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Vascular access intervention therapy (VAIVT) has been positioned as the first choice of treatment for stenosis lesions frequently observed in arteriovenous fistula (AVF) for hemodialysis patients in Japan. Furthermore, increased blood flow can provide a stable dialysis. In contrast, it has been reported that excess blood flow of AVF causes high-output heart failure. Although VAIVT is used to increase blood flow of AVF, the impact of VAIVT on cardiac load has been rarely reported. We examined the factors associated with cardiac load in hemodialysis patients undergoing VAIVT by measuring levels of α human atrial natriuretic polypeptide (hANP) and brain natriuretic peptide (BNP) before and after VAIVT. Data were extracted on hemodialysis patients who underwent measurements of αhANP and BNP in before and after VAIVT at our facility and related facilities between February 2014 and December 2014. Nineteeen patients (median age, 73.0 [66.5-80.5] years; male, 52.6%; 36.8% with diabetes; median duration of dialysis treatment, 50.0 [21-109] months) were enrolled in this study. Flow volume of AVF was higher after VAIVT than that before VAIVT (442.0 vs. 758.0 mL/minute, P

The effects of medium- or long-term use of neutral-pH dialysate on peritoneal transport and peritoneal damage have not been sufficiently researched.We retrospectively evaluated time-dependent changes in the dialysate-to-plasma ratio of creatinine (D/P Cr) and biomarkers of peritoneal damage in the effluent of 65 patients who underwent peritoneal dialysis (PD) with neutral-pH dialysate, including 48 who underwent medium-term PD (≥3 years) and 17 who underwent long-term PD (≥5 years).Patients who underwent medium-term PD initially had a D/P Cr of 0.59 (range: 0.53 - 0.74), nonsignificantly changing to 0.65 (range: 0.55 - 0.73), 0.67 (range: 0.56 - 0.74), and 0.67 (range: 0.62 - 0.72) after 1, 2, and 3 years respectively (p = 0.30, p = 0.26, and p = 0.19). Patients who underwent long-term PD initially had a D/P Cr of 0.57 (range: 0.52 - 0.62), nonsignificantly changing to 0.61 (range: 0.52 - 0.69), 0.64 (range: 0.54 - 0.67), 0.62 (range: 0.57 - 0.66), 0.65 (range: 0.50 - 0.72), and 0.61 (range: 0.48 - 0.7) after 1, 2, 3, 4, and 5 years respectively (p = 0.49, p = 0.31, p = 0.24, p = 0.23, and p = 0.46). After 3 years, a significant increase in effluent hyaluronan (HA) from 90 ng/mL initially (range: 66 - 121 ng/mL) to 144 ng/ mL (range: 116 - 216 ng/mL) was observed (p = 0.04).No significant change in D/P Cr was observed in patients who underwent PD with neutral-pH dialysate. However, effluent HA, which is a biomarker for peritoneal damage, increased. In patients using neutral-pH dialysate, D/P Cr cannot be a biomarker for determining PD discontinuation within 5 years, but effluent HA might be useful.

Background Hyponatremia is one of the most commonly encountered electrolyte disorders in emergency department (ED). Seasonal fluctuations of the prevalence of hyponatremia has been reported. We investigated the impact of age on the seasonal prevalence of hyponatremia in the emergency department in Japan. Methods Total of 8377 patients presented to the ED between January 2015 and December 2016 were reviewed. The adult group aged between 18 and 64 years old consisted of 3656 patients and the elderly group aged over 65 years consisted of 4721 patients. Information collected included age, sex, serum sodium, and serum creatinine. Hyponatremia was defined as a serum sodium leve1

Upon peritoneal dialysis (PD) discontinuation in frail patients, we have re-embedded the catheter and left it subcutaneously buried. However, we have not evaluated the long-term prognosis of those patients after the procedure or the complications associated with buried catheters. We therefore aimed to clarify the long-term prognosis of patients with a re-embedded catheter and to identify any associated complications.The outcomes of 10 patients having a catheter that was re-embedded between February 2010 and May 2016 were assessed by interviewing the patients or their families (when possible), and by reviewing medical records.Catheter re-embedding to reduce the surgical burden was elected by 7 patients, and 3 patients underwent re-embedding because they wanted to resume PD in the future. By the time of the interviews, 6 patients had already died of causes that were unrelated either to the buried catheter or infection. No abnormality was found in any buried catheter. A re-embedded catheter was later externalized to resume PD in 1 of the 4 patients who survived.Catheter re-embedding is safe and allows for PD resumption at the terminal stage of dialysis.

