Laparoscopic observations of adhesions between peritoneal dialysis catheters and intraperitoneal organs: A retrospective, observational study.

Laparoscopy provides extensive data for the decannulation of a peritoneal dialysis catheter and is being increasingly used to diagnose encapsulating peritoneal sclerosis. However, there are few reports on the methods of decannulation of peritoneal dialysis catheters. In this study, we examined the laparoscopic findings and postoperative complications of patients undergoing peritoneal dialysis catheter removal. A total of 119 laparoscopic decannulations of peritoneal dialysis catheters were performed between 2003 and 2018 at the Juntendo University Hospital and Juntendo University Nerima Hospital. Laparoscopy was performed during peritoneal dialysis catheter removal by a gastrointestinal surgeon. Patient characteristics such as age, sex, duration of peritoneal dialysis, history of peritonitis and age at the time of peritoneal dialysis termination were assessed. Of these 119 cases, 19 (16.0%) showed adhesion between the peritoneal dialysis catheter and intraperitoneal organs. There were 13 (10.9%) cases involving a tangled omentum, 4 (3.4%) cases involving the small intestine and 2 (1.7%) cases of adhesions extending from the bowels to the abdominal wall. No postoperative complications were associated with the laparoscopic surgery. In these cases, blind decannulation of the peritoneal dialysis catheter may result in injury to the gastrointestinal tract in patients with adhesions. Therefore, we need to pay attention to adhesions between peritoneal dialysis catheters and intraperitoneal organs, and laparoscopy could be a valuable tool in detecting such adhesions and ensuring patient safety.

Impact of Transferrin Saturation and Anemia on Radial Artery Calcification in Patients with End-Stage Kidney Disease.

Background: Arterial calcification is an important factor in determining the prognosis of patients with chronic kidney disease (CKD). Few studies on aortic calcification have involved radial artery calcification (RAC). This study aimed to analyze risk factors for RAC in patients with end-stage kidney disease (ESKD) and investigate the relationship between subsequent cardiovascular events (CVE) and vascular access trouble (VAT). Methods: This cohort study included 64 consecutive patients with ESKD who initiated hemodialysis and underwent a procedure for the creation of a primary radiocephalic arteriovenous fistula (RCAVF). Small arterial specimens were obtained from patients during RCAVF surgery. Tissue samples were stained with von Kossa, and arterial microcalcification was evaluated. We analyzed the association between preexisting arterial microcalcifications, clinical characteristics, CVE, and VAT. Results: In the univariate analysis, RAC patients demonstrated high systolic blood pressure (sBP), low hemoglobin (Hb), and low transferrin saturation (TSAT) (<0.05, <0.05, and <0.05, respectively). In the multivariate analysis, Hb (HR−0.516 (0.278−0.959), p < 0.05), TSAT (HR−0.0012 (0.00000248−0.597), p < 0.05), and sBP (HR−1.037 (1.001−1.073), p < 0.05) were independent risk factors for RAC. The cumulative incidence rate of CVE/VAT was not associated with RAC for one year. Conclusion: RAC was associated with sBP, TSAT, and anemia; however, no association with CVE/VAT was observed.

Effluent N-terminal expressed in renal cell carcinoma/mesothelin predicts increased peritoneal permeability in patients undergoing peritoneal dialysis.

INTRODUCTION: We investigated whether N-terminal and C-terminal products of expressed in renal cell carcinoma/mesothelin (N-ERC and C-ERC) in peritoneal effluent can predict peritoneal permeability in patients undergoing peritoneal dialysis (PD). METHODS: Thirty-seven peritoneal effluent samples were obtained from 26 PD patients. High transport status was determined by the peritoneal equilibration test as a dialysate/plasma ratio of creatinine (D/P Cr) ≥ 0.81. Effluent cancer antigen 125 (CA125) was used as a reference. RESULTS: Effluent N-ERC concentration was better correlated with D/P Cr than effluent C-ERC or CA125 concentration. In multivariate analyses, effluent N-ERC and C-ERC, but not CA125, were significant predictors of high transport status after adjusting for age, PD duration, and residual renal Kt/V. ROC analysis showed that effluent N-ERC was the best predictor of high transport status among those three biomarkers. CONCLUSION: Effluent N-ERC predicts increased peritoneal permeability in patients undergoing PD.

An Unusual Case of Recurrent Migration of the Peritoneal Dialysis Catheter into the Inguinal Hernia Sac.

