A nationwide statistical survey of 4,226 dialysis facilities was conducted at the end of 2010, and 4,166 facilities (98.6%) responded. The number of new patients introduced into dialysis was 37,512 in 2010. This number has decreased for two consecutive years since it peaked in 2008. The number of patients who died in 2010 was 28,882, which has been increasing every year. The number of patients undergoing dialysis at the end of 2010 was 298,252, which is an increase of 7,591 (2.6%) compared with that at the end of 2009. The number of dialysis patients per million at the end of 2010 was 2,329.1. The crude death rate of dialysis patients in 2010 was 9.8%, and has been gradually increasing. The mean age of the new patients introduced into dialysis was 67.8 years and the mean age of the entire dialysis patient population was 66.2 years. Regarding the primary disease of the new patients introduced into dialysis, the percentage of patients with diabetic nephropathy was 43.6%, which is a slight decrease from that in the previous year (44.5%). Patients with diabetic nephropathy as the primary disease accounted for 35.9% of the entire dialysis patient population, which approaches the percentage of patients with chronic glomerulonephritis as the primary disease (36.2%). The percentage of patients who had undergone carpal tunnel release surgery (CTx) was 4.3%, which is a slight decrease from that at the end of 1999 (5.5%). The decrease in the percentage of patients who had undergone CTx was significant among the patients with dialysis periods of 20-24 years (1999, 48.0%; 2010, 23.2%). A total weekly Kt/V attributable to peritoneal dialysis and their residual functional kidney was 1.7 or higher for 59.4% of patients who underwent peritoneal dialysis.

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The aim of this study was to evaluate the effects of alogliptin benzoate (alogliptin), a dipeptidase-4 inhibitor, as mono-therapy for hemodialysis (HD) patients with type2 diabetes. Among 381 HD patients, 16 diabetic HD patients (13 males and 3 females) with inadequate glycemic control (hemoglobin A1c (HbA1c) levels>6.1% and glycated albumin (GA) levels>20%) on exercise and diet were eligible to participate. No patients were taking other oral antidiabetic drugs nor receiving insulin injection therapy. The mean age was 62.5±9.2 years. Alogliptin was administered to patients at 6.25mg once a day. The following parameters were examined before and after treatment: levels of HbA1c, GA, blood glucose, insulin, C-peptide immunoreactivity, glucagon, and active glucagon like peptide-1 (GLP-1). All samples were obtained before the start of HD treatment. Significance was tested using the Wilcoxon signed-rank test for nonparametric data. HbA1c and GA levels significantly decreased in 8 weeks after the start of the administration of Alogliptin in comparison with before treatment (p<0.05). HbA1c and GA levels decreased from 6.7±0.2 to 5.6±0.2% and from 22.5±0.7 to 19.7±0.5% in 40 weeks after treatment. Among the 16 patients, 13 (81.3%) achieved HbA1c<6.1% and GA<20%. GLP-1 levels were 8.9±5.7pmol/L before treatment and these levels significantly increased by doubling after treatment (p<0.05). None of the patients exhibited significant adverse effects such as hypoglycemia, except one patient who experienced a drug rash event. Alogliptin is expected as one of the new treatment strategies for hemodialysis patients with diabetes whose choices of diabetic treatment are limited.

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The activities of daily living (ADL) of patients who have survived with long-term hemodialysis for over 30 years have not been studied well. We evaluated the ADL, patient history, and clinical data of 26 patients (18 male, 8 female) at our clinic who have undergone hemodialysis therapy for more than 30 years. These patients exhibited the following features: 1) Women had significantly higher ADL scores than men (p<0.001). 2) None of the patients were bedbound. 3) None of the patients had undergone coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty. 4) Underlying diseases included 1 case of systemic lupus erythematosus; the others suffered from chronic glomerulonephritis. None of the patients were diabetic. 5) The ADL status was not correlated with the age at hemodialysis initiation, dry weight, body mass index, history of parathyroidectomy, or surgery for carpal tunnel syndrome, or with levels of albumin, hematocrit, pre-dialysis blood urea nitrogen, and β₂ microglobulin. 6) The patients classified as “ambulatory” on the ADL scale had better kt/v values (p<0.05).

