Hemodilution Impacts Assessment of Thyroid Status before and after Hemodialysis in Patients with End-Stage Renal Disease.

BACKGROUND: To elucidate the role of hemodilution in the alteration of thyroid hormone levels in end-stage renal disease (ESRD), we compared thyroid function before and after hemodialysis (HD). METHODS: Twenty-three male ESRD patients (age <65 years) with either chronic glomerulonephritis (CGN) or diabetic nephropathy (DN), who were enrolled between June 2019 and August 2019, were included in the study. The free thyroxine (fT4), free tri-iodothyronine (fT3), and thyroid-stimulating hormone (TSH), thyroxine-binding globulin (TBG), and thyroglobulin (Tg), measured before and after HD in 12 patients with CGN (48.7 ± 11.8 years [mean ± standard deviation]) and 11 patients with DN (57.6 ± 6.5 years), were compared with 45 healthy controls (52.5 ± 11.9 years). RESULTS: The fT4, fT3, and TBG were significantly low before HD and increased in parallel with an increase in hematocrit and albumin after HD in both ESRD subgroups. The TSH was high before HD and decreased significantly after HD, while Tg remained almost unchanged. In DN, the fT4 levels were nearly identical, while fT3 was lower with slightly higher TSH, compared with CGN. The TSH/fT4 ratios before HD were significantly higher in both subgroups, and the fT3/fT4 ratios after HD were significantly lower in DN than the control. CONCLUSIONS: Our findings suggest that the low fT4 and fT3 levels found in ESRD are due to hemodilution before HD, resulting in a slightly higher TSH level but almost unchanged Tg level, and that DN is associated with decreased T4-to-T3 conversion.

Thyroid function in patients on continuous ambulatory peritoneal dialysis in comparison with chronic kidney disease
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BACKGROUND/METHODS: Thyroid function was evaluated in 14 Japanese patients on continuous ambulatory peritoneal dialysis (CAPD) with end-stage renal disease compared with 11 chronic kidney disease (CKD) stage 1+2 patients (glomerular filtration rate ≥ 60 mL/min/1.73m2). RESULTS: The serum free triiodothyronine (fT3) (2.2 ± 0.3 pg/mL, p < 0.05) levels were lower, and the rate of low triiodothyronine (T3) syndrome was higher (4 of 13 cases, 30.8%) in the CAPD patients than in the CKD stage 1+2 patients (1 of 10 cases, 10.0%, respectively) or the 57 age-matched healthy controls. The serum thyroglobulin (Tg) levels were significantly higher in the CAPD patients (39.7 (13.4 - 178.0) ng/mL) than in the CKD stage 1+2 patients (9.9 (5.5 - 28.8) ng/mL, p < 0.05). High serum Tg levels (> 30 ng/mL) were observed in 66.7% of the CAPD patients. CONCLUSION: The finding from our study suggested the deterioration of thyroid function with higher prevalence of low T3 syndrome in the CAPD patients. Although speculation as to the reasons for this would be unwise at this point, we did note that the serum Tg levels were very high in the CAPD patients.
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The high prevalence of reversible subclinical hypothyroidism with elevated serum thyroglobulin levels in chronic kidney disease patients
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BACKGROUND: We examined the thyroid function of non-dialysis-dependent chronic kidney disease (CKD) patients in Japan. METHODS: Serum-free thyroxine, free triiodothyronine, thyroid-stimulating hormone (TSH), and thyroglobulin (Tg) levels were evaluated in 37 CKD patients. CKD was defined as sustained kidney damage for more than 3 months and was classified as CKD 1+2 (n = 11), 3+4 (n = 10), or 5 (n = 16), which were defined by glomerular filtration rates of ≥ 60, 15 - 59, or < 15 mL/min/1.73m2, respectively. RESULTS: The prevalence of primary hypothyroidism (TSH ≥ 4.83 mU/L) in CKD 1+2, CKD 3+4, and CKD 5 was 9%, 20%, and 56%, respectively (p < 0.05). Unexpectedly, elevated serum Tg levels (> 30 ng/mL), a marker of the reversible recovery of the thyroid function, were found in 67% of the CKD 5 patients (p < 0.05). The serum TSH and Tg levels became lower, without replacement therapy, after the initiation of hemodialysis and iodine restriction, and there was a significant correlation between the serum TSH and Tg levels in the CKD 5 patients (p < 0.05). CONCLUSION: The high prevalence of reversible hypothyroidism and the TSH-dependent elevation of the serum Tg levels was suggested in Japanese patients with advanced CKD. The excess ingestion and the impaired urinary excretion of iodine may be responsible for this reversible thyroid dysfunction.
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Importance of specific reference values for evaluation of the deteriorating thyroid function in patients with end-stage renal disease on hemodialysis.

