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Left ventricular hypertrophy (LVH) is a well-known risk factor for poor clinical outcomes in patients undergoing dialysis. However, little evidence supports the above notion in Japan, and the influence of subtypes of LVH on prognosis.We investigated 367 patients undergoing dialysis who underwent routine echocardiographic examinations between April and September 2018. LVH was defined as any LV mass ≥ 115 g/mLVH was observed in 171 (47%) patients. The primary endpoint was observed in 58 patients (16%) during the median follow-up period of 500 days. Multivariable Cox regression analyses identified four independent risk factors for the primary endpoint: age, pulse rate, serum albumin level, and LV mass index (per 10-g/mJapanese patients with LVH undergoing dialysis had a worse prognosis than those without LVH in terms of the composite clinical endpoint.

Introduction Bone mineral density (BMD) measured with dual-energy X-ray absorptiometry (DXA) can be used to predict fractures, but its clinical utility has not been fully established in chronic kidney disease (CKD) patients. Magnesium is an essential trace element. Although magnesium is associated with the risk of fractures in non-CKD populations, the relationship is unknown in CKD patients. Methods BMD and serum magnesium levels were measured in 358 stable outpatients undergoing maintenance hemodialysis therapy. The primary outcome was fragility fracture. Patients were divided into groups according to the median level of magnesium and the normal threshold value of lumbar spine BMD. Results During the median follow-up period of 36 months, 36 (10.0%) fractures occurred. The cumulative incidence rates of fractures were 17.6% and 5.2% [adjusted hazard ratio (aHR) 2.31, 95% confidence interval (CI) 1.03–5.17, P = 0.030] in the lower ( Discussion/Conclusions The combination of serum magnesium and lumbar spine BMD can be used for fracture risk stratification and synergistically improves the prediction of fractures in CKD patients.

Many studies have reported poor vital prognosis in hepatitis C virus (HCV)-infected dialysis patients. The rate of HCV-infected dialysis patients in Japan is as high as 9.8%, and antiviral therapy is believed to be important for improving vital prognosis. We conducted a multicenter study to examine the administration method for pegylated interferon α-2a (PEG-IFNα-2a) monotherapy in HCV-infected dialysis. We studied 56 patients: 14 with low viral loads (HCV RNA < 5.0 log IU/mL) were treated with 90 μg PEG-IFNα-2a weekly, 42 with high viral loads (HCV RNA ≥ 5.0 log IU/mL) were treated with 135 μg PEG-IFNα-2a weekly. We examined the sustained virological response (SVR), factors affecting the SVR, and treatment safety. The overall SVR rate was 39% (22/56); that for genotype 1, genotype 2, low viral loads, and high viral loads was 29%, 67%, 93%, and 21%, respectively. From receiver operating characteristic (ROC) analysis, the HCV RNA cutoff values likely to achieve SVR for genotypes 1 and 2 were

The aim of this study was to identify the common health problems of Japanese patients on hemodialysis (HD) using the International Classification of Functioning, Disability and Health (ICF). The participants of this study had been on HD for at least five years when they were interviewed. The ICF checklist was used to initially interview 32 HD patients. Fifty-seven categories of the ICF Checklist were identified as impaired; another 35 ICF categories, chosen based on interviews and expert discussion, as well as 8 categories relevant to HD, were included in the final checklist. This final checklist was then used to interview 104 patients. Overall, 10 categories in "Body functions" and 3 categories in "Body structures" were reported as problems by more than 50% of patients. Two categories in "Activities and participation" and 4 categories in "Environmental factors" were reported as restricted or a barrier for more than 30% of patients. A higher percentage of patients who started HD before 50 years of age and had a longer duration of HD reported problems in "Body functions" and "Body structures", while more patients with a shorter duration of HD reported problems in relationships with their family. Japanese patients on maintenance HD have various physical and psychosocial problems. In addition, HD duration and the age when HD was started affect patients' reports of physical and psychosocial problems.

維持血液透析患者における, sevelamer hydrochloride (以下sevelamer) の効果について検討した. 週3回, 4時間以上の維持血液透析を1年以上施行しており, Pi 5.5mg/dL以上, 補正Ca 9.5mg/dL以上の, 炭酸カルシウムを内服している患者20例 (男性15例, 女性5例) を対象とした. 炭酸カルシウムおよびその他のリン吸着剤はすべて中止し, sevelamerを8週間投与した. sevelamerの初期投与量および増減は, 原則として添付文書に従い, 消化器症状等の副作用も考慮して決定した. リン吸着剤変更の4週間前を含む12週間を観察期間とし, 観察期間内は, 透析条件と, ビタミンD製剤などのCa, Piに影響を与え得る薬剤の投与量は変更しなかった. 観察期間内に, 4例が副作用にて脱落した. 8週間sevelamerの投与を継続しえた16名について, 血清Pi, Ca, ALP, intact PTH (i-PTH), 総コレステロール (TC), LDLコレステロール (LDL-C), HDLコレステロール (HDL-C), HCO3-を経時的に測定した. Pi, Ca×Pi積, およびHDL-Cは, 有意な変化は認められなかった. Ca, TC, LDL-C, HCO3-は有意に低下した. ALP, i-PTHは有意に上昇した. sevelamerの単独投与によって, 炭酸カルシウムと同程度のPiコントロールが得られたが, 副作用等で十分な増量ができない症例もあった. いかにして, 副作用をコントロールして十分な量を投与し, また, 他のリン吸着剤と併用していくかが, 今後の課題である.

