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Introduction Cell-free and concentrated ascites reinfusion therapy (CART) is performed by collecting the ascites from the patient, followed by filtration and concentration. Thereafter, concentrated cell-free ascites is reinfused into the patient intravenously. The new type of machine, Plasauto μTM , for managing the process of CART was launched onto the market. Methods We have evaluated the machine through post-marketing clinical study in seventeen patients with malignant ascites. Results The amounts of original and concentrated ascites were 3,673 ± 1,920 g and 439 ± 228 g, respectively. Recovery rates were acceptable regarding values of total protein, albumin, and immunoglobulin G that were 55.6% ±17.3 %, 60.2% ±20.8%, and 58.2% ±20.5%, respectively. Recovery rates were positively associated with amounts of original ascites and negatively associated with total protein concentration. No adverse events related to the machine were observed. Conclusion The new type of machine showed preferable performance in processing malignant ascites. This article is protected by copyright. All rights reserved.

Depression and hopelessness are frequently experienced in chronic kidney disease (CKD) and are generally associated with lessened physical activity. The aim of this study was to quantify the associations between sarcopenia as determined by SARC-F with both depression and hopelessness. This multicenter cohort study involving cross-sectional and longitudinal analyses was conducted in a university hospital and four general hospitals, each with a nephrology center, in Japan. Participants consisted of 314 CKD patients (mean age 67.6), some of whom were receiving dialysis (228, 73%). The main exposures were depression, measured using the Center for Epidemiologic Studies Depression (CES-D) questionnaire, and hopelessness, measured using a recently developed 18-item health-related hope scale (HR-Hope). The outcomes were sarcopenia at baseline and one year after, measured using the SARC-F questionnaire. Logistic regression models were applied. The cross-sectional and longitudinal analyses included 314 and 180 patients, respectively. Eighty-nine (28.3%) patients experienced sarcopenia at baseline, and 44 (24.4%) had sarcopenia at the one-year follow-up. More hopelessness (per 10-point lower, adjusted odds ratio [AOR]: 1.33, 95% confidence interval [95% CI] 1.12–1.58), depression (AOR: 1.87, 95% CI 1.003–3.49), age (per 10-year higher, AOR: 1.70, 95% CI 1.29–2.25), being female (AOR: 2.67, 95% CI 1.43–4.98), and undergoing hemodialysis (AOR, 2.92; 95% CI, 1.41–6.05) were associated with a higher likelihood of having baseline sarcopenia. More hopelessness (per 10-point lower, AOR: 1.69, 95% CI 1.14–2.51) and depression (AOR: 4.64, 95% CI: 1.33–16.2) were associated with a higher likelihood of having sarcopenia after one year. Among patients with different stages of CKD, both hopelessness and depression predicted sarcopenia. Provision of antidepressant therapies or goal-oriented educational programs to alleviate depression or hopelessness can be useful options to prevent sarcopenia.

Diagnosis of renal cell carcinoma (RCC) in patients with autosomal dominant polycystic kidney disease (ADPKD) is challenging and often delayed due to accompanying multiple renal cysts. Sometimes, it is difficult to distinguish RCC from cyst infection or hemorrhage. We herein present the case of a patient with ADPKD undergoing long-term hemodialysis whose sarcomatoid RCC was difficult to diagnose and was confirmed via nephrectomy. A 53-year-old male, undergoing hemodialysis since 20 years for end-stage renal disease secondary to ADPKD, was admitted to our hospital with a 3-week history of fever at > 38 °C and right flank pain. Clinical manifestations were compatible with cyst infection. Magnetic resonance images of the lesion identified in the lower right kidney, revealing slightly high signal intensity on T1-weighted images, low signal intensity on T2 weighted images, and restricted diffusion on diffusion-weighted images, were also consistent with those of cyst infection. Therefore, antibiotic therapy with ciprofloxacin, doripenem, and vancomycin was initiated. However, the patient’s symptoms did not improve. Consequently, right nephrectomy was performed for both diagnosis and treatment, which revealed a sarcomatoid RCC with metastasis to the regional lymph node. The patient gradually developed cachexia and died on day 106 post-admission. The present case illustrates the difficulty of diagnosing RCC in patients with ADPKD, particularly sarcomatoid RCC, which is a rare and aggressive variant of RCC, even with the use of various types of imaging modalities. An early decision of nephrectomy may be necessary in such cases.