We herein report the first case of a patient with recurrent migration of the peritoneal dialysis (PD) catheter into the inguinal hernia sac. A 58-year-old man suffered from end-stage renal disease due to polycystic kidney disease (PKD). A year before starting PD, a PD catheter was implanted with stepwise initiation of PD using the Moncrief-Popovich technique. He complained of drain failure and right inguinal swelling during the induction period and was diagnosed with right inguinal hernia. Further examination revealed that the PD catheter tip had migrated into the inguinal hernia sac. Although surgery was planned, the PD catheter tip spontaneously migrated back into the intra-peritoneal space. 14 months later, he noticed fill and drain failure again. Diagnosis was PD catheter dysfunction due to migration into the right inguinal hernia sac. PD was resumed without issues after repositioning of the PD catheter and repair of the inguinal hernia. Inguinal hernia is a frequent complication in PD patients, especially in those with PKD. Early diagnosis and treatment of hernia should be considered in PD patients.

Predictive Value of 1-Week Postoperative Ultrasonography Findings for the Patency Rate of Arteriovenous Fistula.

INTRODUCTION: Most guidelines in different countries recommend waiting more than 2 weeks for the initial cannulation of an arteriovenous fistula (AVF) after its creation. Although an experienced examiner can subjectively determine if an AVF is ready for early cannulation, there is a lack of objective information to guide whether early cannulation is appropriate or how early cannulation may affect an AVF's primary patency. The current study examined the relationship between the initial cannulation and the prognosis of AVF, considering ultrasonography (US) findings. METHODS: This retrospective observational study enrolled 103 patients with end-stage renal disease who had started hemodialysis therapy from 2013 to 2015 at the Juntendo University Hospital. All patients had been given a primary AVF before or after the initiation of dialysis, had undergone US examinations both before and 7 days after surgery, had initially cannulated the AVF at ≥7 days after surgery, and were observed for over 1 year. RESULTS: The factor associated with the loss of primary patency was a resistance index of brachial artery ≥0.65 on US examination at 7 days after surgery. There was no significant difference in patency rate between the early (within 14 days after surgery) and late initial cannulation groups (≥15 days after surgery). CONCLUSION: Because a resistance index <0.65 on US findings at 7 days after surgery was a good indicator for predicting an excellent patency rate when we performed first cannulation of AVF located in the forearm within 2 weeks after its creation, 1-week postoperative US evaluation may provide crucial information.

Multicenter laparoscopic evaluation of the peritoneum in peritoneal dialysis patients.

Laparoscopic findings have been used to confirm peritoneal degenerations in peritoneal dialysis (PD) therapy. This study evaluated morphological changes in the peritoneum and their clinical relevance in patients undergoing PD. Laparoscopic findings at the rectovesical peritoneum were evaluated and scored using an imaging system at the time of PD catheter removal in this multicenter study. Angiogenesis evaluated by the vascular score (VS), color changes score (CCS), plaque score (PS), PD duration, history of peritonitis, dialysate/plasma creatinine (D/P Cr) levels, and age at PD termination were statistically analyzed. The VS of patients with PD duration more than 96 months was significantly decreased compared with that of the other patients and was negatively correlated with D/P Cr levels at PD termination. The CCS for patients with PD duration more than 96 months were significantly higher than those for the other patients and positively correlated with D/P Cr levels at PD termination. The PS of patients with recurring peritonitis were significantly higher than those of the other patients. Diminished vascularity and increased color changes in the peritoneum may be predictive of D/P Cr levels with peritoneal degradation. Laparoscopic evaluation of the abdominal cavity can provide detailed information about peritoneal injury.

Predictive factors associated with increased progression to dialysis in early chronic kidney disease (stage 1-3) patients.

BACKGROUND: It has been reported that echocardiographic parameters are independently associated with the progression to dialysis in patients with chronic kidney disease (CKD) (stages 3-5). The objective of the present study was to evaluate whether physical, biochemical, and echocardiographic parameters are associated with the progression to dialysis in early CKD (stage 1-3) patients. METHODS: This retrospective study enrolled 272 CKD patients who underwent echocardiography at the time of diet education, renal biopsy, and the examination of kidney injuries at Juntendo University Hospital, Tokyo, Japan, from 2001 to 2010. All of these CKD patients were classified into stages 1-3. The study patients received regular follow-up at our outpatient clinic in our division. The renal end point was defined as commencement of dialysis. RESULTS: Patients with progression to dialysis were significantly associated with higher levels of left ventricular mass index (LVMI), urinary protein, systolic blood pressure, many kinds of anti-hypertensive drugs, and lower levels of albumin and hemoglobin. In a Cox proportional hazard regression analysis, LVMI [hazard ration (HR) 1.018; 95 % confidence interval (CI) 1.007-1.029; p = 0.002], urinary protein and hemoglobin were independently associated with factors for progression to dialysis in early CKD patients. CONCLUSION: This study of patients in early CKD demonstrated that higher LVMI and urinary protein and that lower levels of hemoglobin in blood were associated with progression to dialysis. LVMI evaluated by echocardiography may identify a high risk of progression to dialysis in early CKD patients.

