Peritoneal Dialysis Guidelines 2019 Part 2: Main Text (Position paper of the Japanese Society for Dialysis Therapy)

Background

This article is a duplicated publication from the Japanese version of “2019 JSDT Guidelines for Peritoneal Dialysis” with permission from the Japanese Society for Dialysis Therapy (JSDT). This clinical practice guideline (CPG) was developed primarily by the Working Group on Revision of Peritoneal Dialysis (PD) Guidelines of the Japanese Society for Dialysis Therapy. Recently, the definition and creation process for CPGs have become far more rigorous; traditional methods and formats no longer adhere to current standards. To improve the reliability of international transmission of our findings, CPGs are created in compliance with the methodologies developed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group. Part 2 of this PD guideline is the first CPG developed by our society that conforms to the GRADE approach.

Methods

Detailed processes were created in accordance with the Cochrane handbook and the GRADE approach developed by the GRADE working group.

Results

Clinical question (CQ)1: Is the use of renin-angiotensin system inhibitors (RAS inhibitors), such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB), effective in PD patients?

Recommendation: We suggest the usage of RAS inhibitors (ACEI and ARB) in PD patients (GRADE 2C).

CQ2: Icodextrin or glucose solution: which is more useful as a dialysate among patients with PD?

Recommendation: We suggest using icodextrin when managing body fluids in PD patients (GRADE 2C).

CQ3: Is it better to apply or not apply mupirocin/gentamicin ointment to the exit site?

Recommendation: We suggest not applying mupirocin/gentamicin ointment to the exit sites of PD patients (GRADE 2C).

CQ4: Which surgical approach is more desirable when a PD catheter is placed, open surgery or laparoscopic surgery?

No recommendation.

CQ5: Which administration route of antibiotics is better in PD patients with peritonitis, intravenous or intraperitoneal?

Recommendation: We suggest intraperitoneal administration of antibiotics in PD patients with peritonitis (GRADE 2C).

Note: The National Insurance does not currently cover intraperitoneal administration.

CQ6: Is peritoneal dialysis or hemodialysis better as the first renal replacement therapy in diabetic patients?

No recommendation.

Conclusions

In the future, we suggest that society members construct their own evidence to answer CQs not brought up in this guideline, and thereby show the achievements of Japan worldwide.

Peritoneal Dialysis Guidelines 2019 Part 1 (Position paper of the Japanese Society for Dialysis Therapy)

Approximately 10 years have passed since the Peritoneal Dialysis Guidelines were formulated in 2009. Much evidence has been reported during the succeeding years, which were not taken into consideration in the previous guidelines, e.g., the next peritoneal dialysis PD trial of encapsulating peritoneal sclerosis (EPS) in Japan, the significance of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), the effects of icodextrin solution, new developments in peritoneal pathology, and a new international recommendation on a proposal for exit-site management. It is essential to incorporate these new developments into the new clinical practice guidelines. Meanwhile, the process of creating such guidelines has changed dramatically worldwide and differs from the process of creating what were “clinical practice guides.” For this revision, we not only conducted systematic reviews using global standard methods but also decided to adopt a two-part structure to create a reference tool, which could be used widely by the society’s members attending a variety of patients. Through a working group consensus, it was decided that Part 1 would present conventional descriptions and Part 2 would pose clinical questions (CQs) in a systematic review format. Thus, Part 1 vastly covers PD that would satisfy the requirements of the members of the Japanese Society for Dialysis Therapy (JSDT). This article is the duplicated publication from the Japanese version of the guidelines and has been reproduced with permission from the JSDT.

Anti-pruritic effect of nemolizumab in hemodialysis patients with uremic pruritus: a phase II, randomized, double-blind, placebo-controlled clinical study

BACKGROUND

The pathophysiology of uremic pruritus (UP), which is characterized by systemic and intractable itching, remains unclear. As interleukin (IL)-31 may be involved, we conducted a phase II, randomized, controlled study to evaluate nemolizumab (anti-IL-31 receptor A antibody) in Japanese hemodialysis patients with UP.

METHODS

Patients were randomly assigned (1:1:1:1:1) to one of four double-blind groups (receiving a single subcutaneous injection of nemolizumab 0.125, 0.5, or 2.0 mg/kg, or placebo on Day 1) or an open-label reference group (receiving oral nalfurafine hydrochloride 2.5-5 μg once daily for 12 weeks). The primary endpoint was the difference in the absolute change in pruritus visual analog scale (VAS) at Week 4 between placebo and each nemolizumab group.

RESULTS

The primary efficacy endpoint was not met. The mean change from baseline with all three nemolizumab doses at Week 1, and with 0.5 mg/kg at Week 4, was greater than with placebo. Least square mean differences (95% confidence intervals) in the absolute changes between the placebo arm and each nemolizumab arm were - 2.4 (- 19.7, 14.9) for 0.125 mg/kg, - 8.7 (- 26.6, 9.2) for 0.5 mg/kg, and 0.4 (- 17.0, 17.8) for 2.0 mg/kg. Secondary efficacy parameters including the Shiratori severity score and 5-D itch score failed to show between-group differences. Patients with higher serum IL-31 levels at screening tended to have greater pruritus VAS reductions following nemolizumab treatment.

CONCLUSIONS

In this phase II study in patients with UP, the primary efficacy parameter was not met. Nemolizumab was generally well tolerated with no clinically significant safety concerns.

CLINICAL TRIAL REGISTRATION

JAPIC: JapicCTI-152961, https://www.clinicaltrials.jp/cti-user/trial/ShowDirect.jsp?japicId=JapicCTI-152961 .

Differences in Corrective Mode for Divalent Ions and Parathyroid Hormone between Standard- and Low-Calcium Dialysate in Patients on Continuous Ambulatory Peritoneal Dialysis—Result of a Nationwide Survey in Japan

⋄ Background

In patients on continuous ambulatory peritoneal dialysis (CAPD), dialysate calcium concentration has a strong influence on correction of serum calcium, phosphorus, and parathyroid hormone (PTH); however, the optimal concentration of Ca in PD solution is still uncertain. The aim of the survey reported here was to evaluate the prevalence of patients treated with standard- [SCD (approximately 3.25 – 4.0 mEq/L)] or low-calcium [LCD (approximately 1.8 – 2.5 mEq/L)] dialysate and differences in the clinical effects for correction of abnormalities in divalent ions and PTH.

