Development of a prognostic risk score to predict early mortality in incident elderly Japanese hemodialysis patients

BACKGROUND

Information of short-term prognosis after hemodialysis (HD) introduction is important for elderly patients with chronic kidney disease (CKD) and their families choosing a modality of renal replacement therapy. Therefore, we developed a risk score to predict early mortality in incident elderly Japanese hemodialysis patients.

MATERIALS AND METHODS

We analyzed data of incident elderly HD patients from a nationwide cohort study of the Japanese Society for Dialysis Therapy Renal Data Registry (JRDR) to develop a prognostic risk score. Candidate risk factors for early death within 1 year was evaluated using multivariate logistic regression analysis. The risk score was developed by summing up points derived from parameter estimate values of independent risk factors. The association between risk score and early death was tested using Cox proportional hazards models. This risk score was validated twice by using an internal validation cohort derived from the JRDR and an external validation cohort collected for this study.

RESULTS

Using the development cohort (n = 2,000), nine risk factors were retained in the risk score: older age (>85), yes = 2, no = 0; sex, male = 2, female = 0; lower body mass index (<20), yes = 2, no = 0; cancer, yes = 1, no = 0; dementia, yes = 3, no = 0; lower creatinine (<6.5 mg/dL), yes = 1, no = 0; lower albumin (<3.0 g/dL), yes = 3, no = 0; normal or high calcium (≥8.5 mg/dL), yes = 1, no = 0; and higher C reactive protein (>2.0 mg/dL), yes = 2, no = 0. In the internal and external validation cohorts (n = 739, 140, respectively), the medium- and high-risk groups (total score, 6 to 10 and 11 or more, respectively) showed significantly higher risk of early death than the low-risk group (total score, 0 to 5) (p<0.001).

CONCLUSION

We developed a prognostic risk score predicting early death within 1 year in incident elderly Japanese HD patients, which may help detect elderly patients with a high-risk of early death after HD introduction.

Identification of Prescribing Patterns in Hemodialysis Outpatients Taking Multiple Medications

We investigated the relationship between multidrug administration and the characteristics, pathophysiology, and drug class in outpatients with hemodialysis. A retrospective cross-sectional study was conducted at Saitama Medical University Hospital in October 2018. Multidrug administration was defined as receiving either more than six drugs or more than the median number of drugs. The drugs used were represented by their anatomical classification codes in the Anatomical Therapeutic Chemistry Classification System (ATC classification). A latent class analysis (LCA) was used to identify clusters at risk of receiving multiple medications. A stepwise logistic regression analysis was performed to select ATC classifications prone to being involved in multidrug administration. As of October 2018, 98 outpatients with hemodialysis were enrolled in the study. In the LCA, when diabetes was the main primary disease, oral hypoglycemic agents available to dialysis patients were limited, but the number of drugs administered was large. Old age, poor nourishment, a long history of dialysis, and chronic nephritis were associated with multidrug administration among nondiabetic patients. In the second level of the ATC classification, the drugs frequently used were coded A02 (drugs for acid-related disorders), A07 (antidiarrheal agents, intestinal anti-inflammatory/anti-infective agents), B01 (antithrombotic agents), and N05 (psycholeptics). The prescribing patterns for either diabetic patients or nondiabetic elderly patients were identified in outpatients with hemodialysis taking multiple medications, and drugs for acid-related disorders, antidiarrheal agents, intestinal anti-inflammatory/anti-infective agents, antithrombotic agents, and psycholeptics are frequently used in those patients.

Correction to: Regional prescription surveillance of phosphate binders in the western Saitama area: the substantial role of ferric citrate hydrate in improving serum phosphorus levels and erythropoiesis

In the Original publication, Under the table 1, the number of participants in the April has been incorrectly published as 1373. The corrected table is given below.

Regional prescription surveillance of phosphate binders in the western Saitama area: the substantial role of ferric citrate hydrate in improving serum phosphorus levels and erythropoiesis

BACKGROUND

In April 2015, five types of phosphate binders (PBs) were available by prescription in Japan, namely calcium carbonate, sevelamer hydrochloride, lanthanum carbonate, bixalomer, and ferric citrate hydrate (FeC). FeC reduces serum phosphorus levels and increases the body's iron stores. However, it is unclear whether FeC lowers serum phosphorus relative to other agents in a regional practical setting.

