Search

Aim Proteinuria is known to be an independent risk factor of end-stage renal disease (ESRD). But the associations between changes in dipstick proteinuria and the risk of ESRD in the general population and its appropriate observation period to predict incident ESRD are unknown. Methods We assessed the changes in dipstick proteinuria in 69021 subject aged ≥20 years who participated in health check-up from 1993 and more than once until 1996 in Okinawa, Japan. Development of ESRD until 2011 was identified using dialysis registry. Cox proportional hazards model and receiver operating characteristic (ROC) curve were used. Results At baseline, proteinuria (±) and ≥(1+) were observed in 2.4% and 1.2% of total subjects. 1.5% of subjects had decreased and 9.4% of subjects had increased their proteinuria level after 2-year. After adjustment for confounding factors, hazard ratios (95% confidence interval) of ESRD for subjects with proteinuria change ≤-1, +1, +2, +3, and +4 level during 2-year compared to subjects with no change were 0.89 (0.43-1.87), 3.18 (2.21-4.60), 8.01 (5.55-11.55), 11.17 (6.59-19.95), and 16.59 (5.95-46.25), respectively. Heterogeneity existed between changes in proteinuria level during 1- or 3-year and the risk of ESRD among baseline proteinuria. Area under the ROC curve (95%CI) to predict ESRD by increase in proteinuria level during 1-, 2-, and 3-year were 0.650 (0.623-0.679), 0.779 (0.751-0.808), and 0.778 (0.748-0.808), respectively. Conclusions The changes in dipstick proteinuria were an independent predictor of ESRD in the general population. Changes in proteinuria during 2-year may be appropriate for the risk prediction of ESRD.

Aim The burden of chronic kidney disease (CKD) is growing rapidly around the world. However, there is limited information on the overall regional prevalence of CKD, as well as the prognostic implications and treatment patterns in Asian region. We have established the Asian Renal Collaboration (ARC) with the goal of consolidating region-wide data regarding CKD. Methods This collaborative project will synthesize data and perform meta-analyses of observational studies conducted in Asia. Studies will be identified through a systematic literature search including abstracts, proceedings of meetings, electronic databases such as MEDLINE and EMBASE. Personal enquiry among collaborators and experts in the region will identify additional studies, or other data sources such as registries. Both cross-sectional and longitudinal studies that describe the prevalence of CKD and its complications will be included, as will longitudinal studies that describe important clinical outcomes for people with CKD. Individual participant data will be sought, where possible, from each of the studies included in the collaboration for baseline parameters and subsequent outcomes, in order to maximize flexibility and consistency of data analyses. Conclusions This study is an initiative offering a unique opportunity to obtain information about the prevalence and manifestations of CKD in Asia, as well as its risk factors. The ARC will also provide insights into important outcomes including progression of CKD, CKD complications, cardiovascular disease and death. These findings will improve our understanding of kidney disease in Asia, and thus help inform service provision, preventive care and further research across the region.

Since 2009, the peritoneal dialysis (PD) registry survey has been carried out as part of the annual nationwide survey conducted by the Statistical Survey Committee of the Japanese Society for Dialysis Therapy with the cooperation of the Japanese Society for Peritoneal Dialysis. In this report, the current status of PD patients is presented on the basis of the results of the survey conducted at the end of 2012. The subjects were PD patients who lived in Japan and participated in the 2012 survey. Descriptive analysis of various items was performed, which included the current status of the combined use of PD and another dialysis method such as hemodialysis (HD) or hemodiafiltration (HDF), the method of exchanging dialysate, the use of an automated peritoneal dialysis (APD) machine, and the rates of peritonitis and catheter exit-site infection. From the results of the facility survey in 2012, the number of PD patients was 9514, a decrease of 128 from 2011. Among the entire dialysis patient population, 3.1% were PD patients, a decrease of 0.1%. Among the studied patients, 347 had a peritoneal catheter and underwent peritoneal lavage, 175 were started on PD in 2012 but introduced to other blood purification methods in the same year, and 1932 underwent both PD and another dialysis method such as HD or HDF. The percentage of patients who underwent PD and another dialysis method increased with PD vintage