⋄ Materials and Methods

We used a questionnaire to survey 333 peritoneal dialysis facilities nationwide in Japan. Then, we analyzed serum Ca, P, and PTH levels and the prescription rates for CaCO3 as a P binder and for vitamin D (VitD) analogs.

⋄ Results

The 2384 CAPD patients enrolled in this analysis had a mean age of 60.5 ± 14.2 years and a mean duration of CAPD of 44.1 ± 39.2 months. The prevalences of SCD, LCD, and combination of SCD and LCD were, respectively, 49%, 50%, and 1% at initiation, and 40%, 38%, and 22% at the time of the survey. In 735 and 876 patients respectively, LCD and SCD had been prescribed from initiation to the time of the survey. In these two groups, we observed no difference in initiation and current serum levels of Ca and P. But prescription rates for CaCO3 and VitD analogs were higher in the LCD group than in the SCD group, and PTH levels were higher in the LCD group than in the SCD group.

⋄ Conclusions

A beneficial effect of LCD was revealed in the increased doses of CaCO3 and VitD analogs seen in that group without the occurrence of hypercalcemia; however, PTH levels in that group were not maintained within an acceptable range. The survey suggests that more serious attention should be paid to the Ca concentration in peritoneal dialysate so as to lessen mineral and PTH disorders in CAPD.

A Clinical Significance of Intermittent Infusion Hemodiafiltration Using Backfiltration of Ultrapure Dialysis Fluid Compared to Hemodialysis: A Multicenter Randomized Controlled Crossover Trial

Background: Intermittent infusion hemodiafiltration ­(I-HDF) using repeated infusion of ultrapure dialysis fluid through a dialysis membrane or sterile nonpyrogenic substitution fluid was developed to prevent a rapid decrease in blood pressure by increasing the patient’s circulating blood volume, to enhance the plasma refilling rate by improving peripheral circulation, and to enhance solute transfer from the extravascular space to the intravascular space by enhancing the plasma refilling rate. Furthermore, the effect of fouling caused by attachment of proteins to the membrane as a result of ultrafiltration can be reduced by backflushing of the membrane with the purified dialysate in I-HDF. Although there have been several clinical trials of I-HDF, there have been no comparisons of the clinical significance of and indications for ­I-HDF with those of conventional hemodialysis (HD). Objective: The aim of this multicenter randomized controlled crossover trial was to compare the clinical significance of ­I-HDF with that of HD in Japan. Method: Patients were randomized to receive HD, I-HDF, and HD (group A) or I-HDF, HD, and I-HDF (group B) in that order for 14 weeks each. The sample size of 70 was determined based on the operability and patient availability. Treatment outcomes were evaluated 5 and 14 weeks after the start of each treatment period. The patients received 4-h treatment sessions with no changes in session duration or anticoagulant therapy during the study. I-HDF was performed using a GC-110N dialysis machine. Two hundred milliliters of ultrapure dialysis fluid were infused at a rate of 150 mL/min by backfiltration every 30 min during treatment. The first and last infusions were performed 30 min after the start and 30 min before the end of treatment, respectively. The total estimated infusion volume per session was 1.4 L (i.e., 200 mL × 7 infusions). I-HDF is a type of online HDF with a small fluid replacement volume. An ABH-P polysulfone membrane hemodiafilter was used for ­I-HDF and a class 1 or 2 hemodialyzer with a polysulfone membrane not coated with vitamin E and approved by the Japanese reimbursement system was used for HD. The primary outcomes were the Short Form-36 version 2 summary scores for quality of life and the visual analog scale scores for clinical symptoms. Secondary outcomes were vital signs, number of interventions, and pre-treatment blood test results. These variables were evaluated 1 week before at the start of the study, and at 5 and 14 weeks after the start of each treatment period. The removal characteristics of the various solutes were evaluated when possible on the first day of each treatment period. All patients provided written informed consent to participate. Results: Thirty-two patients in group A and 32 patients in group B completed the trial. There were no differences in the primary or secondary outcomes between I-HDF and HD. Serum α1-microglobulin (MG) levels at 14 weeks were significantly lower for I-HDF than for HD. During treatment, the removal rates for urea and creatinine, which are low molecular weight substances, were significantly lower during I-HDF than during HD. In contrast, the β2-MG and α1-MG removal rates were significantly higher during I-HDF than during HD. Furthermore, there was significantly less albumin leak during I-HDF than during HD. The solute removal results reflect the difference in pore size between the hemodiafilter used for I-HDF and the hemodialyzer used for HD and the difference in convective transport attributable to filtration between the 2 methods. Conclusions: These findings show that the removal rates of low molecular weight substances are significantly lower and those of medium to high molecular weight substances are significantly higher with I-HDF than with HD. They also indicate that there is significantly less albumin leak during I-HDF than during HD, meaning that I-HDF may be a particularly suitable dialysis modality for patients with malnutrition and the elderly in Japan.

The Japanese clinical practice guideline for acute kidney injury 2016

Acute kidney injury (AKI) is a syndrome which has a broad range of etiologic factors depending on different clinical settings. Because AKI has significant impacts on prognosis in any clinical settings, early detection and intervention is necessary to improve the outcomes of AKI patients. This clinical guideline for AKI was developed by a multidisciplinary approach with nephrology, intensive care medicine, blood purification, and pediatrics. Of note, clinical practice for AKI management which was widely performed in Japan was also evaluated with comprehensive literature search.

