Yuka Kamijo

Computed tomography for the management of exit-site and tunnel infections in peritoneal dialysis patients .

PURPOSE To evaluate the effectiveness of computed tomography (CT) for detection of exit-site and tunnel infections with a Tenckhoff catheter. MATERIALS AND METHODS The study enrolled patients with exit-site or tunnel infections who underwent ultrasonography (US), CT scans, and subsequent catheter removal or partial catheter reimplantation from 2010 to 2014. Control cases on peritoneal dialysis who underwent abdominal CT scans for other reasons were randomly selected. Attenuation of the soft tissue around the Tenckhoff catheter was measured in Hounsfield units (HU). RESULTS 9 infected cases and 15 control cases were identified. CT showed increased attenuation around the catheter in all cases, while ultrasonography detected a hypoechoic area only in one case with abscess formation. Maximal attenuation of the inflamed soft tissue was high (median, 36 HU) compared with normal fatty tissue (median, -75 HU). In all cases, one or two sites with increased fat density were observed focally along the catheter, and these areas did not always extend directly from the exit site. CONCLUSIONS In this retrospective study comprising a small number of cases, increased attenuation of fatty tissue around the Tenckhoff catheter correlated with exit-site or tunnel infections. CT might be an auxiliary tool for diagnosis, although CT costs much more than US and is not always available in general practice. Further prospective studies are needed.
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SARCOPENIA AND FRAILTY IN PD: IMPACT ON MORTALITY, MALNUTRITION, AND INFLAMMATION

Background: It is known that sarcopenia is related to malnutrition-inflammation-atherosclerosis (MIA) syndrome and is an important problem in dialysis patients. The notion of frailty includes various physical, psychological, and social aspects. Although it has been reported that sarcopenia is associated with poor prognosis in patients with hemodialysis, reports on peritoneal dialysis (PD) patients are rare. In this study, we examined the morbidity and mortality of sarcopenia and frailty in PD patients. We also investigated the MIA-related factors. Methods: We evaluated 119 patients cross-sectionally and longitudinally. The Asian Working Group for Sarcopenia criteria and the Clinical Frailty Scale (CFS) were used to diagnose sarcopenia and frailty. The primary outcome is all-cause mortality with sarcopenia and frailty. The secondary outcome is the relationship between various MIA-related factors. Results: Morbidity of sarcopenia and frailty in PD patients was 8.4% and 10.9%, respectively. Old age, high values of Barthel Index, Charlson Comorbidity Index, CFS, and low values of body mass index (BMI), muscle strength, muscle mass, and slow walking were associated with sarcopenia. Interleukin-6, albumin, and prealbumin were significantly correlated with muscle mass. During follow-up, the presence of sarcopenia or frailty was associated with the risk of mortality. In multivariate analysis, CFS was related to the mortality rate of PD patients. Conclusions: The presence of sarcopenia or frailty was associated with a worse prognosis.

Total Renal Care Approach for Patients with End-Stage Renal Disease

BACKGROUND Advances in dialysis medicine have enabled end-stage renal disease (ESRD) patients to live longer. ESRD patients and their family members experience the illness in everyday life, and patients are required to manage their own disease to live longer. Psychological flexibility benefits a person and leads to healthier outcomes. Constructing an independent-minded attitude toward their lives with ESRD is preferably needed. SUMMARY Holistic care is needed to see patients with ESRD and their families because they are faced with life-long illness. From the scholastic standpoint, integration of natural science and humanities is needed. After some collaboration with philosophers, sociologists, and cognitive behavioral therapists, we propose a practical method which we call the total renal care (TRC) approach. With the TRC approach, we help patients and their families by adopting a psychosocial educational approach according to the stage of attitude toward their life with ESRD. In the predialysis care and even in the end-of-life process, selection of therapy based on the individual patients life and their viewpoints on family care burden are important. This enables patients and their families to make selections for renal replacement therapy including home dialysis, renal transplantation, and dialysis discontinuation, as well as hemodialysis and peritoneal dialysis. Key Messages: ESRD is a lifelong disease, and acquiring psychological flexibility would benefit patients and lead to healthier outcomes. Sharing the notion of TRC with their caregivers would strengthen this.

Baseline and Time-Averaged Values Predicting Residual Renal Function Decline Rate in Japanese Peritoneal Dialysis Patients

Residual renal function (RRF) is a strong prognostic factor of morbidity and mortality in patients undergoing peritoneal dialysis (PD). We determined predictors of the RRF rate of decline using both baseline values and time‐averaged ones. We retrospectively analyzed 94 patients being treated with PD at the Japanese Red Cross Medical Center. The decline rate of RRF was calculated by a diminution in the weekly renal Kt/V between the first and last follow up divided by follow‐up years. The mean follow‐up period was 2.28 years, and the mean decline rate of weekly renal Kt/V was 0.25 per year. A multivariate analysis using baseline parameters identified dialysis‐to‐plasma ratios of creatinine at 4 h (P = 0.02), urinary protein (P = 0.02), and mean blood pressure (MBP) (P < 0.01) as being positively associated with the RRF rate of decline, while the use of angiotensin converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) had a negative correlation (P = 0.03). When using time‐averaged values as independent variables, a lower weekly total renal Kt/V (P < 0.0001), higher urinary protein (P < 0.0001), and higher MBP (P = 0.04) independently predicted a faster RRF rate of decline. We demonstrated that PD patients with a lower MBP and lower urinary protein both at baseline and throughout their PD duration had a slower RRF rate of decline. We recommend strict control of blood pressure and anti‐proteinuric therapy for PD patients.

