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Lower haemoglobin levels are common among females without kidney diseases. However, little is known about the sex-specific management of anaemia in haemodialysis patients.This prospective cohort study investigated the role of sex differences in the association between categorical baseline or time-varying haemoglobin levels and all-cause mortality via cox regression using data from 6890 patients in the Japan Dialysis Outcomes and Practice Patterns Study (J-DOPPS, 2005-2015). Likelihood ratio tests were used to evaluate the effect modification of sex on the relationship between haemoglobin and mortality.A total of 781 patients died during the median follow-up of 31 months. Mortality risk, adjusted for case mix, varied between five haemoglobin categories, with the highest category (≥12 g/dL) having a hazard ratio of 0.73 (0.41-1.29) for females and 2.02 (1.03-3.95) for males versus 10-10.9 g/dL. Despite this difference, the p-value comparing the overall among males versus females was.35. Similar associations were observed in models stratified by patient age (75 years), time on dialysis (≤1 year), and models lagging the haemoglobin exposure.The results based on this sample of Japanese haemodialysis patients did not support the hypothesis that the association between haemoglobin and survival differed by sex. We also could not conclude that the association was identical, as the parameter estimates are consistent with male patients having a relatively greater mortality risk than female patients at higher haemoglobin levels. More detailed investigations into the effects of higher haemoglobin levels by sex might help better understand strategies for anaemia management.

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.

According to the annual survey of the Japanese Society for Dialysis Therapy Renal Data Registry (JRDR) conducted at the end of 2018, there were a total of 339,841 patients receiving dialysis (hereinafter, dialysis patients) in Japan. The survey included questions regarding the presence/absence of dementia, the performance status (PS), and the exercise habits of individual patients. The survey revealed that 10.8% of all dialysis patients had dementia (1.8% in the age group of less than 65 years, 6.8% in the age group of 65–74 years, and 22.7% in the age group of 75 years or older). These prevalences of dementia were approximately equal to those estimated from the survey conducted in 2010. Regarding PS, the percentage of patients with lower activity levels tended to be relatively high among patients who were less than 15 years old and those who were 60 years old or older. Concerning the exercise habits of dialysis patients, the percentage of patients who were classified as “not at all or hardly” in response to the question about exercise habit was the highest (60–80%) of all the exercise habit classifications in each of the age groups analyzed.

Background There are no reports of a large-scale survey on the infection prevention measures against coronavirus disease 2019 (COVID-19) in nephrology facilities. This study investigated the facility-level nephrology practices adopted during the COVID-19 pandemic and their associated challenges. Additionally, the treatment patterns and outcomes of chronic kidney disease (CKD) patients with COVID-19 were reviewed. Methods We conducted a nationwide questionnaire survey of 704 educational facilities that were certified by the Japanese Society of Nephrology (JSN) from October 20, 2020 to November 16, 2020. The questionnaire reviewed the facility characteristics, infection prevention measures taken during routine nephrology practice, impact of COVID-19 on nephrology practice, experiences in managing CKD patients with COVID-19, and nosocomial transmission in the nephrology unit. Results Of the 347 facilities that responded, 95.1% checked outpatients’ body temperatures and COVID-19 symptoms at their visits. To reduce face-to-face contact, 80% and 70% of the facilities lengthened the intervals between outpatient visits and introduced online/telephonic consultations, respectively. As a result, more than half of the hospitals experienced a decrease in the numbers of outpatients and inpatients (64% and 50%, respectively). During the study period, 347 facilities managed 479 CKD patients with COVID-19. Oxygen administration and mechanical ventilation were performed for 47.8% and 16.5% of the patients, respectively, with a 9.2% total mortality rate. Conclusion This survey demonstrated that JSN-certified educational nephrology facilities adopted multiple measures to manage the COVID-19 pandemic; however, they faced several challenges. Sharing these experiences could standardize these approaches and prepare us better for the future. Supplementary Information The online version contains supplementary material available at 10.1007/s10157-021-02082-z.

Background Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a global pandemic affecting a variety of medical treatments, including hemodialysis. This study aims to investigate the implementation of infection control measures, to examine the shortage of personal protective equipment (PPE) and disinfectants, and to quantify the number of nosocomial COVID-19 transmissions in hemodialysis facilities in Japan during the pandemic. Methods We conducted a nationwide questionnaire survey between 20 October and 16 November 2020 (i.e., between the “second wave” and “third wave” in Japan) in the 4198 dialysis facilities of the Japanese Association of Dialysis Physicians and the Japanese Society for Dialysis Therapy. A total of 2227 facilities (53.0%) responded. The questionnaire consisted of (i) characteristics of facilities, (ii) infection prevention measures in routine dialysis practices, (iii) shortage of PPE, (iv) feasibility of various isolation measures, and (v) nosocomial transmission. Results Half of the responding facilities were hospitals with multiple departments, and the other half were clinics specialized in dialysis. Several infection prevention measures such as health checks of staff and patients, donning of masks before and after hemodialysis, and disinfection of frequently contacted areas were implemented during the COVID-19 pandemic. There was a significant improvement in the implementation rate of these measures during the pandemic, compared to before it, which reached over 90%. More than half of the facilities reported a shortage of disposable masks (67.2%) and hand sanitizer alcohol (56.7%). Isolation of COVID-19 patients in private rooms was possible only in 52.7% of the facilities. The majority of facilities (73.3%) could not accept COVID-19 dialysis patients due to lack of space and manpower. Nosocomial transmission of COVID-19 occurred in 4.0% of the facilities. Of those infected, 51.9% were staff. Conclusions This survey revealed that most hemodialysis facilities in Japan had improved implementation of infection control measures and had shortage of PPEs and disinfectants, though some facilities did not implement infection prevention measures adequately, mainly due to the limited space of the facility. It may be recommended that each facility immediately establishes isolation measures to prepare for the pandemic of COVID-19.

Introduction Aortic arch calcification (AoAC) is related closely to mortality risk in patients undergoing maintenance dialysis. Recent experimentally obtained data suggest that osteoprotegerin/receptor activator for nuclear factor κB ligand signal transmission plays a role in de novo chondrogenic transition of vascular cells leading to calcification that is unrelated to bone metabolism. This study investigated the long-term effects of denosumab, an osteoprotegerin mimic peptide, on AoAC. Methods This study examined 58 patients with an 8 year vintage of dialysis at 1 center for observational study during 2009 to 2020. Denosumab was administered to 28 patients every 6 months. Blood chemical data were used. AoAC proportions were measured using a simple but computed tomography–equivalent computer-based chest X-ray analysis (calcified pieces of areas around the aorta). Results Blood chemical data of the control and denosumab groups that did not differ at the start showed differences of mineral metabolism after 30 months of observation. Remarkably, the AoAC proportion increased from 29.4% to 46.25% in the control group but decreased significantly from 25.0% to 20.0% (P < 0.01) in the denosumab group. Denosumab effects on decalcification were not observed 12 months after initiation. Conclusion We conclude that long-term use of denosumab is effective to reverse or treat AoAC in patients undergoing hemodialysis., Graphical abstract