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A man in his 60s had been treated for psoriasis vulgaris with activated vitamin D₃ (maxacalcitol) ointment and etretinate since 2006. In August 2010, he developed diarrhea, anorexia, and general fatigue. Under a diagnosis of viral enterocolitis, he underwent parenteral fluid therapy by a local physician. However, general fatigue persisted despite improving his diarrhea; therefore, he was admitted to our hospital. Since the serum creatinine level was 11.16mg/dL and potassium was at 8.1mEq/L with metabolic acidosis, hemodialysis was initiated. As he had been treated with maxacalcitol ointment for long periods, we therefore susupected acute renal failure due to hypercalcemia resulting from the maxacalcitol ointment, and so discontinued it. After five hemodialysis sessions and conservative management, his renal function improved to a serum creatinine level of 2.46mg/dL. Finally, this patient was discharged from our hospital with mild renal dysfunction. We should always consider that activated vitamin D₃ ointment may result in hypercalcemia and acute renal failure.

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We report a case of heparin-induced thrombocytopenia (HIT) suspected while performing CHDF procedures, with subsequent successful reexposure to heparin. A 51-year-old female underwent CHDF therapy due to pulmonary edema caused by water-overload. Frequent intra-circuit coagulation during CHDF suggested heparin-induced thrombocytopenia (HIT). Anti-PF4/heparin complex antibody was measured. Since testing for anti-PF4/heparin complex antibody was positive, HIT could not be ruled out and anticoagulant was switched to argatroban. On confirming that anti-PF4/heparin complex antibody titers were seronegative about 3 months after argatroban administration, heparin was re-administered uneventfully without the occurrence of HIT.

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A 65-year-old man who had undergone hemodialysis for chronic renal failure due to diabetes mellitus since 1997 was admitted to the Department of Dermatology for cellulitis on the right lower extremity on April 12, 2010. He had a history of diabetic gangrene and had been treated in the dermatology department since 2007. On his 2nd hospital day, he suddenly showed loss of consciousness. Magnetic resonance imaging diffusion-weighted images (MRI-DWI) revealed fresh multiple cerebral infarctions. An echocardiogram revealed mitral valve vegetation and blood culture grew gram-positive coccus bacteria, confirming the diagnosis of infective endocarditis. On the 5th day, he died of systemic sepsis and multiple organ failure. Subsequently, gram-positive coccus was detected as Methicillin-resistant Staphylococcus aureus (MRSA). At autopsy, the mitral valve showed vegetation of 2cm in diameter and multiple embolizations in the brain, liver, and spleen. Bacterial culture of both the vegetation and emboli revealed the same bacteria as MRSA. This case is very valuable as we could prove that the multiple cerebral infarctions and systemic embolization in the liver and spleen were caused by the mitral valve vegetation of MRSA.

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A 76-year-old male with a history of pulmonary hypertension, diabetes mellitus, hypertension, hyperlipidemia, and old cardiac infarction was admitted to our hospital due to transient unconsciousness and diagnosed with pulmonary embolism (PE). He underwent inferior vena cava filter (IVC filter) application and anticoagulant therapy (Warfarin sodium at 3mg/day, etc.). His baseline creatinine value of 1.1mg/dL had risen to 7.7mg/dL 19 days after admission. Physical examination demonstrated constitutional erythema with itching and purpura of the toes (blue toes). We performed a skin biopsy and diagnosed him with cholesterol crystal embolism (CCE). Predonisolone (PSL) at 40mg/day and LDL apheresis decreased the creatinine level and we tapered the PSL dose. However, gradually, the patient complained of appetite loss and showed deterioration of renal failure, and so hemodialysis (HD) was initiated 48 days after admission. At 269 days from the initiation of HD, the patient complained of chest pain, and was diagnosed with relapse of PE. He died of PE the next day even though he underwent IVC filter use again and anticoagulation therapy (heparin: 20,000 units/day and Warfarin sodium: 2mg/day). At autopsy, numerous organizing blood clots were observed in the pulmonary arteries, and relatively new ones were in the superior lobe branch of the right lung. Cholesterol crystal (CC) emboli were found in the renal interlobular arteries. The lumens of arteries were obstructed by proliferative connective tissue. CCs were also observed in the subcutaneous tissue, liver, pancreas, adrenal gland, and spleen. It was a difficult case to treat as both PE and CCE were involved, requiring therapies contradictory to each other.

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