There are regional differences in the survival of incident dialysis patients, but few studies have investigated the reasons. We assessed the effect of institutional factors on factors on survival (by both cross-sectional assessment and after a 1-year investigation) in a cohort of the Japanese Society for Dialysis Therapy (JSDT). We investigated 20 institutional factors from 3958 dialysis institution data of the 47 prefectures in Japan in 2005 and the JSDT database of 102,011 patients who commenced dialysis during 2004-2006. Univariate regression analysis between 20 factors and 1-year survival rate, Kaplan-Meier method, log-rank test, and Cox's proportional hazard model between the upper 24 and the lower 23 prefectures of the significant factors were carried out. The age-adjusted 1-year survival rate was 0.832 ± 0.027. Deaths occurred in 15.0% in 24 upper survival prefectures and 18.7% in 23 lower survival prefectures (P

Yuzo Watanabe, Hideki Hirakata, Kazuyoshi Okada, Hiroyasu Yamamoto, Kazuhiko Tsuruya, Ken Sakai, Noriko Mori, Noritomo Itami, Daijo Inaguma, Kunitoshi Iseki, Akiko Uchida, Yoshindo Kawaguchi, Seiji Ohira, Masashi Tomo, Ikuto Masakane, Tadao Akizawa, and Jun Minakuchi, for the Japanese Society for Hemodialysis Therapy Guideline Commission of Maintenance Hemodialysis Investigation Subgroup Commission on Withholding and Withdrawal from Dialysis

Yuzo Watanabe, Kunihiro Yamagata, Shinichi Nishi, Hideki Hirakata, Norio Hanafusa, Chie Saito, Motoshi Hattori, Noritomo Itami, Yasuhiro Komatsu, Yoshindo Kawaguchi, Kazuhiko Tsuruya, Yoshiharu Tsubakihara, Kazuyuki Suzuki, Ken Sakai, Hideki Kawanishi, Daijo Inaguma, Hiroyasu Yamamoto, Yoshiaki Takemoto, Noriko Mori, Kazuyoshi Okada, Hiroshi Hataya, Takashi Akiba, Kunitoshi Iseki, Tadashi Tomo, Ikuto Masakane, Tadao Akizawa, and Jun Minakuchi, for “Hemodialysis Initiation for Maintenance Hemodialysis” Guideline Working Group, Japanese Society for Dialysis Therapy

Hypertension is common in approximately 80% to 90% of patients at the start of dialysis therapy and is an established risk factor for cardiovascular disease. Therefore, it should be controlled, even in the chronic dialysis population. Observational studies indicate a U-shaped phenomenon, as the mortality rate is high among those with hypertension as well as those with hypotension. Among chronic dialysis patients, randomized controlled trials on the effect of anti-hypertensive treatment are not conclusive, at least not as demonstrated by studies with a large sample size. Similar to other potentially effective drug therapies such as erythropoietin stimulating agent, statins, and uraemic toxin adsorbents, the benefit of anti-hypertensive treatment remains to be demonstrated in dialysis patients. The blood pressure target level, however, is difficult to determine as evidence for the level of appropriate target is lacking. Currently, it should be determined individually, as the priority is to perform haemodialysis as prescribed. The target levels of blood pressure for chronic haemodialysis patients are not stated except in the Guidelines in the Japanese Society for Dialysis Therapy. In this guideline, systolic blood pressure between 140 to 159 mmHg is preferable among elderly patients with comorbid conditions. Rapid ultrafiltration, such as >600 mL/h, is to be avoided. Intra-dialysis hypotension, muscle cramps, and other complaints during HD are preventable. Moreover, the nutritional status should be maintained within the normal range with adequate intake of protein and calories, but with salt restriction. Further studies are necessary for better management of hypertension in the dialysis population.