Long-term outcome of encapsulating peritoneal sclerosis (EPS) patients in a single center.

BACKGROUND: Encapsulating peritoneal sclerosis (EPS) is the most serious complication of peritoneal dialysis (PD) with a high mortality rate. The objective of the present study was to determine the clinical characteristics, the incidence rate, and the long-term outcome of EPS patients compared with control patients. METHODS: Two hundred and seventy patients with end-stage kidney disease were started on PD from 1987 to 2013 in the Juntendo University Hospital. EPS was diagnosed by clinical findings, radiological findings, and macroscopic inspection at the time of laparoscopy or surgical operation. Patient medical records were analyzed retrospectively, including clinical characteristics, laboratory findings, treatment modality, and outcomes. Using a Kaplan-Meier analysis, we compared the survival rate between EPS patients and control PD patients, matched for age, gender, diabetes, and duration of PD. RESULTS: Among 270 PD patients, 13 patients (4.8 %) developed EPS. The mean duration of PD was 120.5 ± 42.8 months. There were no significant difference in demographic findings between EPS and control PD patients. Among the EPS patients, seven patients died, of which four deaths were directly attributed to EPS. All four patients that had had surgical enterolysis were doing well and had no recurrences. No significant difference in the survival rate between EPS and control PD patients was observed in the Kaplan-Meier analysis. CONCLUSIONS: There was no significant difference in the survival rate between EPS patients and control PD patients. It appears that an early diagnosis by laparoscopy and accurate treatment, including surgical enterolysis, might improve mortality.

Uncoupling of glomerular IgA deposition and disease progression in alymphoplasia mice with IgA nephropathy.

Previous clinical and experimental studies have indicated that cells responsible for IgA nephropathy (IgAN), at least in part, are localized in bone marrow (BM). Indeed, we have demonstrated that murine IgAN can be experimentally reconstituted by bone marrow transplantation (BMT) from IgAN prone mice in not only normal mice, but also in alymphoplasia mice (aly/aly) independent of IgA+ cells homing to mucosa or secondary lymphoid tissues. The objective of the present study was to further assess whether secondary lymph nodes (LN) contribute to the progression of this disease. BM cells from the several lines of IgAN prone mice were transplanted into aly/aly and wild-type mice (B6). Although the transplanted aly/aly showed the same degree of mesangial IgA and IgG deposition and the same serum elevation levels of IgA and IgA-IgG immune-complexes (IC) as B6, even in extent, the progression of glomerular injury was observed only in B6. This uncoupling in aly/aly was associated with a lack of CD4+ T cells and macrophage infiltration, although phlogogenic capacity to nephritogenic IC of renal resident cells was identical between both recipients. It is suggested that secondary LN may be required for the full progression of IgAN after nephritogenic IgA and IgA/IgG IC deposition.

Comparison between the fixation of peritoneal dialysis catheters to the peritoneal wall and the conventional placement technique: clinical experience and follow-up of a new implant technique for peritoneal dialysis catheters.

Peritoneal dialysis (PD) catheters often become severely dislocated, which may lead to malfunction. With the aim of preventing this complication, we have developed a simple method of fixing the catheter downwards in the peritoneal cavity (fixation technique), a technique that does not require a laparoscope. Sixteen patients were implanted using the conventional placement technique and 25 patients were implanted using the fixation technique. The location of the catheter tip was classified from grade 1 (downward, normal) to 5 (dislocated). The frequency of dislocation (defined as the extended time and/or decrease in volume when draining the PD solution) was measured for both the fixation technique and conventional placement technique. There was a significant difference in grade between the fixation technique (2.72 ± 1.01) and conventional technique (3.92 ± 1.31). The time until first dislocation was significantly different between the fixation technique (59.3 ± 48.1 days) and conventional technique (8.8 ± 14.6 days). The time until any dislocation was significantly different between the fixation technique (69.2 ± 41.9 days) and conventional technique (12.9 ± 13.7 days). Complications were not significantly different between the fixation technique and conventional technique. The fixation technique appears to be simple, safe, and useful for preventing severe dislocation and for lengthening the time until dislocation in PD patients.

Experimental evidence of cell dissemination playing a role in pathogenesis of IgA nephropathy in multiple lymphoid organs.

