A nationwide statistical survey of 3, 750 dialysis facilities was conducted at the end of 2003 and 3, 717 facilities (99.12%) responded. The population undergoing dialysis at the end of 2003 was 237, 710, an increase of 8, 172 patients (3.8%) over 2002. The number of dialysis patients per population f 1 million was 1, 862.7. The crude death rate of dialysis patients from the end of 2002 to the end of 2003 was 9.3%. The mean age of patients who started dialysis in 2003 was 65.4 years, and that of the dialysis population at the end of 2003 was 62.3 years. The mean age of dialysis patients at the end of 2003 was nearly equal to that of dialysis patients (62.2 years) at the end of 2002. The distribution of patients who started dialysis in 2003 according to the underlying disease showed that diabetic nephropathy accounted for 41.0% of patients and that chronic glomerulonephritis accounted for 29.1%.
No marked relationship was observed between time from a meal taken to blood sampling and serum triglyceride concentration. The mean serum lipid concentration in all the dialysis patients was 113.9±71.7mg/dL (±s.d.). The mean serum LDL-cholesterol concentration calculated using Friewald's formula was 90.8±30.9mg/dL. Dialysate calcium concentrations were from 3.0mEq/L to less than 3.5mEq/L in 55.4% of dialysis patients and from 2.5mEq/L to less than 2.75mEq/L in 34.7% of patients. Anticoagulants used in patients undergoing blood purification therapy using extracorporeal circulation were tabulated. Heparins were used in 79.3% of the patients, while low-molecular-weight heparin was used in 18.8%.

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Glycohemoglobin (HbA1c; A1c) and glycated albumin (GA) are indices for glycemic control in diabetic patients, however there are several problems in using these indices in clinical practice, especially in dialysis patients. We evaluated the relationship between A1c and GA in chronic dialysis patients. They consisted of 86 hemodialysis (HD) patients (diabetic (DM) 50 and non-diabetic (nDM) 36) and 33 peritoneal dialysis (PD) patients (DM 6 and nDM 27). There were significant correlations between blood glucose levels and GA in DM-HD, nDM-HD and nDM-PD patients (r=0.42, 0.51, 0.44, p<0.01, 0.01, 0.05). However, there were no significant correlations between blood glucose levels and A1c. The correlation between GA and A1c was significant in DM-HD patients (r=0.64, p<0.001). The ratio of GA and A1c (GA/A1c) were 4.0±0.6, 3.7±0.5 and 2.3±0.5 in DM-HD, nDM-HD and PD (DM+nDM) patients. GA/A1c in PD patients was significantly lower than that in HD patients (p<0.001). The ratio tended to increase with erythropoietin dose in DM-HD, nDM-HD and nDM-PD patients with greater GA/A1c. In conclusion, A1c underestimates hyperglycemia compared with GA in DM-HD patients, while GA underestimates hyperglycemia compared with A1c in DM-PD patients. Erythropoietin dose might be one of the factors related to GA/A1c. It is also necessary to consider short-term changes in glycemic control as well as albumin turnover when evaluating GA/A1c in the individual patient.

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Maxacalcitol (OCT), a recently introduced vitamin D analogue is routinely injected intravenously against secondary hyperprathyroidism. Intravenous OCT is sufficient to suppress PTH secretion in some patients, but not in all cases and especially not in those accompanied by hypercalcemia. Although percutaneous injection therapy (PIT), in which OCT or calcitriol is directly injected into enlarged parathyroid glands has been reported to be effective and lowers the incidence of hypercalcemia, consecutive injections are required to suppress serum PTH levels. To avoid insufficient suppression of serum PTH levels by either intravenous OCT or consecutive PITs alone, we continued intravenous OCT, and simultaneously added a single PIT while administering OCT at intervals of a week to a few months according to the effectiveness and persistence of reduction in serum PTH levels. Twelve dialysis patients resistant to conventional intravenous OCT therapy, in whom enlarged parathyroid glands were detected by ultrasonography, were recruited with informed consents. The patients were comprised of five males and seven females with a mean age of 59.8±1.8 years. Their averaged intact PTH level and parathyroid gland volume were 555±78pg/mL and 1.3±0.4cm³, respectively. Among these patients, only one female was absolutely resistant to such combined intravenous and intraglandular injection of OCT. Therefore parathyroidectomy in this case was carried out after the second PIT. The other eleven patients showed either transient or long term suppression of PTH levels in response to the combined therapy without severe elevation of serum Ca levels. Six months after the initial PIT, more than 40% reduction of intact PTH levels were obtained in 5 patients who did not show any apparent differences in clinical parameters compared to those of the other seven cases. Hence we concluded the combined intravenous and intraglandular injection of OCT was an optional or rescue procedure for treating secondary hyperparathyroidism, and might reduce the number of cases indicated for surgical parathyroidectomies.