Introduction: Combination therapy with peritoneal dialysis and hemodialysis (PD+HD) is widely used for PD patients with decreased residual kidney function in Japan; however, hospitalization for this combined dialysis has not been investigated so far. We compared the risk of hospitalization for PD+HD with that for HD. Methods: A multicenter, prospective observational study was conducted on 42 PD+HD and 42 HD patients matched for age and diabetic nephropathy. The main outcome measure was the cumulative incidence of hospitalization for any cause assessed with the Kaplan-Meier method. Hospitalization rates (the number of admissions per 100 patient-years) associated with dialysis modality were also calculated. The impact of dialysis modality on time to hospitalization was analyzed using the Cox proportional hazard model. Results: There was no significant difference between groups in terms of age, sex, dialysis vintage, diabetic nephropathy, and comorbidities. The cumulative incidence of hospitalization did not significantly differ between the groups (log-rank test, P = 0.36). Although total hospitalization rates were 66.0 in PD+HD and 59.2 in HD, hospitalization rates for the sum of PD-related infections (a composite of catheter-related infection and peritonitis) and vascular access troubles were 21.7 in PD+HD and 7.2 in HD. On univariate Cox proportional hazard analysis, dialysis modality had no significant impact on time to hospitalization. Conclusion: The risk of hospitalization was not significantly different between PD+HD and HD, although PD+HD patients had a higher risk of dialysis access–related complications than HD patients. Keywords: cardiovascular event, combined dialysis, end-stage renal disease (ESRD), PD+HD, residual kidney function (RKF), survival

Pregnancy-onset thrombotic thrombocytopenic purpura (TTP) was reported by many obstetricians and hematologists, but less by nephrologists, and the detailed clinical course of its renal complication is not known. Here, we report a case of a 33-year-old pregnant woman who suffered from pregnancy-onset TTP with nephrotic syndrome which was controlled by the termination of pregnancy. On admission, she had periorbital and lower leg edema at 32 weeks of gestation. Her serum albumin level was 2.8 g/dL and the urine protein/creatinine ratio was 4.1 g/g Cr. Besides those, she had thrombocytopenia, hemolytic anemia, and severe deficiency of A Disintegrin-like and Metalloproteinase with Thrombospondin type 1 motifs 13 (ADAMTS-13) activity. Thus, she was diagnosed with nephrotic syndrome due to pregnancy-onset TTP. A cesarean section was performed without complications for the patient and her baby. Then, all her symptoms improved shortly. She was suspected of congenital TTP because of no ADAMTS-13 inhibitor results and the persistent deficiency of ADAMTS-13 activity even after her condition improved. Pregnancy-onset TTP can cause nephrotic syndrome. Termination of pregnancy should be considered in cases with pregnancy-onset TTP to protect kidney function.

We sometimes hesitate to switch renal replacement therapy from peritoneal dialysis (PD) particularly in elderly patients due to their physical tolerance levels and lifestyles. Here, we describe the cases of three patients treated with PD alone despite an anuric status who subsequently developed uremic encephalopathy, which was successfully treated with hemodialysis (HD). The first patient was a 75-year-old woman who developed uremic encephalopathy with an anuric status and inadequate PD after 7 months of treatment. HD immediately improved her condition; encephalopathy did not recur with combined therapy of PD and HD. The second patient was a 69-year-old woman who developed anuria and was treated with combined therapy. Her arteriovenous fistula was obstructed; therefore, she was treated with PD alone. Total weekly Kt/V was sufficiently high at 1.95; however, she developed uremic encephalopathy the following month, which was successfully treated with HD. The third patient was an 84-year-old woman who developed anuria, but was treated with PD alone with adequate total weekly Kt/V of 2.2. PD could not be performed for 2 days because of myocardial infarction intervention; subsequently, she developed uremic encephalopathy, which was successfully treated with HD. These cases are the first of their kinds, wherein patients undergoing PD, developed uremic encephalopathy without any obvious triggers, including drugs, and illustrate the necessity of initiating combined therapy for such patients considering the risk of developing severe uremia leading to uremic encephalopathy, in spite of it being less preferable for elderly patients due to their physical conditions and lifestyles.

