Comparison of the pre-dilution and post-dilution methods for online hemodiafiltration.

Online hemodiafiltration (OL-HDF) is a treatment modality using diffusion and ultrafiltration. There are two types of dilution methods in OL-HDF: pre-dilution, which is commonly provided in Japan, and post-dilution, which is commonly provided in Europe. The optimal OL-HDF method for individual patients is not well studied. In this study, we compared the clinical symptoms, laboratory data, spent dialysate, and adverse events of pre- and post-dilution OL-HDF. We conducted a prospective study of 20 patients who underwent OL-HDF between January 1, 2019 and October 30, 2019. Their clinical symptoms and dialysis efficacy were evaluated. All patients underwent OL-HDF every 3 months in the following sequence: first pre-dilution, post-dilution, and second pre-dilution. We evaluated 18 patients for the clinical study and 6 for the spent dialysate study. No significant differences in spent dialysates regarding small and large solutes, blood pressure, recovery time, and clinical symptoms were observed between the pre- and post-dilution methods. However, the serum α1-microglobulin level in post-dilution OL-HDF was lower than that in pre-dilution OL-HDF (first pre-dilution: 124.8 ± 14.3 mg/L; post-dilution: 116.6 ± 13.9 mg/L; second pre-dilution: 125.8 ± 13.0 mg/L; first pre-dilution vs. post-dilution, post-dilution vs. second pre-dilution, and first pre-dilution vs. second pre-dilution: p = 0.001, p < 0.001, and p = 1.000, respectively). The most common adverse event was an increase in transmembrane pressure in the post-dilution period. Compared to pre-dilution, the post-dilution method decreased the α1-microglobulin level; however, there were no significant differences in clinical symptoms or laboratory data.

The Impact of Tunneled Central Venous Hemodialysis Catheter on Mortality of Elderly Hemodialysis Patients Hospitalized in a Long-Term Care Hospital.

INTRODUCTION: The association between tunneled central venous hemodialysis catheters (TCVCs) and mortality in hospitalized elderly hemodialysis (HD) patients remains unclear. METHODS: This retrospective observational study was conducted in a long-term care hospital. We evaluated the association between TCVC and mortality in HD patients hospitalized between 2015 and 2020. RESULTS: A total of 463 patients were compared: TCVC group (n = 53) and non-TCVC group (n = 410) including arteriovenous fistula (AVF, n = 369), arteriovenous graft (AVG, n = 30), and superficialized brachial artery (SBA, n = 11). The mean ages were 80 and 78 years in the TCVC and non-TCVC groups, respectively. Overall mortality rates for all-cause and cardiovascular diseases (CVDs) were higher in the TCVC group than in the non-TCVC group (log-rank, p = 0.01, and p = 0.009). Overall mortality was higher in the TCVC group than in the AVF group (p = 0.04), but there were no significant differences between the TCVC, AVG, and SBA groups. In Cox proportional hazards regression models, age, dialysis vintage, male sex, Charlson Comorbidity Index (CCI), and serum albumin level were associated with all-cause, CVD, and infectious disease (ID) mortalities, but TCVC was not associated with all-cause (hazard ratio, 1.31; 95% confidence interval, 0.95-1.80; p = 0.1), CVD (1.54; 0.99-2.39; p = 0.051), and ID (0.91; 0.48-1.70; p = 0.8) mortalities. Among patients aged ≥80 years, with dialysis vintage ≥7 years and CCI ≥10, the overall mortality rates were comparable between the two groups. CONCLUSIONS: Among elderly HD patients in the long-term care hospital, TCVC was not associated with mortality.

Association between Dialysis Modality and Infectious Diseases: Peritoneal Dialysis versus Hemodialysis.