Effect of Oral Alfacalcidol on Clinical Outcomes in Patients Without Secondary Hyperparathyroidism Receiving Maintenance Hemodialysis: The J-DAVID Randomized Clinical Trial

IMPORTANCE

Patients with chronic kidney disease have impaired vitamin D activation and elevated cardiovascular risk. Observational studies in patients treated with hemodialysis showed that the use of active vitamin D sterols was associated with lower risk of all-cause mortality, regardless of parathyroid hormone levels.

OBJECTIVE

To determine whether vitamin D receptor activators reduce cardiovascular events and mortality in patients without secondary hyperparathyroidism undergoing hemodialysis.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, open-label, blinded end point multicenter study of 1289 patients in 207 dialysis centers in Japan. The study included 976 patients receiving maintenance hemodialysis with serum intact parathyroid hormone levels less than or equal to 180 pg/mL. The first and last participants were enrolled on August 18, 2008, and January 26, 2011, respectively. The final date of follow-up was April 4, 2015.

INTERVENTIONS

Treatment with 0.5 μg of oral alfacalcidol per day (intervention group; n = 495) vs treatment without vitamin D receptor activators (control group; n = 481).

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite measure of fatal and nonfatal cardiovascular events, including myocardial infarctions, hospitalizations for congestive heart failure, stroke, aortic dissection/rupture, amputation of lower limb due to ischemia, and cardiac sudden death; coronary revascularization; and leg artery revascularization during 48 months of follow-up. The secondary outcome was all-cause death.

RESULTS

Among 976 patients who were randomized from 108 dialysis centers, 964 patients were included in the intention-to-treat analysis (median age, 65 years; 386 women [40.0%]), and 944 (97.9%) completed the trial. During follow-up (median, 4.0 years), the primary composite outcome of cardiovascular events occurred in 103 of 488 patients (21.1%) in the intervention group and 85 of 476 patients (17.9%) in the control group (absolute difference, 3.25% [95% CI, -1.75% to 8.24%]; hazard ratio, 1.25 [95% CI, 0.94-1.67]; P = .13). There was no significant difference in the secondary outcome of all-cause mortality between the groups (18.2% vs 16.8%, respectively; hazard ratio, 1.12 [95% CI, 0.83-1.52]; P = .46). Of the 488 participants in the intervention group, 199 (40.8%) experienced serious adverse events that were classified as cardiovascular, 64 (13.1%) experienced adverse events classified as infection, and 22 (4.5%) experienced malignancy-related serious adverse events. Of 476 participants in the control group, 191 (40.1%) experienced cardiovascular-related serious adverse events, 63 (13.2%) experienced infection-related serious adverse events, and 21 (4.4%) experienced malignancy-related adverse events.

CONCLUSIONS AND RELEVANCE

Among patients without secondary hyperparathyroidism undergoing maintenance hemodialysis, oral alfacalcidol compared with usual care did not reduce the risk of a composite measure of select cardiovascular events. These findings do not support the use of vitamin D receptor activators for patients such as these.

TRIAL REGISTRATION

UMIN-CTR Identifier: UMIN000001194.

The Japanese Clinical Practice Guideline for acute kidney injury 2016

Acute kidney injury (AKI) is a syndrome which has a broad range of etiologic factors depending on different clinical settings. Because AKI has significant impacts on prognosis in any clinical settings, early detection and intervention are necessary to improve the outcomes of AKI patients. This clinical guideline for AKI was developed by a multidisciplinary approach with nephrology, intensive care medicine, blood purification, and pediatrics. Of note, clinical practice for AKI management which was widely performed in Japan was also evaluated with comprehensive literature search.

Possible clinical effects of molecular hydrogen (H2) delivery during hemodialysis in chronic dialysis patients: Interim analysis in a 12 month observation

Background and aim

It is supposed that enhanced oxidative stress and inflammation are involved with the poor clinical outcomes in patients on chronic dialysis treatment. Recent studies have shown that molecular hydrogen (H₂) is biologically active as an anti-inflammatory agent. Thus, we developed a novel hemodialysis (E-HD) system which delivers H₂ (30 to 80 ppb)-enriched dialysis solution, to conduct a prospective observational study (UMIN000004857) in order to compare the long-term outcomes between E-HD and conventional-HD (C-HD) in Japan. The present interim analysis aimed to look at potential clinical effects of E-HD during the first 12 months observation.

Subjects and method

262 patients (140, E-HD; 122, C-HD) were subjected for analysis for comprehensive clinical profiles. They were all participating in the above mentioned study, and they had been under the respective HD treatment for 12 consecutive months without hospitalization. Collected data, such as, physical and laboratory examinations, medications, and self-assessment questionnaires on subjective symptoms (i.e., fatigue and pruritus) were compared between the two groups.

Results

In a 12-month period, no clinical relevant differences were found in dialysis-related parameters between the two groups. However, there were differences in the defined daily dose of anti-hypertensive agents, and subjective symptoms, such as severe fatigue, and pruritus, which were all less in the E-HD group. Multivariate analysis revealed E-HD was an independent significant factor for the reduced use of anti-hypertensive agents as well as the absence of severe fatigue and pruritus at 12 months after adjusting for confounding factors.

Conclusion

The data indicates E-HD could have substantial clinical benefits beyond conventional HD therapy, and support the rationale to conduct clinical trials of H₂ application to HD treatment.