Introduction: Dipeptidyl peptidase-4 (DPP-4) has been hypothesized to improve responsiveness to erythropoiesis-stimulating agent (ESA). We aimed to describe the trend in DPP-4 inhibitor prescription patterns and assess the association between DPP-4 inhibitor prescription and ESA hyporesponsiveness (eHypo) in Japanese hemodialysis (HD) patients with diabetes mellitus (DM). Methods: We analyzed data from the Japan Dialysis Outcomes and Practice Patterns Study phase 4–6 (2009–2017) on patients with DM who underwent HD thrice per week for at least 4 months. The primary exposure of interest was having a DPP-4 inhibitor prescription. The primary analysis outcomes were a binary indicator of eHypo (mean hemoglobin 6,000 units/week over 4 months) and the natural log-transformed ESA resistance index (ERI). We used conditional logistic regression to compare within-patient changes in eHypo before and after initial DPP-4 inhibitor prescription. We used linear generalized estimating equation models to compare continuous ERI outcomes while accounting for within-patient repeated measurements with an exchangeable correlation structure. Results: There was a monotonic increase in DPP-4 inhibitor prescription according to study year up to 20% in 2017. Moreover, 12.8% of patients with a DPP-4 inhibitor prescription were ESA hyporesponsive before the initial DPP-4 inhibitor prescription. After DPP-4 inhibitor prescription, the odds of eHypo and mean log-ERI remained unchanged in the whole cohort of our study. The interaction analysis of DPP-4 inhibitor and sideropenia showed that DPP-4 inhibitors attenuated eHypo in the patients without iron deficiency. Conclusion: Our findings indicate a recent increase in DPP-4 inhibitor prescription among Japanese HD patients with DM. DPP-4 inhibitors could improve ERI in patients undergoing HD without iron deficiency.

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 p = 0.0002), and 3 months after the second vaccination (p = 0.045) than Control group. However, the reduction rate of SARS-CoV-2 IgG titers between 2 weeks and 3 months after the second vaccination was significantly smaller in HD group than in Control (p = 0.048). Stepwise regression analysis revealed that dialysis time was identified as the significant independent factors for SARS-CoV-2 IgG titers at 2 weeks after the second vaccination in HD group (p = 0.002) and longer dialysis time resulted in higher maximum antibody titers. The incidences of fever and nausea after the second vaccination were significantly higher in the HD group (p = 0.039 and p = 0.020). Antibody titers in those with fever were significantly higher than those without fever in both groups (HD: p = 0.0383, Control: p = 0.0096). Conclusion HD patients had significantly lower antibody titers than age- and sex-matched non-dialysis individuals over 3 months after vaccination. Dialysis time was identified as a factor affecting SARS-CoV-2 IgG titers in HD group, with longer dialysis time resulting in higher maximum SARS-CoV-2 IgG titers.

Background It has been difficult to sufficiently achieve body-fluid management using blood volume (BV) monitor during hemodialysis (HD) with constant ultrafiltration (UF) rate. Recently, a relative BV change-guided UF control (BV-UFC) system was developed by combining the concepts of an automatic feedback system that could control the UF rate and profile with real- time monitoring of relative changes in BV (%ΔBV). However, this system has limited application in the clinical setting. Therefore, in this study, we aimed to perform the crossover study on HD with BV-UFC compared to standard HD in terms of hemodynamic stability during HD. Methods Forty-eight patients entered an 8-week crossover period of standard HD or HD with BV-UFC. Prevalence of intradialytic hypotension (IDH) as a primary outcome and changes in blood pressure (BP), differences in %ΔBV, and achievement of the target ultrafiltration volume as secondary outcomes were compared. IDH was defined as a reduction in systolic BP ≥20 mmHg from the baseline value at 10 min after HD initiation. Results No significant differences were found in the prevalence of IDH, frequency of intervention for symptomatic IDH, and achievement of the target ultrafiltration volume between the groups. The %ΔBV was significantly fewer (-12.1 ± 4.8% vs. -14.4 ± 5.2%, p Conclusions HD with BV-UFC did not reduce the prevalence of IDH compared with standard HD. The relief of a relative BV reduction at the end of HD may be beneficial in patients undergoing HD with BV-UFC. Trial Registration UMIN, UMIN000024670. Registered on December 1, 2016.

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Background Fibroblast growth factor 23 (FGF23) plays an important role in chronic kidney disease (CKD)‐related mineral and bone disorders. High FGF23 levels are associated with increased risk of anaemia in non‐haemodialysis CKD patients. FGF23 also negatively regulates erythropoiesis in mice. We hypothesized that higher FGF23 levels are associated with increased erythropoietin hyporesponsiveness among haemodialysis patients. Methods The study included 1044 patients from the Japanese Dialysis Outcomes and Practice Patterns Study (J‐DOPPS) phase 5 (2012‐2015). The outcome was erythropoiesis‐stimulating agent hyporesponsiveness (ESA‐hypo), defined as mean Hgb 6000 u/week over 4 months following FGF23 measurement. The association between ESA‐hypo and FGF23 was estimated using multivariable‐adjusted logistic generalized estimating equation regression models. Results Patients with higher levels of FGF23 were younger and had higher levels of serum albumin, creatinine, albumin‐corrected calcium, phosphorus, PTH, 25(OH)‐vitamin D, and had higher percentages of intravenous (IV) iron, IV vitamin D and cinacalcet use. ESA‐hypo was present in 144 patients (13.8%). Compared with the third quintile of FGF23 levels, the odds ratio (95% CI) of ESA‐hypo was 2.14 (0.99, 4.62) and 1.74 (0.74, 4.11) for the first and fifth quintiles, respectively. Conclusion The lowest and highest levels of FGF23 were associated with higher odds of ESA‐hypo in patients on maintenance haemodialysis, although the associations were not statistically significant. The relationship between FGF23 and anaemia, and particularly the increased risks of ESA‐hypo at low FGF23 levels which might be the result of energy saving, must be confirmed in larger clinical studies., SUMMARY AT A GLANCE The study included 1044 patients in Japan from J‐DOPPS and found that the lowest and highest levels of serum FGF‐23 were associated with increased odds of ESA‐hyporesponsiveness in patients on maintenance haemodialysis, though this did not reach statistical significance. Further study is needed to address the relationship between circulating FGF‐23 and anaemia in dialysis patients.

Most of the diseases for which apheresis therapy is indicated are intractable and rare, and each patient has a different background and treatment course prior to apheresis therapy initiation. Therefore, it is difficult to conduct large-scale randomized controlled trials to secure high-quality evidence. Under such circumstances, the American Society for Apheresis (ASFA) issued its guidelines in 2007, which were repeatedly revised until the latest edition in 2019. The ASFA guidelines are comprehensive. However, in the United States, a centrifugal separation method is mainly used for apheresis, whereas the mainstream procedure in Japan is the membrane separation method. The target diseases and their backgrounds are different from those in Japan. Due to these differences, the direct adoption of the ASFA guidelines in Japanese practice creates various problems. One of the features of apheresis in Japan is the development of treatment methods using hollow-fiber devices such as double filtration plasmapheresis (DFPP) and selective plasma exchange and adsorption-type devices such as polymyxin B-immobilized endotoxin adsorption columns. Specialists in emergency medicine, hematology, collagen diseases/rheumatology, respiratory medicine, cardiovascular medicine, gastroenterology, neurology, nephrology, and dermatology who are familiar with apheresis therapy gathered for this guideline, which covers 86 diseases. In addition, since apheresis therapy involves not only physicians but also clinical engineers, nurses, dieticians, and many other medical professionals, this guideline was prepared in the form of a worksheet so that it can be easily understood at the bedside. Moreover, to the clinical purposes, this guideline is designed to summarize apheresis therapy in Japan and to disseminate and further develop Japanese apheresis technology to the world. As diagnostic and therapeutic techniques are constantly advancing, the guidelines need to be revised every few years. In order to ensure the high quality of apheresis therapy in Japan, both the Japanese Society for Apheresis Registry and the guidelines will be inseparable.

