Diffuse Alveolar Hemorrhage Caused by Disseminated Cryptococcosis in a Patient With Systemic Lupus Erythematosus.

A teenage girl with systemic lupus erythematosus (SLE) was admitted with fever, dry cough, and dyspnea on exertion. Chest computed tomography revealed bilateral diffuse infiltration and swelling of the mediastinal lymph nodes. The bronchoalveolar lavage (BAL) fluid was light red, suggesting diffuse alveolar hemorrhage (DAH). Therefore, glucocorticoid pulse therapy was initiated. However, blood and BAL fluid cultures showed the growth of Cryptococcus neoformans. The patient was diagnosed with disseminated cryptococcosis. The patient was treated with liposomal amphotericin B and flucytosine; the prednisolone dose was rapidly tapered. Infections should be thoroughly ruled out in patients with SLE and DAH.

The impact of malnutrition on the effectiveness of intradialytic exercise in hemodialysis patients: amulticenter cohort study.

PURPOSE: Low physical function can be effectively improved via intradialytic exercise. However, the association between the effects of intradialytic exercise on physical function and malnutrition severity has not been studied extensively. This study aimed to investigate the impact of nutritional status severity on physical function in patients undergoing hemodialysis with low physical function to whom intradialytic exercise was prescribed. METHODS: The participants were patients with decreased mobility [walking speed < 1.0 m/s and/or Short Physical Performance Battery (SPPB) < 12] who had been undergoing hemodialysis thrice a week for 6 months and performing intradialytic exercise program. Patients were divided into groups based on the Geriatric Nutritional Risk Index (GNRI) [Non-malnutrition group (GNRI > 98), Gentle/slim malnutrition group (GNRI ≤ 98, GNRI ≥ 92), Mild malnutrition group (GNRI < 92, GNRI ≥ 82), Severe malnutrition group (GNRI < 82)]. The primary outcomes were Grip strength, isometric knee extension strength (IKES), SPPB, and 10-m walking speed measured at baseline and at 6 months. Statistical analyses were performed using a linear mixed-effects model with the intention-to-treat analysis, including within-group analysis and between-group comparison. RESULTS: A total of 805 participants were included in the study. Within-group comparisons showed significantly improved IKES, 10-m walking speed, and SPPB improved, except in the Severe malnutrition group. Grip strength significantly improved in the Gentle/slim and mild malnutrition groups. Between-group comparison with controls showed that the improvement in Grip strength was significantly bigger in the Gentle/slim malnutrition group [0.98 (0.15 to 1.82) kg] than in the non-malnutrition group. However, IKES in the Severe malnutrition group [- 5.14 (- 9.18 to - 1.10) %] less significantly improve than that in the non-malnutrition group. No significant differences were found in the other indices. CONCLUSION: In patients with severe malnutrition, the changes in IKES scores resulting from Intradialytic exercise were significantly smaller than those observed in non-malnourished patients. Therefore, it is necessary to initiate suitable nutritional and exercise therapy based on the severity of malnutrition.

Factors associated with improved health-related quality of life due to improvements in physical function and dialysis-related symptoms following intradialytic exercise in outpatients undergoing haemodialysis.

PURPOSE: Exercise therapy is a crucial intervention for improving health-related quality of life (HRQOL) in patients undergoing haemodialysis. However, factors that improve HRQOL by improving physical function and dialysis-related symptoms remain unknown. This study aimed to examine the physical function parameters and dialysis-related symptoms that improve HRQOL following intradialytic exercise. METHODS: This multicentre cohort study included 596 patients who participated in an intradialytic exercise program three times per week for a period of 6 months, which comprised of stretching and resistance training. EuroQol 5 dimensions 5-level (EQ5D-5L), grip strength, isometric knee extension strength, 10-m walking speed, Short Physical Performance Battery (SPPB), and improvement in dialysis-related symptoms were measured at the baseline and post-intervention. A linear mixed model was used to analyse the effects of improved physical function and dialysis-related symptoms on improvements in EQ5D-5L. RESULTS: As a physical function index affecting ΔEQ5D-5L, only SPPB showed a significant increase in ΔEQ5D-5L compared with the non-improved group [difference in ΔEQ5D-5L, 0.05 (0.004 to 0.092) point; p < 0.05]). In addition, dialysis-related symptoms with Improved physical conditions [difference in ΔEQ5D-5L, 0.07 (0.02 to 0.13) point] and an Extended walking distance [difference in ΔEQ5D-5L was 0.07 (0.01 to 0.12) point] significantly influenced ΔEQ5D-5L (p < 0.05, both). CONCLUSIONS: The improvements observed in the SPPB scores and self-percieved physical fitness and ambulation range, attributable to intradialytic exercise, may potentially improve HRQOL.

