show any signs of recurrence. In summary, PD-related peritonitis due to Micrococcus species is extremely rare. Since intractable peritonitis can occur, removing the PD catheter should be considered.
A pregnant patient in her early 30s was in the early stages of hydronephrosis-induced end-stage renal failure. She already had one child, and her primary physician recommended that she terminate the pregnancy, but she strongly desired its continuation. The obstetrics and gynecology department concluded that the pregnancy could continue. In the 10th gestational week, the patient’s renal replacement therapy was changed from hemodialysis for 4 hours 3 times a week to predilution online hemodiafiltration (oHDF) for 4 hours 3 times a week. In the 12th week of pregnancy, the treatment was switched to oHDF for 4.5 hours 5 times a week. A clinical engineer fine-tuned the daily dialysis conditions, and the patient’s pregnancy was managed according to our clinic’s standards. No polyhydramnios or other abnormalities were seen during the course of the patient’s pregnancy. She was admitted at 30 weeks, and underwent a caesarean section in the 37th gestational week. We report that women with end-stage renal failure can successfully deliver babies without complications and describe the role of clinical engineering in such cases.
The patient was a 26-year-old female American, who had come to Japan one year earlier as an assistant language teacher. She visited a nearby hospital with a headache and vomiting. She was diagnosed with acute renal failure, hypertension, and thrombocytopenia and was admitted to the hospital. Her renal function gradually worsened, and she was transferred to our hospital. She was diagnosed with scleroderma, as skin sclerosis and symptoms of Raynaud’s disease were seen on her forearm. The cause of the acute renal failure was diagnosed as scleroderma renal crisis, and the patient was treated with ACE inhibitors and other antihypertensive therapies. However, she eventually developed end-stage renal failure. We suggested that she return to the United States and undergo renal replacement therapy, but she strongly preferred to continue working in Japan. Therefore, she was started on peritoneal dialysis in Japan. After her work contract ended, she returned to the United States. This was a rare case, and we report its course from the initiation of peritoneal dialysis to the patient’s return to the United States.
A 38-year-old male hemodialysis patient was referred to our department because of a renal mass (diameter: 3 cm), which was detected on follow-up ultrasonography. On the basis of the findings of contrast-enhanced computed tomography and magnetic resonance imaging, a crossed fused ectopic kidney and renal cell carcinoma were diagnosed. Radical nephrectomy was performed. The histopathological findings were suggestive of acquired cystic disease-associated renal cell carcinoma (pT1aN0M0G2>G3). A case involving a crossed fused ectopic kidney and a renal tumor is reported herein. In addition, the findings of a literature review of this topic are discussed.