Fumihiro Takeguchi

Regression of parathyroid gland swelling by treatment with cinacalcet

Sir, We read with great interest the editorial review about vaccination and chronic kidney disease by Janus et al [1]. Although this article is focused on end-stage renal disease patients, we think that it is possible to mention the meningococcal vaccine. This immunization is usually recommended for people exposed to a case of severe meningococcal infection, or for people travelling in endemic zones (sub-Saharan meningitis belt) in close contact with the local population. In some countries, this vaccine is incorporated in national vaccination programmes [2]. A few years ago, a risk of relapse of nephrotic syndrome was signalled, after meningococcal C conjugate vaccine [3]. However, that has been invalidated by a more recent study where no link was found between vaccination and a risk of relapse [4]. Thus the use of this vaccine, when necessary, can be recommended. However, there is a lack of data upon the degree of the immune response to this kind of vaccine in immunosuppressed patients. For asplenic individuals, for example, a double dose of vaccine has been proposed [5].

Effects of icodextrin on insulin resistance and adipocytokine profiles in patients on peritoneal dialysis.

Abstract:  Icodextrin peritoneal dialysis solution reportedly benefits patients suffering from metabolic derangement due to glucose load from dialysate. However, the effects of icodextrin on insulin resistance and adipocytokine profile remain unclear. Subjects comprised 14 stable patients on peritoneal dialysis for >6 months. Their mean age was 57 ± 11 years and the mean duration of peritoneal dialysis was 49 ± 30 months. Patients were classified into groups according to the index of insulin resistance (index of homeostasis model assessment: HOMA‐IR): Group A, HOMA‐IR < 2.0 (n = 7); and Group B, HOMA‐IR ≥ 2.0 (n = 7). Glucose peritoneal dialysis solution was subsequently switched to icodextrin once daily during the night. Changes in HOMA‐IR and adipocytokine profiles were examined after three months. The glucose absorption dose tended to decrease in both groups after icodextrin introduction, with significant reductions in Group B. No changes were seen in body mass index, fluid status, peritoneal dialysis dose, residual renal function or fasting plasma glucose levels in either group. Plasma insulin levels were unchanged in Group A, but decreased significantly in Group B. The index of insulin resistance was thus unchanged in Group A (from 1.4 ± 0.4 to 1.5 ± 0.8) and significantly decreased in Group B (from 5.9 ± 2.2 to 3.2 ± 0.6; P < 0.01). Regarding plasma adipocytokine profiles, no changes were found in plasma leptin, tissue necrosis factor‐α or total plasminogen activator inhibitor‐1 levels in either group. Plasma adiponectin levels were unchanged in Group A, but significantly increased in Group B. Icodextrin solution could ameliorate insulin resistance by decreasing insulin levels due to a reduction in the glucose load and an increase in plasma adiponectin levels.

Grounds for withdrawing dialysis treatment under criminal law

キーワード:透析の見合わせ,刑法,不作為犯,作為義務,代行判断 〈要旨〉 透析医にとって,透析の見合わせが刑法上許容されるのかは重要な関心事である.透析の見合わせは,不作為とい えるところ,医師は患者との診療契約に基づく刑法上の作為義務を負っていることから,不作為犯に問われる可能 性がある.このため,刑法的許容性の問題は,生じた作為義務が解除される要件は何かという形で問題となる.透 析見合わせの正当化根拠は,患者の自己決定権に基づく透析拒否権に求められる.したがって,患者の透析拒否の 意思表示を要件として作為義務が解除され,透析の見合わせは刑法の規定する「人を殺した」行為に当たらず許容 される.患者本人に意思決定能力がない場合には,もし患者に意思決定能力があれば透析を受け入れないであろう, と他者が代行判断することが許容されるかが問題となるが,意思決定能力がない患者でも,患者の現在の推定的意 思に基づく透析拒否権を尊重すべきであり,慎重にされた場合には代行判断を許容すべきである.