Background In chronic kidney disease (CKD), patients’ adherence to prescriptions for diet and for medications might depend on the degree to which they have hope that they will enjoy life, and that hope could vary with the stage of CKD. The aims of this study were to quantify both the association of CKD stage with health-related hope (HR-Hope), and the association of that hope with psychological and physiological manifestations of adherence. Methods This was a cross-sectional study involving 461 adult CKD patients, some of whom were receiving dialysis. The main exposure was HR-Hope, measured using a recently-developed 18-item scale. The outcomes were perceived burden of fluid restriction and of diet restriction, measured using the KDQOL, and physiological manifestations of adherence (systolic and diastolic blood pressure [BP], and serum phosphorus and potassium levels). General linear models and generalized ordered logit models were fit. Results Participants at non-dialysis stage 4 and those at stage 5 had lower HR-Hope scores than did those at stage 2 or 3 (combined). Those at non-dialysis stage 5 had the lowest scores. HR-Hope scores of participants at stage 5D were similar to those of participants at stage 4, but they were lower than the scores of participants at stage 2 or 3 (combined). Higher HR-Hope scores were associated with lower perceived burdens of fluid restriction and of diet restriction (adjusted ORs per ten-point difference were 0.82 and 0.84, respectively). Higher HR-Hope scores were associated with lower systolic BP (adjusted mean difference in systolic BP per ten-point difference in HR-Hope scores was − 1.87 mmHg). In contrast, HR-Hope scores were not associated with diastolic BP, serum phosphorus levels, or serum potassium levels. Conclusions Among CKD patients, HR-Hope is associated with disease stage, with psychological burden, and with some physiological manifestations of adherence.

Novel coronavirus disease 2019 (COVID-19) is a highly infectious and deadly disease, spreading worldwide. There are limited data about the clinical course of end-stage renal disease (ESRD) patients infected with COVID-19. However, previous cohort studies showed a high mortality rate of ESRD patients infected with COVID-19. We report here two Japanese ESRD patients confirmed with severe COVID-19 pneumonia. Case 1 was a 60-year-old man with ESRD due to diabetic nephropathy who were infected with COVID-19 and exhibited acute respiratory distress syndrome (ARDS) requiring mechanical ventilation and intensive care unit (ICU) admission. He was treated with tocilizumab and intravenous immunoglobulin (IVIG). After 6 days of treatment in ICU, he was extubated. Case 2 was a 68-year-old woman undergoing maintenance hemodialysis for 17 years who also exhibited ARDS due to COVID-19. Her clinical course resembles case 1. Our experience of these two cases indicates that anti-cytokine therapy might be effective for severe COVID-19 pneumonia in ESRD patients.

Membranous nephropathy (MN) is one of the most common biopsy diagnoses in adults, and it has been associated with chronic infections, autoimmune diseases, malignancies, and drugs. However, MN associated with cholesterol crystal emboli has never been reported. Here we present a patient with MN as an unusual manifestation of atheroembolism. A 75-year-old man with worsening renal function after catheter ablation developed moderate proteinuria and underwent a renal biopsy. Findings on light, immunofluorescence, and electron microscopy were all compatible with membranous nephropathy. Moreover, one occluded interlobular artery contained a pathognomonic, biconvex, needle-shaped cleft, which indicated a cholesterol crystal emboli. The degree of proteinuria was in parallel with the number of eosinophils, which indicated a close relationship between MN disease activity and renal atheroembolism. Hypereosinophilic syndrome secondary to atheroembolism may cause MN; thus, corticosteroid therapy was likely to be effective.

Background Takayasu arteritis (TA) is a chronic vasculitis of unknown etiology that primarily affects large vessels. Although renal involvement is frequent in TA, patients with TA undergoing renal replacement therapy, especially long-term peritoneal dialysis (PD) and kidney transplantation (KTx), are rarely reported. We herein present the case of an elderly patient with TA treated by PD for more than 5 years and underwent KTx thereafter. Case presentation A 69-year-old female diagnosed with TA at the age of 19 was treated by PD for seven and a half years for end-stage renal disease due to TA. Dialysate-to-plasma ratio of creatinine, which was well maintained during this period, reflected the efficacy of long-term PD. However, her residual renal function declined; she developed malnutrition, inflammation, and atherosclerosis syndrome and underwent living-related KTx from her husband. Due to the total occlusion of the external iliac arteries with compensatory development of the internal iliac arteries, the right internal iliac artery was used as the anastomosis site. After KTx, the patient developed chronic active antibody-mediated rejection; however, the graft function was maintained throughout the follow-up period. Despite severe aortic calcification and intermittent claudication in the legs, her condition did not worsen, and the blood flow of the graft was preserved. Conclusions The current case illustrating the success of long-term PD and living-related KTx in maintaining kidney function in an elderly patient with TA is the first to demonstrate the potential of PD and KTx as feasible options for renal replacement therapy in TA accompanied by severe cardiac involvement.