Peritoneal Dialysis Registry With 2012 Survey Report

Since 2009, the peritoneal dialysis (PD) registry survey has been carried out as part of the annual nationwide survey conducted by the Statistical Survey Committee of the Japanese Society for Dialysis Therapy with the cooperation of the Japanese Society for Peritoneal Dialysis. In this report, the current status of PD patients is presented on the basis of the results of the survey conducted at the end of 2012. The subjects were PD patients who lived in Japan and participated in the 2012 survey. Descriptive analysis of various items was performed, which included the current status of the combined use of PD and another dialysis method such as hemodialysis (HD) or hemodiafiltration (HDF), the method of exchanging dialysate, the use of an automated peritoneal dialysis (APD) machine, and the rates of peritonitis and catheter exit-site infection. From the results of the facility survey in 2012, the number of PD patients was 9514, a decrease of 128 from 2011. Among the entire dialysis patient population, 3.1% were PD patients, a decrease of 0.1%. Among the studied patients, 347 had a peritoneal catheter and underwent peritoneal lavage, 175 were started on PD in 2012 but introduced to other blood purification methods in the same year, and 1932 underwent both PD and another dialysis method such as HD or HDF. The percentage of patients who underwent PD and another dialysis method increased with PD vintage: <1 year, 4.8%; 1 to <2 years, 9.2%; 2 to <4 years, 16.3%; 4 to <8 years, 32.0%; and ≥8 years, 47.5%. The percentage of PD patients who completely manually exchanged the dialysate was 29.8%. The percentages of PD patients who used a double-bag exchange system with ultraviolet-light irradiation and those who used the same system but with a sterile connecting device were 54.7 and 13.9%, respectively. The percentage of patients on PD for <1 year using an APD machine was 43.4%, and it decreased with a PD vintage of ≥2 years. The mean rate of peritonitis was 0.22 per patient per year. The mean rate of catheter exit-site infections was 0.36 per patient per year.

Mitochondrial biogenesis and degradation are induced by CCCP treatment of porcine oocytes

In this study, we investigated the mitochondrial quality control system in porcine oocytes during meiotic maturation. Cumulus cell oocyte complexes (COCs) collected from gilt ovaries were treated with 10  μM carbonyl cyanide-m-chlorophenylhydrazone (CCCP; a mitochondrial uncoupler) for 2  h. The CCCP treatment was found to significantly reduce ATP content, increase the amount of phosphorylated AMP-activated protein kinase and elevate reactive oxygen species levels in oocytes. When the CCCP-treated COCs were cultured further for 44  h in maturation medium, the ATP levels were restored and the parthenogenetic developmental rate of oocytes to the blastocyst stage was comparable with that of untreated COCs. To examine the effects of CCCP treatment of oocytes on the kinetics of mitochondrial DNA copy number (Mt number), COCs treated with 0 or 10  μM CCCP were cultured for 44  h, after which the Mt number was determined by RT-PCR. CCCP treatment was found to increase the Mt number in the modified maturation medium in which mitochondrial degradation was inhibited by MG132, whereas CCCP treatment did not affect the Mt number in the maturation medium lacking MG132. The relative gene expression of TFAM was furthermore shown to be significantly higher in CCCP-treated oocytes than in untreated oocytes. Taken together, the finding presented here suggest that when the mitochondria are injured, mitochondrial biogenesis and degradation are induced, and that these processes may contribute to the recuperation of oocytes.

Resveratrol improves the quality of pig oocytes derived from early antral follicles through sirtuin 1 activation

During oocyte growth, the number of mitochondria drastically increases and mitochondrial function profoundly affects the oocyte competence. Resveratrol is a well-known activator of sirtuin 1 (SIRT1), which has a role in cellular energy homeostasis and mitochondrial biogenesis. The main aim of the present study was to examine the effect of supplementation of culture media with resveratrol on oocyte development and mitochondrial number and functions. Lipid contents and developmental ability of the oocytes grown in vitro were also examined. Oocyte-granulosa cell complexes were collected from early antral follicles of gilt ovaries and were cultured in medium containing 0 or 2 μM resveratrol for 14 days. Immunostaining revealed that resveratrol enhanced SIRT1 expression in oocytes. Antrum formation during the culture period and survivability of the granulosa cells surrounding the developed oocytes did not differ between the two concentrations of resveratrol. In addition, the ability of oocytes to complete meiotic maturation did not differ between the two concentrations of resveratrol, whereas the ability of oocytes to develop to the blastocyst stage was improved significantly by resveratrol (7.4% vs. 1.6%; P < 0.05). Resveratrol upregulated the ATP content in oocytes grown in vitro, and the addition of 2 μM of the SIRT1 inhibitor 6-Chloro-2,3,4,9-tetrahydro-1H-carbazole-1-carboxamide (EX527) diminished this effect although EX527 alone had no effect on ATP content. The mitochondrial DNA copy number in oocytes determined by quantitative real-time polymerase chain reaction increased during in vitro oocyte development, but resveratrol did not affect the kinetics of the mitochondrial DNA copy number. We found that resveratrol also increased the expression level of phospho-5'-adenosine monophosphate-activated protein kinase in oocytes but decreased the lipid content in oocytes grown in vitro. These results suggest that resveratrol increased the ATP content in oocytes via energy homeostasis and improved the developmental ability of oocytes grown in vitro.

End-stage renal disease in Japanese children: a nationwide survey during 2006-2011

BACKGROUND

End-stage renal disease (ESRD) in children is considered a rare, but serious condition. Epidemiological and demographic information on pediatric ESRD patients around the world is important to better understand this disease and to improve patient care. The Japanese Society for Pediatric Nephrology (JSPN) reported epidemiological and demographic data in 1998. Since then, however, there has been no nationwide survey on Japanese children with ESRD.

METHODS

The JSPN conducted a cross-sectional nationwide survey in 2012 to update information on the incidence, primary renal disease, initial treatment modalities, and survival in pediatric Japanese patients with ESRD aged less than 20 years during the period 2006-2011.

RESULTS

The average incidence of ESRD was 4.0 per million age-related population. Congenital anomalies of the kidney and urinary tract were the most common cause of ESRD, present in 39.8 % of these patients. In addition, 12.2 % had focal segmental glomerulosclerosis and 5.9 % had glomerulonephritis. Initial treatment modalities in patients who commenced renal replacement therapy (RRT) consisted of peritoneal dialysis, hemodialysis, and pre-emptive transplantation (Tx) in 61.7, 16.0, and 22.3 %, respectively. The Japanese RRT mortality rate was 18.2 deaths per 1000 person-years of observation.

CONCLUSION

The incidence of ESRD is lower in Japanese children than in children of other high-income countries. Since 1998, notably, there has been a marked increase in pre-emptive Tx as an initial treatment modality for Japanese children with ESRD.