INTRODUCTION: For dialysis patients with end-stage kidney disease, infectious diseases (IDs) are the most common causes of hospitalization and death. However, the association between dialysis modality and IDs remains unclear. We aimed to determine the association between the dialysis modality and IDs. METHODS: This retrospective observational cohort study compared the emergency hospitalization and mortality for IDs between peritoneal dialysis (PD) and hemodialysis (HD) patients. After propensity score matching, the risk factors were evaluated by the Cox proportional hazard regression models. RESULTS: A total of 260 patients were compared - 130 of 135 PD and 130 of 706 HD patients. When the modality-specific ID (PD-catheter ID/peritonitis- and vascular access-related ID) was excluded, no significant differences in emergency hospitalization and mortality rates for overall IDs were observed between the PD and HD groups. Serum ferritin (HR, 2.17; CI, 1.06-4.43; p = 0.03) and Charlson Comorbidity Index (CCI) (HR, 1.24; CI, 1.01-1.52; p = 0.04) were significant predictors of emergency hospitalization for IDs, whereas age (HR, 1.12; CI, 1.05-1.19; p < 0.001), male (HR, 3.38; CI, 1.01-11.3; p = 0.048), serum alkaline phosphatase (ALP) (HR, 6.87; CI, 2.18-21.7; p = 0.001), C-reactive protein (CRP) (HR, 10.7; CI, 3.55-32.1; p < 0.001), and CCI (HR, 1.79; CI, 1.27-2.52; p < 0.001) were significant predictors of ID mortality. When modality-specific ID was included, the emergency hospitalization rate for overall IDs was higher in the PD groups, and PD was a significant predictor of emergency hospitalization for IDs, whereas no significant difference in mortality rate for overall IDs was found between the PD and HD groups. CONCLUSIONS: ID events were not associated with dialysis modality when modality-specific ID was excluded, whereas the risk of modality-specific IDs was higher in PD than HD. Serum ferritin and ALP as well as age, male sex, CRP, and CCI were the risk factors for ID events.

Association between Dialysis Modality and Cardiovascular Diseases: A Comparison between Peritoneal Dialysis and Hemodialysis.

INTRODUCTION: In patients with end-stage kidney disease (ESKD), cardiovascular diseases (CVDs) are the most common causes of hospitalization and death. OBJECTIVE: We aimed to determine the association between dialysis modality and CVDs. METHODS: This retrospective observational cohort study compared the emergency hospitalization and mortality of patients with CVDs who underwent peritoneal dialysis (PD) versus hemodialysis (HD). After propensity score matching, the risk factors were evaluated using Cox proportional hazards regression models. RESULTS: A total of 260 patients were matched: 130 of 135 PD (75 men; age, 65.4 years; dialysis vintage, 3.3 years) and 130 of 706 HD (70 men [p = 0.5]; 66.6 years [p = 0.4]; dialysis vintage, 3.1 years [p = 0.5]) patients. Emergency hospitalization rates (hospitalizations/person-years) for overall CVDs (0.138 vs. 0.066, p = 0.002) and pulmonary edema (0.048 vs. 0.019, p = 0.03) were significantly higher in patients who underwent PD than those who underwent HD. The log-rank test revealed that all-cause and CVD mortalities were significantly higher in PD (both p < 0.001). Mortality rates (deaths/person-years) for overall CVDs (0.058 vs. 0.015, p < 0.002), cerebrovascular disease (0.019 vs. 0.004, p = 0.03), and ischemic heart disease (0.010 vs. 0, p = 0.02) were significantly higher in PD. The Cox proportional hazards regression model showed that PD and age were significant predictors of emergency hospitalization (hazard ratio [HR] 2.70; 95% CI 1.53-4.77; p = 0.001) and mortality (HR 4.41; 95% CI 1.66-11.72; p = 0.003) for CVDs. CONCLUSIONS: PD is a risk factor for emergency hospitalization and mortality associated with CVDs in dialysis patients with ESKD. Strict control of body fluid balance may prevent cardiovascular events in patients undergoing PD.

Vascular access management after percutaneous transluminal angioplasty using a calcium alginate sheet: a randomized controlled trial.