Background The Japanese Association of Dialysis Physicians, the Japanese Society for Dialysis Therapy, and the Japanese Society of Nephrology jointly established COVID-19 Task Force Committee and began surveying the number of newly infected patients. Methods This registry of the COVID-19 Task Force Committee was used to collect data of dialysis patients; a total of 1010 dialysis patients with COVID-19 were included in the analysis. Overall survival of patients was investigated with stratification by age group, complication status, and treatment. In addition, predictive factors for mortality were also investigated. The overall survival was estimated by Kaplan–Meier methods and compared by using log-rank test. Multivariate analysis was performed to identify the risk factor of mortality. For all statistical analyses, p Results The mortality risk was increased with age (p Conclusion Dialysis patients have a high severity of illness and a high risk of mortality in cases of COVID-19. Treatment with remdesivir might be effective in shortening the duration of hospitalization and reducing the risk of mortality.

Abstract The annual survey of the Japanese Society for Dialysis Therapy Renal Data Registry (JRDR) was conducted for 4413 dialysis facilities at the end of 2017; among which 4360 facilities (98.8%) responded to the facility questionnaire, and 4188 (94.9%) responded to the patient questionnaire. The response rate of the 2017 survey was comparable with the past, even though it was the third year after the new anonymization method. The number of chronic dialysis patients in Japan continues to increase every year; it has reached 334,505 at the end of 2017. The mean age was 68.43 years. The prevalence rate was 2640 patients per million population. Diabetic nephropathy was the most common primary disease among the prevalent dialysis patients (39.0%), followed by chronic glomerulonephritis (27.8%) and nephrosclerosis (10.3%). The rate of diabetic nephropathy and nephrosclerosis has been increasing year by year, whereas that of chronic glomerulonephritis was declining. The number of incident dialysis patients during 2017 was 40,959; it has remained stable since 2008. The average age was 69.68 years and diabetic nephropathy (42.5%) was the most common cause in the incident dialysis patients. These patients caused by diabetes did not change in number for recent several years. Further, 32,532 patients died in 2017; the crude mortality rate was 9.8%. The patients treated by hemodiafiltration (HDF) have been increasing rapidly from the revision of medical reimbursement for HDF therapy in 2012. It has attained 95,140 patients at the end of 2017, which were 18,304 greater than that in 2016. The number of peritoneal dialysis (PD) patients was 9090 in 2017, which had been slightly decreasing since 2014. Further, 19.4% of PD patients treated in the combination of hemodialysis (HD) or HDF therapy (hybrid therapy). And 984 patients were treated by home HD therapy at the end of 2017; it increased by 49 from 2016. Trial registration JRDR was approved by the ethical committee of JSDT (approval number 1-3) and has been registered in “University hospital Medical Information Network (UMIN) Clinical Trials Registry” as a clinical trial ID of UMIN000018641 at 8th August 2015. https://upload.umin.ac.jp/cgi-bin/ctr/ctr_view_reg.cgi?recptno=R000021578 (Accessed 31 July 2019).

The clinical characteristics and treatment of patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) after initiating chronic hemodialysis remain unknown. We retrospectively enrolled 11 adult patients with AAV receiving chronic hemodialysis in our hospital from 2000–2016. We collected data describing each patient's clinical findings and treatment before and after initiating hemodialysis. Patients with AAV with and without post-hemodialysis AAV relapse were compared statistically. The average observation period was 6.8 ± 4.1 years, and the interval between diagnosis and initiating chronic hemodialysis was 1.9 ± 2.6 years. Before initiating chronic hemodialysis, five patients (45%) experienced 12 AAV relapses, with diagnoses made serologically or symptomatically. After initiating chronic hemodialysis, four patients experienced nine relapses, with no significant difference between the number of relapses and the number of patients experiencing relapse (p = 0.067 and 0.083, respectively). For patients' entire clinical courses before initiating chronic hemodialysis, the average steroid dose was 11.6 ± 6.9 g/y. Comparing before and after initiating chronic hemodialysis, the steroid dose decreased significantly to 3.3 ± 1.4 g/y after initiating chronic hemodialysis (p = 0.0012). Two of 11 patients died of serious infections after initiating chronic hemodialysis. Our results showed that the number of relapses tended to be lower despite a significantly different lower amount of steroid after initiating hemodialysis compared with before initiating hemodialysis, and the burn-out phenomenon specific to uremic patients was inferred. We believe that early tapering of steroids should be considered to avoid death rather than focusing only on relapse.

Background/Aims: Cross-classification analyses are rarely reported. We investigated the prognostic factors for chronic kidney disease (CKD) progression using a body mass index (BMI)-based cross-classification approach. Methods: Patients’ renal outcome (≥50% decline in the estimated glomerular filtration rate or end-stage renal disease) in each subcohort was examined. Results: The number of prognostic factors identified in the multivariate Cox analysis was smaller in the “BMI ≥25, female” and CKD stage 3 subcohorts than in other subcohorts. Prognostic factors identified in the “BMI ≥25, CKD stage 3” subcohort only comprised albuminuria and male sex, and those in the “BMI ≥25, female” subcohort only comprised albuminuria, hyperphosphatemia, and anemia. Albuminuria, kidney impairment, male sex, hyperphosphatemia, anemia, and increased pulse pressure × heart rate product (PP × HR; pulsatile stress) were stable renal prognostic factors in almost all subcohorts. On the other hand, the prognostic value of increased BMI, younger age, hypoalbuminemia, increased intact parathyroid hormone, and decreased estimated 24-h urinary potassium excretion (e24hUK) differed according to subcohort. BMI was positively associated with CKD progression in the “BMI ≥25, age ≥65 years” and “BMI ≥25, CKD stages 4–5” subcohorts, whereas it was negatively associated with CKD progression in the “BMI Conclusion: A BMI-based cross-classification approach, which provides more comprehensive findings than that in previous approaches, is expected to be an effective method for evaluating renal prognostic factors in patients with CKD who are affected by multiple risk factors.

Background/Aims: Japan’s aging population has prominent epidemiological and patient characteristics. The number of hemodialysis patients aged ≥70 years is increasing. Age-adjusted mortality is improving, but some cause-specific mortalities remain unchanged, including infectious disease and malignancy, requiring combative strategies. However, survival trends for patients aged 90 years or older are not known. Methods: We examined annual data reported by the ­Japanese Society for Dialysis Therapy Renal Data Registry for the period 1987–2014 to determine survival trends. Results: Survival in the super-aged group (≥90 years) is still mostly unimproved. In terms of cause-specific survival, especially death due to heart failure differs distinctly between this group and the remaining elderly patients, indicating that improving their survival is difficult. Alternative dialysis goals could therefore be considered. The major dialysis objective in this population could be to maintain quality of life and limit functional impairment. Conclusion: Survival of the super-aged population has not improved in the last 2 decades. Thus, withholding or withdrawing dialysis and providing conservative management without dialysis treatment could be an important option for patients aged 90 years or older.

Background: In a typical hemodialysis (HD) session, excessive water removal sometimes induces peripheral circulatory failure and a rapid drop in blood pressure. Intermittent infusion hemodiafiltration (I-HDF), a new modality of dialysis therapy, has been developed to improve peripheral circulation by repeated intermittent infusion of dialysate during an HD session. In a typical I-HDF session, we infuse a volume of 200 mL of ultrapure dialysate by backfiltration at 150 mL/min every 30 min. The same volume is alternately removed from the patient’s blood by filtration at a constant rate after each infusion. However, solute removal characteristics in I-HDF have not been clarified previously. We therefore conducted an in vitro study to investigate the characteristics of solute removal and the factors affecting such removal. Summary: We used human plasma to evaluate the effects of filtration (QF)/infusion (QI) flow rates on solute clearance (CL) and to estimate the time-averaged solute CL (TACL) values. The CL values for all solutes decreased with increasing QI. For small molecules such as urea, the CL values predominantly decreased with increasing QI because of decreasing diffusive transport. For medium and large solutes such as β2 microglobulin or larger, CL values predominantly increased with increasing QF because of increasing convective transport. However, the effects of these changes on TACL values were small compared with the CL value in a typical HD session because of the alternate filtration and infusion in I-HDF. Key Messages: Solute removal characteristics in I-HDF do not differ significantly from those in conventional HD treatment.