BACKGROUND/AIM: We evaluated the thyroid function in end-stage renal disease (ESRD) on maintenance hemodialysis. MATERIAL/METHODS: Thyroid function and clinical hypothyroid score were evaluated in 145 ESRD patients. RESULTS: Comparison of thyroid function between 127 ESRD patients, excluding 18 patients with suppressed or elevated serum TSH level, and age/sex-matched healthy controls (76 in midlife group aged under 65 and 51 in late-life group aged 65 or over) using a multivariate logistic regression analysis suggested significant difference (P < 0.0001), mainly in serum fT4 level (P = 0.0099) and age (P = 0.0492), but not in serum fT3 (not significant; ns), TSH (ns) level or fT3/fT4 ratio (ns). Serum fT3 level and fT3/fT4 ratio were significantly lower (P < 0.001) in late-life group only in ESRD. Reference values calculated for midlife ESRD patients, such as 0.6-1.3 ng/dl for fT4 compared with 0.8-1.7 ng/dl for healthy control, were helpful for the diagnosis of mild but definite hyperthyroidism in whom serum fT4 level was 1.5 ng/dl. The prevalence of primary thyroid dysfunction, compared with the values for ESRD, was 0.7 % for hyperthyroidism, 1.4 % for overt hypothyroidism and 10.3 % for subclinical hypothyroidism. Hypothyroid score was high among those with ESRD independent of thyroid dysfunction. CONCLUSIONS: Serum fT4 level was markedly lower without a change in fT3/fT4 ratio in ESRD. This may suggest typical carbohydrate-sufficient non-thyroidal illness. The specific reference values for ESRD were useful to evaluate borderline thyroid dysfunction and to evaluate the prevalence of the patients with primary thyroid dysfunction in ESRD.

Olmesartan is More Effective Than Other Angiotensin Receptor Antagonists in Reducing Proteinuria in Patients With Chronic Kidney Disease Other Than Diabetic Nephropathy.

BACKGROUND: Angiotensin II receptor antagonists (ARBs) have a protective effect in patients with chronic kidney disease (CKD) by suppressing progression, possibly by controlling hypertension. One marker of progression in such patients is the degree of proteinuria. OBJECTIVE: We aimed to retrospectively examine the protective effect of ARBs (olmesartan, losartan, candesartan, and valsartan) on CKD patients without a history of diabetic nephropathy. METHODS: Data were retrieved from medical records of patients with a diagnosis of CKD (serum creatinine [Cre] <3.0 mg/dL [265.2 µmol/L] and urinary protein of 0.3-3.5 g/g Cre) who were treated with ARBs and those with diabetic nephropathy were excluded. Blood pressure, serum Cre, urinary protein, urinary Cre, and estimated glomerular filtration rate were measured before the research began and at 1, 3, 6, 12, and 24 months after the ARB treatment was started. RESULTS: Forty-four patients completed the research protocol. Of these, 10 took olmesartan, 13 took losartan, 9 took candesartan, 9 took valsartan, and 3 took telmisartan. Systolic blood pressure was decreased in all cases. The extent of this decrease 1 month after starting ARB treatment was greater for olmesartan than for candesartan (P < 0.05), and after 2 years, it was greater than for losartan (P < 0.05). Diastolic blood pressure decreased in all patients; this decrease was significantly greater with olmesartan 1 month after treatment started than with candesartan (P < 0.05). Olmesartan significantly decreased daily urinary protein compared with that with the other ARBs during follow-up. This decrease 1 month after starting ARB treatment was greater for olmesartan than losartan, valsartan, and candesartan (P < 0.01, P < 0.01, and P < 0.05, respectively), and after 2 years, this effect was still significant (P < 0.05, P < 0.01, and P < 0.01, respectively). CONCLUSIONS: Olmesartan is more effective in reducing urinary protein than other ARBs, suggesting that the renal protective effects of olmesartan may be better than those of other ARBs.