BACKGROUND: Management of vascular access (VA) is essential in hemodialysis (HD) patients. However, VA often fails and percutaneous transluminal angioplasty (PTA) is required. Conventional hemostasis at the puncture site is associated with complications. This study aimed to analyze the efficacy and safety of a hemostatic wound dressing made of calcium alginate at the puncture site of VA after PTA and evaluate other factors affecting hemostasis. METHODS: After PTA for VA, 200 HD patients were randomized to a calcium alginate sheet (CA) group (n = 100) or a no drug-eluting sheet (control) group (n = 100). We recorded time to hemostasis at the puncture site every 5 min, noting any complications. RESULTS: In the CA group, rates of hemostatic achievement at 5, 10, 15 and >15 min were 57, 25, 8 and 10%, respectively. In the control group, the rates were 39, 28, 14 and 19%, respectively. Rates of hemostatic achievement at 5 min were significantly higher in the CA group (P = 0.01). In logistic regression analysis, factors affecting hemostasis within 5 min were use of the CA sheet [odds ratio (OR) 2.33; 95% confidence interval (CI) 1.26-4.37], platelet count ≤100 000/µL (OR 0.19; 95% CI 0.04-0.69), number of antithrombotic tablets used per day ≥1 tablet (OR 0.50; 95% CI 0.26-0.94) and upper arm VA (OR 0.16; 95% CI 0.03-0.55). CONCLUSIONS: A CA sheet can safely reduce time to hemostasis at the puncture site after PTA, and should be considered for treating patients with a bleeding tendency.

Increased Frequency of In-Center Hemodialysis as Rescue Therapy: Impact on Hospitalization for Acute Cardiovascular Events.

BACKGROUND: The intermittency of conventional hemodialysis (HD) leads to an increase in cardiovascular events. OBJECTIVE: We aimed to evaluate the effect of in-center frequent HD (FHD, 4-6 times a week) as a rescue option for cardiovascular events. METHOD: Patients who failed to achieve fluid volume control with conventional HD (thrice a week) were administered FHD. A total of 52 patients were divided into 2 groups by left ventricular ejection fraction (LVEF): low ejection fraction (LEF [n = 26], LVEF < 55%) and normal ejection fraction (NEF [n = 26], LVEF ≥55%). Mortality and hospitalization rates were evaluated. RESULTS: All-cause mortality tended to be higher in the LEF than in the NEF group (p = 0.09). The 1-year hospitalization rate for acute cardiovascular events decreased in both LEF (1.24-0.89; p = 0.049) and NEF (0.36-0.16; p = 0.01) groups. In Cox regression models, LVEF < 55% (hazard ratio 3.81; 95% CI 1.15-12.66; p = 0.03) was identified as the risk factor for hospitalization for acute cardiovascular events. CONCLUSION: In-center FHD may decrease acute cardiovascular events.

Impact of Hybrid Therapy Comprising Peritoneal Dialysis and Hemodialysis on Acute Cardiovascular Events.

BACKGROUND: The impact of hybrid therapy comprising peritoneal dialysis (PD) and hemodialysis on cardiovascular events in PD patients remains unclear. OBJECTIVE: We aimed to evaluate the effect of hybrid therapy on cardiovascular events. METHODS: A total of 93 PD patients undergoing hybrid therapy for ≥3 years were divided into 2 groups according to left ventricular ejection fraction (LVEF): lower ejection fraction (LEF [n = 29], LVEF < 60%) and normal ejection fraction (NEF [n = 64], LVEF ≥60%). Hospitalization rates and echocardiographic parameters were evaluated. RESULTS: The 1-year hospitalization rate for acute cardiovascular events decreased after the therapy initiation in both groups (LEF: 0.36-0.11, p = 0.02 and NEF: 0.43-0.06, p < 0.001). In generalized linear mixed models, LVEF (44 ± 15%) improved at 1, 2, and 3 years after initiation (53 ± 18, 55 ± 17, and 58 ± 7%; p < 0.05) in the LEF group, whereas, in the NEF group, LVEF (68 ± 5%) was maintained at 1, 2, and 3 years after initiation (67 ± 8, 67 ± 9, and 68 ± 9%; p > 0.05). Mitral inflow E velocity to tissue Doppler e' ratio was maintained at the same level at 1-3 years after initiation in both groups. Left ventricular mass index (LVMI; 189 ± 41 g/m2) was decreased at 1 (178 ± 35 g/m2; p = 0.8), 2 (160 ± 45 g/m2; p = 0.008), and 3 (166 ± 47 g/m2; p = 0.05) years after initiation in the LEF group, whereas in the NEF group, LVMI (157 ± 45 g/m2) was maintained at 1, 2, and 3 years after initiation (153 ± 40, 155 ± 54, and 158 ± 52 g/m2; p > 0.05). CONCLUSION: Hybrid therapy decreased acute cardiovascular events and improved systolic cardiac function in PD patients in the LEF group.