Effect of a hydrogen (H2)-enriched solution on the albumin redox of hemodialysis patients

Elevated oxidative stress (OS) is associated with severe cardiovascular disease and premature death among patients treated with hemodialysis (HD). Oxidative stress is enhanced by contact between blood and dialysis membranes during HD sessions. This study aimed to clarify whether hydrogen (H2), which is a known antioxidant, is capable of suppressing increased OS induced during HD sessions. Eight patients on regular HD treatment were studied. Two HD sessions were performed in a cross-over design trial using standard and hydrogen-enriched solutions (mean of 50 p.p.b. H2; H2-HD). Blood samples were obtained from the inlet and outlet of the dialyzer during HD to determine changes in plasma levels of glutathione, hydrogen peroxide, and albumin redox state as a marker of OS. Comparison of inlet and outlet blood revealed significant decreases in total glutathione and reduced glutathione, as well as significant increases in hydrogen peroxide in both HD treatments. However, the mean proportion of reversibly oxidized albumin in outlet serum was significantly lower than that in inlet serum following the H2-HD session, whereas no significant changes were found in the standard solution session, suggesting that "intra-dialyzer" OS is reduced by H2 -HD. In conclusion, the application of H2-enriched solutions could ameliorate OS during HD.

Darbepoetin alfa for the treatment of anemia in children undergoing peritoneal dialysis: a multicenter prospective study in Japan

BACKGROUND

Darbepoetin alfa (DA) is an attractive alternative to recombinant human erythropoietin (rHuEPO) in managing renal anemia. Since DA has not been approved by the appropriate Japanese drug regulatory agencies for the indication of renal anemia in children in Japan, we have conducted a multicenter prospective study to determine the efficacy and safety of DA in Japanese children undergoing peritoneal dialysis (PD).

METHODS

Pediatric patients subcutaneously receiving rHuEPO were switched to DA treatment for a period of 28 weeks. The conversion to the initial dose of DA was calculated as 1 μg DA for 200 IU rHuEPO, and DA was administered intravenously once every 2 weeks. The target hemoglobin (Hb) concentration was defined as 11.0 to ≤13.0 g/dL. In some patients, the dose of DA was adjusted appropriately to achieve this target level, and/or the dosing frequency changed to once every 4 weeks.

RESULTS

In the 25 patients switched from rHuEPO to DA the mean Hb concentration increased from 9.9 ± 1.0 to 11.1 ± 1.0 g/dL at 8 weeks following commencement of the DA treatment. The target Hb concentration was achieved in 88 % of these patients, and 60 % maintained this target value on completion of the study. The dosing frequency was extended to once every 4 weeks in 60 % of patients. Twenty-four adverse events were noted in 11 of 25 patients (44 %); however, there was no causality between DA and adverse events.

CONCLUSIONS

The results of this study suggest that intravenous administration of DA once every 2 or 4 weeks is an effective and safe treatment for renal anemia in Japanese children undergoing PD.

Overview of regular dialysis treatment in Japan (as of 31 December 2009)

A nationwide statistical survey of 4196 dialysis facilities was conducted at the end of 2009, and 4133 facilities (98.5%) responded. The number of patients undergoing dialysis at the end of 2009 was determined to be 290 661, an increase of 7240 patients (2.6%) compared with that of 2008. The number of dialysis patients per million at the end of 2009 was 2279.5. The crude death rate of dialysis patients from the end of 2008 to the end of 2009 was 9.6%. The mean age of the new patients introduced into dialysis was 67.3 years old and the mean age of the entire dialysis patient population was 65.8 years old. Primary diseases such as diabetic nephropathy and chronic glomerulonephritis for new dialysis patients, showed a percentage of 44.5% and 21.9%, respectively. Based on the facilities surveyed, 84.2% of the facilities that responded to the questionnaire satisfied the microbiological quality standard for dialysis fluids for the Japanese Society for Dialysis Therapy (JSDT), with an endotoxin concentration of less than 0.05 EU/mL in the dialysis fluid. Similarly, 98.2% of the facilities surveyed satisfied another standard of the society of a bacterial count of less than 100 cfu/mL in the dialysis fluid. The facility survey indicated that the number of patients who were treated by blood purification by both peritoneal dialysis and extracorporeal circulation, such as hemodialysis, was 1720. Among the total number of patients, 24.8% were satisfied with the management target recommended in the treatment guidelines for secondary hyperparathyroidism. These standards are set by the JSDT, based on the three parameters, i.e. serum calcium concentration, serum phosphorus concentration, and serum intact parathyroid hormone concentration. According to the questionnaire, 9.8% of the patients were considered to have a complication of dementia.

Overview of regular dialysis treatment in Japan (as of 31 December 2008)

A nationwide statistical survey of 4124 dialysis facilities was conducted at the end of 2008 and 4081 facilities (99.0%) responded. The number of patients undergoing dialysis at the end of 2008 was determined to be 283,421, an increase of 8179 patients (3.0%) compared with that at the end of 2007. The number of dialysis patients per million at the end of 2008 was 2220. The crude death rate of dialysis patients from the end of 2007 to the end of 2008 was 9.8%. The mean age of the new patients begun on dialysis was 67.2 years and the mean age of the entire dialysis patient population was 65.3 years. For the primary diseases of the new patients begun on dialysis, the percentages of patients with diabetic nephropathy and chronic glomerulonephritis were 43.3% and 22.8%, respectively. Among the facilities that measured bacterial count in the dialysate solution in 2008, 52.0% of facilities ensured that a minimum dialysate solution volume of 10 mL was sampled. Among the patients treated by facility dialysis, 95.4% of patients were treated three times a week, and the average time required for one treatment was 3.92 ± 0.53 (SD) h. The average amounts of blood flow and dialysate solution flow were 197 ± 31 and 487 ± 33 mL/min, respectively. The number of patients using a polysulfone membrane dialyzer was the largest (50.7%) and the average membrane area was 1.63 ± 0.35 m(2). According to the classification of dialyzers by function, the number of patients using a type IV dialyzer was the largest (80.3%). The average concentrations of each electrolyte before treatment in patients treated with blood purification by extracorporeal circulation were 138.8 ± 3.3 mEq/L for serum sodium, 4.96 ± 0.81 mEq/L for serum potassium, 102.1 ± 3.1 mEq/L for serum chloride, and 20.7 ± 3.0 mEq/L for HCO(3) (-) ; the average serum pH was 7.35 ± 0.05. Regarding the type of vascular access in patients treated by facility dialysis, in 89.7% of patients an arteriovenous fistula was used and in 7.1% an arteriovenous graft was used. The percentage of hepatitis C virus (HCV)-positive patients who were HCV-negative in 2007 was 1.04%; the percentage is particularly high in patients with a period of dialysis of 20 years or longer. The risk of becoming HCV-positive was high in patients with low serum creatinine, serum albumin, and serum total cholesterol levels, and/or a low body mass index before beginning dialysis.

