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Abstract Background In Japan dialyzers are classified as type I, II, III, IV, or V on the basis of the β 2-microglobulin clearance. In 2023, Type V dialyzers were defined as super high-flux membrane dialyzers. Herein, we investigate the association between dialyzer type and mortality. Methods A cohort study was conducted using the Japanese Society for Dialysis Therapy Renal Data Registry database from 31 December 2017, to 31 December 2019. We enrolled 181,879 patients on hemodialysis who were divided into type I–V groups per the Japanese classification. We assessed the associations of each group with 2-year all-cause mortality using Cox proportional hazard models. Furthermore, propensity score matching analysis was performed. Results By the end of 2019, 34,196 patients (18.8%) had died. The hazard ratio (95% confidence interval) was significantly higher in the type I (1.25 [1.12–1.39]), type II (1.21 [1.13–1.31]), and type III (1.07 [1.02–1.13]) groups and significantly lower in the type V group (0.86 [0.80–0.92] P

Abstract Dialyzers are classified into five types based on their β2-microglobulin clearance rate and albumin sieving coefficient: Ia, Ib, IIa, and IIb. In addition, a new classification system introduced a type S dialyzer. However, limited information is available regarding the impact of dialyzer type on patient outcomes. A cohort study was conducted using data from the Japanese Society for Dialysis Therapy Renal Data Registry database. Total 181,804 patients on hemodialysis (HD) were included in the study, categorized into four groups (type Ia, IIa, IIb, and S). The associations between each group and two-year all-cause mortality were assessed using Cox proportional hazard models. Furthermore, propensity score-matching analysis was performed. By the end of 2019, 34,185 patients on dialysis had died. After adjusting for all confounders, the risk for all-cause mortality was significantly lower in the type IIa, and S groups than in the type Ia group. These significant findings were consistent after propensity score matching. In conclusion, our findings suggest that super high-flux dialyzers, with a β2-microglobulin clearance of ≥ 70 mL/min, may be beneficial for patients on HD, regardless of their albumin sieving coefficient. In addition, type S dialyzers may be beneficial for elderly and malnourished patients on dialysis. Trial registration number: UMIN000018641

Abstract Background Plasmapheresis is an important preoperative desensitization treatment for ABO-incompatible living kidney transplantation. However, in cases with plasma exchange therapy (PET), it is necessary to consider the risks of perioperative bleeding and healthcare economic costs. This study investigated the association between intraoperative blood loss and the frequency of preoperative double-filtration plasmapheresis (DFPP) and explored the correlation between DFPP frequency and coagulation factors. Furthermore, the study examined the incidence of perioperative bleeding complications. Methods We enrolled 294 patients (205 men and 89 women) who underwent living kidney transplantation at our institution between January 2020 and March 2023, without PET or with only DFPP performed as PET. A single dose of rituximab (200 mg) was administered to ABO-incompatible living kidney transplant patients within 7 days before transplantation. In these patients, PET was performed until anti-blood group IgG and IgM antibody titers were reduced to 32 times or less. Results The intraoperative blood loss increased in accordance with the DFPP sessions. The amount of bleeding significantly increased when DFPP was performed ≥ 2 sessions. Considering this, we initiated serum fibrinogen level measurements from the middle of the study and observed that serum fibrinogen levels decreased in correlation with the number of DFPP sessions. Fibrinogen levels dropped to critical levels (

Abstract Background Approximately 16.4% of patients on hemodialysis (HD) in Japan are treated with intermittent infusion hemodiafiltration (I-HDF). However, large-scale data on clinical outcomes with this modality are lacking. This study aimed to compare the outcomes of I-HDF with those of conventional HD. Methods A cohort study was conducted using the Japanese Society for Dialysis Therapy Renal Data Registry database from December 31, 2017 to December 31, 2019. The subjects were 210,574 patients on maintenance HD. The exposure of interest was I-HDF treatment versus conventional HD. The I-HDF group was divided into two subgroups based on substitution: low-volume (

