Shoichiro Daimon

Comparison of Acetate-Free Citrate Hemodialysis and Bicarbonate Hemodialysis Regarding the Effect of Intra-Dialysis Hypotension and Post-Dialysis Malaise

Compared with acetate dialysate, bicarbonate dialysate has shown beneficial effects in reducing the morbidity associated with dialysis, but a small amount of acetate in bicarbonate dialysate may evoke hypotension or malaise. Acetate‐free citrate hemodialysis (AFHD) may avoid these problems. In 44 hemodialysis patients bicarbonate hemodialysis (BHD) was conducted for three months, followed by a switch to AFHD for three months, and a further switch to bicarbonate hemodialysis (ReBHD). In BHD, AFHD and ReBHD, intra‐dialysis hypotension and post‐dialysis malaise were determined (hypotension: intra‐dialysis systolic blood pressure (SBP) was expressed as a percentage of SBP at the start of hemodialysis, malaise was assessed by a self‐reported 0 to 3 scale, 0: absence of malaise, 3: unbearable malaise). Compared with BHD, AFHD patients complained of less malaise but the intra‐dialysis blood pressure change did not differ significantly (malaise: BHD 0.73 ± 0.76 vs. AFHD 0.32 ± 0.47, P < 0.0001, end hemodialysis SBP: BHD 93.6 ± 8.9 vs. AFHD 93.8 ± 10.1, P = NS). After switching to ReBHD from AFHD, the malaise score increased (AFHD 0.32 ± 0.47 vs. ReBHD 0.77 ± 0.89, P < 0.0001) and the intra‐dialysis blood pressure dropped markedly (end hemodialysis SBP: AFHD 93.8 ± 10.1 vs. ReBHD 87.3 ± 10.5, P < 0.0001). Malaise was very severe in five patients who could not continue ReBHD. After ten days under ReBHD, ReBHD was changed to AFHD again in all patients. Although the exact mechanisms are not known, AFHD may be preferable to BHD to prevent hemodialysis‐induced hypotension and malaise.

LDL apheresis followed by corticosteroid therapy as a possible treatment of cholesterol crystal embolism

Abstract A 66-year-old man with an abdominal aneurysm who developed renal failure and had blue toes after coronary angiography was transferred to our hospital, and cholesterol crystal embolism was diagnosed by renal and skin biopsies. After the initiation of low-density lipoprotein apheresis (LDL-A) following short-term corticosteroid therapy, in pain and the blueness in the toes disappeared rapidly, and inflammation decreased, but after the discontinuance of these therapies renal function and inflammation worsened again. Following the re-administration of corticosteroid, the inflammation disappeared and renal function gradually recovered. Although LDL-A is an effective treatment for the control of pain due to blue toes, its effect is additive. However, corticosteroid is a possible treatment for cholesterol crystal embolism, particularly in patients with severe inflammatory reaction, which suggests the possible participation of inflammatory or immunological factors in the progression of cholesterol crystal embolism.

Histopathologic evaluation of living kidney donor candidates by pre-operative kidney biopsy

Abstract:  A lack of deceased kidney donors in Japan has led to dependence on living donors in as many as 80% of cases. At the same time, indications for living‐donor kidney donation have been expanding in terms of donor medical status as well as HLA matching and ABO compatibility, thus emphasizing the donor shortage. To facilitate final medical decision‐making for living kidney donation, we attempted kidney biopsy in six donor candidates who had problems such as mild diabetes and slight proteinuria. The biopsy specimens showed various degrees of tissue injury ranging from partial glomerular sclerosis to arteriole hyalinization. On the basis of the biopsy findings, kidney donation was subsequently performed in three of the six cases with full informed consent, and not done in the remaining three cases. Longer‐term studies will be needed to clarify the outcome in both the donors and recipients in these cases.

Antineutrophil Cytoplasmic Antibody-Positive Rapidly Progressive Glomerulonephritis Caused by Propylthiouracil: A Case Report

Propylthiouracil, which is used as an antithyroid drug, is associated with many side effects. Vasculitis is a rare complication of this drug. Recently, antineutrophil cytoplasmic antibodies (ANCA) have been described in association with vasculitic disorders, including rapidly progressive glomerulo-nephritis. We report a case of ANCA-positive rapidly progressive glomerulonephritis caused by propylthiouracil administration. Although renal function was improved by discontinuation of the drug and initiation of steroid therapy, assay results for ANCA to myeloperoxidase remained positive throughout the clinical period.