Subclinical hepatitis E virus (HEV) infection among healthy individuals was studied serologically and molecularly. Serum samples collected at screening between March and April 2004 (or just before retirement) from 266 medical staff members (35 males, 231 females) who had been working for 8.8 ± 8.5 (mean ± standard deviation, range, 0.3–35.1) years in a city hospital in Japan and serum samples that had been collected from these staff members at the start of employment were tested for IgA, IgM, and IgG antibodies to HEV (anti-HEV) by in-house enzyme-linked immunosorbent assays. Overall, six subjects (2.3%) tested positive for anti-HEV IgG at the screening; among them, four subjects (1.5%) had already been positive for anti-HEV IgG at the start of employment and two subjects (0.8%) seroconverted after initiation of employment. Periodic serum samples that had been collected from the two seroconverted subjects were tested for HEV antibodies and HEV RNA. The two subjects became positive for anti-HEV IgG in 1978 or 2003, respectively, with no discernible elevation in alanine aminotransferase (ALT) level, and continued to be seropositive up through the screening date. Although anti-HEV IgM was not detectable in the two subjects, one was infected transiently with Japan-indigenous HEV strain of genotype 3 and the other was positive transiently for anti-HEV IgA. The present study indicates that even an individual with subclinical HEV infection had evidence of transient viremia in the absence of ALT elevation and that anti-HEV IgA detection may be useful for serological diagnosis of recent subclinical HEV infection. J. Med. Virol. 76:526–533, 2005. © 2005 Wiley-Liss, Inc.

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.

Orthostatic hypotension is one of the major factors interfering with everyday activities in hemodialysis patients, but there has been no effective agent for treating it. In order to clarify the clinical effects of L-threo-3,4-dihydroxyphenylserine (L-DOPS) on orthostatic hypotension of hemodialysis patients, we conducted a randomized, double-blind comparative trial. 149 regular hemodialysis patients with orthostatic hypotension were randomly allocated to three groups and L-DOPS at doses of 400 mg, 200 mg or placebo was orally administrated to each group 30 min before starting every hemodialysis for 4 weeks. Changes of blood pressure (BP) in orthostatic hypotension immediately after completion of hemodialysis and symptoms related to orthostatic hypotension were compared between the three groups. In the 400-mg group, systolic and diastolic BP after standing increased significantly and the drop of mean BP after standing was also reduced compared with pretreatment levels. No such changes were observed in the placebo group. Fatiguability, malaise/weakness, dizziness and light-headed feeling, the interdialytic symptoms commonly observed in hemodialysis patients who developed orthostatic hypotension, were improved to a significant extent in the L-DOPS group compared with the placebo group. In particular, the improvement was more remarkable for the L-DOPS 400-mg group than the placebo group in patients with diabetic nephropathy, lower systolic BP after standing, and the long duration type of orthostatic hypotension. The incidence of adverse events was comparable between the three groups, and all recovered after discontinuation of L-DOPS or concomitantly administered drugs, or without any treatment. These findings indicate that L-DOPS taken before hemodialysis prevents orthostatic hypotension in patients undergoing hemodialysis, and is also effective for the interdialytic symptoms related to orthostatic hypotension.

Background: Orthostatic hypotension (OH) is a serious complication observed in hemodialysis (HD) patients after HD as well as during the interdialytic period. L-Threo-3,4-dihydroxyphenylserine (L-DOPS) is a nonphysiological neutral amino acid that is directly converted to the neurotransmitter norepinephrine by aromatic L-amino acid decarboxylase. Methods: A placebo-controlled double-blind study for 4 consecutive weeks and a long-term study (24–52 weeks) were conducted to evaluate the efficacy of L-DOPS for OH after HD. The drug was administered orally 30 min before the start of each HD period in both studies. Doses of 400 mg of L-DOPS or placebo were given to HD patients with OH (45 and 41 patients, respectively) in the double-blind study, and doses of 200 or 400 mg of L-DOPS were given to 74 HD patients in the long-term study. Results: In the double-blind study, L-DOPS significantly ameliorated subjective symptoms related to OH, including dizziness/light-headed feeling, and malaise, throughout the interdialytic period. For 19 patients with delayed-type OH, hypotension with the lowest blood pressure recorded 10 min after standing, the decrease in blood pressure was suppressed significantly after L-DOPS treatment (10 patients) as compared with the placebo-treated group (9 patients). In the long-term study, the efficacy of L-DOPS was not attenuated, and the marked fluctuations in the plasma L-DOPS and norepinephrine levels were not noted after long-term use, without increases in incidence or severity of adverse reactions. Conclusions: These results indicate that L-DOPS is effective for improving OH-related interdialytic subjective symptoms in HD patients after short-term as well as after long-term administration.

Many studies have reported poor vital prognosis in hepatitis C virus (HCV)-infected dialysis patients. The rate of HCV-infected dialysis patients in Japan is as high as 9.8%, and antiviral therapy is believed to be important for improving vital prognosis. We conducted a multicenter study to examine the administration method for pegylated interferon α-2a (PEG-IFNα-2a) monotherapy in HCV-infected dialysis. We studied 56 patients: 14 with low viral loads (HCV RNA5.0 log IU/mL) were treated with 90 μg PEG-IFNα-2a weekly, 42 with high viral loads (HCV RNA ≥ 5.0 log IU/mL) were treated with 135 μg PEG-IFNα-2a weekly. We examined the sustained virological response (SVR), factors affecting the SVR, and treatment safety. The overall SVR rate was 39% (22/56); that for genotype 1, genotype 2, low viral loads, and high viral loads was 29%, 67%, 93%, and 21%, respectively. From receiver operating characteristic (ROC) analysis, the HCV RNA cutoff values likely to achieve SVR for genotypes 1 and 2 were5.7 log IU/mL (SVR rate: 64% 9/14) and6.5 log IU/mL (SVR rate: 88% 7/8), respectively. If there was HCV RNA negativation at 4 weeks (rapid virological response), the SVR rate was 94% (16/17), whereas it was 6% (1/16) if there was HCV RNA positivity at 24 weeks. The rate of treatment discontinuation from adverse events or aggravated complications was 25% (14/56). High SVR rates can potentially be achieved with PEG-IFN monotherapy by identifying the target patients, based on virus type and viral load before initiating treatment and by modifying therapy during treatment according to responsiveness.