Age-associated effects of intradialytic exercise on physical function and nutritional status in patients receiving ambulatory hemodialysis: A multicenter cohort study.

INTRODUCTION: Intradialytic exercise is essential for improving physical function for older patients. This study aimed to examine the relationship between the effects of exercise therapy and aging. METHODS: This multicenter cohort study included 1176 patients aged 40-89 years, who participated in an intradialytic exercise program, comprising stretching and resistance training, three times per week for 12 months. Isometric knee extension strength (IKES), 10-m walking speed, Short Physical Performance Battery (SPPB), and Geriatric Nutritional Risk Index (GNRI) were measured at baseline and after 12 months. The patients were divided according to age as follows: 40-59, 60-69, 70-79, and 80-89 years. A linear mixed-effects model examined the improvement within-group and between-control differences, as the 40-59 age group was the control group. FINDINGS: The 40-59, 60-69, 70-79, and 80-89 age groups comprised 180, 317, 466, and 213 participants, respectively. Within-group differences, all the age groups significantly improved IKES and SPPB. The 10-m walking speed [0.02 (0.02) m/s] and GNRI [0.38 (0.33)] did not improved only in the 80-89 age group despite other age groups significantly improved. Between-control differences, IKES of the 70-79 age group [-0.24 (-0.42 to -0.06) %] was significantly lower improvement than control. GNRI of all the older groups were significantly smaller improvement than control (p < 0.05). DISCUSSION: The older group demonstrated difficulty in improving walking ability and nutritional status compared with the younger groups. Clinicians need to consider the difference in effectiveness due to age and prescribe intradialytic exercises accordingly.

Differences in the purpose of exercise between hemodialysis patients who continued or dropped out of exercise programs: a multicenter cohort study.

BACKGROUND: Selecting suitable exercise goals is crucial for fostering adherence to, and maintenance of, exercise therapy. We aimed to evaluate the variance in exercise objectives between individuals who continued and those who dropped out of a 6-month intradialytic exercise program by analyzing an open-ended questionnaire administered to patients undergoing hemodialysis. METHODS: The study consisted of outpatients (n = 541; mean age, 70 years) undergoing maintenance hemodialysis, who had been informed of an intradialytic exercise program and voluntarily agreed to participate. The primary outcome was the exercise purpose. The difference in exercise purpose was quantitatively analyzed between the exercise continuation and dropout groups. A co-occurrence network was created and concepts were constructed. The basic attributes were compared using chi-squared and independent t-tests. RESULTS: Over 6 months, 154 patients (28.5%) dropped out of the intradialytic exercise program. Concepts related to the goals of the program were: (1) physical function and condition, (2) addressing limitations, (3) maintaining daily life activities, and (4) physical condition recognition. Co-occurrence network analysis showed that the exercise continuation group established their objectives based on the health benefits of exercise, and proactively set goals rooted in comprehending their current issues and problems. The dropout group tended to perceive treatment passively as an extension of daily clinical practice, rather than actively formulating exercise objectives. CONCLUSION: The exercise objectives of those who continued the exercise program differed from those who dropped out. Patients in the exercise continuation group set more affirmative and specific exercise objectives, whereas those in the dropout group set more passive and abstract exercise objectives.

The study of exercise therapy using a virtual reality system on healthy subjects assuming hospital use and intradialytic exercise.

