Kazama Jj

Patients undergoing dialysis therapy for 30 years or more survive with serious osteoarticular disorders.

AIMS Increasing numbers of patients are undergoing long-term dialysis therapy. It is crucial for their quality of life to overcome dialysis-related complications, such as dialysis-related amyloidosis (DRA) and other osteoarticular disorder. The aim of the study was to investigate the characteristics, such as dialysis-related complications, in chronic kidney disease (CKD) Stage 5D patients undergoing dialysis therapy for more than 30 years or more. METHODS From 2003 to 2006, 359 CKD Stage 5D patients who were admitted to a single tertiary-care center. The age and the duration of dialysis therapy, the purpose for hospital admission, and history of osteoarticular disorder, such as carpal tunnel syndrome (CTS), destructive spondyloarthropathy (DSA) and joint arthropathy, were studied. RESULTS The proportions of the patients undergoing dialysis therapy for 20 - 24, 25 - 29 years and 30 years or more were 8.9, 5.6, and 4.5% of all admitted patients, respectively. DSA was a major cause of hospital admissions in long-term dialysis patients, especially in those treated for 30 years or more. The rate of surgery for osteoarticular disorder, such as CTS, DSA and joint arthropathy, which may show the presence of DRA, was 25.0, 66.0 and 77.8% in 20 - 24 years, 25 - 29 years and 30 years or more after the initiation of dialysis therapy, respectively. The frequency and severity of osteoarticular disorder accelerated with the duration of dialysis therapy, especially in those treated for 30 years or more. The rate of parathyroidectomy for secondary hyperparathyroidism was performed for 37.5% in 22.1 +/- 2.1 years after the initiation of dialysis treatment in the patients treated for 30 years or more. Mean age at the initiation of dialysis therapy was 27.3 +/- 8.0 years, and primary cause of CKD was mainly chronic glomerulonephritis in the patients undergoing dialysis therapy for 30 years or more. CONCLUSION CKD stage 5D patients undergoing dialysis therapy for 30 years or more survive with characteristics of younger age at initiation of dialysis therapy, chronic glomerulonephritis as a primary cause of CKD, and serious complication of osteoarticular disorders.

Maxacalcitol therapy decreases circulating osteoprotegerin levels in dialysis patients with secondary hyperparathyroidism.

BACKGROUND Osteoprotegerin is a natural glycoprotein which plays a critical role in osteoclast physiology. Elevated levels of circulating osteoprotegerin may account for the development of bone and mineral metabolic abnormalities in uremia. Little is known about the effects of vitamin D therapy on the circulating osteoprotegerin levels in dialysis patients. PATIENTS AND METHODS Fifty chronic dialysis patients whose plasma intact PTH levels were greater than 300 pg/ml were analyzed for the study. Following a four-week washout time during which all vitamin D administration was halted, 10 microg of maxacalcitol was intravenously injected thrice a week. RESULTS The circulating intact PTH, bone-specific alkaline phosphatase and intact osteocalcin levels were significantly lowered, while the serum calcium levels were elevated after the therapy. The osteoprotegerin levels significantly decreased after the therapy (p < 0.0001). CONCLUSION Maxacalcitol therapy reduced the circulating osteoprotegerin levels and improved secondary hyperparathyroidism. The observed effects were the opposite of those expected from previous in vitro studies. Osteoprotegerin may mediate and/or modify the effect of active vitamin D therapy in dialysis patients.

Cost-effectiveness achieved through changing the composition of renal replacement therapy in Japan

Abstract Objective: The cost-effectiveness of renal replacement therapy (RRT) is affected by the composition of treatment. This study aimed to estimate the costs and outcomes associated with changing the composition of RRT modality over time. Methods: By using clinical and cost data from a systematic review, a Markov model was developed to assess the costs and benefits of the four main treatments available for RRT in Japan. The model included direct health service costs and quality-adjusted life years (QALY). Sensitivity analyses were performed to assess the robustness of the results. Results: Over the 15-year period of the model, the current composition of RRT (i.e., the base composition of RRT) was

Knotting of two central venous catheters: a rare complication of pulmonary artery catheterization.

84,008/QALY. The most cost-effective treatment was when the likelihood of a living donor transplant was increased by 2.4-times (

Successful perioperative blood purification therapy in patients with maintenance hemodialysis therapy who underwent living donor liver transplantation

70,581/QALY). Compared with the base composition of RRT, dominant treatments with respect to cost-effectiveness were when the likelihood of a deceased donor transplant was increased by 22-times and when the likelihood of a pre-emptive living donor transplant was increased by 2.4-times. Little difference was found between these two treatments. One-way sensitivity analysis did not change the cost effectiveness except for costs of chronic hemodialysis and a living donor transplant in subsequent years. Limitations: It is difficult to increase the rate of transplant overall in the shorter term nationally and internationally. Conclusions: Appropriate distribution of all transplant options and hemodialysis is necessary to achieve the most cost-effective solution.

Development of hungry bone syndrome after rapid lowering of PTH with intravenous maxacalcitol therapy in a patient with non-uremic secondary hyperparathyroidism.