Rhabdomyolysis and unilateral renal infarction after a motor vehicle crash.

A 46-year-old man with no previous history of abnormal urinalysis findings or renal dysfunction was admitted to a local hospital because of a motor vehicle crash. An open laparotomy was performed to treat a perforation of the small intestine. After operation, oliguria and renal dysfunction developed, and he was admitted to our hospital because of acute renal failure after trauma. Acute renal failure was assumed to be due to rhabdomyolysis with elevated serum creatinine, blood urea nitrogen, and creatine kinase levels and myoglobinemia. Left flank pain occurred several days after admission, and the serum alkaline phosphatase level increased between days 5 and 12 following admission. Although hemodialysis was performed 9 times and the urine output was satisfactory, the creatinine clearance levels increased only to about 50 mL/min/1.73 m2 (0.84 mL/s/m2) at 6 weeks following admission. As a result, a diagnosis of renal infarction due to acute renal artery occlusion was considered. The left kidney was atrophic on an abdominal computed tomographic scan and was nonfunctioning on a renogram. This case shows the importance of not overlooking the possibility of a renal infarction associated with rhabdomyolysis after a motor vehicle crash. In particular, the changes in the serum alkaline phosphatase levels were important in making a correct diagnosis in this case.

Beneficial Effects of Oral Iron in Japanese Patients on Hemodialysis.

Objective Iron deficiency anemia (IDA) has become important with regard to mortality in hemodialysis (HD) patients. Therefore, it is necessary to optimize the treatment of these patients. Methods IDA in end-stage renal disease patients on HD was observed in 42 (33.6%) of 125 patients. We examined the influence of daily orally iron [sodium ferrous citrate (SFC) iron/tablet 50 mg, 1-2 tablets] on the renal function markers, anemia and iron data for about 6 months. Results The hematocrit and hemoglobin levels were significantly increased in the patients treated with SFC [hematocrit: before 28.5%±2.1% (mean ± standard deviation), 1st month 30.0%±2.3%, p<0.05; 3rd month 32.4%±2.9%, p<0.05; 6th month 31.3%±3.4%, p<0.05; and hemoglobin: before 9.25±0.70, 1st month 9.72±0.71, p<0.05; 3rd month 10.54±0.96, p<0.05; 6th month 10.25±1.21 g/dL, p<0.05]. The transferrin saturation (TSAT) and serum ferritin levels were significantly increased in the patients treated with SFC (TSAT: before 21.5%±10.0%, 1st-3rd month, 34.1%±15.1%, p<0.05; 6-8th month 34.7%±11.9%, p<0.05; and ferritin: before 38.2±37.1, 6-8th month 67.5±44.0 ng/mL, p<0.05). The present findings clearly indicate that oral iron is an effective route of iron supplementation in HD patients, and no adverse effects associated with SFC occurred during the treatment and follow-up period. Conclusion Our results clearly indicate that oral iron delivered via SFC is a well-tolerated and effective form of iron supplementation in long-term HD and IDA patients in Japan.

LDL apheresis for cholesterol embolism following coronary artery bypass graft surgery--a case report.

