Long-term outcomes of the Japanese hemodialysis patients with prostate cancer detected by prostate-specific antigen screening.

We investigated the long-term outcomes of the Japanese hemodialysis patients with prostate cancer detected by prostate-specific antigen (PSA) screening. Clinical data of 646 male hemodialysis patients aged 55 years or older who started yearly PSA testing in the period from January 1, 2004 to December 31, 2012 and were followed until December 31, 2017 were analyzed retrospectively. The median follow-up period was 10.4 years. Nineteen (2.9%) patients were diagnosed with prostate cancer, of whom one patient died of the disease. Androgen-deprivation therapy (ADT) was selected for primary prostate cancer treatment in 17 (89.5%) of these 19 patients. Of six prostate cancer patients who underwent primary ADT (PADT) and died of other causes, three died of infectious disease, each one died of cardiovascular disease, liver cancer, and chronic renal failure. No significant difference was observed in regard to overall survival between the prostate cancer patients with PADT and non-prostate cancer patients. Prognosis of hemodialysis patients who were diagnosed with prostate cancer during yearly PSA screening examination and mainly treated with ADT was favorable without increasing cardiovascular events. This result indicates that PSA screening may be useful for detection and management of prostate cancer even in hemodialysis patients. J. Med. Invest. 68 : 42-47, February, 2021.

Treatment of renal anaemia with erythropoiesis-stimulating agents in predialysis chronic kidney disease patients: Haemoglobin profile during the 6 months before initiation of dialysis.

AIM: Erythropoiesis-stimulating agents (ESAs) are all effective for renal anaemia in patients with chronic kidney disease (CKD). However, it was reported that the haemoglobin (Hb) concentration decreases to 8.4 g/dL during the initial phase of dialysis despite treatment with recombinant human erythropoietin (rHuEPO). This study compared Hb at the initiation of dialysis among patients treated with three different ESAs (rHuEPO, darbepoetin alfa [DA], and a continuous erythropoietin receptor activator [CERA]). METHODS: The subjects were 82 CKD patients who started dialysis at Kawashima Hospital between 1 January 2009 and 28 February 2015 and who received only one kind of ESA for at least 6 months before initiation of dialysis. Baseline characteristics and laboratory data at initiation of dialysis were compared among the three groups. Then changes of the Hb, ESA dose, and erythropoiesis resistance index were assessed over time during the 6 months before initiation of dialysis. Differences of Hb at the initiation of dialysis were also assessed. RESULTS: Among the 82 patients, 36 received rHuEPO, 13 received DA, and 33 received CERA. Baseline characteristics and laboratory data of the patients showed no significant differences among the three groups. The monthly Hb decreased gradually during the 6-month period before initiation of dialysis in all three groups. Hb was significantly higher in the CERA group than the rHuEPO group at the initiation of dialysis. CONCLUSION: Long-acting ESAs may be more useful for predialysis patients with CKD because they do not attend hospital frequently, unlike haemodialysis patients.

Vascular access for long-term hemodialysis/hemodiafiltration patients.

PURPOSE: We investigated the characteristics of patients who received long-term hemodialysis/hemodiafiltration (HD/HDF) treatment for over 30 years at our group of hospitals and type of vascular access (VA) used. SUBJECTS AND METHODS: As of August 2014, 950 patients were receiving HD/HDF treatment at one of our hospitals. Of those, we investigated 41 (4.3%) undergoing long-term treatment in regard to their characteristics and VA type. The items subjected to analysis were sex, primary illness, age at time of dialysis initiation, present age, duration (years) of HD/HDF, type of arteriovenous fistula (AVF) and arteriovenous graft (AVG), history of surgery and AVF persistence rate. RESULTS: The subjects consisted of 22 men and 19 women, and their mean HD/HDF duration was 33.4 ± 2.8 years. For primary illness, the majority (n = 31) had chronic glomerulonephritis. The age at time of dialysis initiation was 31.7 ± 7.76 years and present age was 64.5 ± 7.65 years. They had received 3.8 VA surgeries. For present VA type, 23 patients (56.0%) had an AVF and 13 (31.7%) an AVG, while 4 AVF patients (9.7%) had a history of AVG use. One patient (2.4%) had a superficialized artery. The mean HD/HDF duration of the 13 AVG patients was 7 years and the longest was 18 years. AVF persistence rate estimated by the Kaplan-Meier method was 75% at 30 years after dialysis initiation. CONCLUSIONS: The present results suggest that the ratio of patients with AVG increased with prolonged HD/HDF treatment. AVG has a higher probability of complications and lower patency as compared to AVF, thus careful management is needed. On the other hand, AVG contributes more to a good long prognosis, as it offers efficient dialysis. In cases of vascular deterioration due to long-term hemodialysis, it is inevitable to change from AVF to AVG, thus the ratio of AVG patients is expected to increase in cases of long-term HD/HDF.

Reduction or discontinuation of antibiotic prophylaxis in vascular access surgery, tendon sheath incision and PD catheter placement.