The use of vitamin D receptor activators (VDRAs) is an independent predictor of a lower risk of death from cardiovascular disease (CVD) in patients with chronic kidney disease (CKD). We examined whether the use of VDRAs and other CKD-mineral bone disorder (MBD)-related factors are associated with incident CVD or death after CVD in hemodialysis patients. This is a historical cohort study of 37 690 prevalent hemodialysis patients without previous history of CVD at the end of 2004 extracted from a nationwide registry in Japan. The key exposure was the use of VDRAs, and the outcomes were incident CVD (myocardial infarction, cerebral infarction, cerebral hemorrhage, and sudden death) and death after CVD during the 1-year follow-up. VDRAs were used in 57% of the subjects at baseline. We identified 2433 patients with incident CVD and 397 deaths after the events. In multivariate logistic regression models, independent predictors of incident CVD were non-use of VDRA, higher intact PTH, non-use of calcium-based phosphate-binder, and non-use of non-calcium-based phosphate binder. Risk of death after CVD was not significantly associated with VDRA, whereas it was lower in those with lower corrected calcium, and the risk was higher in those with higher phosphate and in non-users of calcium-based phosphate binders. The use of VDRAs was associated with a lower risk of incident CVD but not with death after CVD in this large cohort of hemodialysis patients. The CKD-MBD-related predictors of poor outcomes are associated with the risk of incident CVD, the risk of death after CVD, or both.

A nationwide statistical survey of 4279 dialysis facilities was conducted at the end of 2012, among which 4238 responded (99.0%). The number of new dialysis patients was 38055 in 2012. Since 2008, the number of new dialysis patients has remained almost the same without any marked increase or decrease. The number of dialysis patients who died in 2012 was 30710; a slight decrease from 2011 (30743). The dialysis patient population has been growing every year in Japan; it was 310007 at the end of 2012, which exceeded 310000 for the first time. The number of dialysis patients per million at the end of 2012 was 2431.2. The crude death rate of dialysis patients in 2012 was 10.0%, a slight decrease from that in 2011 (10.2%). The mean age of new dialysis patients was 68.5 years and the mean age of the entire dialysis patient population was 66.9 years. The most common primary cause of renal failure among new dialysis patients was diabetic nephropathy (44.2%). The actual number of new dialysis patients with diabetic nephropathy has been approximately 16000 for the last few years. Diabetic nephropathy was also the most common primary disease among the entire dialysis patient population (37.1%), followed by chronic glomerulonephritis (33.6%). The percentage of dialysis patients with diabetic nephropathy has been continuously increasing, whereas not only the percentage but also the actual number of dialysis patients with chronic glomerulonephritis has decreased. The number of patients who underwent hemodiafiltration (HDF) at the end of 2012 was 21725, a marked increase from that in 2011 (14115). In particular, the number of patients who underwent on-line HDF increased threefold from 4890 in 2011 to 14069 in 2012. From the results of the facility survey, the number of patients who underwent peritoneal dialysis (PD) was 9514 and that of patients who did not undergo PD despite having a PD catheter in the abdominal cavity was 347. From the results of the patient survey, among the PD patients, 1932 also underwent another dialysis method using extracorporeal circulation, such as hemodialysis (HD) and HDF. The number of patients who underwent HD at home in 2012 was 393, a marked increase from that in 2011 (327).

Aims Chronic kidney disease is a risk factor of the development of cardiovascular disease (CVD). However, it is not clear whether decline of glomerular filtration rate (GFR), not reduced GFR, is a risk factor for the incidence of CVD independent of proteinuria. Methods By using a population-based 521 123 person-years longitudinal cohort receiving annual health checkups from 2008 to 2010, we examined whether the annual decline of estimated GFR is a risk factor for CVD development independent of proteinuria. Results During the follow-up period, there were 12 041 newly developed CVD events, comprising 4426 stroke events and/or 8298 cardiac events. As expected, both reduced estimated GFR and proteinuria were risk factors for the development of CVD in our study population. Moreover, annual decline of estimated GFR was a significant and independent risk factor for the incidence of CVD (HR [95% CI], 1.23 [1.18–1.28] in males or 1.14 [1.10–1.18] in females for −10% per year) with covariant adjustment for proteinuria and reduced estimated GFR. Conclusion Annual decline of GFR is an independent risk factor for CVD. Serial measurement of both creatinine and proteinuria would be better to predict the incidence of CVD in the general population.

