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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.

Background and Aims Iron-based phosphate binder (IPB) is a noncalcium phosphate binder that demonstrated sustained serum phosphorus control, good tolerability and lower pill burden compared with sevelamer carbonate in a Phase 3 study conducted in dialysis patients. These efficacy of IPB has been demonstrated for hemodialysis (HD) patients, but few studies have focused on patients undergoing peritoneal dialysis (PD). We evaluated efficacy of IPB and focused on effects for anemia and iron metabolism in patients on PD. Method This study was a cross-sectional, longitudinal multicenter study conducted by PD OASIS, organized committee in Kanagawa Japan. We analyzed the effects of IPB during a 6 months observation period in chronic kidney disease patients on PD who had administrated IPB, Ferric citrate hydrate and Sucroferric oxyhydroxide, between 2017 and 2019. The primary endpoint was the changes of phosphate, and several secondary endpoints were assessed: calcium, intact PTH, RBC, hemoglobin, MCH, RDW-VC, Fe, TSAT, Ferritin, albumin, CRP, monthly dosage of Erythropoietin stimulating agents (ESA) and ESA resistance index (ERI). In addition, we assessed the association between these markers and iron metabolism utilizing multivariate logistic regression analysis. Results A total of 102 patients were registered in the study who had received IPB. The initial doses of Ferric citrate hydrate and Sucroferric oxyhydroxide were 1010.9 ±400.9 mg and 941.7 ±502.9 mg daily, finally increased to 1213.6 ±559.9 mg and 1310.0 ±521.8 mg respectively at the end of the observation. We observed a significant reduction of serum phosphate to 5.27 ± 0.98 mg/dL from 6.56 ± 1.52 mg/dL with follow-up of six months (p < 0.01). At the end of the study, 76.4% of participants had achieved the target of less than 6 mg/dL. The hemoglobin, TSAT and Ferritin increased significantly from 10.47 ±1.26 g/dl, 27.95 ±11.05 % and 139.0 ±147.6 ng/mL to 11.17 ±1.16 g/dl, 40.46 ±15.00 % and 305.9 ±232.0 ng/mL respectively in six months (p < 0.01). No significant changes of serum calcium, intact parathyroid hormone (PTH) and CRP occurred over the study period. The monthly dosage of ESA was significantly decreased after administration with IPB and ERI significantly improved to 0.11±0.12 (μg/month/kg/g Hb) from 0.21±0.16 (μg/month/kg/g Hb) (p Additionally, we assessed the factors of ferritin increase because it was remarkable in follow-up six months compared to HD patients. In multivariate analysis, phosphate (Odds ratio 5.85, 95%CI 1.18-91.77, p=0.027), intact PTH (0.99, 0.97-1.15, p=0.015), hemoglobin (Odds ratio 0.10, 95%CI 0.05-0.59, p=0.025), RBC (Odds ratio 1.16, 95%CI 1.04-1.41, p=0.003), and RDW-CV (Odds ratio 0.44, 95%CI 0.10-0.99, p=0.046) were significantly associated with ferritin increase more than 300 ng/ml ,after adjusted. Conclusion This study confirmed the efficacy of Iron-based phosphate binder, Ferric citrate hydrate and Sucroferric oxyhydroxide, in the treatment of hyperphosphatemia in PD patients. In addition, IBP caused secondary effects of anemia improvement and ESA dosage reduction resulting in ERI improvement. However, in this study, the increase in ferritin levels was remarkable. It may be because PD does not lose iron by treatment compared to HD. Therefore, we should check iron metabolism more frequently for PD patients taking IPB than HD patients. It is necessary to further investigate the effects of IPB on anemia and iron metabolism in PD patients.

