【Objective】We evaluated the effects of a nutritional intervention with novel fortified food on malnutrition in hemodialysis patients with chronic inflammation. 【Subjects】The subjects of the study were 19 patients with inflammation of unknown cause who were maintained on hemodialysis in our unit and were able to ingest food orally. They were not using antimicrobial agents or non-steroidal anti-inflammatory agents. They met the criteria of CRP>0.3 mg/dL and Geriatric Nutritional Risk Index (GNRI) <92 evaluated within a month before the study. Informed consent was obtained from all the patients. 【Methods】They ingested orally a nutritionally fortified acid jelly [200 kcal/pack (125 g)] every day for 4 weeks. Physical examination, biochemical examinations and measurements of CRP, high-sensitivity CRP, IL-6, fetuin-A, 8-OHdG, serum protein, albumin and pre-albumin levels were performed before and after intervention. Adverse events including diarrhea, constipation and allergic reactions were monitored during the study. 【Results】 All the participants other than one withdrawn from the study were able to ingest the jellies orally. CRP and high-sensitivity CRP levels showed a tendency to decrease after 4 weeks compared with those before intervention. IL-6 decreased significantly from 6.58±5.13 pg/mL to 3.90±2.68 pg/mL (p<0.05). Although there was no significant change in serum albumin, serum prealbumin level increased significantly from 21.6±5.0 mg/dL to 23.5±4.7 mg/dL (p<0.01). Plasma fetuin-A level showed a tendency to increase, but there was no significant change in other parameters such as plasma 8-OHdG. 【Conclusion】 The results of this study suggest that the nutritional intervention with novel fortified food may improve nutritional status and inflammation in hemodialysis patients with malnutrition and chronic inflammation.

View full abstract

Substitution therapy using levocarnitine chloride (L-carnitine 600 mg/day, 12 weeks) was carried out in 13 cases of hemodialysis patients requiring high-capacity (9,000 IU/week or more upon rHuEpo conversion) ESA, and its effect against anemia was investigated along with the ESA requirement. The TC and FC values were very low in all patients before levocarnitine administration, and increased to a normal range 4 weeks after the administration and continued to increase over the following 12 weeks. The hemoglobin value increased by 1.0 g/dL or more in 7 of the 13 cases due to levocarnitine administration, while ESA was reduced by 25% or more in 4 cases, and was effective in a total of 9 cases (2 cases satisfying both standards). There were no significant differences between the effective example and ineffective example regarding the TC, FC, and acylcarnitine (AC) values as well as FC/AC ratio prior to levocarnitine administration. The TC and FC values 4 and 12 weeks after administration in the effective example were significantly higher than those in the ineffective example. The FC/AC ratio significantly increased in the effective example 4 and 8 weeks after administration compared with the prior value. Although red blood cell survival was shortened in 3 effective examples prior to administration, this improved following administration. Red blood cell survival in 2 ineffective examples did not improve, even after administration. As a result, levocarnitine substitution therapy appears to be highly effective in anemic hemodialysis patients without complicated diseases requiring high-quantity ESA, and its mechanism of action is mainly the improvement of shortened red blood cell survival.

View full abstract

The fetal and neonatal mortality rate is higher in hemodialysis patients than in healthy patients. According to the diagnosis and treatment guidelines of the Japanese Society of Nephrology, concerning patients with renal disease, pregnancy is not recommended for hemodialysis patients. From 2009 to 2012, we conducted prenatal nutritional management case experiments on three hemodialysis patients. In addition to the basic diet during the dialysis period, they were given an additional amount of water-soluble vitamins, minerals, and amino acids commonly administered to healthy pregnant women. By modifying their diet, we were able to secure the necessary amount of nutrition. Case 1 gave birth by caesarean section at 27 weeks of gestation : neonatal weight 443 g and APGAR score 9 (after 5 minutes), but death about 1 month later. Case 2 gave birth by caesarean section at 35 weeks of gestation : neonatal weight 1,652 g and APGAR score 9 (after 5 minutes). Case 3 gave birth by caesarean section at 34 weeks of gestation : neonatal weight 1,783 g and APGAR score 9 (after 5 minutes). The neonatal development of cases 2 and 3 was good. These three case experiments suggest that individual nutritional management is necessary during pregnancy of hemodialysis patients.

View full abstract

Carbon dioxide (CO₂) narcosis developed in chronically hypercapnic patients during hemodialysis using dialysate with a bicarbonate (HCO₃⁻) concentration of 25-30 mEq/L. The elderly hemodialysis patients had presented with hypoventilation because of atrophy in the respiratory muscles due to malnutrition. The hypercapnic respiratory failure during hemodialysis was prevented by lowering the HCO₃⁻ concentration to 22 mEq/L. During hemodialysis, the supply of HCO₃⁻ from dialysate to the blood desensitizes respiratory chemoreceptors for pulmonary ventilation. The elevation of blood HCO₃⁻ concentration also raises PaCO₂ by the reaction between HCO₃⁻ and H⁺. Dialysate HCO₃⁻ concentration should be modified for patients with ventilatory failure to prevent excessive CO₂ retention.

View full abstract

An 82-year-old male patient with nephrosclerosis had been under maintenance hemodialysis therapy for 10 years when he developed disturbed consciousness. Prior to developing this symptom, the patient had noticed loss of appetite and vertigo for about 3-4 weeks. During the period of observation at an outpatient clinic, the symptoms became worse. About 1 month after the onset of the symptoms, the patient was admitted to our hospital. Magnetic resonance imaging (MRI) showed typical abnormal lesions in the periaqueduct, third periventricle, and over the mammillary bodies, and Wernicke's encephalopathy was diagnosed. In addition, the patient's serum thiamine level was extremely low (10.5 ng/mL). He was immediately treated by intravenous thiamine administration, which resulted in significant improvement. However, thiamine deficiency is often seen in dialysis patients because of dietary restrictions as well as loss of the vitamin during dialysis. Wernicke's encephalopathy is a life-threatening disease, and early detection and prompt treatment are important for recovery. We emphasize that Wernicke's encephalopathy, though a rare complication, should be suspected in all patients on HD who present with altered mental status or confusion.

View full abstract