Abstract Background The 2020 Japanese Society for Dialysis Therapy Renal Data Registry (JRDR) annual survey was sent to 4493 dialysis facilities in Japan. Methods Questionnaires were sent to all facilities that provide patients with dialysis therapy in Japan. Data were collected and compiled to form cross-sectional results of renal replacement therapy from various aspects. Results In total, 4437 facilities (98.8%) responded to the facility questionnaire and 4271 (95.1%) responded to the patient questionnaire. The number of chronic dialysis patients in Japan continues to increase every year, reaching 347,671 at the end of 2020 and giving a prevalence rate of 2754 patients per million population. The mean age was 69.40 years. Diabetic nephropathy was the most common primary disease among the prevalent dialysis patients (39.5%), followed by chronic glomerulonephritis (25.3%) and nephrosclerosis (12.1%). There were 40,744 incident dialysis patients during 2020, representing a decrease of 141 from 2019. The average age of patients on dialysis was 70.88 years, with diabetic nephropathy being the most common underlying disease (40.7%) second most common was nephrosclerosis (17.5%), which was unchanged from the previous year and surpassed chronic glomerulonephritis (15.0%). There were 34,414 patient deaths in 2020; the crude mortality rate was 9.9%. The main causes of death were heart failure (22.4%), infection (21.5%), and malignancy (9.0%), which were almost the same as the percentages for the previous year. Since 2012, the number of patients treated by hemodiafiltration has increased rapidly; in 2020, the number of patients on this modality was 163,825, accounting for 47.1% of all patients on maintenance dialysis. The number of patients on peritoneal dialysis has been on the rise since 2017, reaching 10,338 in 2020; 20.8% of whom received combined therapy with hemodialysis or hemodiafiltration, showing no change from the previous year. A total of 751 patients were on home hemodialysis at the end of 2020, representing a decrease of 9 from the end of 2018. In 2020, coronavirus disease 2019 (COVID-19) infection and malignancy were added as new items in the survey. Continuing on from the 2019 survey, history of kidney donation for a living-donor transplant was investigated. Conclusions Present issues and challenges in renal replacement therapy were identified in the responses to the new questionnaire items included in this survey. A more detailed evaluation with adjustment for patient background factors should clarify the characteristics of the underlying diseases and conditions in dialysis patients. Trial registration The JRDR was approved by the Japanese Society for Dialysis Therapy ethics committee. It was registered in the University Hospital Medical Information Network (UMIN) Clinical Trials Registry on 10 September 2020 and in the UMIN clinical trials registration system (UMIN000018641).

Abstract In patients undergoing hemodialysis, the impact of atrial fibrillation (AF) through cardiac thromboembolism on the development of ischemic stroke may be influenced by the severity of atherosclerosis present. However, there are no large-scale reports confirming whether the severity of atherosclerosis influences the relationship between AF and stroke development in patients requiring hemodialysis. We aimed to investigate the effects of atherosclerotic disease on the relationship between AF and new-onset ischemic stroke. This nationwide longitudinal study based on dialysis facilities across Japan used data collected from the Japanese Renal Data Registry at the end of 2019 and 2020. The exposure was AF at the end of 2019, identified using a resting 12-lead electrocardiography. The primary outcome was the incidence of cerebral infarction (CI) after 1 year. To examine whether the number of atherosclerotic diseases modified the association between AF and the outcome, we estimated the odds ratios (ORs) using a logistic regression model and then assessed the presence of global interaction using Wald test. Following the study criteria, data from 151,350 patients (mean age, 69 years; men, 65.2%; diabetic patients, 48.7%) were included in the final analysis. A total of 9841 patients had AF (prevalence, 6.5%). Between 2019 and 2020, 4967 patients (3.2%) developed ischemic stroke. The adjusted OR of AF for new-onset CI was 1.5, which showed a decreasing trend with an increasing number of atherosclerotic diseases; the interaction was not significant (P = 0.34). While age, diabetes mellitus, smoking, systolic blood pressure, and serum C-reactive protein concentration were positively associated with CI, intradialytic weight gain, body mass index, and serum albumin level were negatively associated. While we demonstrated the association between AF and new-onset CI among Japanese patients on hemodialysis, we failed to demonstrate the evidence that the association was attenuated with an increasing numbers of atherosclerotic complications.