To the Editor: A unique complication of pulmonary artery (PA) catheter use is knotting. We describe a case of a knot between a central venous catheter and a PA catheter, and the successful nonsurgical unknotting and removal of the catheter. A 31-year-old pregnant woman in cardiogenic shock resulting from a tachycardia-induced cardiomyopathy was transferred to the intensive care unit. On admission, a triple-lumen central venous catheter was introduced via the right internal jugular vein. Despite sufficient hydration and continuous infusion of inotropic agents, her blood pressure was unstable. Circulatory supports by intraaortic balloon pump (IABP) and percutaneous cardiopulmonary support system (PCPS) were introduced for severe heart failure (ejection fraction was 10%). On the 6th ICU day, a PA catheter was inserted through the left internal jugular vein to monitor hemodynamic status during weaning from PCPS. The catheter was inserted without difficulty and advanced easily, and the correct position was confirmed on the chest X-ray. Weaning from the PCPS was completed on the 6th ICU day, and the IABP was removed on the 7th ICU day because her hemodynamic status became relatively stable. However, as she still had multiple organ failure, we retained the PA catheter. Although a chest X-ray showed normal configuration of the catheters on the morning of the 11th ICU day, monitoring failure of pulmonary arterial pressure happened abruptly about 9 p.m. without any catheter manipulations. We attempted to remove the PA catheter in the usual manner. However, resistance was felt during withdrawal of the catheter, and repeated traction was unsuccessful. Then, we confirmed a loose knot between the central venous catheter and the PA catheter in the superior vena cava on the chest X-ray (Fig. 1). As the knotting was relatively loose, we pushed the PA catheter forward to unknot the catheters, and then the catheter was successfully removed. The case of knotting of two catheters is rare [1–3]. Cases of knotted catheters functioning normally for several days have not been previously reported. We suspected that the catheter knotted when sudden malfunction of the catheter was found; in fact, the catheter was in normal configuration in the morning. The cause of knotting was not clear, and the catheter was not manipulated before discovery of the knotting. Several technical methods for removal of the knotting have been developed in cases that are more difficult to handle. One approach is to tighten the knot as much as possible so that it may be removed through the vein insertion site. Alternative approaches are to use a retrieval basket, a loop snare formed by a double-over guide wire or loop snares, endomyocardial biopsy forceps, or an inflated angiography balloon to expand the diameter of the knot [4]. Open surgical removal of knotted catheters is reserved for large, multiple loop knots or knots that are fixed within the cardiac chamber. In summary, we experienced a case of a spontaneous knotting between a central venous catheter and a PA catheter several days after placement. A catheter knotting should be considered when malfunction of the catheter is encountered. Withdrawal of a PA catheter should be performed cautiously, and a chest X-ray should be taken S. Hida (&) S. Ohashi H. Kinoshita T. Honda S. Yamamoto J. Kazama H. Endoh Department of Emergency and Critical Care Medicine, Niigata University Faculty of Medicine, 1-757 Asahimachi, Niigata 951-8510, Japan e-mail: ukhida@med.niigata-u.ac.jp

Etiology and prognostic significance of severe uremic pruritus in chronic hemodialysis patients

Living donor liver transplantation (LDLT) is a treatment for end-stage liver failure, and was developed to overcome the distinct insufficiency of cadaveric donors. Case 1 is a 56-year-old man who had undergone maintenance hemodialysis therapy for 4 years. An LDLT was performed for the treatment of advanced liver cirrhosis and hepatocellular carcinoma. Continuous hemodiafiltration (CHDF) was performed from the 2nd to 5th days after the operation. Case 2 is a 55-year-old man with primary amyloidosis and chronic renal failure. An LDLT was performed for the treatment of severe abdominal distention caused by a large liver volume. Although CHDF was started at the 3rd day after the operation, it was discontinued within 24 hours because of an increased urinary volume. CHDF was required again from the 6th-8th days, after which the blood purification mode was switched to regular intermittent hemodialysis. Meanwhile, no major problems occurred in either case. In conclusion, CHDF was required for about 5 days from the 2nd day after the operation. The application of careful and aggressive blood purification therapy during the perioperative period is a key to successful LDLT in dialysis patients.

Basic and clinical aspects of parathyroid hyperplasia in chronic kidney disease

A 41 year-old woman complained of general bone pain and polyuria. She did not have Albright hereditary osteodystrophy. Laboratory examination revealed hypokalemia, hypocalcemia, and an elevation of serum intact PTH concentration. The patient was polyuric and relatively hypercalciuric, though her glomerular filtration rate (GFR) was normal. Neither urinary Pi nor cAMP excretion was remarkably promoted by an exogenous PTH load. An iliac bone biopsy revealed osteopenia, active osteoclastic bone resorption, fibrous transformation in bone marrow tissue, and severely disturbed calcification. Although the oral administration of alfacalcidol showed no effects, 3 weeks of intermittent intravenous injection of maxacalcitol therapy decreased the serum intact PTH concentration from 597 pg/ml to 40 pg/ml, and the bone pain was greatly relieved. However, plasma Ca concentration also decreased and symptoms of tetany appeared. Pseudohypoparathyroidism type Ib was the most likely diagnosis in this patient. In conclusion, maxacalcitol therapy satisfactorily suppressed parathyroid function in a patient with secondary hyperparathyroidism without uremia. Appropriate Ca supplementation was required to perform it safely.