A nationwide statistical survey of 4255 dialysis facilities was conducted at the end of 2011. Responses were submitted by 4213 facilities (99.0%). The number of new patients started on dialysis was 38,613 in 2011. Although the number of new patients decreased in 2009 and 2010, it increased in 2011. The number of patients who died each year has been increasing; it was 30,743 in 2011, which exceeded 30,000 for the first time. The number of patients undergoing dialysis has also been increasing every year; it was 304,856 at the end of 2011, which exceeded 300,000 for the first time. The number of dialysis patients per million at the end of 2011 was 2385.4. The crude death rate of dialysis patients in 2011 was 10.2%, which exceeded 10% for the first time in the last 20 years. The mean age of new dialysis patients was 67.84 years and the mean age of the entire dialysis patient population was 66.55 years. The most common primary cause of renal failure among new dialysis patients was diabetic nephropathy (44.3%). Diabetic nephropathy was also the most common primary disease among the entire dialysis patient population (36.7%), exceeding chronic glomerulonephritis (34.8%) which had been the highest until last year. The survey included questions related to the Great East Japan Earthquake, which occurred on 11 March 2011. The results on items associated with the Great East Japan Earthquake were reported separately from this report. The mean uric acid levels of the male and female patients were 7.30 and 7.19 mg/dL, respectively. Certain drugs for hyperuricemia were prescribed for approximately 17% of patients. From the results of the facility survey, the number of patients who underwent peritoneal dialysis (PD) was 9642 and the number of patients who did not undergo PD despite having a peritoneal dialysis catheter was 369. A basic summary of the results on the survey items associated with PD is included in this report and the details were reported separately.

Hip fracture incidence in Japanese hemodialysis patients is five-fold higher than in the general population, although the mechanisms underlying this difference are not fully understood. Substantial regional variation exists in hip fracture incidence in the general Japanese population, despite a uniform health care and insurance system and lack of ethnic and racial variation. In this study, we determined whether the regional variation seen in the general population also applies to hemodialysis patients in Japan. Standardized incidence ratios were calculated for each regional district, and regional variations of hip fracture incidence among hemodialysis patients were evaluated using data obtained from the Japanese Society for Dialysis Therapy registry (data collected from December 2007 to December 2008). Standardized hip fracture incidence ratios across the districts ranged from 0.71 to 1.29 for male and 0.49 to 1.36 for female hemodialysis patients. Incidence ratios tended to be higher in western Japan and lower in eastern Japan, suggesting that regional variation also exists among hemodialysis patients. Our findings suggest that common risk factors for hip fracture may be shared among the general population and hemodialysis patients. Further research aimed at identifying factors, including those associated with regional variation, may help decrease hip fracture incidence in both the general population and hemodialysis patients in Japan.

Mineral metabolism affects mortality in hemodialysis patients and is identified by imbalances in serum phosphate (P), calcium (Ca), and parathyroid hormone (PTH). We examined associations between annual mineral values (P, Ca, PTH) and mortality in a 3-year cohort (Dec 2006-2009) of 128,125 hemodialysis patients using three models, that is, baseline, time-dependent and time-average Cox models. We also examined associations between achieved Japanese guideline targets (P: 3.5-6.0 mg/dL, corrected Ca 8.4-10.0 mg/dL, intact PTH 60-180 mg/dL) and all-cause survival to elucidate which parameter should be controlled as a priority. High and low serum P (>6.0 or ≤ 3.5 mg/dL), high Ca (>9.5 mg/dL), higher PTH (>300 pg/mL) and lower PTH (≤ 60 pg/mL) were significantly associated with high mortality in all three models (P < 0.01). When we examined the association between combination of mineral targets and mortality, patients who achieved all targets simultaneously (20% of subjects, reference) showed lowest mortality. Those who achieved both P and Ca targets showed the same mortality as the reference group. Those who only met P target had a lower risk of death (hazard ratio = 1.17) compared to those that achieved Ca or PTH target (1.41, 1.47, respectively). As time of achieving P and Ca targets increased, all-cause mortalities diminished incrementally, significantly. Mineral metabolism disorder would lead to high mortality in prevalent hemodialysis patients. Among mineral values, P would be the strongest predictor for high mortality. Consistent achievement of P and Ca targets would lead to good survival.

