[Background] Sarcopenia has been shown to be an independent predictor of overall survival in various kinds of diseases. We investigated the relationship between sarcopenia and prognosis during the initial period of hemodialysis. We performed a retrospective analysis of 82 patients who were started on hemodialysis at our hospital between April 2008 and March 2018. [Methods] Skeletal muscle mass was evaluated using the psoas muscle mass index (PMI: psoas major muscle area at the level of the third lumbar vertebra (cm²) /height×height (m²)) on CT images. [Results] The patients with low PMI exhibited a higher frequency of heart disease and lower serum albumin levels than those with normal PMI. The overall survival rate was significantly lower in the patients with low PMI than in the patients with normal PMI (p<0.0001). A low PMI and older age were identified as prognostic factors for overall survival in the multivariate analysis (hazard ratios (HR) =3.23 and 3.96, respectively; p=0.013 and 0.0089, respectively). [Conclusion] Skeletal muscle mass is closely correlated with mortality among patients that are starting hemodialysis. Clinicians should consider employing nutritional and exercise-based interventions against sarcopenia before initiating hemodialysis in patients with end-stage chronic kidney disease.

[Objectives] This study retrospectively investigated the distribution of serum zinc levels in hemodialysis (HD) patients and the effects of zinc acetate (ZA) on HD patients with zinc deficiency. [Methods] Sixty-one HD patients with serum zinc levels of <80 μg/dL were orally administered 50 mg/kg of ZA. Their serum levels of zinc, copper, hemoglobin (Hb), hematocrit (Ht), and albumin (Alb) were determined. Moreover, the required erythropoiesis-stimulating agent (ESA) dose and ESA resistance index (ERI) were also calculated. A survey of the HD patients’ symptoms was performed during the ZA treatment. [Results] Of a total of 143 HD patients, 132 (92.4%) developed zinc deficiency. In 61 HD patients with zinc deficiency, the serum zinc level exhibited a positive correlation with the serum Alb level at the baseline. ZA significantly increased the subjects’ serum zinc, Hb, and Ht levels, and significantly reduced the required ESA dose and ERI. Symptoms related to zinc deficiency, such as loss of appetite and taste disorders, were ameliorated by ZA treatment. [Conclusion] Zinc replacement therapy with ZA might be a useful adjunct treatment for HD patients because it increases their serum Hb levels and red blood cell counts, decreases their ESA doses, and improves their ERI.

The comprehensive geriatric assessment (CGA) is a tool that can be used to identify the problems faced by elderly people during activities of daily living (ADLs). The results of the CGA can be utilized to provide appropriate patient care and aid doctors, and medical support staff can also share aspects of patients’ conditions through the tool. We considered that a CGA was required for evaluating the physical, mental, and social conditions of elderly hemodialysis (HD) patients who required nursing, assisted care, and/or help with ADLs. Therefore, we developed a new HD-CGA assessment tool, which consists of the CGA plus 8 new test items. These items relate to dialysis, exercise capacity, and social environmental status. We evaluated the effectiveness of this new tool in HD patients. There was a significant positive correlation between the patients’ HD-CGA scores and their conditions. Furthermore, the lower the HD-CGA score, the worse the survival rate and the higher the risk of death. As elderly HD patients have specific dialysis complications, their physical, mental, and social conditions vary on a case-by-case basis. Therefore, being able to reliably evaluate each patient’s status/condition is important. In conclusion, the HD-CGA is a useful tool for evaluating physical/mental/social conditions in elderly HD patients, and it might be applicable to preventative interventions in such patients.

The patient was a 73-year-old male, who had been receiving nafamostat mesilate (NM) as an anticoagulant during hemodialysis (because he was positive for heparin-induced thrombocytopenia antibodies) since he was started on hemodialysis in X−9. In X, he developed a recurrent fever after undergoing hemodialysis. His blood culture results were negative. His condition did not improve after the administration of antimicrobial agents. Although pancytopenia was observed, and the patient was diagnosed with myelodysplastic syndrome based on the detection of chromosomal aberrations and a reduced number of blasts during a bone marrow biopsy, this was not considered to be a likely cause of the fever. The fever was resolved by changing the anticoagulant from NM to argatroban 36 days after its onset, and the patient was diagnosed with a drug-induced fever due to NM. To the best of our knowledge, no previous studies have described drug allergies caused by the continuous, prolonged (9-year) use of NM, as was described in our case. With age and surgical treatment, hemorrhagic complications tend to increase in dialysis patients, and the likelihood of NM being used also increases. We reported a unique case that demonstrated that NM can cause allergies, even during its long-term continuous use.

Patients are frequently forced to make decisions about their treatment plans, leading to conflict between patients, medical teams, and family members. During discussions about the initiation of hemodialysis, some patients with end-stage renal disease are faced with changes and challenges associated with being dialysis patients that cause them to refuse treatment. There is a concern that patients with chronic renal failure might be forced to initiate dialysis against their will, and thereby, suffer worse outcomes and a low quality of life. Therefore, it is worthwhile for clinicians to understand how to support such patients to make decisions. Giving medical advice or persuasion is not only less effective, but can also evoke anxiety or dissatisfaction about treatment. Conversely, activating intrinsic motivation regarding treatment is important because it develops naturally within the individual and not only increases favorable behaviors, but also helps to sustain them for years. Here, we present the case of an elderly patient with renal failure, who refused to start undergoing hemodialysis because of a strong sense of fear based on his prior experience of urgent dialysis. We repeatedly promoted ambivalence concerning his fear and hope regarding the treatment, thereby facilitating intrinsic motivation. As a result, the patient made a commitment to live on dialysis. Motivational interviewing is a communication style that has been shown to be effective at causing behavioral changes in the setting of treating lifestyle-related disease. This is the first reported case in which this psychological intervention was utilized to help a patient who refused to start hemodialysis.

Amantadine is widely used to treat Parkinson’s disease. However, it should not be used in patients with impaired renal function since it is almost exclusively metabolized through renal excretion. We experienced a rare case of amantadine intoxication in a patient with Parkinson’s disease and nephrotic syndrome. A 71-year-old patient initially had normal renal function (eGFR: 62 mL/min/1.73 m²) and received the optimal dose of amantadine (150 mg/day). The patient then developed new-onset nephrotic syndrome with severe hypoalbuminemia (1.6 g/dL), which was complicated by an acute kidney injury. This resulted in amantadine intoxication. Treatment with both direct hemoperfusion (DHP) and hemodiafiltration (HDF) effectively reduced the patient’s serum amantadine concentration; however, this caused neuroleptic malignant syndrome, which manifested as disturbed consciousness, dyskinesia, and elevated serum creatine kinase levels. This case is noteworthy because nephrotic syndrome frequently causes acute kidney injury, which will lead to amantadine intoxication in patients taking the drug. Furthermore, hypoalbuminemia results in reduced binding of amantadine to serum albumin, and hence, an increase in the level of free amantadine, which promotes the accumulation of amantadine in target organs. However, it is also expected to result in amantadine being eliminated more efficiently via DHP/HDF. Thus, decreased serum albumin levels might constitute a critical determinant of the pharmacokinetics of amantadine with regard to the pathogenesis of amantadine intoxication and its responses to blood purification therapies.