Long-Term Peritoneal Dialysis in 2 Patients with Takayasu's Arteritis

1. Reddy DK, Moore HL, Lee JH, Saran R, Nolph KD, Khanna R, et al. Chronic peritoneal dialysis in iron-deficient rats with solutions containing iron dextran. Kidney Int 2001; 59(2):764–73. 2. Suzuki K, Twardowski ZJ, Nolph KD, Khanna R, Moore HL. Absorption of iron from the peritoneal cavity of rats. Adv Perit Dial 1994; 10:42–3. 3. Gupta A, Amin NB, Besarab A, Vogel SE, Divine GW, Yee J, et al. Dialysate iron therapy: infusion of soluble ferric pyrophosphate via the dialysate during hemodialysis. Kidney Int 1999; 55(5):1891–8. 4. Fishbane SN, Singh AK, Cournoyer SH, Jindal KK, Fanti P, Guss CD, et al. Ferric pyrophosphate citrate (TrifericTM) administration via the dialysate maintains hemoglobin and iron balance in chronic hemodialysis patients. Nephrol Dial Transplant 2015;pii: gfv277. [Epub ahead of print]. DOI: 10.1093/ndt/gfv277 https://doi.org/10.3747/pdi.2016.00045

Importance of Neurogenic Bladder as a Cause of Drainage Failure.

Editor: Drainage failure is one of the peritoneal dialysis (PD) catheter-related problems that cause morbidity and greatly reduce quality of life (1). We report here 2 cases of outflow failure due to neurogenic bladder. The f irst case was a 62-year-old female with diabetic nephropathy. Peritoneal dialysis was initiated 4 years prior, and 1 year later, hemodialysis (HD) was combined with PD. She developed outflow failure, but X rays showed no signs of catheter malposition. Suction and injection of fibrinolytic agent had no effect. A plain computed tomography (CT) scan revealed the tip of the catheter pressed against the abdominal wall by a dilated bladder containing a large amount of urine (Figure 1), despite the fact that she had been considered to be anuric for several years. Approximately 1 L of urine was drained by urethral catheterization, and outflow failure was completely resolved. The second case was a 79-year-old male with diabetic nephropathy with a 3-year history of PD, and 8-month history of bimodal therapy with PD and HD. He experienced sudden outflow failure, but X rays, intraluminal suction or injection, and intraluminal fibroscopy were performed without effect. He continued to void 100 – 300 mL of urine per day, but a plain CT scan showed an extended urinary bladder wall and considerable remaining urine, which pushed the tip of the catheter into the rectum (Figure 1). After urethral catheterization, approximately 500 mL of urine flowed out and drainage from the catheter improved dramatically. Major causes of outflow failure include malposition of the catheter tip, catheter omental wrap, and catheter obstruction by luminal plug (2–4); and X rays, catherogram, suction or injection of a fibrinolytic agent, and intraluminal fibroscopy are used to diagnose it (2–5). However, a plain CT scan was critical to diagnose such a case. Moreover, treatment was quite easy with urethral catheterization, while some catheter malfunctions require surgical intervention. An important lesson here is that, even if patients are considered to be anuric or oliguric, they may have urine remaining in the bladder, and urinary bladder dilatation should be suspected as a cause of drainage failure.

Effect of tolvaptan in a patient with autosomal dominant polycystic kidney disease after living donor liver transplantation

Recently, a large randomized placebo-controlled trial indicated a beneficial effect of tolvaptan on the progression of autosomal dominant polycystic kidney disease (ADPKD) with near-normal kidney function. Meanwhile, the evidence of tolvaptan’s efficacy in ADPKD with severe renal insufficiency was limited and higher frequency of liver enzyme elevations were observed in patients taking tolvaptan. Liver transplantation (LT) is the only curative treatment for patients with severe polycystic liver disease associated with ADPKD, but considering that liver injuries should be avoided particularly in patients who underwent LT, we must be careful to start tolvaptan in post-LT ADPKD patients. We describe the case of a patient who had developed severe renal insufficiency after living donor LT, for whom tolvaptan therapy showed marked reduction of total kidney volume and maintenance of renal function without any serious adverse events. This is the first report to show the beneficial effect and safety of tolvaptan, in a post-LT ADPKD patient with severe renal insufficiency, and hopefully will help broaden the spectrum of patients who will benefit from tolvaptan.

Normal peritoneum after nine years of peritoneal dialysis with biocompatible dialysate: a case report.

and vancomycin was administered intravenously after specimens of blood and peritoneal effluent had been collected for culture. Six days later, bacterial culture of the peritoneal effluent yielded gram-negative bacteria, which were further confirmed as b. thetaiotaomicron. Antibiotic susceptibility tests revealed that the organism was sensitive to chloramphenicol and metronidazole, but resistant to clindamycin and penicillin. The antibiotics were therefore changed to metronidazole for 10 days, and the patient recovered completely without complications. To our knowledge, human infection caused by b. thetaiotaomicron is extremely rare. Based on limited case reports, this unusual pathogen had been found to be associated with meningitis, bacteremia, and wound infection (1–5). Here, we document the first case of PD peritonitis caused by b. thetaiotaomicron, which was confirmed by compatible symptoms and signs, and positive bacterial culture from peritoneal effluent. The portal of entry for this infection with b. thetaiotaomicron remains unclear. However, given that the organism resides in and dominates the human intestinal tract, the most probable mechanism is bacterial translocation from the gastrointestinal tract to the peritoneum. To summarize, we report a case of PD peritonitis caused by b. thetaiotaomicron. This case expands the spectrum of infection caused by b. thetaiotaomicron and raises the possibility of b. thetaiotaomicron as a potential cause of PD peritonitis.