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The patient was a 31-year-old man diagnosed with hemophilia B (Factor IX activity <1.0%) at the age of 1 year. A specific inhibitor to factor IX was detected at the age of 13 years. Despite receiving freeze-dried human blood-coagulation factor IX (PCC), he was intermittently hospitalize because of joint bleeding. He was admitted in our hospital because of joint bleeding and the development of nephrotic syndrome (NS) characterized by anasarca, proteinuria and hypo-albuminemia. He started oral steroid therapy with ARB (Angiotensin II recepter blocker) and diuretics for NS but there was no response. His general condition deteriorated daily. To improve anasarca, we performed the extracorporeal ultrafiltration method (ECUM) for steroid-resistant NS. We speculated that human blood-coagulation factor V inhibitor bypassing activity (APCC) would be more effective than PCC in this case. Blood access in the right arm was established without hemorrhagic event after receiving APCC. He did not achieve remission from NS but did become free from anasarca after treatment with ECUM. His general condition is improving and he has been attending the hospital twice a week without symptoms.

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A 70-year-old patient was referred to our hospital for evaluation of ocular disorders. The patient has been on hemodialysis since 1999, but the underlying renal disease causing chronic renal failure remains unknown. He developed a headache in January 2001, followed by diplopia, reduced visual acuity and bilateral ptosis of the eyelid from April 2001. He was then referred to us for evaluation. The patient was admitted immediately. Examinations at admission showed absence of light sensation, atrophy of the optic nerve, and bilateral ptosis of the eyelids. The eyeballs were fixed at the center and there was no reaction to light. Multiple cranial nerve palsies involving the 2nd, 3rd, 4th, and 6th nerves were diagnosed. Cranial MRI with Gd contrast imaging demonstrated hypertrophy of the dura mater in bilateral temporal lobes, the cerebellar tent, and skull base. We diagnosed his condition as hypertrophic pachymeningitis. The symptoms progressed rapidly until blindness developed. Pulse therapy with methylprednisolone 1, 000mg was conducted. Subsequently, colorectal endoscoy demonstrated the presence of colorectal carcinoma of Borrmann type 2. Since there was no metastasis of colorectal cancer detected, surgery was considered to be indicated and Haltmann procedure was performed. Postoperatively, visual acuity was improved from light perception to hand motion, and slight abduction became possible in the left eye. In this patient with hypertrophic pachymeningitis concurrent with colorectal carcinoma, the majority of the physical findings described above were resolved or mitigated by surgical removal of the cancer. The malignant tumor was considered to have been the cause of hypertrophic pachymeningitis. Since the occurrence of these concurrent conditions in a patient on hemodialysis is extremely rare, we documented this case.

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We describe a 53-year-old woman with putaminal hemorrhage who had been undergoing maintenance hemodialysis due to diabetic nephropathy. She developed severe neutropenia and dependency on red blood cell transfusion around 100 days after the initiation of enteral nutrition. Normal results were found for iron, vitamin B₁₂ folate levels and immune serological examinations. However, serum copper and ceruloplasmin levels were reduced to 13μg/dL (normal level: 68-128) and 6mg/dL (normal level: 21-37), respectively. In addition, bone marrow assessment showed vacuoles in the myeloid cells. Intravenous administration of 1.25mg copper sulfate daily led to improvement of anemia and neutropenia, confirming the diagnosis of copper deficiency anemia. Nephrologists should be aware of the risk of copper deficiency anemia in patients receiving prolonged enteral feeding.

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A 60-year-old man who began hemodialysis in December 1987 was admitted to our hospital in October 2002 because of left lower abdominal pain. The patient's medical history included living renal transplantation in June 1988 and left radical nephrectomy for renal cell carcinoma in September 1999. Hemodialysis had been reinstated in November 1993. Urethral bleeding occurred in October 2002, shortly after he was admitted. Cystoscopy demonstrated bleeding from the orifice of the transplanted kidney. Computed tomography showed multiple diverticulae, atrophy of the transplanted kidney and air in the ureter. Urgent surgery was performed the next day. It was necessary to resect the sigmoid colon and extract the transplanted organ due to a sigmoid colontransplanted kidney fistula caused by diverticulitis. This is the first report of such a fistula.

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