Differences in corrective mode for divalent ions and parathyroid hormone between standard- and low-calcium dialysate in patients on continuous ambulatory peritoneal dialysis--result of a nationwide survey in Japan

BACKGROUND

In patients on continuous ambulatory peritoneal dialysis (CAPD), dialysate calcium concentration has a strong influence on correction of serum calcium, phosphorus, and parathyroid hormone (PTH); however, the optimal concentration of Ca in PD solution is still uncertain. The aim of the survey reported here was to evaluate the prevalence of patients treated with standard- [SCD (approximately 3.25 - 4.0 mEq/L)] or low-calcium [LCD (approximately 1.8 - 2.5 mEq/L)] dialysate and differences in the clinical effects for correction of abnormalities in divalent ions and PTH.

MATERIALS AND METHODS

We used a questionnaire to survey 333 peritoneal dialysis facilities nationwide in Japan. Then, we analyzed serum Ca, P, and PTH levels and the prescription rates for CaCO(3) as a P binder and for vitamin D (VitD) analogs.

RESULTS

The 2384 CAPD patients enrolled in this analysis had a mean age of 60.5 +/- 14.2 years and a mean duration of CAPD of 44.1 +/- 39.2 months. The prevalences of SCD, LCD, and combination of SCD and LCD were, respectively, 49%, 50%, and 1% at initiation, and 40%, 38%, and 22% at the time of the survey. In 735 and 876 patients respectively, LCD and SCD had been prescribed from initiation to the time of the survey. In these two groups, we observed no difference in initiation and current serum levels of Ca and P. But prescription rates for CaCO(3) and VitD analogs were higher in the LCD group than in the SCD group, and PTH levels were higher in the LCD group than in the SCD group.

CONCLUSIONS

A beneficial effect of LCD was revealed in the increased doses of CaCO(3) and VitD analogs seen in that group without the occurrence of hypercalcemia; however, PTH levels in that group were not maintained within an acceptable range. The survey suggests that more serious attention should be paid to the Ca concentration in peritoneal dialysate so as to lessen mineral and PTH disorders in CAPD.

Exercise-induced acute renal failure associated with renal hypouricaemia: results of a questionnaire-based survey in Japan

BACKGROUND

A retrospective investigation was conducted to define the clinical features of exercise-induced acute renal failure (ARF) associated with renal hypouricaemia with the aim of clarifying further the clinical features of the disease entity.

METHODS

A questionnaire was mailed to 43 institutions in Japan that had experienced case(s) of exercise-induced ARF associated with renal hypouricaemia. Fifty-four patients (48 males and six females) were identified from 38 institutions.

RESULTS

Median age at the first episode of ARF was 17 years (range 11-46). The maximal serum uric acid and creatinine levels were 4.40+/-2.49 (range 0.4-13.3) and 5.45+/-3.33 mg/dl (range 1.10-17.7), respectively. The serum uric acid level after recovery was 0.70+/-0.25 mg/dl (range 0.1-1.4). The short-term prognosis seemed to be good and histological findings in 28 patients showed minimal change or acute tubular necrosis except for one patient with chronic lesions. ARF episodes occurred predominantly in September, October and May, mostly after strenuous exercise such as a short-distance race. The first symptoms were nausea/vomiting in 51 episodes, loin pain in 35, abdominal pain in 22, general fatigue in 16 and low-grade fever in seven. Thirteen patients (24.1%) experienced recurrent ARF at various intervals. Univariate and multivariate analyses failed to demonstrate any risk factor of ARF recurrence, although no female patients experienced ARF recurrence.

CONCLUSIONS

The reason for the heterogeneity in ARF associated with renal hypouricaemia remains unknown. Further studies, especially on molecular mechanisms, are required to establish the best guidance against ARF recurrence.

Review of combination of peritoneal dialysis and hemodialysis as a modality of treatment for end-stage renal disease

Because the contribution of residual renal function (RRF) to total solute clearance is often significant in continuous ambulatory peritoneal dialysis (CAPD), loss of RRF over time can lead to inadequate dialysis if appropriate prescription management strategies are not pursued. Additionally, declines in ultrafiltration caused by increases in peritoneal permeability may limit continuation of CAPD therapy. Peritoneal dialysis and hemodialysis (PD + HD) combination therapy (complementary dialysis therapy) is an alternative method. This therapy allows the patient to maintain daily activities, as with CAPD, while undergoing once-a-week HD supplements for the insufficient removal of solutes and water. This therapy allows for the continuation of PD without shifting to total HD in PD patients who continue to have uremic symptoms even after individualization of the PD prescription. This treatment option is psychologically more acceptable to patients and may be expected to provide such accompanying beneficial effects as peritoneal resting, improvement of QOL and reduction in medical cost.

Management of Refractory Ascites by Using a Peritoneal Dialysis System with Extracorporeal Ultrafiltration by Hemodialysis Dialyzer

Background

The treatment of refractory ascites remains a challenge in cirrhosis with ascites and end-stage renal disease (ESRD). Successful experiences with continuous ambulatory peritoneal dialysis (CAPD) for treatment of ESRD patients with ascites secondary to liver cirrhosis have been reported, but the CAPD modality has the drawback of protein loss and was observed to cause patients to become severely malnourished. We devised a CAPD method for treatment of ascites without protein loss. We use a peritoneal dialysis (PD) system to drain ascitic fluid and to reinject concentrated ascites into the abdomen after extracorporeal ultrafiltration of the ascitic fluid using a hemodialysis dialyzer and pump. Here, we report our experience with 2 cirrhotic patients with ascites treated by this method.

