We investigated the prevalence of Helicobacter pylori infection in 90 hemodialysis patients and evaluated the efficacy of its eradication. Twenty-one hemodialysis patients were positive for H.pylori infection by measurement of serological antibody against H.pylori immunoglobulin G (IgG). Seven-day triple therapy with lansoprazole (LPZ) at 30 mg/day, clarithromycin (CAM) at 200 mg/day, and amoxicillin (AMPC) at 500 mg/day was administered to 17 H.pylori-positive hemodialysis patients agreeing to H.pylori eradication therapy. Metronidazole (MNZ) at 250 mg/day was administered to 3 hemodialysis patients with resistance to CAM. A total of 16 of the 17 patients (94.1%) were negative for H.pylori infection by measurement of H.pylori stool antigen for assessment of the success of the eradication therapy. Serological antibody against H.pylori IgG level was 24.8±26.4 U/mL before H.pylori eradication therapy and significantly decreased to 13.9±24.3 U/mL 6 months after it (p<0.05). Therefore, in this study, with a dose below half that in the traditional standard triple therapy for H.pylori eradication, side effects were not identified, but a high rate of success of H.pylori eradication was shown.

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[Background and objectives] This prospective, open-label study was aimed at investigating the efficacy and safety of the dipeptidyl peptidase-IV (DPP-4) inhibitor saxagliptin in patients with type 2 diabetes mellitus undergoing hemodialysis. [Design, setting, participants, & measurements] Thirteen patients with type 2 diabetes mellitus and serum glycoalbumin of ≥20% were selected to participate in this 3-month study (11 men, 2 women, age 59.3±14.8 years, hemodialysis duration 8.2±5.5). All of the patients were undergoing hemodialysis therapy 3 times a week at one of our hospitals. Saxagliptin was administered (2.5 mg/day) for the 3-month study period. In the three patients who were already on a DPP-4 inhibitor (2 patients on alogliptin and 1 on linagliptin), the treatment was switched to saxagliptin (2.5 mg/day). We evaluated casual plasma glucose (PG), hemoglobin A1c (HbA1c), and gylcoalbumin (GA), among others, in the patients. [Results] Two patients were excluded : One had heart failure and needed the addition of insulin, and the other developed nausea after the start of treatment with saxagliptin and wanted to drop out of the study. PG was significantly decreased at 1 month and 2 months after the start of saxagliptin administration (from 201±46 mg/dL to 158±40 mg/dL, and to 155±45 mg/dL, respectively ; p<0.05). Decrease of PG was also observed at 3 months after the start of treatment, although the difference did not reach statistical significance (to 167±61 mg/dL, p=0.0527). Significant decreases of both HbA1c and GA were observed at 1, 2, and 3 months after the start of treatment (from 6.8±1.1% to 6.5±1.0%, 6.5±0.9%, and 6.6±0.9%, and from 25.1±3.4% to 23.2±2.8%, 22.7±3.3%, and 22.9±2.6%, p<0.05, respectively). [Conclusion] No serious adverse effects such as hypoglycemia or liver dysfunction were observed in any of the patients. Thus, saxagliptin appears to be an effective treatment for diabetic patients undergoing HD.

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A 90-year-old female patient had been undergoing hemodialysis three times a week due to chronic renal failure caused by MPO-ANCA involving nephropathy since August 2002 ; she had subsequently been taking calcium polystyrene sulfonate (CPS) because of uncontrollable hyperkalemia. In mid-December 2012, the patient visited an emergency outpatient service due to abdominal pain and was observed showing abnormal air patterns in the abdominal cavity and hard feces in the colon by using abdominal computed tomography. We diagnosed the case as gastrointestinal perforation and diffuse peritonitis, and then decided to perform an emergency operation. We recognized a perforation in the descending colon, and performed both transverse colostomy and descending colon resection, and also conducted transverse colostomy. We recognized a crystalline material at the perforated site, which suggested the possibility that the CPS was associated with this colonic perforation. The patient died on the fourth day of illness due to disseminated intravascular coagulation and septicemia, although we had performed multimodal therapy. CPS is a cation exchange resin used to correct hyperkalemia, but it has adverse effects such as obstipation that occurs with high frequency. Some reports suggest that this drug is associated with intestinal perforation, and the drug package insert also warns of this. We conclude that we need to pay attention to the control of defecation during dosing of calcium polystyrene sulfonate.