Morphological characteristics in peritoneum in patients with neutral peritoneal dialysis solution.

Peritoneal dialysis solution (PDS) plays a role in functional and morphological damage to the peritoneum. This study aimed to clarify the effect of neutral PDS in preventing morphological changes by assessing peritoneal damage and comparing morphological alterations between PD patients treated with neutral PDS and acidic PDS. Sixty-one patients participated from seven hospitals. All patients were treated with neutral PDS excluding icodextrin, during their entire PD treatment, and experienced no episode of peritonitis. The thickness of submesothelial compact (SMC) zone and the presence of vasculopathy in the anterior parietal abdominal peritoneum were assessed. The impact of icodextrin, hybrid therapy, and peritoneal rest and lavage in morphological alterations were determined. There was no significant difference in the average SMC thickness between neutral and acidic PDS. The vessel patency in patients using neutral PDS was significantly higher compared to that in acidic PDS at any time during PD. There were no significant suppressive effects from interventions or use of icodextrin with respect to peritoneal morphological injury. A monolayer of mesothelial cell was observed in approximately half the patients, especially in their receiving lavage patients. Neutral PDS, accompanied by other preventive approaches against peritoneal injury, might suppress the development of peritoneal morphological alterations.

Hospitalizations for non-SARS-CoV-2 respiratory infectious diseases among patients on hemodialysis: A comparison before and during the coronavirus disease 2019 pandemic.

INTRODUCTION: The impact of coronavirus disease 2019 (COVID-19) infection control on other infections in patients with dialysis has not received sufficient consideration. METHODS: We compared hospitalization and mortality rates among patients who underwent hemodialysis (HD) at three dialysis centers before (March 2018-February 2020) and during (March 2020-February 2022) the COVID-19 pandemic. RESULTS: This study included 1696 patients undergoing HD (mean age, 70 years; 1099 men). Compared to before the COVID-19 pandemic, the emergency hospitalization rate (per 100 dialysis patient-years) for non-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) respiratory infectious diseases (IDs) (7.0 vs. 4.1, p < 0.001) significantly decreased during the COVID-19 pandemic, whereas the hospitalization rates for other IDs were comparable. The mortality rates for non-SARS-CoV-2 respiratory IDs were comparable before and during the COVID-19 pandemic. CONCLUSIONS: Hospitalizations for non-SARS-CoV-2 respiratory IDs among patients undergoing HD may have decreased owing to the implementation of infection control measures for COVID-19.

Efficacy of drug-coated balloon catheters for patients with short-term recurrent dysfunction of arteriovenous fistula.