Background/Aims: Aortic arch calcification (AoAC) is a fatal complication in dialysis. AoAC progression-related molecules in continuous ambulatory peritoneal dialysis (CAPD) remain unclear. Methods: AoAC was estimated using plain chest radiography scoring (AoACS) in 30 CAPD patients (age 49.3 ± 13.4 years). AoAC progression was defined as increased AoACS on follow-up chest X-ray at the end of the study (progressors). Fibroblast growth factor-23 and osteoprotegerin (OPG) were measured. Results: Median follow-up was 38.5 months. Progressors were older, had shorter PD vintage, higher body mass index, and higher serum OPG levels (255.6 ± 109.2 pg/mL) than nonprogressors (183.4 ± 68.2 pg/mL; p = 0.0400). Progressors also showed higher pulse pressure (62.4 ± 20.0 mm Hg) and pulse wave velocity (1,909.9 ± 310.6 cm/s) than nonprogressors (48.5 ± 13.6 mm Hg; p = 0.0030 and 1,390.1 ± 252.8 cm/s; p = 0.0005, respectively). Conclusion: AoAC progression was associated with increased aortic stiffness. OPG may be associated with AoAC progression in CAPD.

Abstract According to the annual survey of the Japanese Society for Dialysis Therapy Renal Data Registry (JRDR) conducted at the end of 2018, a total of 339,841 patients were receiving dialysis (hereinafter, dialysis patients) in Japan. This survey included an investigation of individual test results for hepatitis B surface antigen (HBsAg), hepatitis C virus (HCV) antibody (HCV-Ab), HCV-RNA, and serum alanine aminotransferase (ALT) (glutamic pyruvic transaminase [GPT]). The survey revealed that among dialysis patients in Japan, the prevalence of HBsAg positivity was 1.38% and the prevalence of HCV-Ab positivity was 4.7% at the end of 2018, both of which were markedly lower than the corresponding rates documented in 2007 (9.8% and 4.7%, respectively). The proportion of HCV-RNA-positive patients among all HCV-Ab-positive patients was 37.5%, which was also markedly lower than the percentage recorded in 2007 (64.0%). The prevalence of HBsAg positivity tended to increase as the dialysis vintage increased. The prevalence of HCV-Ab positivity was also not correlated with the dialysis vintage during the first 30 years of dialysis; however, it tended to increase as the dialysis vintage increased beyond the 30th year. Trial registration University hospital Medical Information Network (UMIN) Clinical Trials Registry, UMIN000018641. The JRDR was approved by the ethics committee of the JSDT (approval number 1-3) and was registered on August 8, 2015 (accessed June 2, 2020).

The Oxford classification of IgA nephropathy (IgAN) can evaluate each MEST-C score individually. We analysed a new grading system that utilised the total MEST-C score in predicting renal prognosis. Altogether, 871 IgAN patients were classified into three groups using the new Oxford classification system (O-grade) that utilised the total MEST-C score (O-grade I: 0–1, II: 2–4, and III: 5–7 points), and the 10-year renal prognosis was analysed. The clinical findings became significantly severer with increasing O-grades, and the renal survival rate by the Kaplan–Meier method was 94.1%, 86.9%, and 74.1% for O-grades I, II, and III, respectively. The hazard ratios (HRs) for O-grades II and III with reference to O-grade I were 2.8 (95% confidence interval [CI] 1.3–6.0) and 6.3 (95% CI 2.7–14.5), respectively. In the multivariate analysis, mean arterial pressure and eGFR, proteinuria at the time of biopsy, treatment of corticosteroids/immunosuppressors, and O-grade (HR 1.63; 95% CI 1.11–2.38) were the independent factors predicting renal prognosis. Among the nine groups classified using the O-grade and Japanese clinical-grade, the renal prognosis had an HR of 15.2 (95% CI 3.5–67) in the severest group. The O-grade classified by the total score of the Oxford classification was associated with renal prognosis.

In Japan, kidney diseases are detected in their early stages by various health checkup systems, and thereafter patients may swiftly be indicated to further examinations and treatments, which are fully covered by the public health insurance system. Pathophysiological approaches for primary glomerular diseases based on a kidney biopsy has been one of the mainstreams in the Japanese nephrology. There were about 340,000 chronic dialysis patients and more than 4000 dialysis facilities in Japan. Most of the patients are treated by in-center hemodialysis; home dialysis (both peritoneal dialysis and home hemodialysis) is not the major option. In in-center dialysis, online hemodiafiltration and protein-permeable dialysis have been usually performed to effectively remove middle molecular uremic toxins, which has been a unique concept of chronic dialysis in Japan. Kidney transplantation is gradually developing, but its volume is not enough, especially deceased donors grafts, which is quite low. The most recent major concern is frailty of the dialysis patients who are older and have long dialysis vintage.

The annual survey questionnaires of the Japanese Society for Dialysis Therapy Renal Data Registry (JRDR) were sent to 4458 dialysis facilities at the end of 2018; 4402 facilities (98.7%) responded to the facility questionnaire, and 4222 facilities (94.7%) responded to the patient questionnaire. This paper reports the results obtained in regard to several issues: dialysis fluid quality, prescription of hemodialysis and hemodiafiltration, current status of peritoneal dialysis, and glycemic indices and treatment of diabetic patients.

Abstract The annual survey of the Japanese Society for Dialysis Therapy Renal Data Registry (JRDR) was sent to 4458 dialysis facilities at the end of 2018; among these facilities, 4402 facilities (98.7%) responded to the facility questionnaire, and 4222 (94.7%) responded to the patient questionnaire. The number of chronic dialysis patients in Japan continues to increase every year; as of the end of 2018, it had reached 339,841 patients, representing 2688 patients per million population. Among the prevalent dialysis patients, the mean age was 68.75 years, and diabetic nephropathy was the most common primary disease among the prevalent dialysis patients (39.0%), followed by chronic glomerulonephritis (26.8%) and nephrosclerosis (10.8%). The number of incident dialysis patients was 40,468, and a reduction by 491 from 2017. The mean age of the incident dialysis patients was 69.99 years old. Diabetic nephropathy was also the most common primary disease (42.3%), representing a 0.2 percent point reduction from 2017. The distribution of diabetic nephropathy appears to have reached a plateau. The number of deceased patients during 2018 was 33,863, and the crude annual death rate was 10.0%. Heart failure was the most common cause of death (23.5%), followed by infection (21.3%) and malignant tumor (8.4%); these causes were similar to those for 2017. The number of patients receiving hemodiafiltration has been increasing since 2012, reaching 125,793 or 37.0% of all dialysis patients at the end of 2018. The number of patients receiving peritoneal dialysis has been gradually increasing since 2017, reaching 9445, and 19.7% of these patients were treated using a combination of peritoneal dialysis and hemodialysis or hemodiafiltration. The proportion of patients receiving combination therapy has remained at around 20% of all peritoneal dialysis patients. The number of patients undergoing home hemodialysis was 720, representing an increase of 36 patients from 2017. The 2018 JRDR survey included several topics such as the present status of the patient kinetics of chronic dialysis patients at the end of 2018, water treatment and hemodiafiltration, peritoneal dialysis, treatments for diabetes, mental and physical conditions, and the present status of viral hepatitis. In this paper, we describe the patient and facility kinetics. Trial registration The JRDR was approved by the ethics committee of the JSDT (approval number 1-3) and was registered in the “University hospital Medical Information Network (UMIN) Clinical Trials Registry” under the clinical trial ID of UMIN000018641 on August 8, 2015: (Accessed June 2, 2020)