Success in peritoneal dialysis (PD) requires a well-functioning catheter, and catheter placement at PD initiation is extremely important for long-term PD. Although several randomized, controlled trials (RCTs) have compared open surgery with laparoscopic surgery, there is controversy regarding which surgical approach is desirable. The present systematic review and meta-analysis was performed to clarify which surgical approach is superior. A systematic literature search for RCTs was performed using the Cochrane Central Register of Controlled Trials and the MEDLINE database, and a meta-analysis was performed using Review Manager Version 5.3.5 (Cochrane Collaboration, Oxford, UK). Catheter survival was the primary outcome, and leakage, hernia, requirement for reoperation, catheter-related infection, postoperative pain, hospitalization period associated with catheter placement, and catheter migration were the secondary outcomes. After screening 913 references, seven RCTs were analyzed. Laparoscopic surgery was found to have no favorable effect on catheter survival (5 trials, 424 patients; risk ratio [RR] 1.02; 95% confidence interval [CI] 0.92–1.13; p = 0.68; low-quality evidence]. The incidence of catheter migration was significantly lower with laparoscopic surgery (6 trials, 526 patients; RR 0.42; 95% CI 0.18–0.96; p = 0.04; moderate-quality evidence). However, the significance decreased on limiting the analysis to RCTs involving laparoscopic surgery without secured suture of the PD catheter (4 trials, 431 patients; RR 0.58; 95% CI 0.27–1.25; p = 0.17; moderate-quality evidence). Other outcomes were similar between open surgery and laparoscopic surgery. The present findings indicate that laparoscopic surgery has a limited advantage over open surgery with respect to PD patients’ outcomes.

Aim Acute kidney injury (AKI) is a common complication of minimal change nephrotic syndrome (MCNS), particularly in adults. We evaluated the prevalence of AKI at the onset of adult MCNS and analyzed the influence of AKI on the duration of achieving complete remission (CR). Methods A retrospective, single-centre, dynamic cohort study was conducted with biopsy-proven, first-onset, adult MCNS patients treated with corticosteroids. Fifty-three consecutive patients diagnosed with MCNS from January 2000 to April 2014 were enrolled. Age, gender, daily urinary protein excretion, and serum creatinine levels were measured. To evaluate AKI during induction, we used the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for AKI and judged AKI stage according to the fluctuations in serum creatinine levels during the first 4 weeks of starting corticosteroid therapy. Results Twenty patients (37.7%) met the AKI criteria and all 53 patients achieved CR within 1 year. Kaplan–Meier analysis showed that the median time to CR was significantly longer in patients with AKI than in patients without AKI. Cox proportional hazard analysis showed that the hazard ratio (HR) associated with the presence of AKI for achieving CR within 4 weeks was 0.36 after adjustment for age, gender, serum albumin, daily urinary protein excretion, hypertension, administration of 25% albumin, and methylprednisolone pulse therapy. A graded association was also observed between AKI stage and HR for achieving CR. Conclusions The prevalence of AKI is high in adult patients with MCNS during induction therapy. AKI is an independent factor that delays the time to CR.

Introduction and Aims: Deposition of C1q occurs in 0 to 45% of patients with IgAN. In order to identify whether mesangial C1q deposition in IgAN is a novel marker for the response to tonsillectomy plus steroid pulse therapy (TSP), we studied the association between mesangial C1q deposition in IgAN and the remission rate after TSP therapy for IgAN. Methods: We conducted a retrospective cohort study at a single Japanese center. We analyzed data on 110 patients diagnosed with IgA nephropathy who received TSP between January 2003 and December 2012. Positive C1q findings were defined as diffuse mesangial C1q deposition. The study outcome was the resolution of abnormal urinary findings and was defined as negative proteinuria and negative occult blood 1 year after steroid pulse therapy. Results: In all enrolled cases, 69 patients (62.7%) went into remission. Ten out of 24 (41.7%) C1q-positive patients experienced remission, and 59 out of 86 (68.6%) C1q-negative patients experienced remission. Multiple logistic regression model analysis showed that the absence of C1q deposition increased the odds ratio for remission (odds ratio 4.41; 95% confidence interval 1.33-15.75, p = 0.017). Conclusions: These results suggest that the absence of diffuse C1q deposition in the mesangial area of the glomerulus in patients with IgA nephropathy is a positive predictive sign for a response to TSP and is associated with the resolution of urinary abnormalities 1 year after TSP.