A nationwide statistical survey of 4226 dialysis facilities was conducted at the end of 2010, and 4166 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 7591 (2.6%) compared with that at the end of 2009. The number of dialysis patients per million at the end of 2010 was 2329.1. 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 durations 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.

Hideki Hirakata, Kosaku Nitta, Masaaki Inaba, Tetsuo Shoji, Hideki Fujii, Shuzo Kobayashi, Kaoru Tabei, Nobuhiko Joki, Hiroki Hase, Masato Nishimura, Shigeyuki Ozaki, Yuji Ikari, Yoshitaka Kumada, Kazuhiko Tsuruya, Shouichi Fujimoto, Tohru Inoue, Hiroyoshi Yokoi, Sumio Hirata, Kazuaki Shimamoto, Kiyotaka Kugiyama, Takashi Akiba, Kunitoshi Iseki, Yoshiharu Tsubakihara, Tadashi Tomo, and Tadao Akizawa

Early initiation of dialysis had been considered one of the most important methods for better prognosis of dialysis patients. One of the reasons for this was that long-term as well as short-term prognosis was poor with late initiation of dialysis. In this study, we analyzed the effects of residual renal function and comorbidity on both short- and long-term outcomes of ESRD patients. The subjects of this study were 20 854 patients who started renal replacement therapy (RRT) in 1989 and 1990, when we conducted national surveillance for new ESRD patients. The effects of glomerular filtration rate (GFR) at dialysis start and comorbidity conditions on survival were measured. Mortality hazard ratio (HR) was calculated using a Cox proportional hazard model. Multivariate analysis included pre-dialysis estimated GFR, age, sex, and underlying renal disease. The mean age of the subjects was 57.7 years old. Mean GFR at dialysis initiation was 5.00 mL/min per 1.73 m(2) and GFR was significantly higher in patients with diabetes. The median survival time from the start of dialysis was 69 months, excluding subjects who died within 3 months; 1-year survival was 89.7%, while 2-year, 3-year, 5-year, 10-year, and 15-year cumulative survival rates were 79.3%, 71.1%, 57.8%, 37.3%, and 26.1%, respectively. For mortality risks, the higher the GFR at dialysis initiation, the worse the HR for mortality in both short-term and long-term prognoses by unadjusted analysis. However, after adjustments for age, gender, underlying renal diagnosis, and symptom at dialysis initiation, both late and early initiation of RRT did not affect long-term prognosis.

A nationwide statistical survey of 4196 dialysis facilities was conducted at the end of 2009, and 4133 facilities (98.5%) responded. The number of patients undergoing dialysis at the end of 2009 was determined to be 290 661, an increase of 7240 patients (2.6%) compared with that of 2008. The number of dialysis patients per million at the end of 2009 was 2279.5. The crude death rate of dialysis patients from the end of 2008 to the end of 2009 was 9.6%. The mean age of the new patients introduced into dialysis was 67.3 years old and the mean age of the entire dialysis patient population was 65.8 years old. Primary diseases such as diabetic nephropathy and chronic glomerulonephritis for new dialysis patients, showed a percentage of 44.5% and 21.9%, respectively. Based on the facilities surveyed, 84.2% of the facilities that responded to the questionnaire satisfied the microbiological quality standard for dialysis fluids for the Japanese Society for Dialysis Therapy (JSDT), with an endotoxin concentration of less than 0.05 EU/mL in the dialysis fluid. Similarly, 98.2% of the facilities surveyed satisfied another standard of the society of a bacterial count of less than 100 cfu/mL in the dialysis fluid. The facility survey indicated that the number of patients who were treated by blood purification by both peritoneal dialysis and extracorporeal circulation, such as hemodialysis, was 1720. Among the total number of patients, 24.8% were satisfied with the management target recommended in the treatment guidelines for secondary hyperparathyroidism. These standards are set by the JSDT, based on the three parameters, i.e. serum calcium concentration, serum phosphorus concentration, and serum intact parathyroid hormone concentration. According to the questionnaire, 9.8% of the patients were considered to have a complication of dementia.