Patients and Method

Ascites are collected by gravity through a Y transfer set into a 3-L plastic bag for intravenous hyperalimentation. The ascitic fluid drained is removed by a pump at a rate of 200 mL/min (AK-90: Gambro Lundia, Lund, Sweden) and passed through a hollow-fiber dialyzer with triacetate membrane (FB-210G: Nipro, Osaka, Japan). Heparin (5 000 U) is infused into the inflow line at the start of the session only. At the end of treatment, about 500 mL concentrated ascitic fluid is returned to the peritoneal cavity by gravity through the Y transfer set. Case 1: A 77-year-old female was referred to us because of massive ascites from hepatic cirrhosis associated with hepatitis B infection and renal insufficiency. Abdominal paracentesis was required once weekly for recurrence of massive ascites. As a result, the patient was obliged to stay in the bed almost all day, and her nutritional condition deteriorated because of poor appetite and respiratory compromise. Using the Y transfer set, we commenced using our method, and performed it thrice or twice weekly. After 9 months of treatment, the patient's body weight was being maintained at 52 kg, and her serum albumin level had risen from 2.4 g/dL to 3.4 g/dL without albumin administration. Case 2: A 61-year-old male with diabetes from the age of 51 was diagnosed with hepatitis C at age 53. At age 60, his renal function deteriorated, requiring hemodialysis (HD). After 3 months, abdominal distention was noted, and HD was frequently complicated by low blood pressure, large weight gains between HD treatments, and interruption of HD sessions. Albumin administration was required to treat the low blood pressure. Ascites was poorly controlled using HD, and tense ascites developed, requiring repeated paracentesis for comfort. At first during application of our method, ascitic fluid volume was 6 L per thrice-weekly HD session. After 5 months, ascitic fluid volume had diminished to about 2 – 3 L per HD session, and we decreased the frequency of our method to once weekly. Protein levels in the ascitic fluid were 6 g/dL at the start of treatment and decreased to 2 – 3 g/dL after 6 months. Hemodynamic instability during HD was reduced.

Conclusion

We conclude that management of refractory ascites by using a PD system with extracorporeal ultrafiltration by an HD dialyzer is useful. The technique compensates for the drawbacks of PD management of ESRD patients with ascites, although further experience with the technique is necessary.

Management of refractory ascites by using a peritoneal dialysis system with extracorporeal ultrafiltration by hemodialysis dialyzer

BACKGROUND

The treatment of refractory ascites remains a challenge in cirrhosis with ascites and end-stage renal disease (ESRD). Successful experiences with continuous ambulatory peritoneal dialysis (CAPD) for treatment of ESRD patients with ascites secondary to liver cirrhosis have been reported, but the CAPD modality has the drawback of protein loss and was observed to cause patients to become severely malnourished. We devised a CAPD method for treatment of ascites without protein loss. We use a peritoneal dialysis (PD) system to drain ascitic fluid and to reinject concentrated ascites into the abdomen after extracorporeal ultrafiltration of the ascitic fluid using a hemodialysis dialyzer and pump. Here, we report our experience with 2 cirrhotic patients with ascites treated by this method.

PATIENTS AND METHOD

Ascites are collected by gravity through a Y transfer set into a 3-L plastic bag for intravenous hyperalimentation. The ascitic fluid drained is removed by a pump at a rate of 200 mL/min (AK-90: Gambro Lundia, Lund, Sweden) and passed through a hollow-fiber dialyzer with triacetate membrane (FB-210G: Nipro, Osaka, Japan). Heparin (5,000 U) is infused into the inflow line at the start of the session only. At the end of treatment, about 500 mL concentrated ascitic fluid is returned to the peritoneal cavity by gravity through the Y transfer set. Case 1: A 77-year-old female was referred to us because of massive ascites from hepatic cirrhosis associated with hepatitis B infection and renal insufficiency. Abdominal paracentesis was required once weekly for recurrence of massive ascites. As a result, the patient was obliged to stay in the bed almost all day, and her nutritional condition deteriorated because of poor appetite and respiratory compromise. Using the Y transfer set, we commenced using our method, and performed it thrice or twice weekly. After 9 months of treatment, the patient's body weight was being maintained at 52 kg, and her serum albumin level had risen from 2.4 g/dL to 3.4 g/dL without albumin administration. Case 2: A 61-year-old male with diabetes from the age of 51 was diagnosed with hepatitis C at age 53. At age 60, his renal function deteriorated, requiring hemodialysis (HD). After 3 months, abdominal distention was noted, and HD was frequently complicated by low blood pressure, large weight gains between HD treatments, and interruption of HD sessions. Albumin administration was required to treat the low blood pressure. Ascites was poorly controlled using HD, and tense ascites developed, requiring repeated paracentesis for comfort. At first during application of our method, ascitic fluid volume was 6 L per thrice-weekly HD session. After 5 months, ascitic fluid volume had diminished to about 2 - 3 L per HD session, and we decreased the frequency of our method to once weekly. Protein levels in the ascitic fluid were 6 g/dL at the start of treatment and decreased to 2 - 3 g/dL after 6 months. Hemodynamic instability during HD was reduced.

CONCLUSION

We conclude that management of refractory ascites by using a PD system with extracorporeal ultrafiltration by an HD dialyzer is useful. The technique compensates for the drawbacks of PD management of ESRD patients with ascites, although further experience with the technique is necessary.