In 2011, the Japanese Society of Nephrology (JSN) published new clinical guidelines for IgA nephropathy (IgAN) with a new risk stratification based on clinical and histological severity. For classification, patients are divided into four groups (low, medium, high, and very high risk). However, differences in responsiveness to each treatment among different groups remain unclear. We evaluate the responsiveness of tonsillectomy plus steroid pulse (TSP) therapy using the new risk stratification. We retrospectively reviewed 111 IgAN patients with TSP therapy between January 2003 and January 2013. Study patients were divided into three groups [low- (n = 40), medium- (n = 43) and high-/very high-risk group (n = 28)]. The primary outcome was clinical remission (CR). The observation period was 1 year following tonsillectomy. 57 out of 111 patients (51.4 %) reached CR. The CR incidence was 70.0, 41.9 and 39.3 % (the low-, the medium- and the high-/very high-risk group, respectively). The incidence of CR was significantly higher in the low-risk group (P = 0.013). In a multivariate logistic regression analysis, both the medium- and the high-/very high-risk group showed significantly lower incidence of inducing CR than the low-risk group [(odds ratio 0.324; 95 % confidence interval 0.106–0.939, P = 0.041) (odds ratio 0.239; 95 % confidence interval 0.058–0.910, P = 0.040), respectively]. The new risk stratification in the 2011 JSN clinical guidelines for IgAN had a positive impact on early CR of TSP therapy.

A 42-year-old female end-stage renal disease (ESRD) patient with reversible posterior leukoencephalopathy syndrome (RPLS) post-transfusion during initiation of hemodialysis is reported. Eleven days after the onset of illness, we diagnosed encephalopathy as a grand mal seizure resulting from diffuse cerebral edema. One reason for the delayed diagnosis was that her symptom, a throbbing headache that occurred during her first dialysis, indicated dialysis disequilibrium syndrome. We must bear in mind that a small amount of transfusion could cause RPLS even during the first dialysis. To our knowledge, this is the first case report on RPLS after blood transfusion in an ESRD patient.

BackgroundThe factors that predict baseline peritoneal permeability remain largely unknown. We noticed that patients that adhered to a strict low protein diet (LPD) during the predialysis period seldom showed high peritoneal permeability on the peritoneal equilibration test (PET) at the introduction of peritoneal dialysis (PD). Therefore, we investigated whether a strict LPD during the predialysis period affects peritoneal permeability.MethodWe retrospectively analyzed 37 patients that started PD in a single Japanese center. Patients were divided into group A and group B by the median amount of daily protein intake (PI) during the predialysis period using urine collected over 24 hours.ResultsThere were no differences between groups A and B in age, gender, proportion of diabetic nephropathy, blood pressure, body mass index, or body surface area. There were also no differences between the groups in laboratory findings, including hematocrit, serum albumin, and serum creatinine. The PETs showed a significantly lower dialysate-to-plasma ratio of creatinine at 4 hours (Cr D/P) for group A than for group B ( p = 0.02). Furthermore, a significant positive correlation between Cr D/P and PI was observed ( r = 0.53, p < 0.01).ConclusionIt is suggested that a strict LPD during the predialysis period may suppress peritoneal permeability at induction of PD.

Pulmonary involvement in cryoglobulinemia usually is mild. We present a rare case of severe lung involvement in mixed cryoglobulinemia. A 73-year-old woman with cryoglobulinemic glomerulonephritis was admitted. Dyspnea appeared suddenly two days later. She received the diagnosis of acute lung injury according to the concept proposed by the American-European Consensus Conference. Management required corticosteroid pulse therapy and plasma exchange. This case is the first description of successful early and long-term management of severe lung involvement observed in cryoglobulinemia. Although she has been free of chest symptoms for seven months, further follow-up may be necessary to assess the potential danger of relapse.

The aim of this study was to investigate the factors influencing serum parathyroid (PTH) levels, including medications for treating chronic kidney disease–mineral and bone metabolism disorder (CKD-MBD) in patients with end-stage renal disease. We enrolled 1,076 patients in nine Japanese facilities who had begun hemodialysis (HD) due to ESRD. We investigated the relationships between intact PTH (iPTH) levels and clinical parameters and medications just prior to beginning HD. Significant decreases in serum iPTH levels were seen in males, in the presence of diabetes mellitus (DM), and with administration of renin–angiotensin system inhibitors (RASIs). Significant correlations were found between serum calcium and iPTH levels. In the patients administered RASIs, there was a significant decrease in serum iPTH levels with DM, male gender, and administration of active vitamin D sterols (VDs) compared with those not administered RASIs, although serum-corrected calcium levels were not different. Multiple regression analysis found gender, age, presence of DM, and serum calcium and phosphate levels to be significant contributing factors. In addition, administration of angiotensin II receptor blockers (ARBs) may also be a contributing factor to iPTH levels at the beginning HD (p = 0.050). In this study, serum iPTH levels were related to administration of ARBs besides gender, age, the presence of DM and serum calcium levels. Our study suggests that the RA system involve serum iPTH levels in uremic patients.