Previous studies have suggested that early initiation of dialysis therapy was not superior in terms of patient survival. In this study, we analyzed the effects of renal function at the start of renal replacement therapy (RRT), duration of nephrology care, and comorbidity on 12-month survival of end-stage renal disease (ESRD) patients. The subjects in this study were 9695 new ESRD patients who started RRT in 2007. The average age of the subjects was 67.5 years, 64.1% of the subjects were male, and 42.9% had diabetes. During the 12-month period after the start of RRT, 1546 patients died, and 35 patients received renal transplantation. Average estimated glomerular filtration rate (eGFR) at the initiation of dialysis was 6.52 ± 4.20 mL/min/1.73 m2. By unadjusted logistic analysis, one-year Odds Ratio (OR) of mortality in patients with eGFR more than 4–6 mL/min/1.73 m2 was increased with increased eGFR at dialysis initiation, but the OR was identical among the groups with eGFR less than 4 mL/min/1.73 m2. After adjustment for age, gender, underlying renal diseases, and other clinical characteristics at dialysis initiation, OR was identical among the groups with eGFR less than 8 mL/min/1.73 m2. Furthermore, an OR increment was observed in eGFR less than 4 mL/min/1.73 m2 group. In terms of the duration of nephrology care before dialysis initiation, 6 months or longer of nephrology care significantly decreased the OR of mortality after adjustment of covariance. Not only patients with sufficient residual renal function at the initiation of dialysis, but also patients with very low eGFR at the initiation of dialysis showed poor survival.

The prevalence of treated patients with end-stage renal disease (ESRD) has been increasing steadily in Japan. High ESRD prevalence could be explained by multiple factors such as better survival on dialysis therapy, luxury acceptance due to insurance system to cover dialysis therapy, and 'truly' high incidence and prevalence of chronic kidney disease (CKD). The growing elderly population may also contribute to this trend. The Japanese Society of Nephrology estimated the prevalence of CKD stage 3 as 10.4%, 7.6% within the range of 50-59 mL/min per 1.73 m(2) in a screened population. Strong predictors of treated ESRD shown by using community-based screening programs and an ESRD registry in Okinawa are dip-stick-positive proteinuria and hypertension. Low glomerular filtration rate per se, which is often observed in the elderly population, is not a significant predictor of developing ESRD unless associated with proteinuria. CKD is common in Japan and is expected to increase, particularly in the elderly population. Benefits of proteinuria screening and automatic reporting of estimated glomerular filtration rate on the incidence of ESRD remain to be determined.