BACKGROUND: In this study, we aimed at clarifying the usefulness of drug-coated balloon catheters (DCBs) for arteriovenous fistulas (AVFs) that repeatedly undergo restenosis over a short period and to examine the factors that influence the patency period after DCB use. METHODS: This retrospective observational study was conducted using IN.PACT AV in 29 cases of AVFs with repeated restenosis within approximately 3 months, and temporary patency before and after DCB use in the same patients was compared. For target participants, the flow volume, resistive index (RI), and vascular diameter of the brachial artery were measured using an ultrasound diagnostic device. Stenosis diameter, reference vessel diameter, and stenosis length of the lesion were measured before and after DCB dilatation using digital subtraction angiography. RESULTS: Before DCB angioplasty, the postintervention primary patency at 3 months was 66%, and the average interval was 92 ± 21 days (mean ± standard deviation). After DCB angioplasty, the postintervention primary patency rates at 3 and 6 months were 92% and 36%, respectively. The postintervention primary patency was significantly higher after than before DCB angioplasty (p < 0.0001). A sub-analysis was performed on 25 patients who were followed up for 4 months or more after DCB. The RI values before and after dilatation with DCB significantly differed between the patency group 4 or more months after DCB and the patency group less than 4 months after DCB. CONCLUSION: For AVFs that require frequent PTA over a short period of time, DCB improved the patency rate 3 months after PTA, but the improvement effect at 6 months was limited. The effect of DCB on prolonging the patency rate of AVFs that require frequent PTA over a short period of time may be correlated with the RI value before and after PTA.

Encapsulating Peritoneal Sclerosis 43 Years after Distal Gastrectomy for Early Gastric Cancer.

We herein report a case of encapsulating peritoneal sclerosis (EPS) in a patient without chronic kidney disease after gastrectomy. A 69-year-old man underwent distal gastrectomy for early gastric cancer at 25 years old. After 43 years, he developed bowel obstruction and underwent enterolysis of the encapsulated small intestine. A pathological examination of the capsular membranes revealed inflammation, foam, and giant cells that destroyed foreign substances. The patient was discharged 1.5 months later. Foreign body reactions to surgical instruments used in gastrectomy are considered a cause of EPS. EPS due to foreign body reactions to surgical instruments should also be considered in such cases.

Iatrogenic arteriovenous fistula in the brachial artery after percutaneous coronary intervention in a patient with end stage kidney disease.

Iatrogenic arteriovenous fistula (AVF) is a complication accompanying venous and arterial puncture. Herein we report a case of ligation closure of an iatrogenic AVF in the brachial artery after percutaneous coronary intervention (PCI) for the patient with end-stage kidney disease (ESKD). A 68-year-old woman presented with a history of several coronary angiographies (CAG) and PCI through the right brachial artery. After PCI, the patient experienced a thrill in the right elbow. Two years later, the patient initiated hemodialysis (HD) using a temporary HD catheter for ESKD and congestive cardiac failure. Ultrasonography and computed tomographic angiography revealed an iatrogenic AVF between the right brachial artery and the medial brachial vein. Blood flow in the brachial artery was 760 mL/min. However, the iatrogenic AVF was unusable as vascular access for HD, and prior ligation closure of the iatrogenic AVF was performed, considering the risk of cardiac failure due to double AVFs after the creation of a new AVF for HD. Subsequently, a new radial-cephalic AVF was created in the left forearm. Therefore, clinicians should consider the possibility of iatrogenic AVF in patients with ESKD having a history of CAG or PCI.

The predictive markers of severity and mortality in hospitalized hemodialysis patients with COVID-19 during Omicron epidemic.

INTRODUCTION: Predictive markers and prognosis remain unclear in hospitalized hemodialysis (HD) patients with coronavirus disease 2019 (COVID-19) during the Omicron epidemic. METHODS: We evaluated characteristics, laboratory parameters, and outcomes in hospitalized HD patients with COVID-19 (n = 102) at two centers between January and April 2022. RESULTS: The 30-day mortality rate was higher in moderate-critical group (n = 43) than mild group (n = 59) (16.3% vs. 1.7%; p = 0.007), and higher in patients with lower CC chemokine ligand 17 (CCL17) levels (<95.0 pg/mL) compared with normal CCL17 levels (19.0% versus 4.9%; p = 0.03). In multivariate analyses, a low CCL17 level (p = 0.003) was associated with moderate-critical conditions, and moderate-critical conditions (p = 0.04) were associated with 30-day mortality, whereas CCL17 was not associated with 30-day mortality. CONCLUSIONS: COVID-19 remains a fatal complication, and CCL17 was a predictive marker of severity in hospitalized HD patients during the Omicron epidemic.