Case presentation A 62-year-old man was diagnosed with peritoneal dialysis (PD)-related peritonitis following diarrhea and determination of a dialysate leukocyte count of 10,224/μL. We cultured peritoneal effluent and started intraperitoneal antibiotic therapy. Peritonitis immediately improved. Peritoneal effluent culture yielded Aeromonas hydrophila. The medical interview revealed that the patient kept goldfish as pets. We suspected that the fish tank water was the source of the infection, considering the association of A. hydrophila with aquatic environments. Culturing of tank water confirmed the presence of Aeromonas. Furthermore, we observed that one of the goldfish was suffering from lepidorthosis, which is commonly caused by Aeromonas, and we then confirmed that the fish's infection was caused by an aeromonad. Conclusion Aeromonas species have rarely been identified as the pathogens in PD-related peritonitis; to our knowledge, there hitherto have been no reports identifying the source of this organism. We present here the process of this infection as elucidated through investigation of the living environment of the patient.

Rationale & Objective Epidemiologic and clinical studies have suggested that urate-lowering therapy may slow the progression of chronic kidney disease (CKD). However, definitive evidence is lacking. Study Design Randomized, double-blind, placebo-controlled trial. Setting & Participants 467 patients with stage 3 CKD and asymptomatic hyperuricemia at 55 medical institutions in Japan. Intervention Participants were randomly assigned in a 1:1 ratio to receive febuxostat or placebo for 108 weeks. Outcomes The primary end point was the slope (in mL/min/1.73 m2 per year) of estimated glomerular filtration rate (eGFR). Secondary end points included changes in eGFRs and serum uric acid levels at 24, 48, 72, and 108 weeks of follow-up and the event of doubling of serum creatinine level or initiation of dialysis therapy. Results Of 443 patients who were randomly assigned, 219 and 222 assigned to febuxostat and placebo, respectively, were included in the analysis. There was no significant difference in mean eGFR slope between the febuxostat (0.23 ± 5.26 mL/min/1.73 m2 per year) and placebo (−0.47 ± 4.48 mL/min/1.73 m2 per year) groups (difference, 0.70; 95% CI, −0.21 to 1.62; P = 0.1). Subgroup analysis demonstrated a significant benefit from febuxostat in patients without proteinuria (P = 0.005) and for whom serum creatinine concentration was lower than the median (P = 0.009). The incidence of gouty arthritis was significantly lower (P = 0.007) in the febuxostat group (0.91%) than in the placebo group (5.86%). Adverse events specific to febuxostat were not observed. Limitations GFR was estimated rather than measured, and patients with stages 4 and 5 CKD were excluded. Conclusions Compared to placebo, febuxostat did not mitigate the decline in kidney function among patients with stage 3 CKD and asymptomatic hyperuricemia. Funding Funded by Teijin Pharma Limited. Trial Registration Registered at the UMIN (University Hospital Medical Information Network) Clinical Trials Registry with study number UMIN000008343.