A statistical survey at the end of 1999 by the Japanese Society for Dialysis Therapy resulted in responses from 3, 220 (99.66%) of 3, 231 institutions providing dialysis. The survey found 197, 213 chronic dialysis patients in Japan, an increase of 6.4% (11, 891 patients) from the 1998 survey. The 1999 survey found a slight decrease in the gross annual mortality percentage compared to 1998 (9.7%). The mean age of patients newly introduced to dialysis increased to 63.4±13.9 (±SD) years in 1999. The mean age of the dialysis population at the end of 1999 was 60.6±13.3 years. The primary diseases leading to dialysis were diabetic nephropathy (36.2%) and chronic glomerulonephritis (33.6%).New survey items for 1999 survey included the following: 1) with/without reverse osmosis, 2) with/without dialysate endotoxin measurement and endotoxin concentration, 3) itchiness, 4) HBs and HBe antigen/antibody, 5) earlier hepatitis B vaccine inoculation, 6) HCV antibody/HCV-RNA, 7) serum glutamic pyruvic acid transaminase (GPT) activity, 8) hepatocellular carcinoma or cirrhosis, 9) previous limb amputation, 10) history of cerebral infarction, cerebral hemorrhage, or myocardial infarction, 11) loss of eyesight due to diabetic retinopathy or retinal circulatory disturbance, 12) serum cholesterol level, 13) number of cigarettes smoked, 14) platelet and leukocyte counts, 15) C-reactive protein levels, 16) height and body mass index (BMI), 17) tuberculosis within the previous year and 18) both the fluid substitution method in hemodiafiltration and the amount of substitution fluid.The survey findings for 1999 included 1) 93.0% of the patients were dialyzed using reverse osmosis 2) endotoxin concentrations tended to be lower in institutions with more patients, and 3) 56.7% of the patients experienced no itchiness and received no treatment for itchiness. Other survey findings were that 84.7% of the patients were HBs antigen (-) antibody (-), 1.9% were HBs antigen (+) antibody (-), and 13.0% were HBs antigen (-) antibody (+). The survey also found that 2.3% of patients were inoculated with Hepatitis B vaccine, 16.1% were HCV antibody (+), and 8.2% were HCV-RNA (+). The survey found that 2.1% of the patients had cirrhotic complications and 0.6% had hepatocellular carcinoma. The mean serum total cholesterol level was 162.84mg/dl, and the mean BMI was 20.61kg/m2. Using the Cox's proportional hazards model, a Kt/V of 1.4, a normalized protein catabolic rate of less than 0.9g/kg/day or more than 1.5g/kg/day, and a low creatinine generation rate were risk factors in the 6-year mid-term prognosis for hemodialysis patients.

透析医療における感染の現況を把握し感染防止の実態の調査を行った. 郵送によるアンケート法により, 日常的に慢性血液透析を行っている本邦の医療施設2910施設を対象とした. アンケート回収は1681施設57.8%と良好だった. 回答率の偏りは, 私的施設の回答率 (44.8%) がその他の施設の回答率 (51.7%) より低かったが, 地域, 施設規模別では差がなく, おおむね偏りのない調査が行われた.81.6%の施設が, 感染対策マニュアルを自施設で作成しており, 施設の74.5%に感染対策委員会が設置され, その3分の2の施設で感染対策委員会が毎月開かれているなど, 多くの施設で, 院内感染予防に対する積極的な対策が講じられていることが明らかにされた.HBs抗原の測定率は施設の94.3%, 患者の97.1%の, HCV抗体測定率は施設の93.3%, 患者の98.9%と良好だった. 患者陽性率はHBs抗原で2.84%, HCV抗体では22.4%だった.HBs抗原, HCV抗体施設陽性率は7地域間で異なり (p=0.00515, p

Background This study had four goals: (1) to evaluate an index of health-related quality of life (HQOL) among renal-transplant recipients in Japan, (2) to compare HQOL of renal-transplant recipients with that of the Japanese population as a whole, and (3,4) to study associations of HQOL with renal function and with the time since transplantation. Methods Questionnaires were distributed to 570 subjects. All were outpatients, were 16 years old or older, and were studied at least 1 year after they had received their latest renal transplant. HQOL was assessed with the Short Form 36-item health survey. Subjects' physicians provided data on renal function. Associations of HQOL with serum creatinine concentration and with the time since transplantation were evaluated by logistic regression. Results The response rate was 83%. Data from patients with diabetes and from those who had had at least two renal transplants were excluded; data from 395 recipients were analyzed. On the physical functioning, general health perception, vitality, and social functioning scales, the patients' scores were significantly lower than the Japanese national-norm scores. General health perception was particularly low. Serum creatinine concentrations were associated with general health perception, vitality, and social functioning. Longer times since transplantation were associated with better social functioning. Conclusions Although social and physical functioning may improve after transplant surgery, a low self-rating of general health seemed to remain. The rarity of renal transplantation in Japan and other psychosocial factors may explain the low self-rating of general health in Japanese renal-transplant recipients.

