In 2009, we started the peritoneal dialysis (PD) registry with the cooperation of the Japanese Society for Peritoneal Dialysis as part of the annual nationwide survey conducted at the end of each year by the Statistical Survey Committee of the Japanese Society for Dialysis Therapy. In this study, we examined the current status of PD patients on the basis of the 2012 survey results. The subjects are PD patients who lived in Japan and participated in the nationwide survey conducted at the end of 2012. Descriptive analysis was performed mainly focusing on the current status of the combined use of PD and another method such as hemodialysis (HD) or hemodiafiltration (HDF), the method of dialysate exchange, the use of an automated peritoneal dialysis (APD) machine, and the incidences of peritonitis and catheter exit-site infection. From the results of the facility survey in 2012, the number of PD patients was 9,514, a decrease of 128 from that in 2011. The percentage of PD patients with respect to all the dialysis patients was 3.1%, a decrease of 0.1%. Among the PD patients, 347 did not undergo PD despite having a peritoneal lavage catheter, 175 were started on PD in 2012 but introduced to other blood purification methods in 2012, and 1,932 underwent both PD and another method such as HD or HDF (PD+HD combination therapy). The percentage of patients who underwent PD+HD combination therapy increased with the number of years on PD (PD period): less than 1 year, 4.8%; 1-2 years, 9.2% ; 2-4 years, 16.3% ; 4-8 years, 32.0% ; and 8 years or longer, 47.5%. The percentage of PD patients for which the dialysate was completely manually exchanged was 29.8%, whereas the percentages of PD patients who used a bag-exchange device based on ultraviolet-light irradiation and thermal sterile joint systems were 54.7 and 13.9%, respectively. The percentage of PD patients who used an APD machine was 43.4% with respect to the PD patients with a PD period of less than one year ; this decreased with increasing PD period beyond two years. The mean incidences of peritonitis and catheter-exit-site infection were 0.22 and 0.36 per patient per year, respectively.

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【Objectives】To evaluate the efficacy of levocarnitine for renal anemia in hemodialysis patients. 【Subjects】Among the 192 patients with maintenance dialysis at our hospital, we conducted a questionnaire survey on the desire for treatment with levocarnitine in 153 of them. Of these patients, 113 wanted to take the drug (Treated group) and 40 did not (Control group). 【Methods】This clinical research involved a non-randomized controlled trial. The Treated group received levocarnitine at 20 mg/kg (maximum dose : 1,200 mg/day). As erythropoiesis-stimulating agents (ESAs), the dose conversion from recombinant human erythropoietin to darbepoetin α was predicted as 200 : 1. Response to ESA therapy was determined by calculation of erythropoiesis resistance index (ERI) using the following parameters : 1) weekly ESA doses and 2) weekly ESA doses/kg/g/dL. 【Results】1) The target levels of Hb and hematocrit were reached during the period from study initiation up to month 6 in both Treated and Control groups. 2) The quantity of ESAs used tended to decrease gradually in the Treated group, showing a significant difference at month 6. Furthermore, the Treated group had a significantly smaller quantity at month 6 compared with the Control group. 3) weekly ESA doses/kg/g/dL showed a significant decrease at month 6 in the Treated group, with a significant difference between the two groups at months 3 and 6. 【Conclusions】The results suggest that levocarnitine can reduce the quantity of ESAs in renal anemia in patients on hemodialysis and improve the response to therapy with ESAs.

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【Background】Decreased activities of daily living (ADL) have been associated with mortality in the general population. Additionally, decreased ADL are more common among hemodialysis patients than in the general population. Therefore, the correlation between ADL and mortality in hemodialysis patients needs to be studied. We assessed the level of ADL using functional independence measure (FIM), which is one of the major surrogate markers of ADL, and the association between the FIM score and all-cause mortality in hemodialysis patients. 【Methods】A total of 132 patients on maintenance hemodialysis (77 men and 55 women ; mean age, 72.3±0.8 years) were enrolled. ADL was assessed using FIM score (total points, 126), which comprises 13 motor items (total points, 91) and 5 cognitive items (total points, 35). A multivariable linear regression model was constructed to determine factors associated with the FIM score. A survival curve was drawn using Kaplan-Meier analysis and stratified into 4 groups using the interquartile range value of FIM score. The Cox proportional hazards analysis was used to calculate mortality hazard ratio and its 95% confidence interval. 【Results】The mean total FIM score was 60.0±2.2, and the scores for FIM motor and cognitive items decreased (34.8±1.5 and 25.7±1.0, respectively). Cerebrovascular disease and Cr were significantly associated with FIM score. Cumulative mortality rate was significantly higher in groups with FIM scores 40—60 and≤39 than in groups with FIM scores 84≤. FIM score, hsCRP, and hANP were significantly associated with mortality, and FIM was the strongest related factor. 【Conclusions】The FIM score decreased by half in hemodialysis patients, especially in motor items. The FIM score is a novel predictive marker in these patients. Our findings suggest the need for comprehensive strategies that could increase the ADL in hemodialysis patients.