Midpeliq reduces glucose load

The rate of technique failure is still high in Japan for peritoneal dialysis (PD) patients. Of the dropouts who have been treated with PD for more than 6 years, about half suffer from ultrafiltration failure. That condition is supposedly related to the bioincompatible aspects of conventional acidic PD solutions. In 2001, a neutral-pH, lactate-buffered PD solution with low glucose degradation products (GDPs), Midpeliq (Terumo Corporation, Tokyo, Japan), was developed and began to be used in Japan. After switching 3 patients from conventional acidic PD solution to Midpeliq, we observed that 2 patients could then use lower-glucose PD solutions. Case 1 was a 42-year-old woman with a 10-year history of PD. In February 2001, she was switched from Peritoliq (Terumo) to Midpeliq. One month later, she complained of dizziness, and her blood pressure was found to be down to 96/60 mmHg. Post-change fluid removal increased to 1,481 mL from 1,238 mL (p < 0.02). Before the solution switch, this patient exchanged 4 times daily, using 2 L of 2.5% Peritoliq each time. From 3 months after the solution switch, she exchanged 3 times daily using 2 L of 2.5% Midpeliq and 1 time daily using 2 L of 1.35% Midpeliq. Fluid volume removal stayed almost the same. Case 2 was a 52-year-old man with a 9-year history of PD. In June 2002, he was switched from Dianeal 4 (Baxter Healthcare, Tokyo, Japan) to Midpeliq. After the change, his daily drainage volume increased from approximately 1,500 mL to 2,000 mL. He began to use 2 L of 1.35% Midpeliq 4 times daily instead of 2 L of 1.5% Dianeal 3 times daily and 2 L of 2.5% Dianeal 1 time daily. At 1 month after the solution switch, his drainage volume was still approximately 1,500 mL daily. Our observations suggest that new, neutral-pH PD solutions such as Midpeliq might reduce the glucose load in addition to having low GDPs and fewer toxic effects on the peritoneum.

Sclerosing encapsulating peritonitis in pediatric peritoneal dialysis patients

The aim of this study was to define the incidence and characteristics of sclerosing encapsulating peritonitis (SEP) in pediatric peritoneal dialysis (PD) patients in Japan. A questionnaire was sent to all dialysis units with at least two pediatric PD patients. Among 687 patients registered, 11 cases (1.6%) of SEP were diagnosed. The mean age of patients with SEP at the start of PD was 9.7+/-3.6 years and at SEP diagnosis, 19.1+/-3.8 years. All patients had undergone PD for more than 5 years, and the mean PD duration was 9.6+/-3.3 years. SEP was diagnosed in 6.6% and 12% of patients dialyzed for >5 years and >8 years, respectively. The incidence of peritonitis among patients with SEP was not different from that among the Japanese pediatric registry. All patients had virtually no residual urine volume and 9 had impaired peritoneal ultrafiltration. Peritoneal calcification was the most-frequent radiological finding. Peritoneal biopsy was performed in 7 patients and confirmed sclerotic peritonitis in all. Ten patients transferred to hemodialysis, and only 1 patient underwent surgery. Three patients died. We recommend that patients on PD for more than 5 years who have impaired peritoneal ultrafiltration or peritoneal calcification should be carefully managed as presumptive cases of SEP.

FLAIR appearance of Wernicke encephalopathy

We performed MR imaging of the brain with both conventional spin-echo (SE) and fluid-attenuated inversion-recovery (FLAIR) sequences in a case of Wernicke encephalopathy. Lesion conspicuity was found to be better with FLAIR imaging.

Microcephaly and early-onset nephrotic syndrome--confusion in Galloway-Mowat syndrome

We report a 2-year-old girl with nephrotic syndrome, microcephaly, seizures and psychomotor retardation. Histological studies of a renal biopsy revealed focal glomerular sclerosis with mesangiolysis and capillary microaneurysms. Dysmorphic features were remarkable: abnormal-shaped skull, coarse hair, narrow forehead, large low-set ears, almond-shaped eyes, low nasal bridge, pinched nose, thin lips and micrognathia. Cases with this rare combination of microcephaly and early onset of nephrotic syndrome with various neurological abnormalities have been reported. However, clinical manifestations and histological findings showed a wide variation, and there is a lot of confusion in this syndrome. We therefore reviewed the previous reports and propose a new classification of this syndrome.

Urinary excretion of terminal complement complexes in glomerular disease

To evaluate renal terminal complement activation in patients with glomerular diseases, we measured terminal complement complexes (TCCs) in plasma and urine with sandwich enzyme-linked immunosorbent assay (ELISA) using a monoclonal antibody against a C9 neoepitope expressed on TCC and a polyclonal antihuman C7 antibody. TCCs were detectable in plasma but not in urine in most of normal controls. In plasma, TCC levels were elevated in 4 of 22 patients with lupus nephritis and in 6 of 12 with membranoproliferative glomerulonephritis. However all patients with IgA nephritis, focal glomerulosclerosis, idiopathic membranous nephritis and idiopathic minimal change nephrotic syndrome (MC) showed normal values. In urine, TCCs were detectable in almost all patients with heavy proteinuria (greater than or equal to 100 mg/ml) except MC. The TCCs present in urine were partially purified by gel filtration using Sepharose 6B and were found to contain C5, C6, C7, C8, C9 and S protein by ELISA. Although the molecular weight of TCC is similar to that of IgM, the fractional excretion rate of TCC was about 100 times higher than that of IgM. These results suggest that TCCs detectable in urine contain SC5b-9 complexes and are mostly of renal origin.

IgA nephritis in Behçet's disease: case report and review of the literature

We describe a 13-year-old girl with the incomplete type of Behçet's disease who had recurrent oral and genital ulcers, folliculitis, proteinuria and hematuria. Renal biopsy specimens revealed diffuse proliferative glomerulonephritis with strongly positive IgA deposits in the glomerular mesangial area, which is histologically indistinguishable from primary IgA nephritis. Further studies of the IgA subclasses showed that IgA1 deposits were predominant in the glomerular mesangium. Primary IgA nephritis is thought to be associated with polymeric IgA1. So it appears that there may be a common underlying disease or mechanism involved in both primary IgA nephritis and the IgA nephritis in Behçet's disease.