BACKGROUND: Since the pathogenesis of immunoglobulin A (IgA) nephropathy (IgAN) remains unclear, the rationale for current IgAN therapies is still obscure. Recent studies have shown that galactose-deficient IgA1 (GdIgA1) plays a critical role in the pathogenesis of IgAN and can be a non-invasive IgAN biomarker, although the origin of the pathogenic cells producing GdIgA1 is unknown. We examined the cell types and localization of pathogenic cells in IgAN-prone mice. METHODS: We transplanted bone marrow (BM) or spleen cells with or without specific cell types from IgAN-prone mice, which have many features similar to human IgAN, to identify cell types responsible for the IgAN phenotype and to determine their localization. RESULTS: BM transplantation and whole spleen cell transfer from IgAN-prone mice reconstituted IgAN in normal and severe combined immunodeficiency mice. Depletion of CD90(+) spleen cells had no affect on reconstitution, whereas CD19(+) B cells from the spleen were sufficient to reconstitute IgAN in both recipients. CONCLUSIONS: These results indicate that CD19(+) B cells, which can regulate nephritogenic IgA production in a T-cell-independent manner, are responsible for the disease and are disseminated in peripheral lymphoid organs.

Risk of overestimation of kidney function using GFR-estimating equations in patients with low inulin clearance.

BACKGROUND: Accurate estimation of the glomerular filtration rate (GFR) is very important in clinical practice. Although renal inulin clearance (Cin) is the gold standard for measuring GFR, the procedure for Cin measurement is complicated. Use of GFR-estimating equations has been increasing recently due to their simplicity. The objectives of the present study are to analyze the correlation between Cin and other GFR-estimating parameters and to investigate their clinical usefulness and limitation. METHODS: Seventy-two Japanese patients were enrolled in this study. Cin was measured by the continuous infusion method. Serum creatinine (s-Cr), cystatin C, uric acid (UA), and hemoglobin (Hb) were measured. The Japanese formula of estimated GFR (eGFR) was as follows: eGFR (ml/min/1.73m(2) ) = 194 × s-Cr(-1.094) × Age(-0.287) × 0.739 (if female). The endogenous creatinine clearance test was also performed. RESULTS: Levels of Cin were highly correlated with those of endogenous creatinine clearance (Ccr) (R(2) = 0.7585) and eGFR (R(2) = 0.5659). However, patients with lower Cin showed unexpectedly elevated levels of endogenous Ccr and eGFR. Moreover, the levels of eGFR tended to be unexpectedly increased in patients with low body surface area. CONCLUSION: Although GFR-estimating equations are useful for estimating GFR accurately, they pose a risk of overestimation of kidney function in patients with decreased GFRor a poor physique.

Reevaluation of the mucosa-bone marrow axis in IgA nephropathy with animal models.

Impaired immune regulation along the 'mucosa-bone marrow axis' has been postulated to play an important role in the pathogenesis of IgA nephropathy (IgAN). Animal models have allowed us to study such changes in detail. Recently, we established several useful animal models, including IgAN-prone mice. Using these animal models, our group is approaching the underlying mechanisms by which bone marrow and mucosal cell interrelate and finally induce this disease. Accumulating evidence from these approaches suggests that there is dysregulation of innate and cellular immunity in IgAN resulting in changes in the mucosal immune system. These changes appear to be closely linked to disruption of mucosal tolerance, resulting in abnormal priming and dissemination of cells to sites such as the bone marrow where they are responsible for synthesis of nephritogenic IgA. Our clinical studies further support these ideas and indicate that the tonsils may be a major mucosal priming site in human IgAN. In addition, our findings also suggest clinical application of nephritogenic IgA (IgA1) as a biological marker and possible future treatment strategies that focus on manipulating the priming and dissemination of these memory cells in order to prevent the appearance of nephritogenic IgA (IgA1) in the systemic compartment.

Pathological role of tonsillar B cells in IgA nephropathy.

Although impaired immune regulation along the mucosa-bone marrow axis has been postulated to play an important role, the pathogenesis of IgA nephropathy (IgAN) is unknown; thus, no disease-specific therapy for this disease exists. The therapeutic efficacy of tonsillectomy or tonsillectomy in combination with steroid pulse therapy for IgAN has been discussed. Although randomized control trials for these therapies are ongoing in Japan, the scientific rationale for these therapies remains obscure. It is now widely accepted that abnormally glycosylated IgA1 and its related immune complex (IC) are probably key molecules for the pathogenesis, and are thus considered possible noninvasive biomarkers for this disease. Emerging evidence indicates that B cells in mucosal infections, particularly in tonsillitis, may produce the nephritogenic IgA. In this paper, we briefly summarize characteristics of the nephritogenic IgA/IgA IC, responsible B cells, and underlying mechanisms. This clinical and experimental information may provide important clues for a therapeutic rationale.