A 76-year-old man without any prior history of abnormal urinalysis findings or renal insufficiency demonstrated mild renal dysfunction after coronary bypass graft surgery (CABG). Two months after CABG, pain and blueness in the toes (blue toe syndrome) appeared and, the serum creatinine level (S-Cr) increased from 1.2 to 2.0 mg/dL. On admission (3 months later), the urinary protein level was 0.5 g/day, white blood cell count 8,300/microL with eosinophils (Eo) 10.5%, S-Cr 2.1 mg/dL, and low-density lipoprotein (LDL) 106 mg/dL. Acute renal failure and blue toe syndrome due to a cholesterol embolism (CE) were diagnosed. Alprostadil 40 microg/day orally for 2 weeks and alprostadil 40 microg/day intravenously were used for 5 weeks, and Eo were 250/microL, S-Cr 2.5 mg/dL; however, blue toe syndrome gradually developed. At 8 weeks after admission, limaprost alfadex 30 microg/day orally was used for 3 weeks. However, the Eo gradually rose to 1,520/microL, S-Cr to 3.0 mg/dL, and LDL to 135 mg/dL, and LDL apheresis was therefore performed 20 times for CE. The data just after LDL apheresis was performed 10 times were as follows: Eo 1,120/microL, S-Cr 4.0 mg/dL, and LDL 89 mg/dL, and blue toe syndrome had disappeared. At 10 months after the first LDL apheresis, the Eo were 630/microL, S-Cr 2.9 mg/dL, and LDL 109 mg/dL. As a result, LDL apheresis was found to be beneficial for the treatment of CE with acute renal failure and blue toe syndrome after CABG.

Changes of the glycemic control and therapeutic regimen for diabetes mellitus in the Japanese patients on hemodialysis.

OBJECTIVES/METHODS: Diabetes mellitus (DM) has become important with regard to mortality in hemodialysis (HD) patients, so it is necessary to optimize the treatment of these patients. We examined the changes in glycemic control and therapeutic regimen, including insulin and oral hypoglycemic agent (OHA) and the diet/exercise in the HD patients. RESULTS: Although DM was observed in 42 (32.6%) of the 129 (male/female 89/40) patients, there was a male predominance, with 35 DM patients being male (83.3%). The therapeutic regimens of DM patients were as follows: insulin was used in 13, OHA in 20, and diet/exercise in nine patients. The DM patients, who had not used insulin, included five patients receiving OHA (25.0%) and diet/exercise in five patients (55.6%). Nineteen of 20 OHA patients used a dipeptidyl peptidase-IV inhibitor. Although the postprandial blood glucose (PBG) in insulin was 191 ± 89 (the mean ± standard deviation [SD]) mg/dL, that in OHA group was 140 ± 36 mg/dL. The mean and the SD of the PBG were larger in insulin than in OHA group. The body mass index (BMI) and hemoglobin A1c were higher in patients treated with insulin (24.1 ± 4.2 kg/m(2), 7.1 ± 1.2%) than in patients treated with the OHA (21.2 ± 2.8 kg/m(2), 5.8 ± 0.5%; P<0.05) or diet/exercise (19.2 ± 3.6 kg/m(2), 5.3 ± 0.6%; P<0.05). The BMI and hemoglobin A1c were higher in diet/exercise compared to OHA and insulin groups. CONCLUSION: The patients undergoing HD develop DM, especially males. The BMI and hemoglobin A1c were useful to determine whether there should be a change from insulin to OHA or to diet/exercise therapy. A dipeptidyl peptidase-IV inhibitor might be a preferable treatment for the DM patients with HD in terms of the mean and SD of PBG.

Phosphate binders and metabolic acidosis in patients undergoing maintenance hemodialysis­sevelamer hydrochloride, calcium carbonate, and bixalomer.

The serum bicarbonate (HCO3(-)) levels are decreased in chronic hemodialysis (HD) patients treated with sevelamer hydrochloride (SH). We assessed the effects of bixalomer on the chronic metabolic acidosis in these patients. We examined 12 of the 122 consecutive Japanese patients with end-stage renal disease on HD, who orally ingested a dose of SH (≥2250 mg), and an arterial blood gas analysis and biochemical analysis were performed before HD. Patients whose serum HCO3(-) levels were under 18 mmol/L were changed from SH to the same dose of bixalomer. A total of 12 patients were treated with a large amount of SH. Metabolic acidosis (a serum HCO3(-) level under 18 mmol/L) was found in eight patients. These patients were also treated with or without small dose of calcium carbonate (1.2 ± 1.1 g). The dose of SH was changed to that of bixalomer. After 1 month, the serum HCO3(-) levels increased from 16.3 ± 1.4 to 19.6 ± 1.7 mmol/L (P < 0.05). Metabolic acidosis was not observed in four patients (serum HCO3(-) level: 20.3 ± 0.7 mmol/L) likely because they were taking 3 g of calcium carbonate with SH. In the present study, the development of chronic metabolic acidosis was induced by HCl containing phosphate binders, such as SH, and partially ameliorated by calcium carbonate, then subsequently improved after changing the treatment to bixalomer.