Rupture of the peritoneal dialysis (PD) catheter is rare complication. Here, we report a case of catheter rupture that occurred because of exercise after partial catheter reimplantation.A 66-year-old man with a history of end-stage kidney disease secondary to diabetic nephropathy experienced refractory exit-site and tunnel infection. After the infected parts of the catheter were excised, a partial catheter reimplantation was performed. At the time of that surgery, a presternal location was selected for the new exit site, and a titanium extender was used to connect the two catheters. The patient was discharged on postoperative day 3, but was readmitted for a pericatheter leak 5 days later. Fluoroscopy performed to investigate the cause demonstrated a pericatheter leak from the connecting portion between the titanium extender and the catheter.Surgery performed to repair the leak revealed that the catheter had ruptured. We believe that the cause of the rupture was mechanical stress induced by the patient's stretching exercise program. The PD catheter was made of silicone rubber with high elasticity. Even when such resilient materials are used, we recommend that, to avoid PD catheter rupture after partial reimplantation, clinicians should discourage the patient from stretching excessively.

Peritoneal dialysis (PD)-related infections (PDIs) such as peritonitis, exit-site infection, and tunnel infection are serious complications affecting patients on PD. Because patients with diabetes (DM) and of older age have increased in number in Japan, the number of patients with visual impairment is estimated also to have increased. Near vision is necessary for performing proper PD daily care. However, no studies have reported whether visual impairment is likely to increase the risk of PDIs.Our study included 31 PD patients (16 men, 15 women; mean age: 61.5 ± 11.8 years; mean PD duration: 27.3 ± 20.3 months; 38.7% with DM; 54.8% wearing glasses) who performed their own PD care. At our facility and related facilities, we used a standard near-vision test chart, which classifies vision into 12 grades, from 0.1 (poor) to 1.5 (clear), to assess near-vision binocular visual acuity in those patients between March 2015 and September 2015. In addition, we retrospectively examined the medical records of the patients to determine their history of PDIs. We then evaluated the correlation between near-vision acuity and the incidence of PDIs.Mean measured near-vision acuity was 0.61 ± 0.29, and we observed no significant difference in the visual acuity of patients with and without DM (0.55 ± 0.31 vs. 0.63 ± 0.26 respectively, p = 0.477). In addition, we observed no significant difference in the incidence of PDIs between patients with and without DM (1.298 ± 1.609 per year vs. 1.164 ± 0.908 per year respectively, p = 0.804). We did not find a correlation between near-vision acuity and the incidence of PDIs (r = -0.071, p = 0.795).

a Department of Rehabilitation Medicine, St. Marianna University School of Medicine Hospital, Kawasaki, Japan b Department of Rehabilitation Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan c Graduate School of Health Sciences, Kobe University, Kobe, Japan d Division of Nephrology and Hypertension, Department of Medicine, Kawasaki Municipal Tama Hospital, Kawasaki Japan e Division of Nephrology and Hypertension, Department of Medicine, St. Marianna University School of Medicine Hospital, Kawasaki, Japan f Japan Community Health Care Organization Tokyo Takanawa Hospital, Tokyo, Japan

Vascular access intervention therapy (VAIVT) has been positioned as the first choice of treatment for stenosis lesions frequently observed in arteriovenous fistula (AVF) for hemodialysis patients in Japan. Furthermore, increased blood flow can provide a stable dialysis. In contrast, it has been reported that excess blood flow of AVF causes high-output heart failure. Although VAIVT is used to increase blood flow of AVF, the impact of VAIVT on cardiac load has been rarely reported. We examined the factors associated with cardiac load in hemodialysis patients undergoing VAIVT by measuring levels of α human atrial natriuretic polypeptide (hANP) and brain natriuretic peptide (BNP) before and after VAIVT. Data were extracted on hemodialysis patients who underwent measurements of αhANP and BNP in before and after VAIVT at our facility and related facilities between February 2014 and December 2014. Nineteeen patients (median age, 73.0 [66.5-80.5] years; male, 52.6%; 36.8% with diabetes; median duration of dialysis treatment, 50.0 [21-109] months) were enrolled in this study. Flow volume of AVF was higher after VAIVT than that before VAIVT (442.0 vs. 758.0 mL/minute, P 0.001). Moreover, resistance index (RI) of AVF after VAIVT was lower than that before VAIVT (0.61 vs. 0.53, P 0.01). Although αhANP did not change before and after VAIVT (55.6 vs. 54.9 pg/mL, P = 0.099), BNP after VAIVT was significantly higher than that before VAIVT (145.2 vs. 175.0 pg/mL, P 0.05). Factors correlated with the increase in BNP were flow volume of AVF before VAIVT (r = -0.458, P = 0.049) and levels of BNP before VAIVT (r = 0.472, P = 0.041). There was no significant correlation between the increase in αhANP with flow volume of AVF before VAIVT, levels of αhANP before VAIVT. Patients with high levels of BNP and low flow volume of AVF before VAIVT were considered to have a high risk of developing heart failure after VAIVT.

