Relationship between Dose of Bolus Dialysate Infusion and Blood Pressure in Intermittent Infusion Hemodiafiltration.

BACKGROUND: Intermittent infusion hemodiafiltration is a recently developed convective method of renal replacement therapy using cyclic back-filtration infusion. Quick and regular infusion prevents intradialytic hypotension. However, the optimal dose of bolus dialysate infusion required to stabilize blood pressure has not been reported. Here, we investigated the relationship between the dose of bolus dialysate infusion and blood pressure. SUMMARY: A total of 77 patients on maintenance hemodialysis were enrolled in this study. Dialysate was infused rapidly by backward filtration at a rate of 150 mL/min at 30-min intervals using an automated dialysis machine. The effects with two bolus infusion volumes (100 and 200 mL) were compared, each for an observation period of 2 weeks. Systolic blood pressure (SBP) was measured at the start and at the end of each dialysis session, and the highest SBP and lowest SBP measurements were also recorded. Patients were divided according to dry weight into a <52 kg group and a ≥52 kg group, and various parameters were compared between the 100 and 200 mL bolus infusion volumes in each group. Among patients in the <52 kg group, SBP did not vary at any of the time points. However, for patients in the ≥52 kg group, SBP at the end of treatment was significantly lower in the 100-mL group than in the 200-mL group (141 ± 20 vs. 144 ± 21 mm Hg, p = 0.041), and the minimum SBP was also lower in the 100-mL group than in the 200-mL group (127 ± 17 vs. 131 ± 18 mm Hg, p = 0.010). Key Messages: Among patients with a dry weight of ≥52 kg, blood pressure was more stable when a bolus fluid volume of 200 mL was used, compared with a volume of 100 mL. However, for patients with a dry weight of <52 kg, the significance of the difference in bolus fluid volumes disappeared. Thus, the replacement fluid volume might be better determined based on the patient's dry weight. TRIAL REGISTRATION: UMIN 000028145, Registered July 10, 2017.

Seroprevalence of IgG1 and IgG4 class antibodies against Mycobacterium avium subsp. paratuberculosis in Japanese population.

Mycobacterium avium subsp. paratuberculosis (MAP) is the established causative agent of Johne's disease in cattle and other ruminants, and it has also been speculated to be a putative etiological agent of several human autoimmune diseases. It is acknowledged that dairy products deriving from infected animals play a role (could be vehicles) in exposing humans to MAP. MAP could stimulate the human immune system by means of their complex antigen (in the case of lipids, multivalent antigens) and may modulate it, acting as adjuvant molecules such as Freund's complete adjuvant. The immune system might be abnormally stimulated by the constant presence of MAP antigens (for example, in the dairy products), and this might be particularly relevant in genetically predisposed individuals. However, there is limited understanding about the current human exposure to MAP. The present study analyzed the antibody recognition profile of MAP lipophilic antigens in a cohort of 126 healthy Japanese. We measured the serum levels of total immunoglobulin G (IgG) and subclasses targeting MAP surface antigens through ethanol vortex indirect enzyme-linked immunosorbent assay (EVELISA) by using serum absorbed with Mycobacterium phlei. Elevated IgG (especially IgG1 and IgG4) responses were observed in 14% of the sera. To assess the specificity of EVELISA, the same samples were analyzed by means of a commercially available Johnelisa II kit. It was noteworthy that a high degree of correlation was observed when comparing the two methodologies (rs=0.7, p<0.0001). Moreover, in order to investigate the specificity of the binding, inhibition assay experiments were carried out also searching for antibodies against Bacillus Calmette-Guérin antigens, but no cross-reaction was observed. The result obtained represents the first evidence implying that the Japanese population is exposed to MAP, and additionally the existence of a foodborne chain of exposure that transmits MAP antigens to humans.

A functional variant in FCRL3, encoding Fc receptor-like 3, is associated with rheumatoid arthritis and several autoimmunities.