Penile calciphylaxis in patients with end-stage kidney disease undergoing dialysis: Invasive treatment and pain management.

INTRODUCTION: Penile calciphylaxis is rarely reported in dialysis patients. METHODS: We experienced cases of dialysis patients who had penile calciphylaxis between 2003 and 2020. RESULTS: Seven patients undergoing dialysis were treated for penile necrosis (hemodialysis [HD], 5; peritoneal dialysis [PD], 1; hybrid therapy comprising PD and HD, 1). Their mean age was 62.8 years and their mean dialysis vintage 116.1 months. All had severe penile pain and were clinically diagnosed with calciphylaxis. Four received partial penectomy and three received percutaneous transluminal angioplasty (PTA) due to rapid aggravation. The number of analgesia types and the critical-care pain observation tool score significantly decreased after invasive treatment (both, p = 0.008). The 90-day and 1-year survival rates after onset were 85.7% and 57.1%, respectively. CONCLUSION: In dialysis patients, penile calciphylaxis has poor prognosis; however, invasive treatments for pain management are effective. PTA may be beneficial in dialysis patients in poor condition.

COVID-19-associated pulmonary aspergillosis in hemodialysis patients.

Background: Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) is a fatal complication in the general population. However, there are few reports on CAPA in patients undergoing hemodialysis (HD). Methods: This retrospective observational cohort study was conducted at a single center between December 2020 and June 2021. We enrolled 21 HD patients with COVID-19 undergoing treatment and divided them into two groups, CAPA and non-CAPA (COVID-19 with and without pulmonary aspergillosis), and evaluated their characteristics, clinical outcomes and comorbidities. Results: The log-rank test revealed that the 90-day survival rate after the initiation of treatment for COVID-19 was significantly lower in the CAPA (n = 6) than in the non-CAPA group (n = 15) (P = 0.0002), and the 90-day mortality rates were 66.6% and 0% in the CAPA and non-CAPA groups, respectively. In the CAPA group, four patients died due to respiratory failure (on Days 6 and 20), gastrointestinal bleeding (Day 8) and sepsis (Day 33); the reverse transcription-polymerase chain reaction (RT-PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remained positive when they died. The remaining two patients survived and the negative conversion of RT-PCR for SARS-CoV-2 was confirmed on Days 10 and 15. The negative conversion of serum (1, 3)-ß-d-glucan (BDG) was confirmed on Day 15 in one patient; the BDG remained positive on Day 64 in the other. Conclusions: CAPA is a fatal complication in HD patients and the general population. Therefore, clinicians should consider the possibility of testing for CAPA in patients undergoing HD. Mycological workups may be helpful for the early detection of CAPA.

Seventeen years' experience of surgical options for encapsulating peritoneal sclerosis.

Encapsulating peritoneal sclerosis (EPS) is a serious complication of long-term peritoneal dialysis (PD). The mortality rate for EPS has been high, primarily because of complications related to bowel obstruction. However recent advances in clinical research have established the pathogenesis and course of the condition and a treatment strategy. The final therapeutic option for EPS is surgical enterolysis, and we have performed 239 surgical procedures in 181 patients and observed favorable outcomes. Of 181 patients opting for surgery 64 (35.40%) died. Death was related to EPS in 33 patients (18.2%), including 14 who died postoperatively. The overall survival rate at 1, 2, 3, 5, and 8 years after diagnosis was 93%, 83%, 78%, 71%, and 60% respectively. The survival rate for EPS-related death at 1, 2, 3, 5, and 8 years after diagnosis was 95%, 90%, 87%, 81%, and 74% respectively. Median survival after diagnosis, considering death from any cause and death from EPS, was 43.9 months and 35.7 months respectively. In conclusion, we present favorable outcomes with EPS surgery in 181 patients encountered over a period of 17years. These data reconfirm that surgical treatment is essential for EPS patients. Encapsulating peritoneal sclerosis may no longer be a fatal complication and can be improved with accurate diagnosis and treatment.