Rationale & Objective Depression is prevalent and highly associated with mortality among patients with chronic kidney disease (CKD). Psychological flexibility can be captured as acceptance in psychology, and its improvement by behavioral therapy is associated with reduced depression in some clinical settings. However, no study has been reported on patients with CKD. This study aimed to examine the association between psychological flexibility and depression in patients with CKD. Study Design Cohort study. Setting & Participants This multicenter study of 5 hospitals in Japan included patients with nondialysis stage 3-5 CKD or stage 5D CKD receiving hemodialysis or peritoneal dialysis. Predictor Psychological flexibility measured using the 7-item Acceptance and Action Questionnaire (AAQ-II). Outcomes The prevalence and incidence of depression after 1 year, which was defined by a score ≥ 16 points on the Center for Epidemiologic Studies Depression (CES-D) questionnaire. Analytical Approach Gamma regression was used in the examination of correlates of the psychological flexibility value. Modified Poisson regression models were fit for the prevalence and incidence of depression. Results The cross-sectional and longitudinal analyses included 433 and 191 patients, respectively. Lower (ie, worse) psychological flexibility levels were associated with hemodialysis and peritoneal dialysis. Higher (ie, better) psychological flexibility levels were associated with lower prevalence of depression (per 5-point increase; adjusted prevalence ratio, 0.75; 95% CI, 0.70-0.80) and lower incidence of depression (per 5-point increase; adjusted risk ratio, 0.72; 95% CI, 0.61-0.85). Limitations Depression was assessed using the CES-D questionnaire. Cultural differences may exist in the interpretation of AAQ-II scores. Conclusions Better psychological flexibility was associated with lower prevalence and incidence of depression in patients with CKD. Further studies are warranted to determine the possible prevention and treatment of depression by the development of behavioral interventions to improve psychological flexibility., Graphical abstract

Background Low tongue pressure contributes to oral frailty. It is a condition in which the pressure between the tongue, palate, and food decreases due to a decrease in tongue muscle function. Low tongue pressure interferes with chewing and swallowing and causes bloating, increasing the risk of malnutrition and aspiration pneumonia due to decreased intake. Its causes include aging, neuromuscular disease, trauma, sequelae, low nutrition, and sarcopenia. Although quantitative evaluation of tongue function has been reported to be useful for prevention of low tongue pressure, there is no report of the evaluation’s effectiveness in patients with high-risk renal failure. This study aimed to evaluate the prevalence of low tongue pressure and to clarify the relationship between the tongue pressure value and sarcopenia in peritoneal dialysis (PD) patients. Methods A cross-sectional study of 105 PD patients (67 ± 13.5 years old, 73.3% men, 26.7% women; 26.7% with diabetes) was conducted in our hospital. At the start of the study, clinical backgrounds were investigated from the patients’ medical records. Sarcopenia was diagnosed by muscle mass, grip strength, and walking speed. Inflammatory, nutritional, and cardiovascular markers were measured. Univariate and multivariate analyses with muscle and nutrition markers were performed to determine the low tongue pressure prevalence rate in PD patients. Results Low tongue pressure prevalence rate was 55.2% in patients under 65 and 64.1% in patients 65 and over. Significantly lower tongue pressure (p = 0.019) was observed in the patients in the sarcopenic group. The tongue pressure value was positively correlated with albumin (p = 0.0003), pre-albumin (p = 0.006), body mass index (p = 0.004), grip strength (p

The aim of this paper is to investigate cortical excitability in patients with end-stage renal disease receiving peritoneal dialysis (PD) without any symptoms suggestive of uremic encephalopathy. We performed transcranial magnetic stimulation for 52 PD patients and 28 normal subjects. We compared the active motor threshold (AMT), resting motor threshold (RMT), root latency, central motor conduction time (CMCT), and cortical silent period (CSP) in PD patients to those in normal subjects. AMT, RMT, CMCT, and CSP were not significantly different between PD patients and normal subjects. However, root latency was significantly prolonged in PD patients compared to normal subjects. The root latency correlated linearly with HbA1c or duration of PD in the patients. The results suggest that the corticospinal tract and the cortical and spinal excitabilities are preserved but the peripheral nerves are disturbed in PD patients. The severity of peripheral neuropathy corresponds to the severity of DM and the duration of PD. We uncovered no evidence suggestive of any subclinical abnormality of the motor cortical excitability in PD patients.

Calcium pyrophosphate dihydrate deposition disease (pseudogout) is a crystal arthritis characterized by pyrophosphate dihydrate crystal deposition in the articular cartilage or synovium. In chronic kidney disease patients, the major causes of crystal arthritis are calcium oxalate crystals and basic calcium phosphate crystals. However, pseudogout is apparently infrequent among such patients. This report describes a rare case of tophaceous pseudogout (tumoral form of pseudogout) involving the hip joint in a peritoneal dialysis patient, as revealed by CT scan and synovial fluid aspiration. Fluid aspiration and oral NSAIDs improved the clinical symptoms. This report is the first to describe tophaceous pseudogout in a peritoneal dialysis patient, which suggests that pseudogout should be suspected in dialysis patients with unexplained arthritis.