Rheumatoid arthritis is a common autoimmune disease with a complex genetic etiology. Here we identify a SNP in the promoter region of FCRL3, a member of the Fc receptor-like family, that is associated with susceptibility to rheumatoid arthritis (odds ratio = 2.15, P = 0.00000085). This polymorphism alters the binding affinity of nuclear factor-kappaB and regulates FCRL3 expression. We observed high FCRL3 expression on B cells and augmented autoantibody production in individuals with the disease-susceptible genotype. We also found associations between the SNP and susceptibility to autoimmune thyroid disease and systemic lupus erythematosus. FCRL3 may therefore have a pivotal role in autoimmunity.

Association between high-molecular-weight adiponectin and bone mineral density in hemodialysis patients.

BACKGROUND: Chronic kidney disease-mineral and bone disorder is a regular complication seen in hemodialysis patients and leads to substantial increases in the fracture rate, morbidity, and mortality. Discovered a few years ago, several clinical studies have shown a negative correlation between adiponectin and bone mineral density (BMD) independently of confounding factors. The relationship between adiponectin and bone metabolism in hemodialysis patients has not been fully described yet. We conducted this study to investigate the relationship between serum adiponectin concentration and the BMD in hemodialysis patients. METHODS: We enrolled 92 hemodialysis patients who were receiving maintenance hemodialysis therapy at Towa Hospital. A peripheral blood sample was obtained, and standard biological data and the serum high-molecular-weight (HMW) adiponectin level were measured. BMD was assessed using dual-energy X-ray absorptiometry scans. RESULTS: In male hemodialysis patients, BMD was negatively related to age (r = -0.299, P = 0.012), duration of hemodialysis therapy (r = -0.31, P = 0.009), and log [HMW-adiponectin] (r = -0.31, P = 0.009) and positively related to body weight (r = 0.332, P = 0.004) and BMI (r = 0.297, P = 0.013). In female hemodialysis patients, BMD was negatively related to age (r = -0.499, P = 0.018) and log [HMW-adiponectin] (r = -0.46, P = 0.030) and positively related to triglyceride (r = 0.491, P = 0.020). CONCLUSIONS: HMW adiponectin may affect bone metabolism in both male and female hemodialysis patients.

Characteristics of the 6th Japanese wave of COVID-19 in hemodialysis patients.

Background: We examined the clinical characteristics of hemodialysis patients with COVID-19 during the 6th wave of infection (mainly Omicron variant) in Japan. Methods: Hemodialysis patients admitted in January 2022 and thereafter were grouped as the 6th wave group (n = 53), while others were grouped as the 1st-5th wave group (n = 47). Results: The proportion of vaccinations was significantly higher in the 6th wave group than in the 1st-5th wave group (96.2% vs 10.6%, p < 0.0001). Neutralizing antibody and molnupiravir were used more frequently in the 6th wave group (75.5% and 88.7%) than in the 1st-5th wave group (14.9% and 0%, both p < 0.0001). The critical disease was seen in 21.3% of the patients in the 1st-5th wave group and 0% in the 6th wave group (p < 0.001). Conclusion: The prognosis of hemodialysis patients in the 6th wave group was good. The vaccination and advances in the treatment may have contributed to the outcomes.

Characteristics of hemodialysis patient with critical COVID-19.

INTRODUCTION: The clinical course of hemodialysis patients with COVID-19 still remains unclear. METHODS: Thirty-four hemodialysis patients were retrospectively enrolled. Patients were divided according to disease severity, and clinical symptoms and laboratory data at admission were compared. RESULTS: The serum C-reactive protein (CRP) level, d-dimer level, and white blood cell (WBC) count were significantly higher in the group with critical disease than in the group with mild to severe disease (p = 0.005, p = 0.039, and p = 0.045). The serum CRP level exceeded 10 mg/dl within 7 days of clinical onset in all the cases with critical disease. CONCLUSION: Hemodialysis patients with COVID-19 who have elevated serum CRP and d-dimer levels, and an elevated WBC count at admission and patients with serum CRP levels exceeding 10 mg/dl before day 7 after clinical onset should be carefully monitored for possible progression to critical disease.