A comparison of the long-term effects of lanthanum carbonate and calcium carbonate on the course of chronic renal failure in rats with adriamycin-induced nephropathy.

Lanthanum carbonate (LA) is an effective phosphate binder. Previous study showed the phosphate-binding potency of LA was twice that of calcium carbonate (CA). No study in which LA and CA were given at an equivalent phosphate-binding potency to rats or humans with chronic renal failure for a long period has been reported to date. The objective of this study was to compare the phosphate level in serum and urine and suppression of renal deterioration during long-term LA and CA treatment when they were given at an equivalent phosphate-binding potency in rats with adriamycin (ADR)-induced nephropathy. Rats were divided into three groups: an untreated group (ADR group), a CA-treated (ADR-CA) group and a LA-treated (ADR-LA) group. The daily oral dose of LA was 1.0 g/kg/day and CA was 2.0 g/kg/day for 24 weeks. The serum phosphate was lower in the ADR-CA or ADR-LA group than in the ADR group and significantly lower in the ADR-CA group than in the ADR group at each point, but there were no significant differences between the ADR and ADR-LA groups. The serum phosphate was also lower in the ADR-CA group than in the ADR-LA group, and there was significant difference at week 8. The urinary phosphate was significantly lower in the ADR-CA group than in the ADR or ADR-LA group at each point. The urinary phosphate was also lower in the ADR-LA group than in the ADR group at each point, and significant difference at week 8. There were no significant differences in the serum creatinine or blood urea nitrogen among the three groups. In conclusion, this study indicated the phosphate-binding potency of LA isn't twice as strong as CA, and neither LA nor CA suppressed the progression of chronic renal failure in the serum creatinine and blood urea nitrogen, compared to the untreated group.

A case of endocapillary glomerulonephritis associated with peripheral blood natural killer cell proliferation.

A 69-year-old male was admitted to our hospital due to rapidly progressive glomerulonephritis. A peripheral blood smear showed a marked increase in large granular lymphocytes. Flow cytometry analysis of the blood showed a marked increase in CD3-negative and CD56-positive natural killer (NK) cells. A renal biopsy showed a characteristic pathological pattern that involved endocapillary proliferation, a predominance of mononuclear cells and mesangiolysis. Prednisolone was administered, and the patient's renal function subsequently improved concomitant with the amelioration of NK cell proliferation. In our case, there was evidence of a strong association between NK cell proliferation and glomerulonephritis.

Fluid flow stress affects peritoneal cell kinetics: possible pathogenesis of peritoneal fibrosis.

BACKGROUND: Peritoneal fibrosis is an essential precursor condition to the development of encapsulating peritoneal sclerosis (EPS). This serious complication leads to a high mortality rate in peritoneal dialysis (PD) patients. Although several factors, including highly concentrated glucose in the dialysis solution, are believed to be potent agents for peritoneal fibrosis, the underlying mechanism remains unclear. During PD, the dialysis solution continuously generates fluid flow stress to the peritoneum under peristalsis and body motion. Fluid flow stress has been implicated as playing a critical role in the physiologic responses of many cell types. We therefore hypothesized that fluid flow stress may be involved in the pathogenesis of peritoneal fibrosis leading to EPS. METHODS: To generate fluid flow stress, culture containers were placed on a rotatory shaker in a thermostatic chamber. In this system, the shaker rotated at a speed of 25 rpm with a radius of 1.5 cm. Mesothelial cells were cultured in low-glucose (1000 mg/L) or high-glucose (4500 mg/L) complete medium with and without flow stress. RESULTS: Fluid flow stress promoted hyperplasia and epithelial-mesenchymal transition (EMT) of mesothelial cells independent of glucose concentration. Fluid flow stress inhibited expression of ERK (extracellular signal-regulated kinase) and p38 MAPK (mitogen-activated protein kinase) in mesothelial cells. Administration of ERK and p38 MAPK inhibitors replicated the stress-induced morphology of mesothelial cells. CONCLUSIONS: The present data indicate that fluid flow stress promotes hyperplasia and EMT of mesothelial cells via the MAPK axis, suggesting that fluid flow stress may be involved in the pathogenesis of peritoneal fibrosis.