We analyzed serum short peptides comprehensively to know whether they were useful to characterize IgA nephropathy (IgAN). Serum samples from 26 patients with untreated IgAN and 25 healthy donors were tested. Short peptides with molecular weights of approximately 7 kDa, purified from the serum samples by magnetic-beads-based weak cation exchange, were detected by mass spectrometry. Then the peptide peaks detected were subjected to the multivariate data analysis by SIMCA-P+ containing principal component analysis (PCA) and orthogonal partial-least-squares-discriminate analysis (OPLS-DA). A total of 92 peptide peaks were detected in the tested serum samples. The OPLS-DA analysis revealed that the profile of all the peptide peak intensities discriminated the IgAN group and the healthy group completely with a high R2 value (0.919) and a high Q2 value (0.861). Further, the profile of only five peptide peaks was found to discriminate the two groups. By tandem mass spectrometry and database searching, three of the five peptides which increased in the IgAN group were identified as fragments of fibrinogen alpha chain, and the two peptides which increased in the healthy group were identified as fragments of complement C3f and kininogen-1 light chain. Taken together, the profile of the serum short peptides would be useful to discriminate IgAN and healthy conditions. Further, the five peptides may be candidate serum markers for IgAN and may be related to pathogenesis of IgA.

In Japan, peritoneal dialysis (PD) catheter insertion has been performed by both nephrologists and surgeons. However, nephrologists have fewer opportunities to train in the insertion procedure. We therefore used a PD access simulator to provide training in this operative technique for nephrologists. A PD access simulator developed by Terumo Medical Corporation was used for the training. The simulator uses a mannequin made of acrylic resin. The abdominal wall of a pig is attached to the abdominal area, and a plastic bag represents the abdominal cavity. The simulator enables the surgical procedure to be performed from skin incision to PD catheter insertion. Between October 2011 and December 2013, 3 supervising doctors used the simulator to guide 17 nephrologists with no experience through a PD catheter insertion. One-on-one training was provided in a single 2- or 3-hour session. In a questionnaire survey after the training, trainees gave high marks to the handling of surgical instruments, the environment of the operating room, and the surgical guidance during training. However, the supervising doctors required the ability to respond flexibly, because trainees had individual differences in skills. The PD access simulator might be useful for providing guided training in operative technique for PD catheter insertion.

Few studies have attempted to evaluate the relationship between peritoneal permeability and fluid status in peritoneal dialysis (PD). The aim of the present study was to clarify the relationship between change in the dialysate-to-plasma ratio of creatinine (D/P Cr) and change in fluid status as evaluated by natriuretic peptides. We studied 49 PD patients (29 men, 62 ± 11 years, 36.7% with diabetes) who underwent a peritoneal equilibration test at least twice after PD initiation. We evaluated correlations between the rate of change in the D/P Cr (R C-D/P Cr), the rate of change in a human atrial natriuretic polypeptide (RC-αhANP), and the rate of change in brain natriuretic peptide (RC-BNP). The RC-αhANP was strongly correlated with RC-BNP (r = 0.637, p0.001). In contrast, the RC-D/P Cr was not correlated with RC-αhANP (r = 0.041, p = 0.781) or with RC-BNP (r = 0.114, p = 0.435). However, positive correlations between RC-D/P Cr and RC-αhANP (r = 0.530, p = 0.006) and between RC-D/P Cr and RC-BNP (r = 0.625, p = 0.001) were observed in patients with increased D/P Cr The present study showed a positive correlation between change in peritoneal transport characteristics and change influid status in patients whose D/P Cr increased.