This study aimed to investigate the basic data on the effectiveness and safety of the system in healthy subjects using an immersive virtual reality (VR) exercise system specialized for therapeutic exercise therapy during dialysis or hospital use. A total of 15 healthy adult subjects performed four exercises, namely lifting and rowing exercises using VR and each movement exercise without VR (control). The simulator sickness questionnaire (SSQ) was administered pre- and post-operatively to assess for VR sickness. Blood pressure, heart rate (HR), rating of perceived exhaustion, Profile of Mood States 2nd Edition Japanese version, and muscle activity (iEMG) were measured using electromyography. The correlation between changes in mood states and HR or iEMG results was examined. The SSQ measured post-VR exercise was 11.2 (18.7-7.5) and 11.2 (7.5-29.9) points in the lifting and rowing VR, respectively. The HR in lifting (VR, 82.5 ± 12.7 vs control, 71.6 ± 10.6 bpm, P<0.05) and rowing (VR, 94.2 ± 13.1 vs control, 83.5 ± 12.0, P<0.05) with VR exercise was significantly higher than in control. No significant differences were observed between the other variables. There was a positive correlation between HR and negative mood in the lifting VR condition (r=0.64, P<0.05), but not in the control group. Contrastingly, there was a positive correlation between iEMG and negative mood in rowing control (r=0.56), but not VR. Safety was confirmed, with no VR sickness or discontinuation of the system. Exercise therapy using VR resulted in a higher exercise load. This VR system has the potential for additional effective intradialytic exercises and hospital use.

Factors affecting presenteeism in workers with nocturnal hemodialysis: A two-center cross-sectional study.

INTRODUCTION: Presenteeism and work dysfunction in dialysis patients should be assessed to improve disease management and work productivity. Therefore, this study aimed to investigate the prevalence and factors surrounding presenteeism and work dysfunction in workers with nocturnal hemodialysis. METHODS: This multicenter cross-sectional study included 42 workers with nocturnal hemodialysis. Presenteeism was measured in patients using the Work Functioning Impairment Scale (WFun), employment status, exercise habit, and exercise self-efficacy (SE). RESULTS: The WFun score was 12.5 ± 6.3 points, and patients with mild presenteeism were 12 (28.6%), moderate was 2 (4.8%), and severe was 1 (2.4%). Multiple regression analysis, which was adjusted for few confounding factors, showed that WFun had a significant relationship with lower exercise SE (r = -0.32) and normalized protein catabolism rate (r = 0.31). CONCLUSIONS: Working patients with nocturnal hemodialysis had presenteeism and a significant correlation with exercise SE and nPCR. This study provides a framework to prevent work dysfunction in nocturnal hemodialysis patients.

Factors associated with dropout from an intradialytic exercise program among patients undergoing maintenance hemodialysis.

BACKGROUND: Continuation of an intradialytic exercise program is necessary to improve and maintain physical function in patients undergoing hemodialysis. Factors associated with dropout must be identified to ensure program continuation. This study aimed to investigate the dropout rates from an intradialytic exercise program at 6 and 12 months in patients undergoing hemodialysis and to identify dropout predictors. METHODS: This was a multicenter, retrospective observational study. Overall, 980 patients were enrolled in this study. Grip strength, 10-m walking speed, physical function, demographics and blood sampling data were measured at baseline, and dropouts were observed. Patients were classified as either continued or dropped out of the program at 6 and 12 months. The dropout rate was calculated for each time point. Multivariate logistic regression analysis was performed to identify the predictors of dropout. RESULTS: The dropout rate was 26.4% (n = 259) after 6 months, 24.1% (n = 172) between 6 and 12 months, and 44.3% (n = 424) overall at 1 year. Significant predictors of dropout after 6 months were slower 10-m walking speed, older age and high C-reactive protein level. Predictors of dropout after 12 months were slower 10-m walking speed and lower standardized dialysis volume. CONCLUSIONS: Walking capacity, age, inflammation and hemodialysis volume were determinants of dropout from the exercise program. Our findings provide new and important insights into the potential risk factors for dropout from long-term intradialytic exercise programs in patients undergoing hemodialysis.

Influence of Malnutrition on the Improvement of Physical Function by Intradialytic Resistance Exercise in Patients Undergoing Hemodialysis.