Involvement of interleukin-8 in dialysis-related arthritis. To elucidate the role of interleukin (IL)-8, a chemotactic factor for neutrophils, in dialysis-related arthritis (DRA) of patients on long-term hemodialysis, the concentration of IL-8 was measured in the synovial fluids of DRA patients with acute arthralgia and joint swelling, and was compared with those in patients with rheumatoid arthritis (RA) and patients with osteoarthritis (OA). We noted a marked elevation of IL-8 in the joint fluids of patients with DRA and RA as compared with OA. Furthermore, to determine the role of IL-8 in synovitis, we examined the in vivo effect of intra-articular injection of human recombinant IL-8 on leukocyte infiltration into the joint space of rabbits. A single injection of IL-8 to the joints of rabbits induced rapid infiltration of neutrophils into the joint space and synovial tissues, which reached a maximum in four hours. The oral administration of indometacin farnesil (a prodrug that is converted to indomethacin after intestinal absorption) before the injection of IL-8 alleviated the infiltration of neutrophils. When human synovial cells were incubated with tumor necrosis factor (TNF)-α, the expression of IL-8 mRNA and IL-8 production in the cultured synovial cells were increased. The TNF-α-stimulated expression of IL-8 mRNA and IL-8 production in the cultured synovial cells were markedly inhibited by dexamethasone. In conclusion, IL-8 levels were markedly elevated in the joint fluids of patients with DRA. Interleukin-8 released from synovial cells may be an important factor to induce acute inflammation in DRA. Dexamethasone and indomethacin may be effective for DRA by inhibiting the production and chemotactic actions of IL-8, respectively.

血液透析患者に発生する破壊性脊椎関節症 (DSA) の危険因子を明らかにする目的で, 我々は314名の患者において断面的調査を行った. DSAは40例 (12.7%) の患者に認められ, 頸椎病変が最も多く第4-6頸椎の病変で全体の80%を占めた. DSAを有する患者群と有さない患者群との比較では, DSAを有する患者群の方が高年齢で, 透析期間も有意に長かった (61.2±1.5vs55.6±0.7歳, P=0.005, 119±10vs91±4か月, P=0.007). しかし, 透析導入後6年以内の短期例でもDSAを9例に認めた. DSA発症に関与すると推測される諸因子との単因子相関では, 骨嚢胞の存在と手根管症候群の合併例でDSAの発症頻度が有意に高かった (それぞれX2=35.2, P

維持透析患者の種々の合併症の中で, 透析後の起立性低血圧に伴う諸症状は透析患者の日常生活の重要な阻害因子であるが, 現在は的確な治療手段がない.L-threo-3,4-dihydroxyphenylserine (L-DOPS) は, 経口投与可能な天然型ノルエピネフリンの前駆物質で, 我々はこれまでに, 本剤が透析患者の透析直後の起立性低血圧と透析後から翌々日までの自覚症状の改善に高い有用性を有することを報告してきた. 今回, 先の用量設定試験で有効性の認められたL-DOPS 400mgとプラセボの二重盲検比較試験を実施した.対象は, 透析終了後の起立時に収縮期血圧 (2回の透析日における平均値) が15mmHg以上低下し, かつそれに付随する自覚症状を呈する維持透析患者107例で, そのうち, 有効性を86例, 安全性を104例で評価した. 各透析日の透析開始約30分前に薬剤を4週間投与し, 透析終了時の起立試験における血圧と透析終了から透析翌々日までの自覚症状を評価した. 透析後血圧と起立による平均血圧の低下はL-DOPS群で有意に抑制され, 「めまい・ふらつき・たちくらみ, 起立障害, 倦怠感・脱力感」の改善度がL-DOPS群で有意に高かった. 血圧と自覚症状とから判定した最終全般改善度は, L-DOPS群がプラセボ群に比して有意に優れ (中等度改善以上: 53.3% vs 14.6%), より重症と考えられる症例で特に効果が認められた. 副作用はL-DOPS群に3例, プラセボ群に6例みられたがいずれも重篤なものではなく, 臨床検査値の異常変動は両群ともに認められなかった. 以上の結果から, L-DOPSの透析患者の起立性低血圧とその付随症状に対する有用性が確認された.

インタクト副甲状腺ホルモン値 (i-PTH) が極端に低値 (

日本透析療法学会総務委員会感染対策小委員会は日本の慢性透析患者のHCV感染の実態を把握しようとした. 1993年2月, 施設会員2,309施設にアンケートを発送し, 61.0%の施設, 血液透析患者の57.7%, CAPD患者の52.1%の回答を得て, これらを解析した. 7地区別の回答率に差がなく, 回答された私的診療所の割合は母集団と有意差がなかった.第2世代HCV抗体陽性率血液透析患者の23.9%, CAPD患者の11.2%で, 陽性率は有意に血液透析が高値だった. 陽性率は血液透析で東京地区の19.6%から中国四国地区の26.7%まで, CAPDで北海道・東北地区の7.6%から九州沖縄地区の14.0%まで分布していた.最近3年間に経験したHCV陽性肝硬変症はHCV陽性透析患者1,000人1年当たり8.57人, HCV陽性の肝癌はHCV陽性患者1,000人1年当たり3.87人だった.最近3年の透析従事者のHCV陽性患者の用いた針による針刺事故は透析従事者1,000人当たり15.2人/年だった. 入職後の透析従事者のHCV抗体陽性化は透析従事者1,000人当たり1.14人/年だった.HCV陽性患者の取扱いマニュアル, HCV陽性患者に使用した針による針刺事故時のマニュアルを持っていると回答したのは各21%, 25%のみであった.以上の調査結果から慢性透析療法を受けている患者とそのスタッフはHCVウイルス感染罹患率が一般人口より高いことが定量的に明らかとなった. 今後その対策を明らかにすることが感染対策小委員会に求められている.