Objectives Patients undergoing hemodialysis (HD) may have poor nutritional status and hyperphosphatemia. Nephrologists sometimes manage hyperphosphatemia by prescribing phosphate binders and/or recommending restriction of dietary phosphate including protein-rich foods; the later may, however, adversely affect nutritional status. Design and Methods The analysis includes 8805 HD patients on dialysis ≥ 120 days in 12 countries in Dialysis Outcomes and Practice Patterns Study (DOPPS) phase 4 (2009-2011), from 248 facilities. The primary exposure variable was response to the following question: “For patients with serum albumin 3.0 g/dL and phosphate 6.0 mg/dL, do you recommend to (A) increase or (B) decrease/no change in dietary protein intake (DPI)?”. The association between medical director’s practice of recommending an increase in DPI and all-cause mortality was analyzed with Cox regression adjusted for potential confounders. Linear and logistic regressions were used to model the cross-sectional associations between DPI advice practice and intermediate markers of patient nutrition. Results Median follow-up was 1.6 years. In the case scenario, 91% of medical directors in North America had a practice of recommending DPI increase compared to 58% in Europe (range = 36%-83% across 7 countries) and 56% in Japan. The practice of advising DPI increase was weakly associated with lower mortality [HR (95% CI): 0.88 (0.76-1.02)]. The association tended to be stronger in patients with age 70+ years [HR (95% CI): 0.82 (0.69-0.97), P = .12 for interaction]. The practice of advising DPI increase was associated with 0.276 mg/dL higher serum creatinine levels (95% CI: 0.033-0.520) after adjustment for case mix. Conclusions Medical director’s practice of recommending an increase in DPI for HD patients with low albumin and high phosphate levels was associated with higher serum creatinine levels and potentially lower all-cause mortality. To recommend protein intake liberalization in parallel with phosphate management by physicians may be a critical practice for better nutritional status and outcomes in HD patients.

In Japan, the first case of COVID‐19 in dialysis patients was reported on March 1, 2020. A total of 31 cases were reported by April 10, and it increased to 95 by May 15. Thereafter, with the rapid increase in the number of COVID‐19 cases in the general population since late March, there was a not surprising increase in the number of COVID‐19 cases in dialysis patients. The mortality rate is 16.2% (16/99 cases) in dialysis patients, which is higher than 5.3% (874/16532 cases) in the general population. This higher mortality rate in dialysis patients with COVID‐19 might be related to their age; the majority of COVID‐19 cases are aged between 70 and 90 years in dialysis patients, compared with between 20 and 60 years in the general population. As COVID‐19 presents with severe symptoms and is associated with a high mortality rate in dialysis patients, dialysis patients who have contracted SARS‐CoV‐2 infection confirmed by polymerase chain reaction (PCR) testing are required to be hospitalized under Japanese government policy. In cases of COVID‐19 hospitalizations, it is essential to prevent nosocomial infection. Therefore, patients must be sufficiently instructed in infection prevention and robust measures to prevent contraction and spread of the infection must be taken at dialysis facilities. This article is protected by copyright. All rights reserved.

Longitudinal studies evaluating the association between visceral fat area (VFA) and kidney function decline in patients with chronic kidney disease (CKD) are limited, and little is known about VFA interactions contributing to the kidney prognosis (e.g. interactions between VFA ≥ 100 cm2 and age, sex, and CKD category). In this study, we stratified patients with CKD according to VFA category, as well as age, sex, CKD category, hyperglycemia, and diabetes mellitus, and determined the ability of obesity-related indicators (body mass index, waist circumference, subcutaneous fat area, visceral-to-subcutaneous fat ratio) to predict the renal prognosis. Kidney outcomes (≥ 50% estimated glomerular filtration rate decline or end-stage kidney disease) were examined in 200 patients with CKD (median follow-up, 12.3 years). On multivariable Cox analysis, an increase in VFA (10-cm2 increase) was significantly associated with kidney outcomes in the entire cohort, and VFA was significantly associated with kidney disease progression even in the VFA

Whether the visceral-to-subcutaneous fat ratio (V/S ratio) is associated with renal prognosis in patients with chronic kidney disease (CKD) remains unclear. Furthermore, little is known about the effect of sex and the absolute amount of visceral fat accumulation such as visceral fat area (VFA) ≥100 cm2on the V/S ratio in relation to renal prognosis. In this study, 200 patients with CKD were evaluated for renal prognosis. Survival analyses and logistic regression analyses were conducted, generating time-series pseudo-R2values. The mean and percent change of the pseudo-R2values from the 6thyear to the 10thyear (6Y–10Y Mean and 6Y–10Y Change, respectively) were calculated for determining the cut-off points for the medium-term renal prognosis. Multivariate Cox regression analysis revealed that the V/S ratio was significantly associated with renal outcomes and that the VFA category (VFA ≥ 100 cm2) had significant interactions with the V/S ratio regarding renal prognosis. The hazard ratio (HR) of the V/S ratio was higher in the sub-cohort of VFA<100 cm2than in the sub-cohort of VFA ≥ 100 cm2(HR: 6.42 vs. 1.00). Regarding sex differences, a strong association was noted between the V/S ratio and renal prognosis in women but not in men (HR: 2.40 vs. 1.10). On the other hand, 6Y–10Y Mean of the pseudo-R2values indicated differences in the cut-off points of the V/S ratio between men and women (V/S ratio: 0.75 vs. 0.5). Our findings indicate that it may be clinically meaningful to consider the differences in sex and the amount of VFA ≥100 cm2for the V/S ratio in relation to renal outcomes in patients with CKD. The 6Y–10Y Mean of the pseudo-R2values contributed to determining the cut-off points of the V/S ratio according to the sex difference.

The annual survey of The Japanese Society for Dialysis Therapy Renal Data Registry (JRDR) was conducted for 4396 dialysis facilities at the end of 2016, among which 4336 facilities (98.6%) responded. The response rate of the 2016 survey was comparable with the past, even though it was the second year after the new anonymization method. The number of chronic dialysis patients in Japan continues to increase every year; it has reached 329,609 at the end of 2016. The mean age was 68.15 years. The prevalence rate was 2597 patients per million population. Diabetic nephropathy was the most common primary disease among the prevalent dialysis patients (38.8%), followed by chronic glomerulonephritis (28.8%) and nephrosclerosis (9.9%). The rate of diabetic nephropathy and nephrosclerosis has been increasing year by year, whereas that of chronic glomerulonephritis was declining. The number of incident dialysis patients during 2016 was 39,344; it has remained stable since 2008. The average age was 69.40 years, and diabetic nephropathy (43.2%) was the most common cause in the incident dialysis patients. These patients caused by diabetes did not change in number for recent several years. Thirty-one thousand six hundred eight patients died in 2016; the crude mortality rate was 9.7%. The patients treated by hemodiafiltration (HDF) have been increasing rapidly from the revision of medical reimbursement for HDF therapy in 2012. It has attained 76,836 patients at the end of 2016, which were 21,503 greater than that in 2015. The number of peritoneal dialysis (PD) patients was 9021 in 2016, which had been slightly decreasing since 2014; 20.3% of PD patients treated in the combination of hemodialysis (HD) or HDF therapy. Six hundred thirty-five patients were treated by home HD therapy at the end of 2016; it increased by 63 from 2015. JRDR was approved by the ethical committee of JSDT and has been registered in “University hospital Medical Information Network (UMIN) Clinical Trials Registry” as an approved number of UMIN000018641 on August 8, 2015.

