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BACKGROUND Identifying characteristics of patients at high risk of poor adherence before transplantation would be advantageous. However, the optimal approach for characterizing such patients remains unknown.We aimed to evaluate the association between factors for hemodialysis nonadherence and post-transplant renal prognosis. We hypothesized that these factors would influence post-transplantation adherence and worsen renal prognosis. MATERIAL AND METHODS We reviewed patients on hemodialysis who underwent kidney transplantation at our hospital between 2000 and 2017 to identify risk factors associated with poor prognosis. The patients' background and pre-transplantation data, known hemodialysis nonadherence factors, serum phosphate and potassium levels, and interdialytic weight gains were evaluated. The primary endpoint was renal death. We also evaluated the fluctuation of calcineurin inhibitor concentration and weight gain after transplantation. RESULTS Seventy-seven patients were eligible, and the mean observational period was 83.2 months (standard deviation, 50.5). Thirteen patients reached the endpoint.Cox proportional hazards regression analysis showed that pre-transplantation serum phosphate level was a risk factor for renal death (p, Annals of transplantation, 24, pp.260-267; 2019

The effect of statin on hemodialysis patients is controversial. Although previous large-scale studies did not clarify its effect in this population, recent studies suggest that statins could be useful in reducing the risk of cardiovascular events and all-cause mortality in specific groups of patients undergoing hemodialysis. The aforementioned large-scale studies included a small percentage of Asians, and few studies have investigated the effects of statins in Asians undergoing hemodialysis. Thus, we investigated the benefits of statins in patients undergoing maintenance hemodialysis at a single center in Japan. We obtained demographic, clinical, and hemodialysis data of all patients who underwent maintenance hemodialysis at the Nagasaki Renal Center between July 2011 and June 2012. Patients were followed-up until June 2018. We studied 339 patients, of which 51 (15.0%) were prescribed pitavastatin. The mean observation period was 4.1±2.3 years, 43% were women, and the median hemodialysis vintage at baseline was 4.7 years. During the follow-up, 198 patients (58%) died, of which 22 (43%) were prescribed pitavastatin and 176 (61%) were not prescribed any statins. After propensity score matching based on age, sex, dialysis vintage, dialysis time, diabetes mellitus, ischemic heart disease, dry weight, left ventricular ejection fraction, and serum albumin, an intergroup comparison between those who received statins and those who did not (44 patients in each group) showed significant differences in survival rate based on the log-rank test (P, PLoS ONE, 14(10), art.no.e0224111; 2019

Hemodialysis-related portal-systemic encephalopathy (HRPSE) is characterized by the presence of portosystemic encephalopathy without liver dysfunction, usually caused by changes in the systemic venous flow related to hemodialysis. We herein describe the case of a 75-year-old woman who developed hepatic encephalopathy five years after the initiation of hemodialysis. Abdominal contrast-enhanced computed tomography (CT) and three-dimensional CT angiography revealed a portosystemic venous shunt, and the patient was diagnosed with portosystemic encephalopathy. Occlusion therapy ameliorated her disturbance of consciousness. HRPSE should be recognized as a treatable neuropsychiatric disorder.

Background: High serum calcium levels should be avoided in patients on hemodialysis (HD) because they can induce cardiovascular diseases and worsen the patient's prognosis. In contrast, low serum calcium levels worsen the prognosis of patients with cerebral hemorrhage in the general population. So far, whether serum calcium levels in patients on HD are associated with cerebral hemorrhage remains unknown. This study aimed to reveal the association between serum calcium and cerebral hemorrhage in patients on HD, including in-hospital death, volume of hematoma, and onset of cerebral hemorrhage. Methods: This cross-sectional case-control study included 99 patients on HD with cerebral hemorrhage at a single center between July 1, 2007 and December 31, 2017. Controls included 339 patients on HD at a single HD center between July 1, 2011 and June 30, 2012. Data on serum calcium level, patient demographics, and comorbid conditions were collected, and associations between cerebral hemorrhage and subsequent death were evaluated by multivariate logistic regression analysis. Further, the association of these backgrounds and hematoma volume was evaluated by multiple regression analysis. Results: Of the 99 patients, 32 (32%) died from cerebral hemorrhage. The corrected serum calcium level (odds ratio [OR], 2.49; 95% confidence interval [CI], 1.43-4.35; P < 0.001) and antiplatelet drug use (OR, 3.95; 95% CI, 1.50-10.4; P = 0.005)had significant effects on the prognosis. Moreover, the corrected serum calcium (P = 0.003) and antiplatelet drug use (P = 0.01) were significantly correlated with hematoma volume. In the patients, the corrected serum calcium level (OR, 1.54; 95% CI, 1.07-2.22; P = 0.02) was associated with the onset of cerebral hemorrhage, as was pre-hemodialysis systolic blood pressure (per 10 mmHg) (OR, 1.40; 95% CI, 1.23-1.59; P < 0.001). Conclusions: Although the precise mechanisms remain unknown, a high serum calcium level is associated with cerebral hemorrhage in patients on HD. Thus, we should pay attentions to a patient's calcium level., BMC Nephrology, 20(1), art.no.210; 2019