Impact of combination therapy with peritoneal dialysis and hemodialysis on peritoneal function.

Peritoneal dialysis (PD) is a continuous, slow dialysis method advantageous for retaining residual renal function; however, after renal function is lost, increasing the PD dose is difficult, resulting in insufficient dialysis. The addition of hemodialysis (HD) to PD [combination therapy with PD and HD (PD+HD)] increases the ultrafiltration volume and optimizes the dialysis dose. Based on this situation, we have applied concomitant HD after loss of residual renal function in PD patients. In the present study, we investigated peritoneal function in patients who underwent PD+HD therapy. The subjects were 76 patients in whom PD+HD therapy continued for 6 months or longer. In PD+HD therapy, patients underwent PD 6 days each week and a 4-hour HD session once each week. The patients were divided into four groups based on their dialysate-to-plasma ratio of creatinine (D/P Cr) in a peritoneal equilibration test (PET) at the initiation of PD+HD therapy: high [H (n = 5)], high-average [HA (n = 29)], low-average [LA (n = 26)], and low [L (n = 16)]. Before and after initiation of PD+HD therapy, we measured PET D/P Cr values and effluent levels of fibrin degradation products (eFDPs) and cancer antigen 125 (eCA125) in the 4-hour PET effluent. In addition, we evaluated the ratio of overnight effluent to serum beta2-microglobulin (overnight D/P beta2MG) every year. In the H group, D/P Cr remained high after initiation of PD+HD therapy, but it declined significantly in the HA group and tended to decline in the LA and L groups. Overnight D/P beta2MG remained high in the H group after PD+HD therapy, but significantly declined in the HA group and remained unchanged in the LA and L groups. After PD+HD therapy initiation in the H group, eFDPs declined markedly, although that change was not significant. No decrease was noted in any other group. Peritoneal dialysis was discontinued in 33 of the 76 patients (43.4%) who underwent PD+HD therapy: in 5 of the 5 patients in the H group (100%), in 16 of 29 in the HA group (552%), in 7 of 26 in the LA group (26.9%), and in 5 of 16 in the L group (31.3%). On long-term follow-up, the PET D/P Cr tended to decrease in the H and LA groups; it did not change in the LA and L groups. No significant changes were noted in any group for overnight D/P beta2MG, eFDPs, or eCA125. We suggest that concomitant HD facilitates the continuation of PD treatment and the retention of peritoneal function in patients with uremic symptoms and excess body fluid associated with a loss of residual renal function. However, improvement in peritoneal function cannot be expected for patients in whom peritoneal function has already deteriorated. In those patients, a change of treatment method should be considered.

Perforative peritonitis confused with peritoneal dialysis-related peritonitis: Report of three cases.

INTRODUCTION: Perforative peritonitis in patients on peritoneal dialysis (PD) is a serious adverse event associated with significant mortality. The signs and symptoms of perforative peritonitis in patients on PD are often confused with those of PD-related peritonitis; therefore, early diagnosis is often difficult. PRESENTATION OF CASES: In all three cases, antibiotic therapy was started for peritonitis. Although contrast-enhanced computed tomography (CT) was not performed, perforative peritonitis was suspected due to severe cloudiness of PD effluents, and emergency surgeries were performed 8, 5, and 6 days after therapy onset in cases 1, 2, and 3, respectively. In case 1, the ileum was perforated owing to ischemia, and partial ileal resection and divided ileostomy were performed. The patient died 18 days postoperatively. In case 2, partial ileal resection and divided ileostomy were performed for an incarcerated obturator hernia and perforated ileum. The patient was transferred for hemodialysis (HD) and discharged 117 days postoperatively. In case 3, lavage drainage was performed for peritonitis because of mesenteric penetration of a sigmoid colon diverticulum. The patient was then transferred for HD, and colostomy was subsequently performed. He was discharged 159 days postoperatively. DISCUSSION: Early diagnosis between PD-related peritonitis and perforative peritonitis is often difficult since the washing effect of the peritoneal dialysate might relieve peritoneal irritation. CONCLUSION: In PD patients with refractory peritonitis, it is necessary to keep in mind the possibility of perforative peritonitis, and the differential diagnosis should be performed using contrast-enhanced CT within at least 5 days after antibiotic therapy.