The annual survey of Japanese Society for Dialysis Therapy Renal Data Registry (JRDR) was conducted for 4380 dialysis facilities at the end of 2015, among which 4321 facilities (98.7%) responded. The response rate of the 2015 survey was comparable with the past, even though it was the first year after the new anonymization method. The number of chronic dialysis patients in Japan continues to increase every year; it has reached 324,986 at the end of 2015. The mean age was 67.86 years. At the end of 2015, the prevalence rate was 2592 patients per million population. Diabetic nephropathy was the most common primary disease among the prevalent dialysis patients (38.4%), followed by chronic glomerulonephritis (29.8%) and nephrosclerosis (9.5%). The rate of diabetic nephropathy and nephrosclerosis has been increasing year by year, whereas that of chronic glomerulonephritis was declining. The number of incident dialysis patients during 2015 was 39,462; it has remained stable since 2008. The average age was 69.20 years, and diabetic nephropathy (43.7%) was the most common cause in the incident dialysis patients. These patients caused by diabetes did not change in number for the last several years. Meanwhile, 31,608 patients died in 2015; the crude mortality rate was 9.6%. The patients treated by hemodiafiltration (HDF) have been increasing rapidly from the revision of medical reimbursement for HDF therapy in 2012. It has attained 53,776 patients at the end of 2015, which were 10,493 greater than that in 2014. In particular, the number of online HDF patients increased about ten times 2012. The number of peritoneal dialysis (PD) patients was 9322 in 2015, which was slightly increased than 2014. Twenty percent of PD patients treated in the combination of hemodialysis (HD) or HDF therapy. Five hundred seventy-two patients underwent home HD therapy at the end of 2015; it increased by 43 from 2014. Further JRDR data analyses could clarify the relationships between various dialysis modalities, patient care, and clinical outcomes; furthermore, it could also make it possible to establish clinical practice guidelines or medical reimbursement revisions based on the evidence. JRDR was approved by the ethical committee of JSDT and has been registered in the “University hospital Medical Information Network (UMIN) Clinical Trials Registry” as an approved number of UMIN000018641 since 2015.

Background/Aims: Potential relationships between serum sclerostin levels and the levels of bone metabolic markers in maintenance hemodialysis (MHD) patients have yet to be evaluated. This study sought to determine whether serum sclerostin levels are associated with mortality in MHD patients. Methods: We measured serum sclerostin levels in a Japanese MHD cohort, classified the patients into tertiles according to these levels, and followed their course for a 42-month period. Results: The cohort consisted of 389 MHD patients and there were 75 deaths. Kaplan-Meier analyses showed that the tertile of serum sclerostin was not associated with mortality risk. Cox analyses showed that there were no significant associations between serum sclerostin level and mortality. Conclusion: Serum sclerostin level was not an independent predictor of mortality in MHD patients after adjustment for several confounders. However, whether clinical interventions to modulate serum sclerostin levels in MHD patients would improve their survival remains to be determined.

Diaphoresis therapy to remove water and solutes for the treatment of advanced chronic kidney disease (CKD) and chronic dialysis patients is an inadequately characterized treatment that was first reported over 50 years ago. Intensive diaphoresis, induced by heat treatment with saunas (dry heat) or hot baths (wet heat), can substantially increase cutaneous losses of water, urea, sodium, potassium, chloride, lactate, and possibly other solutes. How effectively diaphoresis therapy might remove many uremic toxins is not known. Diaphoresis therapy is not sufficiently effective to replace dialysis treatments, but theoretically it might be used to delay the start of chronic dialysis, supplement infrequent dialysis therapy, or augment chronic dialysis treatment perhaps especially for dialysis patients with excessive salt and water intake. Diaphoresis might be helpful for managing edema resistant states. Because it is inexpensive, diaphoresis may be particularly valuable in lower income countries where some patients may need to pay for dialysis. Diaphoresis might enhance some aspects of dietary treatment. The short-term and long-term effectiveness, safety, and patient acceptance of diaphoretic therapy need to be more carefully investigated.

Immunoadsorption with a tryptophan-conjugated column has a limited capacity and reduces fibrinogen. We speculated that immunoadsorption with a selective plasma separator has higher efficiency in removing immunoglobulins than ordinary immunoadsorption without affecting coagulation factors. This study investigated the efficacy of immunoadsorption with a selective plasma separator in vitro. The sieving coefficients, the pool concentration, and the adsorbed amount were investigated serially with up to 5 L of processed plasma. The sieving coefficients of the selective plasma separator were 0.8, 0.5, and 0.1 for albumin, immunoglobulin G (IgG), and factor 13, respectively. The trend of concentrations for the ordinary plasma separator in the pool reached its nadir at 1.5 L and 3.5 L of plasma processed for IgG, IgG1, or IgG2, and IgG3, respectively. However, the volume was doubled for the selective plasma separator. The trends of fibrinogen and factor 13 concentrations differed significantly between two plasma separators. The trends of the absorbed amount were mirror images of the concentration in the pool. Comparison of the peak amount absorbed indicated that the amounts were almost identical between the two separators for IgG, IgG1, and IgG2. On the other hand, the peak amounts were less for albumin, fibrinogen, and IgG3 with the selective plasma separator than with the ordinary separator. Although further investigations about bradykinin are required, immunoadsorption with the selective plasma separator supports the administration of more frequent and intensive treatments to remove IgG1 or IgG2 without affecting coagulation factors.

Background: Hypothesizing that statins may be useful as adjuvant treatment for renal anemia, we examined the association between statin prescription (Rx) and erythropoiesis-stimulating agent (ESA) hyporesponsiveness in Japanese hemodialysis (HD) patients prescribed ESAs. Methods: We examined 3,602 patients in 60 HD facilities dialyzed 3 times/week for ≥4 months from the Japan Dialysis Outcomes and Practice Patterns Study phases 3-5 (2005-2015). Statin Rx was reported at the end of a 4-month interval (baseline) for each patient. ESA hyporesponsiveness in the subsequent 4 months was then defined as a binary indicator (mean hemoglobin [Hgb] level 6,000 units/week) and separately as the ESA resistance index (ERI; mean ESA dose/[dry weight × mean Hgb]). We used adjusted logistic and linear regressions to evaluate the associations between statin Rx and ESA hyporesponsiveness. Results: At baseline, 16.2% of patients reported statin Rx; 12.8% were classified as having ESA hyporesponsiveness during 4 months of follow-up. Compared to patients without statin Rx, patients with statin Rx had lower odds of ESA hyporesponsiveness (OR 0.87; 95% CI 0.66-1.15). Similarly, the ERI was lower for those with statin Rx than without (ratio of means, 0.94; 95% CI 0.89-0.99) after adjustment for possible confounders. Conclusions: Our results suggest that statins may slightly reduce ESA hyporesponsiveness in HD patients. However, any causal inference is limited by the observational study design and unmeasured compliance with statin Rx.

In recent years, a concept of renal rehabilitation has become widely known among nephrology specialists, dialysis specialists, kidney transplantation specialists, rehabilitation specialists, nutrition specialists, guideline specialists, nurses, physiotherapists, and representatives of patients. Therefore, in order to make it clear the definition, methods, and effectiveness of renal rehabilitation in Japan, we launched Renal Rehabilitation Guideline Preparation Committee in 2016 as a part of works in the Japanese Society of Renal Rehabilitation, and created a guideline in accordance to the “Minds Handbook for Clinical Practice Guideline Development 2014”. Here, we report systematic reviews and recommendations of exercise therapies in patients with kidney diseases based on the guideline preparation committee works. Six recommendations for the condition of each kidney disorder, groups addressing nephritis/nephrosis, chronic kidney diseases, dialysis therapy, and kidney transplantation were created. All the recommendation grades were determined by a consensus conference participated in by representatives of patients and various professionals. The purpose of this report is to provide an evidence-based, best practice summary to optimize the quality, safety and efficacy, and availability of renal rehabilitation service, and to provide care for maximum patient prognosis, quality of life, and satisfaction.