Potential benefit of statin therapy for dyslipidemia with chronic kidney disease: Fluvastatin Renal Evaluation Trial (FRET).

BACKGROUND: Dyslipidemia is a common complication of chronic kidney disease (CKD) and contributes to cardiovascular morbidity and mortality of CKD patients. AIM: The aim of the present study was to determine whether fluvastatin, which is mostly characterized by its pleiotropic anti-oxidant effects, has renoprotective effects in dyslipidemic patients with CKD. METHODS: In 43 dyslipidemic patients with CKD taking fluvastatin 10 mg/day, 20 mg/day or 30 mg/day, renal functions as well as lipid profiles were assessed. RESULTS: After 3 months of treatment with fluvastatin, LDL-cholesterol level significantly decreased. Serum creatinine level, estimated glomerular filtration rate (eGFR), urinary albumin excretion (UAE), urinary liver-type fatty acid binding protein (L-FABP) level and urinary 8-hydroxydeoxyguanosine (8-OHdG) level did not change in overall patients. However, in patients with microalbuminuria (baseline UAE ≥ 30 mg/g·creatinine; n = 23), the UAE significantly decreased [2.43 ± 0.67 to 1.98 ± 0.80 log(mg/g·creatinine), p = 0.01]. In patients with high L-FABP group (baseline L-FABP ≥ 11 µg/g·creatinine; n = 18), the urinary L-FABP level was significantly decreased (1.52 ± 0.45 to 1.26 ± 0.43 µg/g·creatinine, p < 0.01). In the limited 23 patients with microalbuminuria, the L-FABP level was significantly decreased [1.20 ± 0.62 to 1.03 ± 0.49 log(µg/g·creatinine), p = 0.042], although the LDL-cholesterol level (139 ± 28 to 129 ± 23 mg/dL, p = 0.08) only showed a tendency to decrease. The 8-OHdG level also was significantly decreased (13.6 ± 9.6 to 9.8 ± 3.8 ng/g·creatinine, p = 0.043). In the overall patients, changes in the values for UAE and urinary L-FABP were not correlated with the changes in LDL-levels. CONCLUSION: Fluvastatin reduces both UAE and the urinary L-FABP level, and thus, has renoprotective effects, independent of its lipid lowering effects in dyslipidemic patients with CKD.

Ultrasonographic detection of thyroid nodules in hemodialysis patients in Japan.

The study of thyroid nodules in hemodialyzed patients using ultrasonography has been described in a limited number of reports. The thyroid glands of 143 patients with end-stage renal disease on hemodialysis were examined by ultrasonography using frequency probes. Although a goiter (thyroid volume > 20 mL) was observed in only 20 patients (14%), nodular lesions of the thyroid gland were more frequent and found in 85 patients (59.4%), especially in female patients (42 patients, 72.4%). The etiology of thyroid nodular lesions was as follows: cyst in 43 (30.0%), adenomatous goiter in 14 (9.8%), adenoma in 11 (7.7%), hypoechoic lesion in 17 (11.9%), and intrathyroid calcification in 8 (5.6%). Ultrasound-guided fine-needle aspiration cytology was performed in 5 patients, but no abnormal cells were found. Compared to patients without nodules, the age was higher in patients with cysts (54 +/- 15 vs. 63 +/- 13 years; P < 0.05) and hypoechoic lesions (70 +/- 13 years; P < 0.05). The serum thyroglobulin level was higher in patients with adenomatous goiters (26 +/- 28 vs. 148 +/- 166 ng/mL; P < 0.05). The thyroid volume was greater in patients with adenomatous goiters (14.2 +/- 5.7 vs. 19.0 +/- 7.3 mL; P < 0.05) and adenomas (18.2 +/- 6.7 mL; P < 0.05). In conclusion, patients undergoing hemodialysis frequently develop thyroid abnormalities and ultrasonography is a useful imaging modality to identify these lesions.

