Chie Saito

Japanese Society for Dialysis Therapy Clinical Guideline for “Hemodialysis Initiation for Maintenance Hemodialysis”

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

Annual decline in estimated glomerular filtration rate is a risk factor for cardiovascular events independent of proteinuria

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.

A case of multicentric Castleman's disease with membranoproliferative glomerulonephritis type 3-like lesion

Renal involvement is a significant complication of multicentric Castlemans disease (MCD) and various glomerular involvements have been reported. A 45‐year‐old Japanese man presented with persistent proteinuria, with lymphadenopathy and hypergammaglobulinemia. He had been diagnosed 4 years previously with MCD. As his renal impairment had progressed to renal failure, he underwent a renal biopsy. Histology revealed diffuse and global membranous lesions with large and heterogeneous epimembranous deposits. In addition, mesangial cell proliferation and focal extracapillary lesions were found. Under immunofluorescence, granular staining for anti‐IgG, IgG1, IgG2 and IgA was strongly positive in the capillary loop, and weakly positive in the mesangium. As such, there was a diversity of histological features. Our perspective with regard to pathogenesis is that the formation of the immune‐complex contributed to the membranoproliferative glomerulonephritis type 3‐like lesion. This histological multiform with MCD is valuable for increasing our understanding of the mechanism for onset of immune‐complex glomerular deposition and cellular proliferation of glomerulonephritis.

Secondary membranous glomerulonephritis associated with recipient residual lymphoma cells after allogeneic bone marrow transplantation

A 29-year-old man with malignant lymphoma developed membranous nephropathy (MN) after allogeneic bone-marrow transplantation (BMT). There had been no obvious findings of graft versus host diseases (GVHD) after BMT, and the dosage of immunosuppressant drugs had not been reduced during this period. At the onset of MN, a few lymphoma cells still remained in the bone marrow; the patient achieved complete remission of MN after the disappearance of the lymphoma cells. In this case it is suggested that immune complexes including antigens expressed by lymphoma cells might induce MN. Therefore, this is a significant case that may reveal an alternative mechanism of the onset of MN related to BMT.

Birth Weight and End‐Stage Diabetic Nephropathy in Later Life: A Japanese Multicenter Study

Dear Editor, Low birth weight (LBW) of less than 2500 g is a surrogate marker for low nephron number, and emerging evidence suggests that it is an important risk factor for both the progression of renal diseases (1,2) and the incidence of end-stage renal disease (ESRD) (2,3). Individuals with an inborn nephron deficit are susceptible to progressive loss of kidney function due to aging-related glomerular alterations (1). However, most study participants have been younger than 40 (2,3), because little well-organized information on birth weight is available for the old general population as comparison subjects in most countries. Diabetes mellitus is currently the most frequent primary disease of patients receiving dialysis, and the mean age of initiation of RRT in DM nephropathy is over 60 years old in Japan. Furthermore, the effect of generational differences must be considered when analyzing the correlation between birth weight and ESRD (4). Therefore, birth weight for each individual should be compared to the mean birth weight from an age-matched population. In January 2010 in nine centers in Ibaraki and Chiba prefectures in Japan, 1130 Japanese patients undergoing maintenance hemodialysis were identified. We surveyed the patients by using a selfcompleted questionnaire containing questions about birth weight. Data were obtained from 230 patients (20.3%). Mean birth weight in each year from 1903 to 1951 was estimated based on three nationwide surveys held in 1951, 1930 and 1903. Mean birth weight from 1951 to 2010 is available in the Annual Vital Statistics of National Population Dynamics Survey conducted by the Ministry of Health, Labor, and Welfare of Japan. We defined mean birth weight in each patient’s birth year as age-matched mean birth weight. We divided our subjects into those with and without DM and used the age of 60 years old in each group as thresholds to further classify subjects as younger and older. We then compared the actual birth weight provided on the questionnaire to the age-matched mean birth weight in each group. Older patients with DM had significantly lower birth weight than age-matched mean birth weight, whereas no significant differences between them existed in younger patients in the DM group or in any patients in the non-DM group, which consists of 101 patients with chronic glomerulonephritis and 45 with miscellaneous diseases (Fig. 1). Ichikawa et al. reported the dynamics of LBW and ESRD in Japan by using an ecological approach. However, they did not consider the effect of aging or the cause of ESRD in individuals (4). In contrast, we analyzed the effect of them by evaluating birth weight separately in younger and older individuals with or without DM. We considered that older diabetic patients with a small number of glomeruli due to significantly lower birth weight may have more severe long-term nephron damage than older nondiabetic patients. Therefore, we speculated that lower-than-mean birth weight would be a risk for ESRD in patients with DM in later life.