Cell-free and concentrated ascites reinfusion therapy (CART) is now attracting rising attention as one of the strategies against cancer-related malignant ascites in Japan. Several studies report the safety, effectiveness, and complications of CART applied to patients with malignancies. However, its mechanism reflecting these effects still remains unclear. We evaluated concentration of inflammatory cytokines including interleukin (IL)-1β, IL-6, IL-8, IL-12, tumor necrosis factor (TNF)-α, and immunosuppressive cytokine IL-10 in ascites before CART procedures. We investigated their impacts on survival. IL-1β, IL-6, IL-8, TNF-α, and IL-10 were detected in ascites of the patients undergoing CART. Significant body temperature elevation, one potential complication of CART, was observed among the patients although it was not clinically important. There were no significant correlations between changes in body temperature and the concentration of IL-6, IL-8, and IL-10. The presence of IL-10 in ascites significantly related to longer survival after the first session of CART procedures. However, we observed no other clinically important correlation between cytokine concentrations and changes in WBC and CRP. Concentration of inflammatory cytokines in ascites did not relate to body temperature change, the chief complication of CART. Surprisingly, the presence of IL-10 in ascites related to longer survival after CART. Immunological environment of cancer-related ascites may reflect the outcome of CART and improve survival in those with malignancy.

Since 2009, the peritoneal dialysis (PD) registry has been carried out as part of the annual nationwide survey conducted by the Statistical Survey Committee of the Japanese Society for Dialysis Therapy with the cooperation of the Japanese Society for Peritoneal Dialysis. In this study, the current status of PD patients is reported on the basis of the results of the survey conducted at the end of 2013. The subjects were PD patients who lived in Japan and participated in the 2013 survey. Descriptive analysis was performed for various items including the current status of the combined use of PD and another dialysis method such as hemodialysis (HD) or hemodiafiltration (HDF), the method of exchanging dialysate, the use of an automated peritoneal dialysis (APD) machine, and the incidences of peritonitis and catheter exit-site infection. From the results of the facility survey in 2013, the number of PD patients was 9392, a decrease of 122 from that in 2012. Among the entire dialysis patient population, 3.0% were PD patients, a decrease of 0.1%. Among the studied patients, 292 had a peritoneal catheter and underwent peritoneal lavage, 174 were started on PD in 2013 but introduced to other blood purification methods in 2013, and 1920 underwent both PD and another dialysis method such as HD or HDF. The percentage of patients who underwent PD and another dialysis method increased with the number of years on PD

Background: Transferrin saturation (TSAT) is an index that represents the iron-binding capacity of transferrin, which is the main transport protein for iron, and is widely used to evaluate iron status. Objective: To evaluate the prognostic importance of TSAT in Japanese patients on maintenance hemodialysis (MHD). Methods: A total of 398 patients on MHD were recruited and divided into 3 groups on the basis of their baseline TSAT levels (40%). Results: There was no difference in the proportion of patients on erythropoiesis-stimulating agents or iron supplements between the 3 groups. During a mean follow-up period of 52.2 ± 1 6.3 months, 130 patients died of cardiovascular causes (n = 63, 15.8%) or infection (n = 47, 11.8%). Compared with the reference group (TSAT 20–40%), patients with a TSAT p = 0.0452). Kaplan-Meier analysis showed that all-cause mortality rate was significantly higher in patients with TSAT p = 0.0353). Conclusions: Low TSAT was a significant independent risk factor for all-cause mortality in a cohort of Japanese patients on MHD. The findings of this study suggest that the adverse clinical outcomes in patients with low TSAT can be partly attributed to infection-related iron deficiency.

The concentration of sodium in dialysis fluid, a major determinant of extracellular fluid volume and blood pressure, plays a major role in the sodium balance in end-stage renal disease patients. A low dialysate sodium concentration (DNa) reduces interdialytic weight gain (IDWG) and blood pressure and might help ameliorate endothelial dysfunction and inflammation. However, low DNa can also increase the incidence of hypotensive episodes and muscle cramps. Sodium profiling, as typically prescribed in which the DNa is ramped up from above 140 mEq/L to nonphysiological levels, might reduce hypotension in patients with hemodynamic instability but at the cost of the consequences of hypernatremia. Serum sodium concentrations of individual patients fall within a narrow range around a "sodium setpoint." The sodium gradient, the difference between the sodium set point and the DNa, is associated more robustly with clinical outcomes than DNa itself. Sodium concentration presents several issues: the influence of the net negative charge of plasma proteins on sodium flux across the dialysis membrane (Donnan equilibrium); and the clinically important problems in measuring sodium levels. This article presents a review of the clinical effects of DNa and of basic aspects of sodium balance in hemodialysis patients.

Shunji Suzuki,1,2 Norio Hanafusa,3 Kenji Kubota,1 Ken Tsuchiya,3 Kosaku Nitta2 1Department of Nephrology, Kawaguchi Saiseikai Hospital, Kawaguchi, Japan; 2Department of Medicine, Kidney Center, Tokyo Women’s Medical University, Tokyo, Japan; 3Department of Blood Purification, Kidney Center, Tokyo Women’s Medical University, Tokyo, Japan Background: Fluid overload in chronic kidney disease (CKD) is generally controlled by diuretics, with potentially harmful effects on renal function. The efficacy of tolvaptan, a vasopressin V2-receptor antagonist and aquaretic, has not been evaluated for fluid control in CKD with reduced renal function.Methods: Each patient from a group of 24 CKD patients on tolvaptan 15 mg/d plus conventional diuretics (T group) was matched by age and sex with a patient from a group of 24 CKD patients on conventional nonaquaretic diuretics alone not associated to tolvaptan other than tolvaptan (C group). Changes in renal function were compared between the groups for 1 year.Results: There were no significant differences in blood pressure, hemoglobin levels, cardiac function, urine specific gravity, and urinary sodium concentration between the 2 groups at the beginning of the follow-up period and 1 year after. The estimated glomerular filtration rate (eGFR) by the formula developed by Japanese Society of Nephrology (in mL/min/1.73 m2) decreased: C group (from 28.3±13.6 to 23.0±12.3, p=0.09), T group (from 22.7±12.4 to 19.4±12.2, p=0.18), but both did not reach significance. A 50% reduction in eGFR was observed in 4 patients in the C group and 1 in the T group (p

Background/Aims: Aortic arch calcification (AoAC) is frequently detected in maintenance hemodialysis (MHD) patients and is associated with cardiovascular and all-cause mortality. We investigated the factors associated with AoAC and analyzed the relationship between the factors including bone-derived biomarkers and AoAC. Methods: We enrolled 389 stable MHD patients. AoAC was assessed using chest-X ray examination. Demographic data was collected in addition to serum levels of biochemical and bone-derived biomarkers, including sclerostin and fibroblast growth factor-23 (FGF-23). Results: Two hundred sixteen patients (55.5%) had AoAC. Patients with AoAC score ≥ 4 were older, with a higher percentage being male, and exhibited lower serum levels of albumin and triglyceride. Serum FGF-23 levels were inversely associated with AoAC severity, and FGF-23was directly related to vascular calcification. Age, gender, and dialysis vintage were independent predictors of AoAC. Conclusion: MHD patients have a high prevalence of AoAC. The grade of AoAC was dependent on older age in association with longer dialysis vintage. Levels of circulating FGF-23 but not sclerostin were related to AoAC severity. Serum FGF-23 levels were independently associated with AoAC.