Successful steroid treatment in a patient with membranoproliferative glomerulonephritis associated with hepatitis C virus.

Thirteen years ago, a 65-year-old woman was diagnosed to have chronic active hepatitis with hepatitis C virus. After starting interferon alpha administration, she noticed edema and hypoalbuminemia. Renal biopsy revealed mesangial proliferation with focal endocapillary proliferation, and double contour of the glomerular basement membrane due to mesangial interposition. Interferon alpha was discontinued, and proteinuria and edema gradually decreased. She was re-admitted due to a relapse of proteinuria 8 years later. Biopsy revealed moderate mesangial and endcapillary proliferation presenting a lobular pattern, in addition to the presence of hyaline thrombi. Granular staining of immunoglobulin M and of C3 in capillary walls were detected. Since cryoglobulinemia was positive, a final diagnosis of cryoglobulinemic membranoproliferative glomerulonephritis was made. Prednisolone was started with an initial dose of 20 mg/day. Proteinuria and hypoalbuminemia improved, and prednisolone was tapered to 5 mg/day 9 months after the 2nd renal biopsy. The hepatitis C virus-RNA titer fluctuated.

Partial blood recirculation: a new trial for prolonging filter life during continuous hemodiafiltration.

Although continuous hemodiafiltration (CHDF) has been widely accepted in the management of complicated acute renal failure, the requirement for prolonged continuous systemic anticoagulation appears to be a major drawback. We herein describe the case of a patient who developed postoperative multiple organ failure and received CHDF therapy with partial blood recirculation (PBR). PBR is a mode of extracorporeal circulation used as an anticoagulation modality. The technique accelerates the blood flow rate with the goal of extending filter life, and it was performed because the filter life had been significantly shortened (10.5 +/- 5.1 h) during the CHDF process in this case. Despite increasing the dose of the anticoagulant, changing the hemofilter and changing the mode from postdilution to predilution, we did not obtain amelioration of filter life. The filter life was significantly improved (41.5 +/- 1.4 h) when we performed PBR. It is difficult to minimize the bleeding risk and maintain filter life during CHDF. Our success in prolonging the filter life during this case therefore suggests that PBR might resolve one of the main problems related to CHDF, although more study is needed to clarify the advantages of this system.

A case report of nephrotic syndrome due to collapsing focal segmental glomerulosclerosis treated with low-density lipoprotein apheresis.

We herein report the case of a 73-year-old woman with steroid and cyclosporine resistant collapsing focal segmental glomerulosclerosis (FSGS) whose refractory proteinuria and hypoproteinemia were controlled with low-density lipoprotein apheresis (LDL-A). She was initially treated with steroid therapy, including methylprednisolone pulse and cyclosporine therapy. However, her hypoproteinemia, accompanied with renal insufficiency, persisted despite these therapies. We treated her using LDL-A and found improvement in her urine protein excretion, hyperlipidemia, hypoproteinemia, and renal function as a result of this treatment. This suggests that LDL-A may therefore be an effective therapy for nephrotic syndrome due to collapsing FSGS.

Role of amyloidosis in determining the prognosis of dialyzed patients with rheumatoid arthritis.

The role of secondary amyloidosis in determining the prognosis of dialyzed patients with rheumatoid arthritis (RA) was examined in 22 patients with a mean age of 60.1 years included 21 renal amyloidosis. RA duration until the start of dialysis was 19.5 +/- 7.2 years and the observation period after introduction 27.1 +/- 26.4 months. Of the 14 dead cases, four died due to sepsis, three due to gastrointestinal tract bleeding, two due to congestive heart failure, and eight cases died within 5 months after starting dialysis. When comparing the eight survivors and the nine non-survivors who died within 2 years after the start of dialysis, the former patients showed significantly higher serum albumin, and lower electrocardiogram score and cardiothoracic ratios at the time of introduction to dialysis. The careful prevention and treatment of infection, cerebrovascular and/or gastrointestinal tract complications seem to be necessary to improve the prognosis of RA patients after the initiation of renal replacement therapy.