Abstract Background The Japanese Society for Dialysis Therapy is conducting the survey annually since 1968. The results provide a comprehensive picture of dialysis therapy in Japan. The survey for the year 2019 was performed as of December 2019. Methods Questionnaires were sent to all facilities that provide patients with dialysis therapy in Japan as an Excel file. Data were collected and compiled to form cross-sectional results of dialysis therapy from various aspects. Results At the end of 2019, the annual survey of the Japanese Society for Dialysis Therapy Renal Data Registry (JRDR) was conducted at 4487 dialysis facilities, of which 4411 facilities (98.3%) responded to the facility survey and 4238 facilities (94.5%) responded to the patient survey. The number of chronic dialysis patients in Japan continues to increase every year; it reached 344,640 at the end of 2019, and the prevalence ratio of dialysis patients was 2732 per million population. In the patient survey, the mean age of prevalent dialysis patients was 69.09 years. The most prevalent primary disease among prevalent dialysis patients was diabetic nephropathy (39.1%), followed by chronic glomerulonephritis (25.7%) and nephrosclerosis (11.1%). In 2019, there were 40,885 new patients on dialysis, an increase of 417 over 2018. The average age of incident dialysis patients was 70.42 years, and diabetic nephropathy (41.6%) was the most common cause. The second cause was nephrosclerosis, followed by glomerulonephritis. As 34,642 patients passed away in 2019, the crude mortality rate for the year was 10.1%. Heart failure (22.7%), infectious disease (21.5%), and malignancy (8.7%) were the three leading causes of death. Since 2012, the number of patients treated by hemodiafiltration (HDF) has increased substantially. The figure reached 144,686 by year's end, representing 42.0% of all dialysis patients. In 2019, the number of peritoneal dialysis (PD) patients was 9,920, a small rise from 2017. 19.2% of PD patients also received hemodialysis (HD) or HDF to compensate for the reduction in dialysis dosage or in fluid removal by PD alone (hybrid therapy). At the end of 2019, 760 patients received home HD therapy, an increase of 40 from 2018. In 2019, a detailed survey was conducted on the current status of CKD-MBD treatment, 10 years after the previous survey in 2009. The clinical efficacy of newly released medications during this time period and the impact of the 2012 revisions to the CKD-MBD guidelines require further investigation. These analyses would serve as the foundation for the next revision of the CKD-MBD guidelines and may reveal deeper therapeutic insights regarding CKD-MBD. Conclusions The results obtained by the survey revealed the comprehensive practice patterns of dialysis therapy and served as a basis for future guidelines. Trial registration: JRDR was approved by the ethics committee of JSDT (approval number 1–5) and registered in the "University hospital Medical Information Network (UMIN) Clinical Trials Registry" on 10th September 2019 with a clinical trial ID of UMIN000018641. https://upload.umin.ac.jp/cgi-bin/ctr/ctr_view_reg.cgi?recptno=R000021578 (Accessed 20 November 2020).

BackgroundInformation 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 methodsWe 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.ResultsUsing 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 (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) (pConclusionWe 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.

Abstract Approximately 340,000 people in Japan are on chronic dialysis, and this number continues to increase. Even today, hemodialysis is the most frequently selected modality for renal replacement therapy in Japan, accounting for approximately 97% of chronic dialysis patients. This is because the facilities and insurance for hemodialysis were developed early in Japan, and the results of treatment were very good. Most cases of kidney disease are associated with diabetes or hypertension, and the average age of patients on dialysis is increasing, which means that many dialysis patients experience reduced activities of daily living (ADL) and quality of life (QOL). To address those issues, shared decision-making and advance care planning are now widely used in the process of selecting RRT. Because of the work required, including multiple processes and information sharing, medical professionals must practice team medicine in order to improve ADL and QOL for dialysis patients and renal transplant recipients as well as promote appropriate selection of RRT. Accordingly, the “Renal Replacement Therapy Professional Instructor” certification system was established to meet this need. In addition, due to the aging of dialysis patients, there are more situations where it is necessary to consider forgoing dialysis in terms of general condition and QOL. In such cases, conservative kidney management must be offered, and the “Renal Replacement Therapy Professional Instructor” is also required to participate in them. It is hoped that a comprehensive medical system centered around Renal Replacement Therapy Professional Instructors will be created to meet the increasingly diverse needs of patients with end-stage kidney disease and their families, with the aim of providing support that will enable them to lead richer lives.

Chronic kidney disease—mineral and bone disorder (CKD-MBD) is a systemic disorder that increases the risk of morbidity and mortality in dialysis patients. CKD-MBD is highly prevalent in dialysis patients, and appropriate treatment is important for improving their outcomes. Inorganic phosphate, fibroblast growth factor 23, parathyroid hormone, and calciprotein particles are markers for critical components and effectors of CKD-MBD, and higher circulating levels of these markers are linked to cardiovascular diseases. In this short review, we focus on the pathogenesis and management of CKD-MBD in CKD patients, especially those on dialysis therapy, and discuss the prospects for improving the management in CKD patients, including those on dialysis.

Abstract Frailty has become an emerging public health problem in the aging society and is regarded as a state of vulnerability to developing increased dependency and/or mortality when exposed to a stressor. As the proportion of elderly dialysis patients is increasing worldwide, frailty has recently influenced on the clinical outcomes among those patients also caused great attention. The prevalence of frailty among dialysis patients has ranged from 3.0- to 10-fold higher than in community-dwelling elderly. 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. Moreover, clinical research should be focused on the possibility that early rehabilitation of dialysis patients might improve poor outcomes. Current clinical question should aim to take an appropriate strategy to address frailty, including identifying the optimal timing for intervention.