OBJECTIVE: Intradialytic exercise improves physical function. However, malnutrition may be an essential factor affecting the effectiveness of exercise to improve physical function. Few studies of the relationship between malnutrition and the effectiveness of intradialytic exercise to improve physical function exist. Therefore, this study investigated malnutrition at the beginning of intradialytic exercise and how it affects the subsequent improvement in physical function. METHODS: Patients who performed intradialytic exercise for 12 months were enrolled in this study. A Geriatric Nutritional Risk Index of 91.2 was defined as malnutrition. Patients were assigned to 2 groups using propensity score matching to adjust for confounding factors. Physical function outcomes were handgrip strength, isometric knee extension strength, short physical performance battery, and 10-m walking speed; these were compared at baseline, 3 months, 6 months, and 12 months. The 2 groups were further divided into another 2 groups as per whether the nutritional status had improved after 12 months; therefore, a total of 4 groups were analyzed. RESULTS: After matching, the data of 154 patients in each group were analyzed. During the intragroup comparison, isometric knee extension strength, short physical performance battery, and 10-m walking speed improved significantly in both groups after intradialytic exercise was started compared with before intradialytic exercise was started. However, there was no significant improvement in handgrip strength in the malnutrition group. There were no significant differences in any of the physical function measurements or changes from the baseline values among the 4 groups divided as per subsequent recovery of the nutritional status. CONCLUSION: Malnutrition may not impact the effectiveness of intradialytic exercise to improve lower-leg physical function. Its effect on the improvement of handgrip strength requires further investigation.

Exercise intolerance and malnutrition associated with all-cause mortality in elderly patients undergoing peritoneal dialysis: a single-center prospective cohort study.

BACKGROUND: Low physical function and malnutrition in elderly patients undergoing peritoneal dialysis (PD) are important issues that may be associated with prognosis. We aimed to determine the association between physical function and nutritional status and survival in elderly patients undergoing PD. METHODS: This single-center, prospective cohort study included 45 stable, ambulatory patients undergoing PD. Physical function was measured using the 6-min walk distance (6MWD) test, 10-m walk speed, handgrip strength, lower extremity muscle strength, and short physical performance battery. Nutritional status was assessed using albumin levels and the Geriatric Nutritional Risk Index (GNRI). Patients were divided into two groups according to adverse events. Receiver operating characteristic curve analysis was used to predict mortality. The relationships between all-cause mortality and physical function and nutritional status were studied using Kaplan-Meier analysis and the log-rank test. RESULTS: The mean patient age was 75.3 ± 6.5 years. The median follow-up time was 32 (interquartile range 18-51) months, during which 11 deaths occurred. Death during follow-up was significantly associated with lower 6MWD (237.4 ± 120.2 vs. 355.2 ± 105.9 m), lower GNRI (77.3 ± 16.3 vs. 89.3 ± 8.1), and lower albumin levels (2.8 ± 0.6 vs. 3.3 ± 0.4 mg/dL) at baseline (p < 0.05). The cut-off values were 338 m, 83.3, and 2.95 g/dL for the 6MWD, GNRI, and albumin levels, respectively. The 6MWD test, GNRI, and albumin levels were significantly associated with all-cause mortality (p < 0.05). Additionally, the group with combined exercise intolerance and malnutrition had a lower survival rate (p < 0.05). CONCLUSION: Lower 6MWD and malnutrition are predictors of mortality in elderly patients undergoing PD.

Tacrolimus Induction Therapy for Nephrotic Syndrome Caused by Minimal Mesangial Lupus Nephritis with Lupus Podocytopathy: A Case-Based Review.

BACKGROUND Nephrotic syndrome caused by minimal mesangial lupus nephritis is considered rare. Nephrotic syndrome can be caused by minimal mesangial lupus nephritis with diffuse epithelial foot-process effacement and lupus podocytopathy. CASE REPORT A 23-year-old Japanese woman diagnosed with mixed connective tissue disease was admitted because of weight gain and generalized edema for 2 weeks prior to admission. She had butterfly-shaped erythema on her cheeks, proteinuria, leukocytopenia with lymphocytopenia, and hypoalbuminemia. She was positive for antinuclear antibodies, and specific autoantibodies were only positive for the ribonucleoprotein (RNP) antigen. She was diagnosed with systemic lupus erythematosus. Renal biopsy showed minor glomerular abnormalities, and immunofluorescence revealed peripheral deposits of IgM and complement C3c. Electron microscopy revealed diffuse podocyte foot-process effacement of >80% of the capillary loop surfaces, with only a few subendothelial deposits. Consequently, we diagnosed minimal mesangial lupus nephritis with lupus podocytopathy. On hospital day 4, we administered 1000 mg/day of methylprednisolone for 3 days, followed by prednisolone 50 mg/day, but proteinuria persisted. On day 12, we administered tacrolimus (3 mg/day). Proteinuria improved and then disappeared on day 17. Prednisolone was gradually tapered and stopped after 3 years, although tacrolimus 3 mg/day was continued. No flare-up was observed 4 years after admission. CONCLUSIONS Tacrolimus showed good efficacy in this case of minimal mesangial lupus nephritis with lupus podocytopathy. Prospective and randomized controlled trials should be conducted to demonstrate the efficacy of tacrolimus for this indication.