A nationwide survey of 4325 dialysis facilities was conducted at the end of 2013, among which 4268 (98.7%) responded. The number of new dialysis patients was 38,095 in 2013. Since 2008, the number of new dialysis patients has remained almost the same without any marked increase or decrease. The number of dialysis patients who died in 2013 was 30,751. The dialysis patient population has been growing every year in Japan; it was 314,438 at the end of 2013. The number of dialysis patients per million at the end of 2013 was 2470. The crude death rate of dialysis patients in 2013 was 9.8%. The mean age of new dialysis patients was 68.7 years and the mean age of the entire dialysis patient population was 67.2 years. The most common primary cause of renal failure among new dialysis patients was diabetic nephropathy (43.8%). The actual number of new dialysis patients with diabetic nephropathy has almost been unchanged for the last few years. Diabetic nephropathy was also the most common primary disease among the entire dialysis patient population (37.6%), followed by chronic glomerulonephritis (32.4%). The percentage of dialysis patients with diabetic nephropathy has been increasing continuously, whereas the percentage of dialysis patients with chronic glomerulonephritis has been decreasing. The number of patients who underwent hemodiafiltration (HDF) at the end of 2013 was 31,371, a marked increase from that in 2012. This number is more than twice that at the end of 2011 and approximately 1.5 times the number at the end of 2012. In particular, the number of patients who underwent online HDF increased approximately fivefold over the last 2 years. Among 151,426 dialysis patients with primary causes of renal failure other than diabetic nephropathy, 10.8% had a history of diabetes. Among those with a history of diabetes, 26.8% used glycoalbumin as an indicator of blood glucose level; and 33.0 and 27.6% were administered insulin and dipeptidyl peptidase (DPP)-4 inhibitor, respectively, as a medication of diabetes. The facility survey showed that 9392 patients underwent peritoneal dialysis (PD). The patient survey revealed that 1920 of these PD patients also underwent another dialysis method using extracorporeal circulation, such as hemodialysis (HD) or HDF. The number of patients who underwent HD at home at the end of 2013 was 461, a marked increase from that at the end of 2012 (393).

Since 2009, the peritoneal dialysis (PD) registry survey has been carried out as part of the annual nationwide survey conducted by the Statistical Survey Committee of the Japanese Society for Dialysis Therapy with the cooperation of the Japanese Society for Peritoneal Dialysis. In this report, the current status of PD patients is presented on the basis of the results of the survey conducted at the end of 2012. The subjects were PD patients who lived in Japan and participated in the 2012 survey. Descriptive analysis of various items was performed, which included the current status of the combined use of PD and another dialysis method such as hemodialysis (HD) or hemodiafiltration (HDF), the method of exchanging dialysate, the use of an automated peritoneal dialysis (APD) machine, and the rates of peritonitis and catheter exit-site infection. From the results of the facility survey in 2012, the number of PD patients was 9514, a decrease of 128 from 2011. Among the entire dialysis patient population, 3.1% were PD patients, a decrease of 0.1%. Among the studied patients, 347 had a peritoneal catheter and underwent peritoneal lavage, 175 were started on PD in 2012 but introduced to other blood purification methods in the same year, and 1932 underwent both PD and another dialysis method such as HD or HDF. The percentage of patients who underwent PD and another dialysis method increased with PD vintage

There are regional differences in the survival of incident dialysis patients, but few studies have investigated the reasons. We assessed the effect of institutional factors on factors on survival (by both cross-sectional assessment and after a 1-year investigation) in a cohort of the Japanese Society for Dialysis Therapy (JSDT). We investigated 20 institutional factors from 3958 dialysis institution data of the 47 prefectures in Japan in 2005 and the JSDT database of 102,011 patients who commenced dialysis during 2004-2006. Univariate regression analysis between 20 factors and 1-year survival rate, Kaplan-Meier method, log-rank test, and Cox's proportional hazard model between the upper 24 and the lower 23 prefectures of the significant factors were carried out. The age-adjusted 1-year survival rate was 0.832 ± 0.027. Deaths occurred in 15.0% in 24 upper survival prefectures and 18.7% in 23 lower survival prefectures (P

The Japanese Society for Dialysis Therapy (JSDT) collects the clinical data from all the facilities to create a nation-wide registry system named JSDT Renal Data Registry (JRDR). This survey was begun in 1966 as a form of facility survey. Patient survey started in 1983. More than 95% of facilities respond to the survey on the basis of voluntary work of facility staffs. Therefore, JRDR has the longest history and the most comprehensive coverage. As for the prevalent patients, 304,856 patients are treated by dialysis therapy in Japan as of the year 2011. The demographics of the Japanese dialysis population have been markedly changing in terms of age, primary diagnoses and dialysis vintage. The mean age of prevalent population reaches 66.55 years at the end of 2011. The increase in the numbers of dialysis population is due to the growth of those older than 65 years old. Patients with the vintage longer than 20 years account for 8% of the entire population. Around 38 thousands patients started their dialysis treatments, whereas 31 thousands deceased. The disease burden of cardiovascular diseases as well as infection is substantial due to the demographic changes. Many evidences have been reported from the data obtained from JRDR to date. These findings covers a wide range of dialysis practice and are utilized for the development of JSDT guidelines. Therefore, JRDR has provided indispensable and fundamental data of Japanese dialysis population.

Yuzo Watanabe, Kunihiro Yamagata, Shinichi Nishi, Hideki Hirakata, Norio Hanafusa, Chie Saito, Motoshi Hattori, Noritomo Itami, Yasuhiro Komatsu, Yoshindo Kawaguchi, Kazuhiko Tsuruya, Yoshiharu Tsubakihara, Kazuyuki Suzuki, Ken Sakai, Hideki Kawanishi, Daijo Inaguma, Hiroyasu Yamamoto, Yoshiaki Takemoto, Noriko Mori, Kazuyoshi Okada, Hiroshi Hataya, Takashi Akiba, Kunitoshi Iseki, Tadashi Tomo, Ikuto Masakane, Tadao Akizawa, and Jun Minakuchi, for “Hemodialysis Initiation for Maintenance Hemodialysis” Guideline Working Group, Japanese Society for Dialysis Therapy

Background: Continuous renal replacement therapy (CRRT) is performed mainly in patients with acute kidney injury, severe sepsis, or septic shock. Evidence has emerged about the indications for and therapeutic conditions of CRRT. In this review, we focus on the evidence for CRRT to date. Summary: CRRT employs diffusion, convection and adsorption to remove solutes from plasma. Indications can be divided into renal and non-renal indications. Concrete renal indications have not yet been determined, except for life-threatening absolute indications. Modality selection is a point of debate. Intermittent renal replacement therapy is reportedly equivalent to CRRT in terms of overall survival. However, the selection of modality must consider individual circumstances. The optimal dosage of CRRT has proven to be lower than that previously recommended, and the dosage is almost the same as the one employed in the ‘real-world' setting. Patients treated by CRRT often have bleeding complications. In this situation, regional citrate anticoagulation can be used, but nafamostat is widely used in Japan. The right jugular vein is the most preferred vascular access site because it has the lowest likelihood of catheter malfunction. As for the complications of CRRT, hypophosphatemia and nutrient loss should be managed properly. When CRRT is no longer necessary, we should consider the appropriate timing of discontinuation. Key Messages: Even though CRRT is an established technique, several points remain under debate. Individualization of therapy should be considered in light of the changes in patient characteristics.