Step-sections of 96 whole kidneys from 50 chronic hemodialysis patients were subjected to a histopathological and quantitative investigation with regard to the development of renal neoplastic lesions. The range of hemodialysis duration was from 1 to 222 months. A total of 349 renal cell adenomas were found in 41 cases (82%). They were commonly multiple and present bilaterally. Renal cell carcinomas were evident in four cases (8%), with hemodialysis durations of 54, 57, 112 and 222 months. The incidence of adenomas increased in a hemodialysis duration-dependent manner, indicating a high risk of renal cell tumor development in chronic hemodialysis patients. Furthermore, acquired cystic disease of the kidney (ACDK) was also observed in 12 cases (24.0%), where the mean hemodialysis period was 143.4 +/- 48.0 months. This value was significantly longer than that of non-ACDK cases (P < 0.001). There was, however, no clear relationship between the appearance of ACDK and renal cell tumors. The present results underline the necessity for attention to possible neoplasia of the kidney in patients on long-term hemodialysis.

Between 1989 and 1991, ultrasonograms (US) and CT films of 13 patients undergoing continuous ambulatory peritoneal dialysis (CAPD) were obtained to evaluate splenomegaly, other abdominal splanchnic systems, distribution of CAPD fluid in the abdominal cavity and the condition of the bowel and mesentery.In this group, there were no cases with splenomegaly, while in hemodialyzed patients, splenomegaly is often demonstrated, as has previously been reported by us. Furthermore there was no statistical correlation between splenic index (SI) and duration of CAPD or platelet count in CAPD patients, though these have been recognized in hemodialyzed patients. There is a definite difference between CAPD and hemodialysis with respect to how the machines are used, so it may be concluded that splenomegaly is caused by hypersplenism resulting from blood cell injury due to mechanical stimulation with, for example, the dialyzer.Other organs in the abdominal cavity showed no differences between CAPD patients and hemodialyzed patients.Distribution of CAPD fluid in the abdominal cavity was different in each case, and in addition, the contact surface between it and the bowel or mesentery was localized. Furthermore, measurement of mesentery thickness tended to be affected by peristalsis, and differed according to various sites in the same patient. Therefore, mesentery thickness measured by US as an index of CAPD efficiency must be evaluated cautiously.

381名の透析患者を対象に血中PTH濃度を4種類のPTH assay系にて検討した. 使用したPTH assay法はPTH-MC (三菱), HS-PTH (ヤマサ), C-PTH (栄研), intact-PTH (メディフィジックス) の4種類である. PTH-MCは中間部PTHを認識する新しい測定系であり, その特徴ならびに4種類間での相関を比較検討した. PTH-MCの測定範囲は広く (0.1-50ng/ml), 測定精度は高かった (同時再現性: 1.5-2.5%, 日差再現性: 2.0-5.5%). 4者間の相関は極めて良好であった. しかし, PTH-MC, HS-PTH, C-PTHの3者とintact-PTHとの相関について, 3者の測定値がintact-PTH値に換算して100pg/ml相当以下に該当する患者に限って検討すると, PTH-MCが他の2者より良好な相関を示した. また, この低値例の検討では, intact-PTH値が他の測定系の値に相関せず, 高値を示す患者群が存在した. PTH低値例では, PTH-MCがintact-PTHとの間で最も良好な相関を示したので, PTH-MC系はこのような相関から外れる患者数が最も少ない測定系と考えられた. intact-PTHは即時的なPTH分泌状況を良く反映する検査方法であるが, 血清Ca濃度などの測定条件により敏感に値が変動する. 一方, 他の3者は体内に貯留したPTH fragmentを反映する系と考えられており, 腎不全患者では値が強調される. この特質は二次性副甲状腺機能亢進症の早期診断に関しての利点と考えられる. 実際, intact-PTH値が測定感度以下の患者も存在したが, このような患者でも他の3者では測定感度内にあった. のようなPTH低値例でも, 長期の透析により二次性副甲状腺機能亢進症が顕在化しうる可能性を有している. これらの結果を考慮すると, PTH-MCは低値領域からの測定も安定しており, 広い範囲の測定感度を有しているので, 透析患者の長期経過観察に適した方法と考えられる.

Hepatitis C virus infections in medical personnel after needlestick accidents have been documented generally by detection of seroconversion to a hepatitis C virus nonstructural region antigen, c100-3 (a marker of infection). We tested for hepatitis C virus core-derived antibodies and genomic RNA in addition to c100-3 antibody in 159 cases of needlestick exposure that did not involve patients positive for HBsAg. Of these we found 68 cases with index patients positive for both hepatitis C virus RNA and antibodies and members negative for antibodies to HCV core or c100-3 before the needlestick accidents. Seven of these medical personnel became infected with hepatitis C virus after the accidents. Their hepatitis was generally subclinical or self-limited and transient, except for one patient in whom liver enzyme elevation persisted along with the antibodies. In our study, the risk of hepatitis C virus transmission from a single needlestick accident with hepatitis C virus RNA–positive blood was 10%, considerably higher than the 4% estimated in a previous study. We found that donor blood with antibody to an hepatitis C virus core-derived peptide with enzyme-linked immunosorbent assay optical densities greater than 2.0 carried a significant risk of transmitting hepatitis C virus to needlestick victims. No hepatitis C virus seroconversions occurred in medical personnel exposed to hepatitis C virus antibody– negative or hepatitis C virus RNA–negative blood; however, one such exposure resulted in a very mild non-A, non-B, non-C hepatitis. (HEPATOLOGY 1992;16:1109–1114.)