Hints to the diagnosis of uromodulin kidney disease

Abstract Background Uromodulin kidney disease (UKD) is an inherited kidney disease caused by a uromodulin (UMOD) gene mutation. The UMOD gene encodes the Tamm–Horsfall protein (THP), which is the most abundant protein in healthy human urine. Because of its rarity, the incidence of UKD has not been fully elucidated. The purpose of the present study is to clarify the frequency of UKD among patients who underwent renal biopsy. Methods Immunostaining for THP was performed for patients <50 years of age with renal insufficiency and hyperuricemia without overt urinalysis abnormality from renal biopsy databases. Serum and urinary THP concentrations were evaluated in available individuals. Results Fifteen patients were selected for immunostaining from a total of 3787 patients. In three independent patients, abnormal THP accumulation in renal tubular cells was observed. A novel missense A247P UMOD mutation was detected in two of the three patients, including one having a typical family history of familial juvenile hyperuricemic nephropathy. Serum and urinary THP concentrations of all available patients with UMOD A247P mutation were significantly lower than those of controls. Conclusions In the present study, UKD was detected in <1 in 1000 subjects who underwent renal biopsies. However, in subjects meeting all of the above criteria, abnormal THP accumulation was detected in 20% (3/15), suggesting that renal biopsy with immunostaining for THP is a good tool for diagnosing UKD. Also, low serum THP concentration detected in the present subjects might be a good diagnostic marker or important in understanding the pathogenesis of UKD.

Efficacy of Coronary Artery Screening Tests and Intervention in Hemodialysis Patients

Although cardiovascular disease (CVD) is an important cause of death in patients on hemodialysis, evidence of a beneficial effect of percutaneous intervention (PCI) on stable heart disease is scarce. We investigated the cardiovascular outcomes of hemodialysis patients under our policy of encouraging coronary artery screening tests to the extent possible. A total of 147 hemodialysis patients have been treated in our clinic so far. In 98 of them, coronary artery screening tests were performed, three in unstable and 95 in asymptomatic patients. Significant coronary artery stenosis was detected in 29 at the first tests and in 11 during subsequent tests (40/98, 40.8%), and PCI or coronary artery bypass grafting (CABG) was performed. Multiple PCIs were needed in 21 patients. In the other 49 patients, coronary artery screening tests were not undertaken based on the nephrologists decision or patient refusal. At the end of the study, 73 (74.5%) patients with tests, and 14 (28.6%) without tests were still outpatients (P < 0.01). Of 40 patients transferred to other hospitals for medical reasons or who died before transfer, there was cerebrovascular accident in eight, malignancy in six, congestive heart failure without CVD in four, infection in three, sudden cardiac death in one, and others 18. No patient with tests died of CVD and the only patient who died of sudden cardiac death probably due to myocardial infarction was a patient who had declined the screening tests. Coronary artery screening tests, intervention and subsequent periodic tests for asymptomatic hemodialysis patients can reduce the occurrence of cardiovascular events in this population.

Comparison of the effect of the same dose of a 4-weekly continuous erythropoietin receptor activator administered once every 2 or 4 weeks in hemodialysis patients.

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Adverse Effect of Antithrombotic Medications on Bleeding Events and Comparison of Antithrombotic Agents in Hemodialysis Patients: Antithrombotic Therapy in HD Patients

Antithrombotic medications (AM) are mandatory for many hemodialysis patients, but the bleeding risk associated with this therapy is elevated. The frequency of bleeding events requiring discontinuation of AM, cessation of heparin use, and/or hospitalization was compared between hemodialysis patients with and without AM. All the hemodialysis patients in our clinic were investigated. AM were prescribed in 130 of 222 patients. Except for patients with cilostazol, those with AM had significantly more frequent bleeding events than those without AM (P < 0.01). Bleeding event frequency per 10 000 days of aspirin, clopidogrel, cilostazol, and warfarin prescription was 7.37, 5.95, 2.41, and 9.81, respectively, when restricted to administration of a single AM, which was 4.96, 2.87, 0.7, and 16.06, respectively. In patients without AM, it was 0.91. The bleeding risk associated with AM is elevated in hemodialysis patients and differs markedly depending on the agent used, with the lowest risk associated with cilostazol.