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

A 64-yr-old man with end-stage kidney disease caused by hypertensive nephrosclerosis underwent living-unrelated ABO-identical kidney transplantation (KTx) at the age of 60 yr from his 60-yr-old wife. Maintenance trough concentration of cyclosporine A (CsA) was 100 ± 30 ng/mL. Five months after KTx, proteinuria gradually increased to around 1 g/d. TRBx at eight months after KTx revealed the new-onset alteration of mild arteriolosclerosis with intimal hyalinosis, which might reflect calcineurin inhibitor (CNI)-associated arteriopathy (CAA). Nearly one and half years after KTx, urinary protein excretion became nearly 2 g/d. TRBx revealed the advanced CAA and findings of focal segmental glomerulosclerosis (FSGS). Then, CNI was switched from CsA to tacrolimus (TAC). TRBx at two and half years after KTx revealed progressed arteriolar transmural thickening and striped fibrosis, which were supposed to be induced by an increase in serum TAC concentration because of acute enterocolitis. Then, TAC dose was reduced to serum trough concentration 5-8 ng/mL, but urinary protein excretion was increased up to 10 g/d. Reduction of TAC to trough concentration 2.0 ± 0.5 ng/mL reduced urinary protein excretion. Attempts to elevate TAC trough concentration within normal range (4-8 ng/mL) reproducibly induced the recurrence of an increase in sCr or urinary protein excretion. All these findings supported the etiology of graft dysfunction, and proteinuria of this case was FSGS.

Background. The epithelial-to-mesenchymal transition (EMT) of mesothelial cells was observed in patients on peritoneal dialysis and may be involved in peritoneal thickening. Conventional peritoneal dialysis fluids (PDFs) that contain glucose degradation products (GDPs), such as methylglyoxal (MGO) and formaldehyde (FA), are bioincompatible. The aim of this study is to analyse the participation of EMT in peritoneal thickening induced by GDPs in rats. Methods. Rat mesothelial cells were cultured with various GDPs, and the gene expression of Snail was analysed by polymerase chain reaction (PCR). SpragueDawley rats were administered intraperitoneally 20mM MGO/PDFs, 20mM FA/PDFs or 0.1% chlorhexidine gluconate (CHX)/15% ethanol/saline every day for 21 days. On Day 22, the expression of transforming growth factor-β (TGF-β), collagen 1, matrix metalloproteinase-2 (MMP-2), vascular endothelial growth factor (VEGF), Snail and receptor for advanced glycation end-products (RAGE) was analysedbyPCR,enzyme-linkedimmunoassayorimmunohistological staining. Results. In cell-culture experiments, the expression of Snail was enhanced by MGO, but not FA. In rats treated with 20mM MGO, peritoneal fibrous thickening with the proliferation of mesenchymal-like mesothelial cells was observed. The expression of TGF-β, collagen 1, MMP-2, VEGF, Snail and RAGE increased significantly (P < 0.01). In FA- or CHX-treated rats, the peritoneum was thickened withsparsecollagenfibres,butmesenchymal-likemesothelial cells were not observed. Conclusions. MGO induced peritoneal fibrous thickening with the proliferation of mesenchymal-like mesothelial cells in vivo. These cells may be transdifferentiated from mesothelial cells by EMT via Snail and play an important role in peritoneal fibrous thickening.

A new catalytic process for allyl ester cleavage has been developed by using a robust cationic CpRu(IV) π-allyl complex of 2-quinolinecarboxylic acid that can be stored for over six months in air without any loss of catalytic activity. The deprotection of various alcohols and acids can be attained simply with high reactivity and chemoselectivity under mild conditions. Furthermore, with continuous removal of the low-boiling point coproduct, a turnover number of 1 000 000 can be achieved.