日本の慢性透析患者の高齢化の実態を明らかにしその要因をさぐるため, 日本透析療法学会統計調査委員会が年度末に行っている全透析施設に対するアンケート調査の1980年から1990年の報告を集計分析した.慢性腎不全による透析導入患者の平均年齢は10年間で9.8年, 透析患者平均年齢は9年間で8.3年高齢化した. その要因として, 日本人母集団の老化のみならず, (1) 透析導入にいたった原疾患が10年間で慢性糸球体腎炎は約2/3から1/2へ減少, 糖尿病は約1/10から1/4に増加, 腎硬化症は軽度増加したこと, (2) 小児の透析導入数および患者数は10年間で1/3以下に減少したこと. (3) 長期透析患者が増加したこと, (4) 徐々にではあるが腎移植が行われ, 若年者が透析を離脱すること, などが挙げられた.このような透析患者の高齢化に伴い, 適切な医療・社会援助システムを構築・整備することが必要である.

If a natural disaster or other event causes damage that makes dialysis therapy impossible, what steps should be taken? Many actions will be required, including disaster recovery activities in the affected area as well as the performance of dialysis at substitute dialysis facilities outside the affected area. The Japanese Association of Dialysis Physicians (JADP), in collaboration with the Japan Association for Clinical Engineering Technologists (JACET), operates an "information sharing system" that will be essential when carrying out post-disaster activities. This system consists of a website and mailing lists on the Internet, and it has been used in 11 disasters so far.The JADP is an organization of doctors engaged in dialysis therapy. This association conducts investigation and research, education, and crisis management for dialysis therapy. The JACET is an organization that aims to enhance scientific knowledge and skills and to improve capabilities. This association also pursues improvement of the reliability of medical care involving life support systems and other medical equipment.

本研究の目的は増子記念病院における各種シャント手術の遠隔成績を呈示し, ブラッドアクセスとして現在主流を占めているシャントの開存にいかなる因子が影響を与えるかを解析, 検討することである.慢性腎不全のために血液透析を受けている316症例975手術を解析の対象とした. 解析されたシャント手術の内訳は自己血管内シャントが364手術, polytetrafluoroethylene (PTFE) 内シャントが211手術, 自己血管外シャントが260手術, PTFE外シャントが138手術であった.自己血管内シャントの3年開存率は65%, 5年では57%であり, 一方PTFE内シャントの場合は3年では31%, 5年では21%と自己血管内シャントが有意に良好な結果であった (p

透析患者の血清β2-MGレベルを透析歴と使用透析器膜の観点から検討を加えた. β2-MG除去不可能な従来膜透析器使用透析患者群において血清β2-MG値は, 透析導入後約3年間上昇するが, その後一定の値を保つことがわかった. 従来膜で導入された患者に対し, β2-MG除去可能なHP膜に変更しても, その後の血清β2-MG値のレベルに変化はなかったが, 導入期からHP膜を使用すると, 従来膜に比べ血清β2-MGレベルは有意に低値を保つことができた (28.7±2.3mg/l対41.5±3.4mg/l: 透析導入後12か月の時点). 透析アミロイド症の原因物質であるβ2-MGの血清レベルを低値に保つためには, 透析導入期よりHP膜透析器を使用する必要があると思われる.

End-stage renal disease (ESRD) affects 230,000 Japanese, with about 36,000 cases diagnosed each year. Recent increases in ESRD incidence are attributed mainly to increases in diabetes and a rapidly aging population. Renal transplantation is rare in Japan. In private dialysis clinics, the majority of treatment costs are paid as fixed fees per session and the rest are fee for service. Payments for hospital-based dialysis are either fee-for-service or diagnosis-related. Dialysis is widely available, but reimbursement rates have recently been reduced. Clinical outcomes of dialysis are better in Japan than in other countries, but this may change given recent ESRD cost containment policies.

A statistical survey of 3932 nationwide hemodi- alysis (hereafter, dialysis) facilities was carried out at the end of 2004, and 3882 facilities (98.73%) responded. The population undergoing dialysis at the end of 2004 was 248 166, an increase of 10 456 patients (4.4%) from that at the end of 2003. The number of dialysis patients per million people was 1943.5. The crude death rate of dialysis patients from the end of 2003 to the end of 2004 was 9.4%. The mean age of patients who underwent dialysis in 2004 was 65.8 years, and that of the total dialysis population was 63.3 years. The percentage distribution of patients who underwent dialysis according to a newly underlying disease showed that 41.3% of patients had diabetic nephropathy and 28.1% had chronic glomerulonephritis. The frequency of calcium carbonate use for dialysis patients was 75.1% and that of sevelamer hydrochloride use was 26.2%. The frequency of sevelamer hydrochloride use does not neces- sarily have a strong correlation with the dose of calcium carbonate. Patients who received high doses of sevelamer hydrochloride tended to have a low concentration of arte- rial blood HCO 3- . Approximately 15% of dialysis patients used an intravenous vitamin D preparation, generally max- acalcitol. The longer the patients had been on dialysis, the higher the frequency of use of an intravenous vitamin D preparation. When the concentration of serum intact par- athyroid hormone (PTH) was more than 200 pg/mL, the frequency of use of an orally administered vitamin D pre- paration decreased; but that of intravenous vitamin D preparation increased. The percentage of dialysis patients who received percutaneous ethanol injection therapy (PEIT) was 1.4%. The percentage was more than 50% in the patients who had been on dialysis for more than 10 years. The percentage of patients who received PEIT again was 35.0%. The percentage of patients who had been on hemodialysis for more than 10 years and received PEIT again was more than 50%. Key Words: Calcium carbon- ate, Death rate, Intact parathyroid hormone, Sevelamer hydrochloride.