Effects of exertional dyspnea on early mobilization of patients with acute decompensated heart failure.

[Purpose] In this study, we investigated the association between exertional dyspnea and length of the mobilization program in patients with acute decompensated heart failure. [Participants and Methods] We recruited all consecutive patients with heart failure who were hemodynamically stabilized after administration of intravenous medication and were able to walk >10 m before admission. Exertional dyspnea was evaluated using the visual analog scale in all patients after the 10-m walk during each session of the mobilization program. Multiple regression analysis was used to determine the factors associated with length of the mobilization program. [Results] Our study included 52 patients. Multiple regression analysis showed that the length of the mobilization program was significantly associated with the visual analog scale on day 3 and the length before the start of the mobilization program; however, the length of the mobilization program showed no significant association with age and blood urea nitrogen levels. The standardized coefficients for the visual analog scale scores on day 3 and the length before the start of the mobilization program were 0.49 and 0.33, respectively. [Conclusion] Exertional dyspnea is a good predictor of the length of the mobilization program. Our findings highlight the importance of evaluation of exertional dyspnea.

Influence of sex differences in maintenance-hemodialysis participants on motivation of exercise therapy implementation: a multicenter cross-sectional study.

BACKGROUND: Exercising requires continuing training and maintenance of motivation. Support for exercise continuation by setting sex-appropriate goals is needed. However, this has not been investigated in patients undergoing hemodialysis. This study aimed to investigate sex differences in exercise motivation by analyzing an open-ended questionnaire of patients undergoing hemodialysis. METHODS: This multicenter, cross-sectional study was conducted among participants undergoing outpatient hemodialysis at 21 dialysis clinics. Before the intradialytic exercise program, a self-reported questionnaire was used to assess exercise purpose using open-label questions. Exercise purpose was analyzed between sexes by quantitative analysis of text, extracting frequently occurring words, creating a co-occurrence network, and constructing concepts. The basic attributes of the two groups were compared using the chi-squared and independent t tests. RESULTS: The analysis of 669 participants who attended an exercise program showed that the common words for exercise purpose in both sexes were strength, maintenance, walking, exercise, and muscle strength. Significant differences were observed in exercise purpose. Concepts related to the purpose of exercise were categorized into (1) physical function and condition, (2) addressing limitations, and (3) maintaining daily life activities. Physical appearance was important in both sexes. The main purpose of exercise for men was to increase physical fitness and muscle strength, while that for women was to maintain or improve their current functional status and prevent limb weakness. Women had significantly weaker muscle strength and poorer exercise habits than men and had more difficulty in daily life, suggesting that their purpose for exercise was to reduce difficulties in daily life and the burden on family. Women had significantly weaker muscle strength and poorer exercise habits than men and had more difficulty in daily life, suggesting that their purpose for exercise was to reduce difficulties in daily life and the burden on family. Furthermore, fear of falls was higher in women and prevention of falls may be a key for motivation. CONCLUSION: Exercise purpose in patients undergoing hemodialysis was summarized into the categories of physical function and condition, exercise, and daily life. Men aimed to maintain and increase their current physical status, and women aimed to reduce anxiety regarding their lower limbs and lack of exercise. It is necessary to consider sex differences in exercise purpose when designing exercise regimens and motivating participants.

Effectiveness and Safety of Rehabilitation for Pediatric Patients with Nephrotic Syndrome in the Acute Phase: A Case Study.