Dietary Nutrient Intake Assessment in Maintenance Hemodialysis Patients by Comparing Two Food Record Forms

This study aimed to evaluate the accuracy of dietary assessment in hemodialysis patients by comparing the nutrition intake estimated from two food record forms with the actual nutrition intake. Thirty-nine outpatients receiving stable maintenance hemodialysis in Japan were analyzed. Each patient was provided meals with known nutrient contents for two days and instructed to record the food intake at each meal using a standard food record form (method A) or a semi-quantitative food record form (method B). Each patient underwent two assessments by the two methods in a crossover manner. The concordance proportions between estimated dietary food intake by method A or method B and the actual dietary intake were compared for energy, protein, fat, carbohydrate, potassium, phosphorus, and salt. Estimated energy intake using method B (96.2%) was significantly closer (p<0.05) to actual energy intake, compared to method A (90.9%). However, estimated fat intake using method A (96.9%) was significantly closer (p<0.01) to actual fat intake compared to method B (113.4%). A significant difference (p<0.05) was observed between actual and estimated energy intake by method A (88.2%) in females. A significant difference (p<0.001) was observed between actual and estimated total energy intake (86.7%) or carbohydrate intake (85.0%) for method A in subjects aged ≥ 65 years. Method B has improved accuracy compared to method A in estimating energy intake, but still underestimates energy intake. Method B also underestimates carbohydrate intake and overestimates fat intake. Further study is required to improve the accuracy of dietary assessment method.

Effectiveness of Plasmapheresis in a Patient with Anti-glomerular Basement Membrane Antibody Glomerulonephritis with Advanced Kidney Dysfunction

Patients with anti-glomerular basement membrane antibody glomerulonephritis (anti-GBM GN) have severe kidney dysfunction, leading to end-stage renal disease. The effect of plasmapheresis and immunosuppressive treatment in patients with severe glomerular changes is controversial. A 62-year-old man was admitted with rapidly progressive glomerulonephritis and diagnosed with anti-GBM GN. He required hemodialysis. All glomeruli in the kidney biopsy specimen had cellular crescents without fibrotic changes, suggesting reversible damage. He was treated with plasmapheresis until the anti-glomerular basement membrane antibodies disappeared. His kidney function recovered, and dialysis was able to be discontinued. Frequent plasmapheresis in patients with dialysis-dependent anti-GBM GN may improve the kidney prognosis.

Annual Decline in Pentraxin 3 Is a Risk of Vascular Access Troubles in Hemodialysis Patients

Pentraxin 3 (PTX3), a multifunctional modulator of the innate immunoinflammatory response, is higher in patients undergoing hemodialysis than healthy control. Our study focused on annual change in PTX3 levels in patients with chronic hemodialysis, because regularly undergoing hemodialysis for many years modifies vascular inflammatory status. To demonstrate whether annual change in PTX3 is associated with vascular events, we measured blood levels of pentraxins (PTX3 and high-sensitivity C-reactive protein (hsCRP)) at baseline and in the next year in 76 hemodialysis patients and observed 20 patients with vascular access troubles during follow-up years. The annual decline in PTX3, but not hsCRP, is a significant risk of the incidence of vascular access trouble that is a critical and specific complication for hemodialysis patients (hazard ratio; 0.732 per +1 ng/mL/year in PTX3, * P = 0.039). This study is the first to focus on the annual change of pentraxins in a hemodialysis cohort.