A statistical survey conducted at the end of 2005 covered 3985 medical facilities across Japan, and 3940 facilities (98.87%) responded. The dialysis population in Japan at the end of 2005 was 257,765, which showed an increase of 9599 patients (3.87%) from the end of the previous year. The number of patients per million was 2017.6. The crude death rate for one year (from the end of 2004 to the end of 2005) was 9.5%. The mean age of the patients who began dialysis (in 2005) was 66.2 years, and the mean age of the entire dialysis population was 63.9 years. The primary diseases of the patients who began dialysis were diabetic renal disease (42.0%) and chronic glomerulonephritis (27.3%). The mean (+/-SD) serum ferritin concentration of all the dialysis patients was 191 (+/-329) ng/mL. The percentages of antihypertensive agents administered to the hemodialysis patients were as follows: calcium-channel blocker, 50.3%; angiotensin-converting enzyme inhibitor, 11.5%; and angiotensin II-receptor blocker, 33.9%. Of the peritoneal dialysis patients, 33.4% used automated peritoneal dialysis devices. Moreover, 7.3% of the peritoneal dialysis patients received dialysis treatment only in the daytime, and 15% received the treatment only at night. Icodextrin solution was used by 37.2% of the peritoneal dialysis patients. The average amount of dialysis solution used by the peritoneal dialysis patients was 7.43 (+/-2.52) L/day and the average amount of removal fluid was 0.81 (+/-0.60) L/day. A peritoneal equilibration test was conducted on 67% of the patients, and the mean dialysate to plasma creatinine ratio was 0.65 (+/-0.13). The annual incidence of peritonitis in the peritoneal dialysis patients was 19.7%. Of the 126 040 patients who responded to the inquiry of the therapeutic situation of peritoneal dialysis, 676 (0.7%) had a history of encapsulated peritoneal sclerosis and 66 (0.1%) were treated for encapsulated peritoneal sclerosis. The mean life expectancy of the dialysis population in 2003 was calculated according to sex and age. Results showed that the mean life expectancy of the dialysis population was approximately 40-60% of that of the general population of the same sex and age.

In patients on chronic hemodialysis, the incidence of cardiovascular events and mortality rate are higher than those in the general population. These events are associated with coronary, aortic valve, or mitral valve calcification, and show a poor prognosis. However, no study has investigated coronary or cardiac valve calcification in patients on chronic hemodialysis and its prognosis. In this study, we performed electron beam computed tomography (EBCT) in 400 patients who underwent chronic hemodialysis at four dialysis units in Okinawa Prefecture, Japan, between 1996 and 2003, and measured the coronary artery calcification score (CACS), aortic valve calcification score (AVCS), and mitral valve calcification score (MVCS) to analyze the association of these parameters with the prognosis. In addition, we examined the effects of sevelamer hydrochloride, which reduces the serum phosphorus level, reducing CACS. We reached the following conclusions with respect to the following examination items: (i) Factors involved in an increase in CACS in patients undergoing dialysis: in these patients with a rapid increase in CACS, the serum triglyceride and LDL cholesterol levels were higher than the values in the control group; (ii) Cut-off value of CACS influencing the outcome in patients on dialysis: we reviewed 104 chronic dialysis patients after EBCT was initiated. The group with a CACS of 200 or more showed a significantly poorer outcome compared to the group with a CACS of less than 200; (iii) Accuracy (sensitivity, specificity) of CACS screening on EBCT: we investigated the sensitivity and specificity of CACS based on the presence or absence of coronary artery disease on coronary angiography. The CACS values ranged from 100 to 3000, and their diagnostic accuracy was not satisfactory. Therefore, in patients without symptoms, EBCT may not be appropriate for coronary disease screening; (iv) Does sevelamer hydrochloride inhibit an increase in CACS by reducing the serum phosphorus level in patients on chronic hemodialysis?: in 98 patients on dialysis, this agent reduced the serum phosphorus level, and we examined whether it inhibits an increase in CACS. However, no significant results have been obtained due to a short follow-up period; and (v) Correlations of CACS, AVCS, and MVCS with the outcome in patients on hemodialysis: AVCS was correlated with the outcome. Aortic valve calcification may markedly influence cardiac hemodynamics.