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A 66-year-old man treated for chronic renal failure was admitted to our hospital with acute onset of thrombocytopenia, following deterioration of renal function with symptoms of diarrhea and vomiting. His platelet count remained low after admission, and the results of serological and bone marrow examination led to a diagnosis of idiopathic thrombocytopenic purpura (ITP). Initial therapy of oral prednisolone (40 mg/day) with Helicobacter pylori eradication was not effective, and thrombocytopenia persisted for the first four weeks. Then, in addition to the steroid, an oral thrombopoetin receptor agonist (TRA) drug, eltrombopag, was started, but the platelet count did not change. This oral TRA was then switched to a subcutaneously injectable TRA, romiplostim, which resulted in improvement of the thrombocytopenia and made it safe to initiate hemodialysis using arteriovenous fistula. TRAs must be administered with great caution to patients with renal dysfunction. We report here that romiplostim showed safety and efficacy in an ITP patient with end-stage renal disease.

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We report a case of mucinous tubular and spindle cell carcinoma of the kidney in a patient on chronic hemodialysis. A 65-year-old man complained of intermittent macrohematuria. Computed tomography revealed a 65-mm tumor in the left kidney and paraaortic lymphadenopathy. We performed left retrograde ureteropyelography and collected urine from the left renal pelvis. We diagnosed left renal cell carcinoma (cT1bN2M0) and performed radical left nephrectomy and lymph node dissection. The tumor occupied the upper pole and tumor section showed a tan-yellow lesion. Histologically, the tumor comprised high-grade tumor cells in a tubular and papillary architecture with mixed spindle-shaped cells. Immunohistologically, tumor cells were positive for CK7, vimentin, CD10, and P504S and negative for CK34βE12, TFE3, and CA9. The myxoid stroma was positive on Alcian blue staining. We diagnosed mucinous tubular and spindle cell carcinoma. The patient remains alive without recurrence 6 months postoperatively.

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The patient was a 65-year-old woman with diabetes mellitus. She was diagnosed with influenza B infection, and was treated with oseltamivir and clarithromycin in February 2014. Her urinary output gradually fell and the patient developed vomiting and a feeling of general malaise two weeks after she presented at the hospital. She developed hyperkalemia and required emergency dialysis, so she was admitted to the hospital. The urinary output improved following the second dialysis, hemodialysis was successfully administered on two other occasions, and her general condition improved. The causes of acute kidney injury can vary. The current case was thought to have been due to drug-induced kidney injury based on the timing of drug administration and the development of symptoms. Both medicines are frequently used during routine medical treatment, and patients' responses to these medications must be carefully monitored.

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Pulmonary congestion due to fluid retention is a major cause of pulmonary edema in dialysis patients. However, congestive heart failure that is not associated with marked fluid retention has recently been designated as Clinical Scenario 1 (CS1). We report four dialysis patients who suffered from pulmonary congestion that occurred in accordance with CS1. The patients were transferred to the ER because of dyspnea, which had developed during the night within a week prior to the first dialysis day. Peripheral blood hypoxemia was recognized and chest X-ray demonstrated pulmonary edema. Marked hypertension and elevation of serum BNP were shown, despite a moderate degree of body weight gain (3.8-9.2% above the dry weight). All of the patients were treated by infusing nitroglycerin and nicardipine intravenously. Non-invasive positive pressure ventilation (NPPV) was applied for two patients. Since hypertension and hypoxemia improved sufficiently by performing these therapies, emergency dialysis was carried out only for two patients while removing a fluid volume that corresponded to the interdialytic weight gain plus 0.5-0.8 kg. At 9-18 hours after admission, all of the patients became supported only by nasal oxygen inhalation because of the improvement of oxygenation induced by NPPV and vasodilator therapy. Increased afterload, which was caused by rapidly elevated blood pressure following arterial vasoconstriction (afterload mismatch), and a shift of circulating blood from the venous reservoir to the heart and the lungs (central volume shift) are considered to be the background mechanisms of CS1. By carefully evaluating the reason for congestive heart failure in dialysis patients, an attempt should be made to redistribute circulating blood from the cardiopulmonary compartment to peripheral vessels by using vasodilator agents rather than removing a large volume of fluid by emergency hemodialysis in cases of CS1.

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