METHODS

We performed a retrospective observational cohort study of regional hemodialysis surveillance in the western Saitama area of Japan, which included 1374 hemodialysis patients enrolled from 32 satellite dialysis units. The clinical data and prescribing information were retrospectively collected and analyzed. The difference in serum phosphorus among the groups administered five types of PBs (new or additional) from April to September 2015 was the primary outcome.

RESULTS

As of April 2015, the median values of serum phosphorus, corrected calcium, and intact parathyroid hormone were 5.4 mg/dL, 9.1 mg/dL, and 147 pg/dL, respectively (N = 1374). Unexpectedly, with an increase in the number of PBs administered, serum phosphorous levels increased (p < 0.001). The significant changes in the serum phosphorus and hemoglobin levels were associated with the prescription of FeC but not with that of the other PBs.

CONCLUSIONS

This regional survey suggests that serum phosphorus is well managed and that FeC has the potential to reduce the serum phosphorus level relative to other PBs and to ameliorates anemia.

Electrical stimulation of denervated rat skeletal muscle retards trabecular bone loss in early stages of disuse musculoskeletal atrophy

OBJECTIVES

We aimed to determine the intensity of muscle stimulation required to prevent structural failure as well as bone and skeletal muscle loss after denervation-induced disuse.

METHODS

Seven-week-old rats (weight, 198-225 g) were randomly assigned to age-matched groups comprising control (CON), sciatic nerve denervation (DN) or direct electrical stimulation (ES) one day later [after denervation] with 4, 8 and 16 mA at 10 Hz for 30 min/day, six days/week, for one or three weeks. Bone architecture and mean osteoid thickness in histologically stained tibial sections and tension in tibialis anterior muscles were assessed at one and three weeks after denervation.

RESULTS

Direct ES with 16 mA generated 23-30% maximal contraction force. Denervation significantly decreased trabecular bone volume fraction, thickness and number, connectivity density and increased trabecular separation in the DN group at weeks one and three. Osteoid thickness was significantly greater in the ES16 group at week one than in the DN and other ES groups. Trabecular bone volume significantly correlated with muscle weight.

CONCLUSIONS

Relatively low-level muscle contraction induced by low-frequency, high-intensity electrical muscle stimulation delayed trabecular bone loss during the early stages (one week after DN) of musculoskeletal atrophy due to disuse.

[A young patient of acute encephalitis complicated with acyclovir encephalopathy without renal dysfunction]

A previously healthy 30-year-old woman was admitted to our hospital because of impaired consciousness after convulsion. A temporary diagnosis of herpes simplex encephalitis was made, and intravenous acyclovir (ACV) therapy (250 mg four times daily in normal saline over 2 hours) was started. Three days later, she became confused, and was having hallucinations, dysarthria and generalized painful seizures occurred without focal neurologic deficit. Whether the neuropsychiatric symptoms were related to herpes simplex encephalitis or acyclovir neurotoxity was initially unclear. The brain MRI and lumbar puncture findings were initially normal, but abnormal FLAIR lesions appeared later. ACV-associated encephalopathy was considered. ACV was discontinued, and she recovered from the neurological disorder within 24 hours. Although blood levels of acyclovir were not determined, it is unlikely that they were in a toxic range, in view of her normal renal function.

Gastric angiodysplasia in patients undergoing maintenance dialysis

We successfully used argon plasma coagulation (APC) to treat two cases of dialysis patients with hemorrhagic gastric angiodysplasia. Gastric angiodysplasia is recognized as an important cause of gastrointestinal bleeding. Angiodysplastic lesion confined to the gastric antrum was first described in 1953 and named gastric antral vascular ectasia (GAVE). The condition is characterized as submucosal capillary dilatation and fibromuscular hyperplasia. The typical finding of GAVE is the so-called watermelon stomach, attributable to vasodilatation. In case 1, a 69-year-old man was introduced continuous ambulatory peritoneal dialysis (CAPD) in July 1997 because of chronic renal failure due to nephrosclerosis. He was hospitalized for severe anemia in December 1997. Gastrointestinal fiberscopy (GIF) showed oozing in the antrum, and gastritis and esophagitis with sliding hernia. Famotidine was started and recombinant human erythropoietin (rHuEPO) was used for anemia. However, the severe anemia did not improve. The patient was hospitalized again for severe anemia and hematemesis. Another GIF showed typical watermelon stomach, which corresponded with GAVE. An APC was performed without complications. Three months later, the anemia was improved, and the dose of rHuEPO was reduced. In case 2, a 57-year-old woman was introduced to hemodialysis in 1998 for uremia due to nephrosclerosis. In October 2000, she was hospitalized for rHuEPO-resistant anemia. A GIF showed oozing in the antrum with diffuse vasodilation in the antrum; GAVE was diagnosed. An APC was carried out without complications. Three months later, anemia was improved. Recently, gastric angiodysplasia was reported to be an important complication in dialysis patients and was recognized as an important cause of rHuEPO-resistant anemia. Argon plasma coagulation is an effective treatment for gastric angiodysplasia in patients on dialysis.