To compare the epidemiologic profiles of hepatitis A virus (HAV) and hepatitis E virus (HEV) infections in Japan, the prevalence of clinical or subclinical HAV and HEV infections was investigated serologically and molecularly among 128 consecutive patients (age, mean +/- standard deviation, 37.5 +/- 14.7 years) who contracted acute hepatitis between 1989 and 2005 in a city hospital, and among 416 hemodialysis patients (60.1 +/- 12.6 years) and 266 medical staff members (34.6 +/- 11.4 years) at the same hospital, using stored periodic serum samples collected since the start of hemodialysis or employment, respectively. Between 1989 and 1995, among 93 patients with acute hepatitis, 51 (54.8%) were diagnosed with hepatitis A and only one patient with hepatitis E. Between 1996 and 2005, however, among 35 patients, only 3 (8.6%) were diagnosed with hepatitis A and 2 (5.7%) with hepatitis E. Although subclinical HEV infection was recognized in four hemodialysis patients (one each in 1979, 1980, 1988, and 2003) and two medical staff members (1978 and 2003) in previous studies, none of the 191 hemodialysis patients who had been negative for anti-HAV at the start of hemodialysis contracted HAV infection during the observation period of 7.6 +/- 6.4 years. Only one (0.4%) of the 246 medical staff members who had been negative for anti-HAV at the start of employment acquired hepatitis A during the observation period of 7.9 +/- 8.0 years: none had subclinical HAV infection. Clinical or subclinical HEV infection has occurred rarely during the last three decades, while HAV infection has markedly decreased at least since 1996.

A statistical survey of 3750 nationwide dialysis facilities was carried out by the Japanese Society for Dialysis Therapy (JSDT) at the end of 2003, with answers to the questionnaires received from 3717 facilities (99.12%). The population of dialysis patients in Japan at the end of 2003 was 237,710, and the number of dialysis patients per million people was 1862.7. The crude death rate during a 1-year period from the end of 2002 to the end of 2003 was 9.3%. The mean age of patients newly introduced to dialysis was 65.4 years, and the mean age of the entire dialysis population was 62.3 years. The primary diseases in the patients newly introduced to dialysis in 2003 included diabetic nephropathy (41.0% of patients) and chronic glomerulonephritis (29.1% of patients). The mean serum neutral fat concentration for all the dialysis patients was 113.9 +/- 71.7 mg/dL (+/- SD). The mean serum low density lipoprotein (LDL)-cholesterol concentration was 90.8 +/- 30.9 mg/dL. Dialysate calcium concentrations ranging from 3.0 mEq/L to less than 3.5 mEq/L were used for majority of the dialysis patients (55.4%). Among anticoagulants given to the dialysis patients, heparins were the most commonly used in 79.3% of the dialysis patients. The relationship between blood pressure during dialysis and life expectancy for 1 year was analyzed for 43,465 patients who had undergone dialysis three times per week at the end of 2001. Results showed a significantly high mortality risk for patients who had systolic blood pressure of less than 100 mm Hg at the start of dialysis, systolic blood pressure of less than 100 mm Hg at the end of dialysis, and the greatest decrease (lowest) in systolic blood pressure of less than 120 mm Hg during dialysis. Patients who received vasopressor therapy during dialysis had a higher mortality risk than those who received no vasopressor therapy.

To investigate the prevalence of hepatitis E virus (HEV) infection among patients on maintenance hemodialysis, serum samples collected in January 2003 from 416 patients who had been undergoing hemodialysis for 7.6 ± 6.3 (mean ± standard deviation) (range, 0.3–26.0) years in a dialysis unit in Japan and serum samples that had been collected from these patients at the start of hemodialysis were tested for IgG antibodies to HEV (anti-HEV IgG) by an “in-house” enzyme-linked immunosorbent assay (ELISA). Overall, 39 patients (9.4%) had anti-HEV IgG in January 2003, and included 35 patients (8.4%) who had already been positive for anti-HEV IgG at the start of hemodialysis and 4 patients (1%) who seroconverted after initiation of hemodialysis. Periodic serum samples that had been collected from the four seroconverted patients were tested for HEV antibodies and HEV RNA. The four patients became positive for anti-HEV IgG in 1979, 1980, 1988, or 2003, and continued to be seropositive until the end of the observation period. Although anti-HEV IgM was not detectable in the four patients, three were infected transiently with apparently Japanese indigenous HEV strains of genotype 3. The patient who contracted HEV infection in 1979 had been transfused with 2 U of blood 21 days before the transient viremia: one of the two stored pilot serum samples had detectable HEV RNA with 100% identity to that recovered from the patient. Our study provides evidence of transfusion-transmitted HEV infection in Japan in 1979, and that the prevalence of de novo HEV infection during hemodialysis was low (1.1% or 4/374). J. Med. Virol. 74:563–572, 2004. © 2004 Wiley-Liss, Inc.