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The importance of endotoxin measurement in safety management of dialysis fluid is widely recognized and many hemodialysis facilities are evaluating the purity of dialysis fluid by endotoxin testing. As endotoxin testing using Limulus reagent is known to be influenced by differences in equipment, instrumentation, and environment in the test laboratory, the Bacterial Endotoxins Test chapter in the Japanese pharmacopoeia specifies that a concurrent endotoxin standard series should be included with each test. To simplify testing, standard curve information provided by the reagent's manufacturer is also often utilized to create an archived standard curve consisting of stored standard line parameters. However, there has been little study on the effectiveness of the archived standard curve in terms of accuracy and precision. In this study, recovery of added endotoxin, detection limit in distilled water, quantitation limit in dialysis fluid, and intermediate precision were evaluated for the use of archived standard curve to measure endotoxin in dialysis fluid according to the draft guidelines for validation of the endotoxin test in dialysis fluid prepared by a study group in the Japanese Society for Hemodiafiltration. The results demonstrate the effectiveness of archived standard curves in endotoxin measurement in dialysis fluid when used under properly controlled conditions of the measurer and instrumentation.

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Pain from a number of causes is the most common problem affecting hemodialysis (HD) patients. This population also has a high prevalence of restless legs syndrome (RLS). We report on a woman in her seventies undergoing HD with severe back pain and RLS. She had been treated with oral pramipexole since developing RLS about 2 years previously. After that, she suffered from severe back pain, and opioid buprenorphine transdermal patch was prescribed for 7 months. Recently, the buprenorphine use was discontinued according to her wishes. RLS symptoms were provoked within a few days, and became severe enough to disturb her HD therapy with time. Readministration of the buprenorphine patch rapidly relieved her symptoms, so the exacerbation was considered to have been associated with the withdrawal of buprenorphine. As subsequent discontinuation could be difficult, it would be prudent to select opioid analgesics for chronic pain in HD patients with RLS.

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The patient was a 72-year-old female who had myelodysplastic syndrome and had been receiving maintenance hemodialysis for 2 years due to purpura nephritis. Two months previously, she had developed a fever for which antibiotics were not effective. One week previously, disturbance of consciousness appeared. She was admitted to our hospital and underwent a lumbar puncture. The opening pressure was elevated by 40 cmH₂O and examination of the CSF with India ink demonstrated encapsulated yeast forms. CSF and serum cryptococcal antigen tests were positive and, by culturing the organisms from CSF and blood Cryptococcus neoformans was isolated. We diagnosed cryptococcal meningoencephalitis. We used liposomal amphotericin B and flucytosine adjusted for renal function and repeated lumbar drainage. CSF and blood cultures became negative, but the disturbance of consciousness did not improve. Hemodialysis patients are immunocompromised due to defects in their cell-mediated immunity and neutrophil function, and are likely to have fungal infections. Cryptococcal infections have no characteristic symptoms, but are diagnosed by antigen tests. Delayed treatment is associated with increased mortality, so we should consider this disease when investigating fever of unknown origin in hemodialysis patients.

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A 52-year-old man was admitted to our hospital for the management of glycemic control. He had been diagnosed with diabetes mellitus at the age of 31. Oral hypoglycemic agents were started at the age of 40 and insulin treatment at the age of 50. Eight months after the initiation of insulin treatment, his glycemia become significantly unstable, with frequent manifestation of hypoglycemia as well as rash at the site of insulin injection. He exhibited prominent hyperinsulinemia and anti-insulin antibodies with low affinity and high binding activity in his serum, which we thought to be attributable to his unstable glycemic control. Because the cessation of insulin resulted in the marked deterioration of the glycemia, we performed double-filtration plasmapheresis to remove the anti-insulin antibodies. This treatment rapidly improved glycemic control as well as rash. His glycemic control has been maintained at good levels by the administration of oral hypoglycemic agents even two years after the double-filtration plasmapheresis. These results suggest that double-filtration plasmapheresis was useful for long-lasting treatment in a case of diabetes with unstable glycemia induced by anti-insulin antibodies.

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