PURPOSE: Immune response in dialysis patients is suppressed and these patients are susceptible to bacterial infections. Therefore, minimal use of antibiotics in dialysis patients is recommended to avoid generating drug-resistant bacteria. However, minor surgeries including vascular access surgery, tendon sheath incision and peritoneal dialysis (PD) catheter placement are inevitable in dialysis patients and evidence-based recommendations on the judicious use of antibiotics are not currently available for these procedures. In this study, the optimal antibiotic prophylaxis for minor surgeries was evaluated. METHODS: This is a retrospective study. In dialysis patients at Kawashima Hospital, a three-step reduction of antibiotic use was performed in 651 cases of arteriovenous fistula (AVF) and tendon sheath incision surgeries from July 2009 through October 2012. Moreover, general surgical guidelines-recommended dose of preoperative antibiotics only were used in 532 cases of arteriovenous graft (AVG) and PD catheter placement from January 2010 through October 2012. The surgical site was observed for 2 weeks after the surgery. RESULTS: In only one case of AVF surgery, redness of the skin around the stitches was noticed 5 days after the surgery, which was healed with antibiotics taken orally for 3 days. Neither AVG nor PD catheter placement demonstrated any infection at the surgical site during the 2-week observation period. CONCLUSIONS: Even in dialysis patients, neither pre- nor postoperative antibiotics are necessary for AVF and tendon sheath incision surgeries. AVG and PD catheter placement surgeries require only a small amount of antibiotics preoperatively.

[Neobladder-rectal fistula as early postoperative complication of radical cystectomy and orthotopic neobaldder construction].

We report a case of neobladder-rectal fistula that developed as an early postoperative complication of radical cystectomy and orthotopic neobladder construction procedures. A 75-year-old man underwent a radical cystectomy and orthotopic neobladder construction using Studer's method for locally invasive bladder cancer (cT2N0M0). The patient had severe watery diarrhea on postoperative day 20, and was diagnosed with a neobladder-rectal fistula based on cystography findings. We inserted a Foley catheter into the neobladder, and performed conservative treatment. Four months after development of the fistula, cystography revealed that it had spontaneously closed. A neobladder-rectal fistula is an extremely rare complication, with no other known reports. Herein, we present this case of neobladder-rectal fistula and discuss its formation, diagnosis and treatment, along with reference to previous reports of neobladder-vaginal fistulas.

[Pseudosarcomatous myofibroblastic proliferation of the bladder-case report].

A 66-year-old man with a history of sporadic von Recklinghausen' s disease was treated for pseudosarcomatous myofibroblastic proliferation in the bladder. The patient had a history of repetitive recurrence of bladder carcinoma requiring transurethral resection (TUR) 4 times and 1 course of intravesical BCG instillation. Three months after the fourth TUR, an intravesical solid mass 4 cm in diameter was detected. Suspicion of recurrent bladder carcinoma led to a fifth TUR procedure. Pathological findings showed submucosal growth of myofibroblasts with myxoidal stroma and we made a diagnosis of Pseudosarcomatous myofibroblastic proliferation. The patient was well with no evidence of recurrence after 1 year.

[Two cases of prostatic carcinoma causing a disorder of gastrointestinal transit due to rectal stenosis].

A 64-year-old man, was admitted to the Department of Gastroenterology at another hospital in October, 2005 because of constipation and urinary retention. Endoscopic and computed tomographic (CT) examinations of biopsy specimens obtained from the rectal mucous membrane which appeared to be thickened revealed evidence of proctitis but no evidence of malignancy. The patient was referred to our hospital because of a high prostate specific anyigen (PSA) level (74.17 ng/ml), and hydronephrosis accompanied with hydroureter at the right side. Biopsy specimens taken from a prostatic tumor through a transrectal route showed histological features consistent with anaplastic adenocarcinoma which was positively stained with PSA antibody. We treated the patient with maximium androgen blackade (MAB), resulting in a decrease in plasma PSA level and amelioration of constipation as well. A 77-year-old man, visited a hospital because of constipation and high plasma carcinoembryonic antigen and carbohydrate antigen (CA) 19-9 values in May, 2005, and was diagnosed as having hyperplastic mucous membrane and atypical glands of the rectum by means of a rectal biopsy. Having been referred to our hospital, the patient received a prostate biopsy, specimens of which revealed moderately differentiated adenocarcinoma with negative PSA staining. A pelvic evisceration was performed. The eviscerated samples showed no abnormality in the rectal mucous membrane but cancer with light PSA staining in the prostatic ducts. The hormone therapy was initiated in the patient under the diagnosis of anaplastic cancer in the prostate. Since the therapy for the invasion of prostatic cancer on the rectum differs markedly from that for a primary tumor in the rectum, it is very important to differentiate accurately the one from the other.

[A case of bilharziasis diagnosed 10 years later].

A 31-year-old Japanese man had macroscopic hematuria 5 or 6 years previously. When he was examined at a local hospital, he was pronounced normal. However he still had macroscopic hematuria, so he visited our department. Urine cytodiagnosis was class II. Cystoscopy revealed irregular mucosa at the anterior wall and dome of the bladder. CT and MRI also demonstrated irregular thickness at the anterior wall of the bladder. A diagnosis of bilharziasis was made by histological specimen obtained by TUR-biopsy. The specimen did not show evidence of malignancy. When questioned about overseas travel, he said he had visited Malawi in Africa when he was 20 years old. As international exchange between Japan and other countries is now increasing, we will be examining more patients who have traveled to epidemic areas. In such patients, we should consider the possibility of Schistosomiasis.