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.

Orthostatic hypotension (OH) is a serious complication observed in hemodialysis (HD) patients after HD as well as during the interdialytic period. L-Threo-3,4-dihydroxyphenylserine (L-DOPS) is a nonphysiological neutral amino acid that is directly converted to the neurotransmitter norepinephrine by aromatic L-amino acid decarboxylase.A placebo-controlled double-blind study for 4 consecutive weeks and a long-term study (24-52 weeks) were conducted to evaluate the efficacy of L-DOPS for OH after HD. The drug was administered orally 30 min before the start of each HD period in both studies. Doses of 400 mg of L-DOPS or placebo were given to HD patients with OH (45 and 41 patients, respectively) in the double-blind study, and doses of 200 or 400 mg of L-DOPS were given to 74 HD patients in the long-term study.In the double-blind study, L-DOPS significantly ameliorated subjective symptoms related to OH, including dizziness/light-headed feeling, and malaise, throughout the interdialytic period. For 19 patients with delayed-type OH, hypotension with the lowest blood pressure recorded 10 min after standing, the decrease in blood pressure was suppressed significantly after L-DOPS treatment (10 patients) as compared with the placebo-treated group (9 patients). In the long-term study, the efficacy of L-DOPS was not attenuated, and the marked fluctuations in the plasma L-DOPS and norepinephrine levels were not noted after long-term use, without increases in incidence or severity of adverse reactions.These results indicate that L-DOPS is effective for improving OH-related interdialytic subjective symptoms in HD patients after short-term as well as after long-term administration.

Orthostatic hypotension is one of the major factors interfering with everyday activities in hemodialysis patients, but there has been no effective agent for treating it. In order to clarify the clinical effects of L-threo-3,4-dihydroxyphenylserine (L-DOPS) on orthostatic hypotension of hemodialysis patients, we conducted a randomized, double-blind comparative trial. 149 regular hemodialysis patients with orthostatic hypotension were randomly allocated to three groups and L-DOPS at doses of 400 mg, 200 mg or placebo was orally administrated to each group 30 min before starting every hemodialysis for 4 weeks. Changes of blood pressure (BP) in orthostatic hypotension immediately after completion of hemodialysis and symptoms related to orthostatic hypotension were compared between the three groups. In the 400-mg group, systolic and diastolic BP after standing increased significantly and the drop of mean BP after standing was also reduced compared with pretreatment levels. No such changes were observed in the placebo group. Fatiguability, malaise/weakness, dizziness and light-headed feeling, the interdialytic symptoms commonly observed in hemodialysis patients who developed orthostatic hypotension, were improved to a significant extent in the L-DOPS group compared with the placebo group. In particular, the improvement was more remarkable for the L-DOPS 400-mg group than the placebo group in patients with diabetic nephropathy, lower systolic BP after standing, and the long duration type of orthostatic hypotension. The incidence of adverse events was comparable between the three groups, and all recovered after discontinuation of L-DOPS or concomitantly administered drugs, or without any treatment. These findings indicate that L-DOPS taken before hemodialysis prevents orthostatic hypotension in patients undergoing hemodialysis, and is also effective for the interdialytic symptoms related to orthostatic hypotension.

Report on the annual statistical survey of the Japanese Society for Dialysis Therapy in 1996. Background Nearly 170,000 patients were treated by maintenance renal replacement therapy (RRT) in Japan in 1996. The current status of Japanese patients on RRT might, in some way, be suggestive for patients on RRT in other countries. Methods The Japanese Society for Dialysis Therapy conducts a questionnaire survey of virtually every dialysis facility in Japan at the end of each year. Here we present the results of our survey of patients undergoing RRT as of the end of 1996, as well as five-year trends (1992–1996) in some of the data. Results The response rate was 99.8%. At the end of 1996, there were 167,192 patients on maintenance RRT in Japan (1,328 persons per million population). The numbers of patients on maintenance RRT continued to increase during the five-year period. The gross mortality rate for that period ranged from 9.4% to 9.7%. Cuprammonium rayon was the most commonly used material (24.0%) for dialyzer membranes, followed by cellulose triacetate (18.7%). Approximately 5.0% of hemodialysis (HD) patients had a prior history of surgical release of carpal tunnel. The longer the years on HD therapy, the greater the proportion of patients with a history of such an operation. The predialysis plasma β2-microglobulin concentration was highest in patients aged 30 to 45years and declined slightly after the age of 45. There was no significant difference in the HbA1c level between continuous ambulatory peritoneal dialysis and HD patients, both in whom diabetes was the disease causing renal failure. Moreover, among HD patients with diabetes, there was a clear tendency for the HbA1c level to be higher when the normalized protein catabolic rate was higher. Conclusion This report summarizes the latest results of the survey on Japanese patients on RRT.

A 54-year-old woman with nephrotic syndrome underwent renal biopsy. By light microscopy, the glomerular capillary lumen was remarkably narrowed because of diffuse accumulation of Periodic acid Shiff (PAS) positive material along the glomerular capillary wall. By electron microscopy, collagenous fibers were observed in the mesangium and subendothelial area. The fibrous material reacted with antibodies against type I and III collagen but not with those against laminin or type IV collagen by an indirect immunofluorescence technique. This case seemed to be a case of collagenofibrotic glomerulonephropathy.