Fully automated dialysis system based on the central dialysis fluid delivery system.

The fully automated dialysis system (FADS) was developed as an improvement over previous patient monitors used in the treatment of hemodialysis, with the aim of standardizing and promoting labor-saving in such treatment. This system uses backfiltration dialysis fluid to perform priming, blood rinse back and rapid fluid replenishment, and causes guiding of blood into the dialyzer by the drainage pump for ultrafiltration. This requires that the dialysis fluid used be purified to a high level. The central dialysis fluid delivery system (CDDS) combines the process of the creation and supply of dialysis water and dialysis fluid to achieve a level of purity equivalent with ultrapure dialysis fluid. FADS has the further advantages of greater efficiency and streamlined operation, reducing human error and the risk of infection without requiring the storage or disposal of normal saline solution. The simplification of hemodialysis allows for greater frequency of dialysis or extended dialysis, enabling treatment to be provided in line with the patient's particular situation. FADS thus markedly improves the reliability, safety and standardization of dialysis procedures while ensuring labor-saving in these procedures, making it of particular utility for institutions dealing with dialysis on a large scale.

Peritoneal dialysis patients with high effluent fibrin degradation products.

Encapsulating peritoneal sclerosis (EPS) is a major and fatal complication of peritoneal dialysis (PD). For treatment, the efficacies of steroids, tamoxifen, immunosuppressants, and surgical total intestinal enterolysis have been reported, but the results have not been sufficient. Because treatment after the onset of EPS is limited, a prophylactic therapy is needed. We previously reported that the level of effluent fibrin degradation products (eFDPs) is predictive of EPS. In the present study, we investigated the clinical course of PD cases with high eFDP levels, and the effect of prophylactic steroid therapy against EPS. Between January 2002 and August 2008, we investigated 310 PD patients, of whom 22 had an eFDP level of 30 microg/mL or more in 4-hour effluent from a fast peritoneal equilibration test (PET). Mean patient age was 62.6 +/- 11.1 years, and mean duration of dialysis was 42.7 +/- 45.5 months (range: 1 - 202 months). During a fast PET performed every 6 months, we measured, in 4-hour effluent, eFDPs, cancer antigen 125 (eCA125), and dialysate-to-plasma creatinine (D/P Cr). In addition, we calculated D/P beta2-microglobulin (beta2MG) from levels in overnight dialysis effluent and blood. In the 22 cases, the mean eFDP level was 66.6 +/- 39.2 microg/mL; the D/P Cr 0.78 +/- 0.1; and the D/P beta2MG 0.45 +/- 0.2. Steroid (5 - 30 mg daily) was administered to 8 of the 22 patients. In the 8 treated cases, the eFDP level, the D/P Cr, and the D/P beta2MG declined, but did not return to normal, and EPS developed in 2 patients. The eFDP level was high when dialysis was introduced, but returned to normal in 2 of the remaining 14 patients. In 1 of the 14 cases, peritonitis developed 5 times, followed by rapid elevation in the eFDP level. The patient with this intractable peritonitis was switched to hemodialysis. The other 11 patients received no steroid therapy. In 1 of these 11 patients, the eFDP level declined, but not in the others. We suggest that active steroid therapy for patients with a high level of eFDPs may prevent EPS development.