Peritoneal dialysis (PD) catheter-related infection is still is the most troublesome problem for continuation of PD without the need to switch to hemodialysis. We have been performing subcutaneous pathway diversion (SPD) as a surgical treatment for refractory exit-site and tunnel infection (ESTI). To clarify the efficacy and safety of SPD, we conducted a retrospective study. From August 2008 to August 2013, 30 SPDs were performed in 26 patients (16 men, 10 women; mean age: 58 +/- 13 years; 54% with diabetes; mean body mass index: 23.9 +/- 3.5 kg/ m2). The reasons for the SPDs were ESTI in 25 patients, and outer cuff extrusion in 1 patient. All patients resumed PD immediately after SPD, and the duration of hospitalization was 11.7 +/- 10.1 days. After SPD, one patient experienced a dialysate leak, and another patient experienced a mild subcutaneous hematoma. Another 4 patients developed exit-site infection (ESI) and underwent a second SPD. Of those 4 patients, 3 presented with another ESI unrelated to the first episode, and all developed an ESI after 6 months or more. The remaining 20 patients experienced no such complications. Furthermore, catheter survival after SPD was 17.4 +/- 13.4 months. To eradicate ESTTI we suggest that SPD, which does not require catheter removal or interruption of PD, is useful compared with the unroofing technique or catheter removal.

The proportion of elderly people requiring renal replacement therapy has been increasing in Japan. Although several studies have shown the benefits of peritoneal dialysis (PD) in the elderly, few have reported on outcomes, including prognosis, in elderly PD patients, especially those more than 80 years of age. The purpose of the present study was to evaluate clinical outcomes in elderly (more than 80 years of age) PD patients. We retrospectively evaluated the medical records of elderly PD patients who commenced PD between 2007 and 2011. The frequency of perioperative complications, rate of PD-associated peritonitis, technique survival, overall survival, and utilization of nursing-care insurance systems were investigated as clinical outcomes. The 12 patients eligible for this study (7 men, 5 women; mean age: 85 +/- 3 years) had a median duration of follow-up of 1.2 years (interquartile range: 0.65-1.74 years). Perioperative complications were not observed in any of the patients. The frequency of PD-associated peritonitis was 1 episode in 56 months. During follow-up, 6 patients died, and 3 patients switched to hemodialysis because of tunnel infection or lack of family support. The overall survival rate at 12 months was 83%. Nursing-care insurance was used by 63% of patients. In elderly patients, it is important to predict the potential short-term issues at the initiation of PD to facilitate implementation of social services, such as home-visit nursing-care services, at the time of worsening general condition.

We analyzed serum short peptides comprehensively to know whether they were useful to characterize IgA nephropathy (IgAN). Serum samples from 26 patients with untreated IgAN and 25 healthy donors were tested. Short peptides with molecular weights of approximately 7 kDa, purified from the serum samples by magnetic-beads-based weak cation exchange, were detected by mass spectrometry. Then the peptide peaks detected were subjected to the multivariate data analysis by SIMCA-P+ containing principal component analysis (PCA) and orthogonal partial-least-squares-discriminate analysis (OPLS-DA). A total of 92 peptide peaks were detected in the tested serum samples. The OPLS-DA analysis revealed that the profile of all the peptide peak intensities discriminated the IgAN group and the healthy group completely with a high R2 value (0.919) and a high Q2 value (0.861). Further, the profile of only five peptide peaks was found to discriminate the two groups. By tandem mass spectrometry and database searching, three of the five peptides which increased in the IgAN group were identified as fragments of fibrinogen alpha chain, and the two peptides which increased in the healthy group were identified as fragments of complement C3f and kininogen-1 light chain. Taken together, the profile of the serum short peptides would be useful to discriminate IgAN and healthy conditions. Further, the five peptides may be candidate serum markers for IgAN and may be related to pathogenesis of IgA.