Effects of antihypertensive drugs on peritoneal vessels in hypertensive dogs with mild renal insufficiency

The transport capacity of any membrane depends on its surface area and permeability. In addition, peritoneal capillaries are probably barriers to solute transport. Although no decisive use of antihypertensive drugs has been reported in continuous ambulatory peritoneal dialysis (CAPD) patients with hypertension, those drugs are known to have various effects on vessels. In the present study, we used a charge-coupled-device (CCD) camera in renovascular hypertensive dogs with mild renal insufficiency to investigate the effects of various antihypertensive drugs on the peritoneal capillaries. Renovascular hypertension was induced in the dogs by placing silver clips on both renal arteries to create 90% occlusion. After confirmation of elevation of blood pressure (usually 20 days after the operation), each dog's abdomen was opened while the animal was under general anesthesia. Using a CCD camera, the diameters of the small arteries of the peritoneum were measured after 3 days' oral administration of a placebo (n = 5); or of 8 mg CS866, a selective angiotensin II type 1 receptor blocker (n = 5); or of 10 mg benazepril, an angiotensin-converting enzyme inhibitor (n = 5); or of 10 mg amlodipine, a calcium antagonist (n = 5). In dogs receiving CS866, blood pressure decreased to 128 +/- 6 mmHg from 160 +/- 6 mmHg (p < 0.01). A similar decrease in blood pressure was observed with the use of the other drugs. The diameter of the small vessels increased by 28% +/- 6% in dogs receiving CS866 and by 24% +/- 5% in dogs receiving benazepril, as compared with 3% +/- 3% in dogs receiving the calcium antagonist. These data clearly demonstrate that blockade of the renin-angiotensin system produces an increase in solute clearance in hypertensive dogs with mild renal insufficiency and that such blockade may be applicable as therapy for hypertensive patients on CAPD.

[Renal microscopic polyarteritis replaced by pericarditis with episodic increases in MPO-ANCA in a patient with systemic lupus erythematosus]

A 41-year-old female was admitted to our hospital with acute renal failure. The renal biopsy showed focal necrotizing crescentic glomerulonephritis, and her serology revealed a high titer of MPO-ANCA. The diagnosis of MPO-ANCA-associated microscopic polyarteritis was made, and her basic illness proved to be systemic lupus erythematosus (SLE) because of renal injury, polyarteritis, pancytopenia, anti-double-strand DNA antibody, and anti-nuclear antibodies. After treatment with prednisolone (PSL) and cyclophosphamide, her renal function improved and her MOP ANCA titer was lowered. After 2 years, she was readmitted due to dyspnea. Chest X-ray and echocardiography revealed pericarditis and bilateral pleural effusion. Renal biopsy was carried out again because of an increase in MPO-ANCA, which showed minor abnormalities. PSL therapy led to remission of pericarditis, resulting in a decrease in MPO-ANCA. In this case, MPO-ANCA is likely to be associated not with the activity of polyarteritis, but with that of SLE, and care should be taken in evaluating the clinical usefulness of MPO-ANCA in cases with SLE.

Effects of the GABA mimetic drug, sodium valproate, on event-related potentials and its relation to the law of initial value

The effects of gamma-aminobutyric acid (GABA) mimetic drug sodium valproate (VPA) on event-related potentials (ERPs) were investigated in 18 healthy volunteers during an auditory odd ball task. VPA (200 or 400 mg) or an inactive placebo was administered according to a completely randomized double-blind, cross-over design. ERPs were recorded one hour after medication was given. VPA did not affect the latencies of N100, P200, N200 and P300. Although on the whole VPA had no effect on the amplitudes of the ERP components in the subjects, it increased the P300 amplitude in the low P300 amplitude subjects and decreased it in the high P300 amplitude subjects. This tendency toward a bidirectional response was also seen in the P200 and N200 amplitudes. It was concluded that the response which takes place being dependent on the difference in the initial values was recognized on the effect of a single administration of 200 or 400 mg VPA to ERPs. The results of this study are discussed, especially in relation to the law of initial value.