連続携行式腹膜透析 (continuous ambulatory peritoneal dialysis: CAPD) が日本に導入されて約25年が経過し, PDについて再検討する時期と考えられる. 今回, PD自己管理・手技・定期検査についてのアンケート調査を東京地区でPD患者を診療している63施設の医師と看護師を対象に実施した.医師の32名, 看護師の37名から回答があり, 回収率は50.8%, 58.7%であった. バッグ交換時の指導内容は, 手洗い100%・マスク着用100%・窓の閉鎖97.0%・空調の中止81.8%・ドアの施錠9.1%・ヘアキャップ着用6.1%であった. 排液方法は, 完全排液75.7%・時間制限排液13.5%であった. 自己測定を毎日/毎回行うように指導する施設は, 排液量100%・除水量100%・体重91.9%・血圧86.5%・注液量73.0%・水分バランス54.1%・尿量43.2%・脈拍43.2%・体温24.3%であった. 出口部ケア時の指導内容は, 手洗い100%・カテーテルと腹部の固定100%・ケアの毎日施行94.6%・出口部保護94.6%・窓の閉鎖86.5%・マスク着用81.1%・空調の中止62.2%・チタニウムアダプター保護37.8%・ドアの施錠5.4%・ヘアキャップ着用2.7%であった. オープンシャワーは30.6±25.5日 (中央値25.5日), 入浴は36.7±26.2日 (中央値30.0日) から開始し, 洗浄方法は「石鹸で軽く洗った後にシャワーでよく流すように指導」29.7%・「石鹸でよく洗った後にシャワーでよく流すように指導」13.5%・「シャワーのみでよく流す」13.5%・「シャワーのみで軽く流す」5.4%であった. 接続チューブ交換時の指導内容は, マスク着用 (施行者100%・介助者100%・患者91.9%)・ヘアキャップ着用 (施行者16.2%・介助者15.2%・患者5.4%)・窓の閉鎖97.3%・空調の中止70.3%・ドアの施錠16.2%であった. 定期検査の施行頻度は, 血算・生化学検査・腹部エコー・腹部・心エコー・便潜血・上部消化管内視鏡検査・眼底検査・骨密度検査・腹膜平衡機能検査の施行頻度は施設間で差が少なかったが, 胸部X線・KUB・心電図・至適透析指標 (蓄尿) には大きな差を認めた.各施設によって異なっているPDの自己管理・手技・定期検査の内容について再検討し, よりよい医療/看護を患者に提供するとともにevidenceを確立しなければならない.

To prevent complement-mediated autologous tissue damage, host cells express a number of membrane-bound complement inhibitors. Decay-accelerating factor (DAF, CD55) is a GPI-linked membrane complement regulator that is widely expressed in mammalian tissues including the kidney. DAF inhibits the C3 convertase of both the classical and alternative pathways. Although DAF deficiency contributes to the human hematological syndrome paroxysmal nocturnal hemoglobinuria, the relevance of DAF in autoimmune tissue damage such as immune glomerulonephritis remains to be determined. In this study, we have investigated the susceptibility of knockout mice that are deficient in GPI-anchored DAF to nephrotoxic serum nephritis. Injection of a subnephritogenic dose of rabbit anti-mouse glomerular basement membrane serum induced glomerular disease in DAF knockout mice but not in wild-type controls. When examined at 8 days after anti-glomerular basement membrane treatment, DAF knockout mice had a much higher percentage of diseased glomeruli than wild-type mice (68.8 ± 25.0 vs 10.0 ± 3.5%; p < 0.01). Morphologically, DAF knockout mice displayed increased glomerular volume (516 ± 68 vs 325 ± 18 × 103 μm3 per glomerulus; p < 0.0001) and cellularity (47.1 ± 8.9 vs 32.0 ± 3.1 cells per glomerulus; p < 0.01). Although the blood urea nitrogen level showed no difference between the two groups, proteinuria was observed in the knockout mice but not in the wild-type mice (1.4 ± 0.7 vs 0.02 ± 0.01 mg/24 h albumin excretion). The morphological and functional abnormalities in the knockout mouse kidney were associated with evidence of increased complement activation in the glomeruli. These results support the conclusion that membrane C3 convertase inhibitors like DAF play a protective role in complement-mediated immune glomerular damage in vivo.

Background: Although pegylated interferon (PEG-IFN) is now the standard treatment for chronic hepatitis C, there are few reports targeting dialysis patients and treatment protocol for hepatitis C virus (HCV) infection has not been determined, particularly in patients on peritoneal dialysis. Case: A 34-year-old woman with chronic hepatitis C started peritoneal dialysis because of progressive renal disease 2 years after peripheral blood stem cell transplantation for aplastic anaemia. The regimen was a single 6-h dwell of 2L glucose dialysate. Considering that her HCV genotype was 2a and that she was a candidate for cadaveric kidney transplant, we decided to treat her with PEG-IFN alpha-2a monotherapy 1 year after the beginning of peritoneal dialysis. We adopted a dose escalation strategy to minimize the total amount of PEG-IFN administration, thereby reducing the risk of adverse effects. Her HCV-RNA disappeared at the 17th week and sustained virus response was achieved thereafter. Only minor side effects were observed including flu-like symptoms and mild anaemia, and residual renal function remained stable during the treatment of 48 weeks (renal Kt/V; from 1.28 to 1.26). Conclusion: PEG-IFN monotherapy with dose modification may be a safe and effective treatment for HCV infection in patients undergoing peritoneal dialysis.