In the autumn two patients with general malaise were consecutively admitted to the department of internal medicine of our hospital in the northern region of Nagasaki Prefecture. Since both patients were engaged in rice farm work and showed conjunctival suffusion and pain of the gastrocnemius muscle, leptospirosis was suspected. The first patient required temporary hemodialysis for renal dysfunction, whereas liver dysfunction developed in the second patient. The disease was remitted by antimicrobial agents. A diagnosis of leptospiro sis was made serologically in both patients. Leptospirosis should be considered as a differential diagnosis when a patient engaged in farm work in the autumn has typical symptoms, and an early initiation of treatment after onset is important., Internal Medicine, 49(12), pp.1143-1147; 2010

Immunosuppressive treatment using antithymocytic globulin (ATG) is the treatment of choice for severe aplastic anemia patients [1, 2]. Iron chelation therapy is also effective for patients with frequent blood transfusions [3–5]. However, the effects of these treatments on hemodialysis patients have not been reported. Here, we present a case of severe aplastic anemia on hemodialysis, treated with immunosuppressive and iron chelation therapy. A 49-year-old male presented in December 2007 with fever and pancytopenia. He required regular hemodialysis following history of chronic renal failure 25 years earlier, and had also been treated with recombinant epoetin beta. Laboratory studies revealed a white blood cell count of 1.2 9 10/ll, neutrophil cell count of 468/ll, platelet count of 0.9 9 10/ll, hemoglobin concentration of 5.4 g/dl, and reticulocytes at only 0.9 9 10/ll. Bone marrow biopsy revealed severe hypoplasia. He was diagnosed with severe aplastic anemia, and required frequent transfusions of PC and RBC to maintain a 2 9 10/ll platelet level and 8.0 g/dl hemoglobin concentration. He was given the antibiotic, meropenem, for febrile neutropenia, which rapidly controlled his fever. The same drug, epoetin beta, was continued for treatment. Cyclosporin A and granulocyte colony-stimulating factor (G-CSF) were given as the first therapy for severe aplastic anemia, but his bone marrow remained hypoplastic. Horse ATG was added at a dose of 15 mg/kg for 5 days. Methylprednisolone was used at a dose of 2 mg/kg/day for 5 days, and then tapered off. The only adverse event was a grade 2 allergic reaction. His hematopoietic system recovered slightly, and G-CSF was lowered, but transfusion frequency could not be reduced. An anabolic steroid was added, but yielded no improvement. Then, 8 months after the first ATG, a second rabbit ATG was given at a dose of 5 mg/kg for 5 days. Methylprednisolone was given concomitantly, and no significant adverse event was seen, except an acute allergic reaction. Total red-blood cell transfusion volume was over 80 Japanese units, so deferasirox was given. Bone marrow biopsy revealed a moderate number of positive granules on iron staining, which were not observed at the initial examination. The initial dose was 10 mg/kg/day, due to renal failure, but the serum ferritin level remained above 3000 ng/ml. The dose was increased to 20 mg/kg/day. Six months later, the serum ferritin level was below 1000 ng/ml. Transfusion frequency was reduced. One year later after the second ATG therapy, he became transfusionfree (Fig. 1). Bone marrow biopsy revealed the recovery of hematopoiesis, but on iron staining, a moderate number of positive granules were still observed. During this course of treatments, he continued dialysis three times per week in an open space, and bacterial infection was not a threat. J. Hiraga (&) R. Sakemura S. Mizuno Department of Hematology, Toyota Memorial Hospital, 1-1 Heiwa-cho, Toyota 471-8513, Japan e-mail: junji_hiraga@mail.toyota.co.jp

Muscle wasting is common and insidious in end-stage renal disease (ESRD). Loss of muscle quantity and quality reduces quality of life and increases mortality in ESRD patients. Additionally, secondary hyperparathyroidism (SHPT) causes muscle atrophy. Meanwhile, vitamin D, which is used for SHPT treatment, plays an essential role in muscle growth. We prospectively investigated the effect of active vitamin D administration on muscle mass. We measured muscle mass based on bioelectrical impedance analysis in 68 hemodialysis patients. Patients were divided into a control group (without active vitamin D administration) and a VitD group (with active vitamin D administration). We compared muscle mass at the beginning of treatment and 1 year later. We also investigated health-related quality of life (HR-QOL) using the Medical Outcome Study Short Form-36 (SF-36). The VitD group experienced a significant increase in the amount of change in total muscle mass and muscle mass percentage in men (p = 0.025) but not in women (p = 0.945). By multivariable logistic regression analysis, active vitamin D administration was independently associated with increased muscle mass percentage in men only. In the SF-36, the physical functioning (PF) scores were significantly decreased at the end of the study in the patients without active vitamin D treatment, especially in women. Our results suggested that active vitamin D treatment was associated with increased muscle mass in men, and it might have a favorable effect on maintaining PF in HR-QOL in hemodialysis patients.