Background: Exercise therapy for patients with pediatric nephrotic syndrome is necessary to improve physical function to maintain the patient's activities of daily life and school life while managing the risk of relapse; however, few studies have examined exercise therapy in the acute phase of the syndrome. This case study aimed to evaluate the efficacy and safety of exercise therapy in a patient with acute pediatric nephrotic syndrome being treated with steroids. Case: The patient was a 10-year-old boy diagnosed with primary nephrotic syndrome. Prednisolone (50 mg) was started on the 3rd day of hospitalization. Exercise therapy (moderate-intensity, 40 min, five times a week) was started on the 15th day. The urine protein/creatinine ratio from the 15th day (at the start of rehabilitation) to discharge decreased from 1.1  to 0.4, with no recurrence of nephrotic syndrome. At the initial, middle, and final evaluations, respectively, the grip strength was 10.1, 8.9, and 8.3 kg; the knee extension strength was 0.38, 0.46, and 0.45 kgf/kg; the sit-up test results were 18, 18, and 15 times; the side-step test results were 34, 36, and 31 times; the sit-and-reach test results were 22.9, 24.5, and 23.8 cm; and the 6-min walk test results were 420, 490, and 520 m. Leg muscle strength and exercise tolerance improved, but upper limb strength, trunk muscle strength, and agility decreased. Discussion: Moderate-intensity exercises may be effective and safe for pediatric patients with nephrotic syndrome in the acute phase. Exercise therapy may be beneficial to improve physical function and prevent decline during hospitalization in pediatric nephrotic syndrome patients.

Effect of intradialytic exercise on geriatric issues in older patients undergoing hemodialysis: a single-center non-randomized controlled study.

PURPOSE: This study investigated the effect of 1 year of intradialytic exercise on older hemodialysis patients with geriatric issues. METHODS: Forty-six patients aged ≥ 70 years were non-randomly assigned to two groups (exercise group: 27, control group: 19). Intradialytic exercise consisted of 30 min of aerobic exercise using a cycle ergometer, and resistance training comprising four exercises using an elastic tube three times per week for 1 year. Handgrip strength, leg extremity muscle strength, 10-m walk speed, short physical performance battery, serum albumin, Geriatric Nutritional Risk Index (GNRI), geriatric depression scale, frailty, and mobility were each assessed before and after the intervention. RESULTS: The control group exhibited a significant reduction in handgrip strength, 10-m walking speed, serum albumin, and GNRI after intervention compared to baseline (p < 0.05). Conversely, no significant reductions were observed in the exercise group. The ΔGNRI (effect size, 0.69; 95% confidence interval [CI] - 5.21, - 0.1; p < 0.05) and Δserum albumin (effect size, 0.72; 95% CI - 0.31, - 0.02; p < 0.05) before and after the intervention declined significantly less in the exercise group than in the control group. Other between-group values were not significantly different. The number of frail patients and patients requiring walking assistance exhibited no significant intra-group or between-group differences before and after the intervention. CONCLUSION: Intradialytic exercise prevented the worsening of nutritional status and physical function in the exercise group compared to the control group. Exercise therapy during dialysis is an important aspect of patient care that helps prevent functional decline in older patients.

Investigation of presenteeism, physical function, and exercise habits in workers with CKD: three case reports with literature review.

Management of presenteeism in the context of chronic kidney disease (CKD) is essential for disease management, ensuring the workforce's availability, and reducing health-related costs. The purpose of this case study was to investigate presenteeism, physical function, and exercise habits in three working patients with CKD and discuss their effects. Case 1 was a 71-year-old male security guard; Case 2 was a 72-year-old male agricultural worker; and Case 3 was an 83-year-old male civil engineering employee. Presenteeism was measured using the work functioning impairment scale (WFun), and physical function was measured using grip strength, skeletal muscle mass index, 10 m walk test, short physical performance battery, and exercise habits. The WFun assessment showed that only Case 3 had moderate presenteeism, and the barrier to employment was fatigue. Each value of physical function was higher than the reference value, but Case 3 had the lowest physical function values. All three patients had no exercise habits and were in the interest stage of behavior change. This case report indicates the existence of workers with CKD who need care for presenteeism, even if they have no problems with physical function or activities of daily living. To ensure work productivity in workers with CKD, clinicians may need to evaluate presenteeism, physical function, and exercise habits in addition to popular treatment and care.