A cationic CpRu(II) complex in combination with quinaldic acid shows high reactivity and chemoselectivity for the catalytic deprotection of hydroxyl groups protected as allyl ethers. The catalyst operates in alcoholic solvents without the need for any additional nucleophiles, satisfying the practical requirements of operational simplicity, safety, and environmental friendliness. The wide applicability of this deprotection strategy to a variety of multifunctional molecules, including peptides and nucleosides, may provide new opportunities in protective group chemistry. [structure: see text]

♦Background Morphology changes of the peritoneal membrane after long-term peritoneal dialysis (PD) consist of denudation of peritoneal mesothelial cells, interstitial sclerosis, and hyalinizing vasculopathy. Those changes are considered to be the result of uremia and bioincompatible effects of conventional acidic lactate-buffered dialysate with glucose degradation products (GDPs). In the last decade, biocompatible dialysate with neutral pH and low GDPs has become widely used. Clinical practice has been modified in Japan, especially for anuric patients, and now includes the use of hybrid therapy. The impact on peritoneal morphology has not been well reported. ♦ Objective The aim of the present study was to investigate the long-term effect on peritoneal morphology and function of biocompatible fluid use and current clinical practice in Japan, including hybrid dialysis therapy. ♦Methods We evaluated peritoneal biopsy specimens from patients who had undergone PD for more than 3 years. We used the average peritoneal thickness (APT) of the submesothelial compact zone as a marker of interstitial sclerosis and the lumen/vessel diameter ratio (L/V ratio) at postcapillary venules as a marker of hyalinizing vasculopathy. Demography and other data for the patients, including dialysate-to-plasma (D/P) ratio of creatinine, were obtained at baseline and every 6 months by peritoneal equilibration test. ♦Results Between 2002 and 2009, 110 patients started PD therapy with biocompatible dialysate at Tokyo University Hospital. Among them, 11 patients (8 men, 3 women; age: 54.2 ± 11.8 years; 1 with diabetes mellitus) were enrolled into this morphology study. The mean duration of PD in this group was 61 ± 11.3 months, and the mean time to peritoneal biopsy was 58 ± 15.1 months. The median APT was 180 μm (96 – 1424 μm), and the median L/V ratio was 0.66 (0.46 – 0.74). No obvious correlations between APT, L/V ratio, and PD duration were detected. The D/P creatinine of the 11 patients was maintained at a favorably low value, comparable with that of the other 99 patients. ♦Conclusions Peritoneal dialysis therapy using biocompatible dialysate in conjunction with modification of clinical practice may minimize the progression of peritoneal interstitial sclerosis and hyalinizing vasculopathy, preserving favorable peritoneal function for more than 3 years.

A 67-year-old Japanese woman with end-stage renal disease due to autosomal dominant polycystic kidney disease was initiated on continuous ambulatory peritoneal dialysis after insertion of a straight Tenckhoff catheter. Peritoneal dialysis exchanges were uncomplicated until 3 weeks after the operation, when the catheter was found to be suddenly obstructed during both fluid infusion and drainage. The patient complained of abdominal pain in the lower left quadrant, especially during attempted peritoneal exchanges. She was suspected of having catheter obstruction by intra-abdominal viscera, and underwent surgical exploration, which revealed that the catheter was obstructed by an incarcerated sigmoid colon wall (Figure 1). The colon wall was separated from the catheter and the catheter was fixed to the posterior wall of the bladder. After surgery, the catheter functioned properly.

We examined the effects of the extracellular matrix proteins fibronectin, laminin, and matrigel on 72-kDa progelatinase secretion by human lip fibroblasts (KD) and skin fibroblasts (MRC9 and HSF). By gelatin zymography, 1.7 +/- 0.2-fold, 1.7 +/- 0.2-fold, and 1.8 +/- 0.3-fold increases were observed in 72-kDa progelatinase secretion from KD cells treated with fibronectin, laminin, and matrigel, respectively. Laminin and matrigel, but not fibronectin, stimulated 72-kDa progelatinase secretion from HSF cells. Fibronectin, laminin, and matrigel did not stimulate 72-kDa progelatinase secretion by MRC9 cells. Anti-alpha2 integrin antibody-stimulated 72-kDa progelatinase secretion and induced the 62-kDa activated form of 72-kDa progelatinase by KD cells. Activated p42 MAP kinase (MAPK) expression was down-regulated by anti-alpha2 integrin antibody. Anti-alpha2 integrin antibody stimulated 72-kDa progelatinase secretion by HSF cells without inducing the 62-kDa activated form. The data suggest that interaction between fibroblasts and extracellular matrix components via alpha2 integrin plays an important role in regulating secretion and activation of 72-kDa gelatinase and that down-regulation of activated p42 MAPK may be involved in the 72-kDa progelatinase activation mechanism.

