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The dialysis population is growing and aging worldwide. The aging dialysis population exhibits specific conditions, including sarcopenia, protein-energy wasting, and frailty, that are associated with worse outcomes. Thus, strategies to address these conditions are indispensable to improving prognosis, quality of life, and ability to perform activities of daily living in older patients.Several strategies have been employed to manage these conditions. The two major approaches are nutritional therapy and exercise training. These correlate strongly with each other and each is necessary to maintain the health of patients. Ensuring adequate protein and energy intake is the mainstay of nutritional therapy. However, older dialysis patients often have reduced appetite, and appropriate nutritional therapy can enhance appetite. Conversely, nutritional therapy without an appropriate exercise training system will fail to enhance physical function. Thus, the focus of attention has been on exercise training both during dialysis treatment and while at home. The Japanese Society of Renal Rehabilitation has issued a guideline for exercise training in patients with kidney disease. It encourages using the time during dialysis treatment for performing both nutritional intake measures and exercise training. Nutritional care in dialysis patients has previously focused on restriction of dietary intake. However, patients with these malnutrition-wasting conditions should be encouraged to improve their dietary intake and physical activity. Older dialysis patients have heterogenic characteristics in terms of frailty, so their nutritional and exercise plans should be individualized. Key Messages: Individualized management should be used in the heterogeneous older dialysis population, with special considerations for malnutrition-wasting conditions.

Carnitine deficiency is a common condition in hemodialysis patients. Therefore, abnormalities in fatty acid metabolism and organic acid metabolism are also common in dialysis patients. Tandem mass spectrometry is a standard technique in pediatric and neonatal medicine. However, it could be a new powerful tool in other fields for estimating the state of intracellular fatty acid metabolism.Tandem mass spectrometry has recently revealed the relationships between carnitine profile and dialysis patients' anemia, reduced physical function, and survival rate. Fatty acid and organic acid metabolism, which could previously only be evaluated qualitatively, can now be quantitatively assessed. Key Message: The applications of tandem mass spectrometry are expected to expand not only in the field of dialysis but also in clinical medicine in general.

Vascular calcification (VC) is common in patients with chronic kidney disease (CKD) including end-stage renal disease (ESRD). The pathogenesis of VC is complex, resulting in increased arterial stiffening, which is associated with cardiovascular mortality. In addition to traditional cardiovascular risk factors, CKD patients also have a number of non-traditional cardiovascular risk factors that may play an important role in the pathogenesis of VC.Management of CKD-mineral bone disorder using conventional therapeutic approaches, which include restricting dietary phosphate, administering phosphate binders, and using active vitamin D and calcimimetics, may inhibit the progression of VC, but these approaches remain controversial because recommended biochemical targets are difficult to achieve. Current treatment strategies focus on correcting abnormal calcium, phosphate, parathyroid hormone, and vitamin D levels in ESRD patients. Novel therapies for addressing VC include magnesium and vitamin K supplementation, which are currently being investigated in randomized controlled trials. This review summarizes current treatment strategies and therapeutic targets for the management of VC in patients with ESRD. Key Messages: A better understanding of the potential therapeutic approaches to VC may lead to improved mortality rates among patients with CKD including those on dialysis. Fetuin-A inhibits VC by binding to the nanoparticles of calcium and phosphate, preventing mineral accretion. These particles are known as calciprotein particles and may provide an important pathway for mineral transport and clearance. This review article summarizes the current management of VC in patients with ESRD.

Serum ferritin is one of the most important and widely used markers of iron metabolism, and is a recommended standard index of iron dynamics in guidelines for renal anemia in many countries. However, serum ferritin measurement has several disadvantages. For example, it is prone to being influenced by underlying disease, and there is considerable systematic bias among different methods of measurement.Systematic bias affects not only the measurement results, but also the therapeutic strategy to be used in accordance with the relevant guidelines, and consequently the cost of medical treatment. Key Messages: Manufacturers should reduce variability in their serum ferritin assay kits. Researchers should take into account propagation of error in the analysis of measurement values, and clinicians should evaluate laboratory data with care.

The older dialysis population is growing, and malnutrition and wasting syndrome are great concerns in this population. The management of these syndromes includes appropriate nutritional intake and physical activity. However, whether management in the form of an increase in protein intake has a beneficial effect on muscle mass has not been demonstrated. In this study, we investigated an association between changes of normalized protein catabolic rate (nPCR), as a proxy for protein intake and percent creatinine generation rate (%CGR), as a proxy for muscle mass in patients receiving hemodialysis. Multiple linear regression models were employed, and we included several sensitivity analyses. The results showed that increases in nPCR were associated with increases in %CGR. The association was stronger in patients with baseline %CGR levels below 100%. This was the first study to demonstrate that an increase in dietary protein intake might increase the muscle mass, but this study had certain limitations. Future interventional studies will be needed to investigate whether increases in protein intake have a beneficial effect on sarcopenia, protein-energy wasting, and frailty.

Frailty is a clinical state in which there is an increase in the individual's vulnerability to developing increased dependency and/or mortality when exposed to a stressor. Since the mean age of dialysis patients is increasing worldwide, frailty has recently come to be considered one of the risk factors for mortality in the older dialysis population. The prevalence of frailty among dialysis patients has ranged from 3.0- to 10-fold higher than in community-dwelling elderly, depending on the method of assessing frailty and patient characteristics. Since frailty has been found to be associated with higher mortality, independent of clinical characteristics and comorbidity, interventions to improve frailty have the potential to contribute to better quality of life and lower mortality among dialysis patients. In addition, greater attention should be focused on the possibility that early rehabilitation of dialysis patients might improve poor outcomes. Clinical research should aim at devising an adequate strategy to address frailty, including identifying the optimal timing for intervention.

Home hemodialysis (HHD) is rapidly becoming more widespread because HHD programs enable patients to receive a sufficient dialysis dose to improve their quality of life and survival rate without compromising their lifestyle.Although HHD in Japan has a long history, the 529 dialysis patients being treated with HHD as of the end of 2014 account for only 0.17% of all dialysis patients. HHD is well indicated for patients who are younger, male, and nondiabetic. The major HHD dialysis programs were provided 4-6 times per week for 3-5 h per session, and 79.3% of HDD patients showed treatment adequacy with a hemodialysis product72. Key Messages: To expand HHD in Japan, several challenges must be overcome. First, the government should clearly state that home medicine is the way forward and incentivize facilities to provide, and patients to receive, HHD. Second, we need to establish a typical business model for HHD to include the supply of medical devices, collection of disposals, and development of a special machine for HHD.

Home hemodialysis (HHD) is one of the best choices for improving the quality of life and survival rate of dialysis patients because it can lead to longer and more frequent dialysis programs to aid in achieving adequate dialysis. There were 461 dialysis patients treated with HHD as of the end of 2013 in Japan, comprising only 0.1% of all dialysis patients in this country. Although this is a very small expansion rate, the number of HHD patients has been rapidly increasing in recent years. The Japanese Society for Home Hemodialysis was established in 1998 and formed the following 3 working groups to survey various problems underlying current HHD: Patient Registry, Supply and Waste, and Self-pay Burden. In order to achieve a successful HHD program in Japan, there are several issues to be resolved, including the development of standard recruitment and education programs, optimization of the composition of dialysis fluid, sufficient reimbursement for HHD, and the establishment of a business model for HHD similar to that for peritoneal dialysis.