Diabetes mellitus (DM) has been the leading cause of incident dialysis in Japan since 1998, according to the Japanese Society for Dialysis Therapy (JSDT). In particular, the number of male DM dialysis patients is increasing. DM is becoming a worldwide epidemic in both developed and developing countries. Strategies to detect individuals at high-risk of developing CKD and end-stage renal disease (ESRD) are needed that can be implemented on a population-basis. Among the commonly measured variables, dipstick urinalysis (proteinuria, haematuria), blood pressure, serum creatinine, body mass index (BMI), and serum uric acid are significant predictors of ESRD. Recently, we evaluated the effect of DM as a risk factor of developing ESRD. DM was diagnosed when the fasting plasma glucose (FPG) was 126 mg/dL or more in participants (n = 78529) of the 1993 screening program in Okinawa. The prevalence of DM was 5.2%. The odds ratio (95% CI) of DM for developing ESRD was 3.098 (1.738-5.525, P = 0.0001) after adjusting for possible confounding variables. Early detection and treatment of DM might prevent DM-related ESRD. We examined 7125 non-DM screenees who underwent a 1-day health check between April 1997 and March 1998. They were followed-up until March 2000 to determine whether they developed DM. Over the 2 years, the cumulative incidence of DM was 2.3%, 2.9% in men and 1.3% in women. Proteinuria was the most robust predictor of the development of DM; the adjusted relative risk (95% CI) was 1.90 (1.14-3.17). Obesity, per se, is also recognized as a risk factor for developing proteinuria. The higher the BMI, the higher the risk of developing ESRD; the adjusted odds ratio (95% CI) was 1.273 (1.121-1.446, P = 0.0002) for men. Other than being overweight (BMI = 25.0 kg/m2), a smoking habit was a significant predictor of developing proteinuria. The prevalence of obesity and DM is increasing in Japan. It is possible that the impact of obesity and complications of DM are different among races and ethnicities. Public relations regarding the risk of DM and its complications are especially important in Asian countries. Asians have more fat than non-Asians, even at the same BMI levels. Knowledge of the predictors of DM-ESRD is crucial as a first step toward prevention. Consistent with this notion, initiatives on the management of CKD and ESRD were recently organized in Japan and internationally.

Questionnaire forms for an annual survey conducted at the end of 2001 were sent out to 3520 institutions, and 3485 replies were received (response rate, 99.00%). According to the survey, the dialysis population of Japan at year end was 219 183 patients, up 6.3% (13 049) over the year before. This equals 1721.9 dialysis patients per million population. The gross mortality rate was 9.3% for the year extending from the end of 2000 to the end of 2001. The mean age of patients beginning dialysis was 64.2 years (+/- 13.7 SD). The mean age of the overall dialysis population in the study year was 61.6 years (+/- 13.1 SD), which was also a higher age than the year before. Among dialysis patients, the primary disease was diabetic nephropathy in 38.1% of patients, slightly down from 39.1% the previous year. Chronic glomerulonephritis was the primary disease in 32.4% of cases, a decrease from 34.7% the previous year. This survey included for the first time the items of the lowest blood pressure during hemodialysis session, vasopressor therapy before dialysis and vasopressor therapy during dialysis session. An analysis of the relationship between the type of vascular access used at the initiation of dialysis and the survival prognosis revealed a significantly higher risk of death in patients undergoing dialysis with synthetic arterio-venous (AV) fistula, AV shunt, or catheter implantation into a central vein than in those receiving dialysis treatments with a native fistula. There was a significantly lower risk of death in the patient group in whom the vascular access was created at 3-6 months before initiation of dialysis than in those in whom such access was created at the time of initiation or within 3 months before the initiation of dialysis. An analysis of the risk factors affecting survival prognosis in maintenance hemodialysis patients showed that risk factors for death are post-dialysis systolic blood pressure over 180 mm Hg and lower than 120 mm Hg, blood pressure elevating progressively from the start to the end of dialysis, serum high density lipoprotein cholesterol concentration of less than 30 mg/dL, and a higher ultrafiltration rate. In comparisons of the death risk between the patient group with a history of intervention for ischemic heart disease and the patient group with a history of myocardial infarction or heart failure but without such intervention, among diabetes patients, those who underwent percutaneous transluminal coronary angioplasty had a significantly lower risk of death than those in whom no intervention was made.

Summary: Epidemiological studies in Okinawa showed that the incidence and prevalence of ESRD were increasing. the significant predictors of ESRD were proteinuria, haematuria, diastolic blood pressure and serum creatinine. However, most people who showed these predictors were not referred and treated appropriately. Future studies should be focused on the role of early referral and intervention such as dietary change or life-style modification, which may reduce the incidence of ESRD.