Abstract Background Dialysis patients are predisposed to severe disease and have a high mortality rate in coronavirus disease 2019 (COVID-19) due to their comorbidities and immunocompromised conditions. Therefore, dialysis patients should be prioritized for vaccination. This study aimed to examine how long the effects of the vaccine are maintained and what factors affect antibody titers. Methods Hemodialysis patients (HD group) and age- and sex-matched non-dialysis individuals (Control group), receiving two doses of BNT162b2 vaccine, were recruited through the Japanese Society for Dialysis Therapy (JSDT) Web site in July 2021. Anti-SARS-CoV-2 immunoglobulin (IgG) (SARS-CoV-2 IgG titers) was measured before vaccination, 3 weeks after the first vaccination, 2 weeks after the second vaccination, and 3 months after the second vaccination, and was compared between Control group and HD group. Factors affecting SARS-CoV-2 IgG titers were also examined using multivariable regression analysis and stepwise regression analysis (least AIC). In addition, we compared adverse reactions in Control and HD groups and examined the relationship between adverse reactions and SARS-CoV-2 IgG titers. Results Our study enrolled 123 participants in the Control group (62.6% men, median age 67.0 years) and 206 patients in the HD group (64.1% men, median age 66.4 years). HD group had significantly lower SARS-CoV-2 IgG titers at 3 weeks after the first vaccination (p

Abstract Background Patients with coronavirus disease 2019 (COVID-19) who receive dialysis therapy develop more severe disease and have a poorer prognosis than patients who do not. Although various data on the treatment of patients not receiving dialysis therapy have been reported, clinical practice for patients on dialysis is challenging as data is limited. The Infection Control Committee of the Japanese Society for Dialysis Therapy decided to clarify the status of treatment in COVID-19 patients on dialysis. Methods A questionnaire survey of 105 centers that had treated at least five COVID-19 patients on dialysis was conducted in August 2021. Results Sixty-six centers (62.9%) responded to the questionnaire. Antivirals were administered in 27.7% of facilities treating mild disease (most patients received favipiravir) and 66.7% of facilities treating moderate disease (most patients with moderate or more severe conditions received remdesivir). Whether and how remdesivir is administered varies between centers. Steroids were initiated most frequently in moderate II disease (50.8%), while 43.1% of the facilities initiated steroids in mild or moderate I disease. The type of steroid, dose, and the duration of administration were generally consistent, with most facilities administering dexamethasone 6 mg orally or 6.6 mg intravenously for 10 days. Steroid pulse therapy was administered in 48.5% of the facilities, and tocilizumab was administered in 25.8% of the facilities, mainly to patients on ventilators or equivalent medications, or to the cases of exacerbations. Furthermore, some facilities used a polymethylmethacrylate membrane during dialysis, nafamostat as an anticoagulant, and continuous hemodiafiltration in severe cases. There was limited experience of polymyxin B-immobilized fiber column-direct hemoperfusion and extracorporeal membrane oxygenation. The discharge criteria for patients receiving dialysis therapy were longer than those set by the Ministry of Health, Labor and Welfare in 22.7% of the facilities. Conclusions Our survey revealed a variety of treatment practices in each facility. Further evidence and innovations are required to improve the prognosis of patients with COVID-19 receiving dialysis therapy.

Coronavirus disease 2019 (COVID-19), caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is now a pandemic. Although several treatment guidelines have been proposed for patients who have both inflammatory bowel disease and COVID-19, immunosuppressive therapy is essentially not recommended, and the treatment options are limited. Even in the COVID-19 pandemic, adjuvant adsorptive granulocyte and monocyte apheresis may safely bring ulcerative colitis (UC) into remission by removing activated myeloid cells without the use of immunosuppressive therapy. Our patient was a 25-year-old Japanese male with UC and COVID-19. This is the first case report of the induction of UC remission with granulocyte and monocyte apheresis treatment for active UC associated with COVID-19.

Humoral and cellular responses are critical in understanding immune responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. Here, we evaluated these responses in hemodialysis (HD) patients after the booster vaccination. SARS-CoV-2 immunoglobulin (IgG) levels, neutralizing antibody titers, and the T-SPOT®.COVID test (T-SPOT) were measured prior to, three weeks after, and three months after the booster administration. The HD group had significantly higher SARS-CoV-2 IgG levels and neutralizing antibody titers against the original strain at three weeks and three months after the booster vaccination compared to the control group, albeit the HD group had lower SARS-CoV-2 IgG levels and neutralizing antibody titers before the booster administration. Moreover, the HD group had significantly higher T-SPOT levels at all three time points compared to the control group. The HD group also had significantly higher local and systemic adverse reaction rates than the control group. By booster vaccination, HD patients could acquire more effective SARS-CoV-2-specific humoral and cellular immunity than the control group.