Effect of dwell time on carbonyl stress using icodextrin and amino acid peritoneal dialysis fluids.BackgroundDeterioration of the peritoneal membrane limits the technical survival of peritoneal dialysis (PD). Advanced glycation of the membrane has been incriminated in this evolution. Advanced glycation end products (AGEs) develop under the influence of glucose and of its degradation products, mainly reactive carbonyl compounds (RCOs) such as glyoxal (GO), methylglyoxal (MGO), and 3-deoxyglucosone (3-DG). The present study was undertaken to evaluate the impact of recently developed glucose-free PD fluids on AGE generation.MethodsRecently developed glucose-free PD fluids containing either icodextrin or amino acids were investigated. GO, MGO, and 3-DG [high-performance liquid chromatography (HPLC)] and total RCOs (spectrophotometry) were measured in fresh solutions and in effluents after various dwell duration. The AGE formation potential of PD fluids and effluents was assessed by incubation at 37°C, for one week, with bovine serum albumin and by the eventual measurement of pentosidine (HPLC) and Nε-carboxymethyllysine (CML; gas chromatography/mass spectrometry).ResultsGO, MGO, and 3-DG (P < 0.001) as well as total RCOs levels (P < 0.01) were significantly lower in icodextrin and amino acid PD fluid than in commercial, heat-sterilized, 1.36% glucose PD fluid. Pentosidine and CML generation were also significantly lower (P < 0.001) in icodextrin and amino acid PD fluid than in conventional 1.36% glucose PD fluid. The levels of total RCOs, however, increased in icodextrin and amino acid PD fluid effluents with dwell time. AGE formation potential rose accordingly, as demonstrated by a parallel increase in the generation of pentosidine and CML during incubation of PD effluents.ConclusionThe present data demonstrate lower RCO contents and AGE formation potential in fresh icodextrin and amino acid PD fluids than in fresh heat-sterilized glucose PD fluids. However, this difference decreases progressively during dwell time, mainly as a result of the influx of total RCOs.

Background Cardiovascular disease is a frequent cause of death in peritoneal dialysis patients. Biocompatible peritoneal dialysis solutions with neutral pH have been anticipated to reduce cardiovascular disease more than conventional peritoneal dialysis solutions with low pH, but it remains unclear which factors at peritoneal dialysis initiation increase cardiovascular risk in patients using biocompatible peritoneal dialysis solutions. This study was undertaken to investigate which clinical factors at peritoneal dialysis initiation, including peritoneal transport status, are associated with cardiovascular event in patients using biocompatible peritoneal dialysis solution. Methods This retrospective cohort study of peritoneal dialysis patients using biocompatible solutions with neutral pH assessed relations of clinical parameters at peritoneal dialysis initiation to cardiovascular event during the subsequent five years. Results Of 102 patients who started peritoneal dialysis, cardiovascular event occurred in 18. Age, history of cardiovascular disease before peritoneal dialysis initiation, hemoglobin, serum albumin, C-reactive protein, peritoneal permeability defined by the ratio of dialysate to plasma creatinine concentration at 4 hr (D/Pcre) in peritoneal equilibration test (PET), number of patients in each PET category defined by D/Pcre, and peritoneal protein clearance significantly differed between patients with and without cardiovascular event. For patients divided according to PET category using Kaplan–Meier method, the group of high average to high peritoneal transporters exhibited significantly high incidence of cardiovascular event and mortality compared with the groups of low and low-average peritoneal transporters (Log rank; p = 0.0003 and 0.005, respectively). A Cox proportional hazards model showed independent association of PET category classification with cardiovascular event. Conclusions Peritoneal permeability expressed as PET category at peritoneal dialysis initiation is an independent cardiovascular risk factor in peritoneal dialysis patients using biocompatible peritoneal dialysis solution with neutral pH. Greater peritoneal permeability at peritoneal dialysis initiation might reflect subclinical vascular disorders. Electronic supplementary material The online version of this article (doi:10.1186/1471-2369-15-173) contains supplementary material, which is available to authorized users.