[Successful rituximab therapy for MALT lymphoma complicating cryoglobulinemic glomerulonephritis].

We report a case of nephrotic syndrome associated with MALT lymphoma. The patient was a 66-year-old woman who had a 21-year history of MALT lymphoma. She was admitted to our hospital for the evaluation of systemic edema and purpura during two months. Urinary protein excretion was quantified at 3.3 g/24h. Serum creatinine was elevated to 1.63 mg/dL. An immunoserological investigation showed the presence of IgM-kappa type monoclonal cryoglobulin accompanied by a decreased serum complement level. HCV infection was negative. A renal biopsy specimen revealed membranoproliferative glomerulonephritis (MPGN) with cryoglobulin deposition and focal atypical lymphoid cells infiltration in the renal interstitium. Immunoperoxidase staining of the atypical lymphoid cell population was positive for CD20 and CD79. Combined therapy with prednisolone, plasma exchange and rituximab was commenced. Her proteinuria disappeared and renal function improved after rituximab therapy. In our case, nephrotic syndrome due to cryoglobulinemic glomerulonephritis was successfully treated mainly by rituximab.

[Morphological analysis of bone dynamics and metabolic bone disease. A case report of recurrent renal hyperparathyroidism].

A 39-years-old chronic hemodialysis patient who developed recurrent hyperparathyroidism after total parathyroidectomy with immediate autotransplantation (PTX-AT) is now reported. The patient had undergone bilateral nephrectomy due to bilateral renal cell carcinoma at 4 and 5 years after the initiation of dialysis, followed by the treatment with interleukin-2 administration. Secondary hyperparathyroidism was treated by PTX-AT, followed by confirmation of reduced bone turnover. The parathyroid glands were huge and the total weight of the parathyroid glands was 14.3 gr. Pathological examination revealed nodular hyperplastic parathyroid tissue in all four glands. However, the serum intact parathyroid hormone (iPTH) increased again at 7 years after the PTX, and bone biopsy revealed high turnover bone disease. The recurrent hyperparathyroidism was treated with cinacalcet hydrochloride to reduce the serum iPTH level.

Characteristics of body composition and nutritional status in patients receiving hemodialysis therapy for more than 30 years.

BACKGROUND/AIMS: We investigated the body composition and nutritional status of extremely long-term (more than 30 years) hemodialysis patients. METHODS: Eighty outpatients receiving maintenance hemodialysis (including 18 for more than 30 years) were enrolled. We classified the patients according to the duration of hemodialysis therapy (less than 10 years, 10-20 years, 20-30 years, or over 30 years) and compared the laboratory and anthropometric data. RESULTS: No significant differences in age or the total protein, albumin, total cholesterol, triglyceride or CRP levels were observed. The corrected body mass index (BMI) was significantly lower in the more than 30 years than in the less than 10 years group. The corrected arm muscle area (AMA) was significantly lower in the more than 30 years group than in the other groups. CONCLUSION: In extremely long-term hemodialysis outpatients, the BMI and AMA were reduced, whereas nutritional markers were relatively preserved.

The importance of low blood urea nitrogen levels in pregnant patients undergoing hemodialysis to optimize birth weight and gestational age.

Most published reports indicate that intensified hemodialysis results in better pregnancy outcomes. Here we studied clinical characteristics and the outcomes of 28 pregnant women receiving hemodialysis. We found an association between maternal blood data and birth weight, and gestational age and outcomes. There were 18 surviving infants who were followed up for one year. In the others there were 4 spontaneous abortions, 1 stillbirth, 3 neonatal deaths and 2 deaths after birth. Analysis of blood chemistry for 20 pregnancies from 12 weeks of gestation until delivery showed that the average hemoglobin level was significantly higher in the group that successfully delivered than in the unsuccessful group. There were significant negative relationships between the blood urea nitrogen (BUN) level and the birth weight or gestational age in the latter cohort. A birth weight equal to or greater than 1500 g or a gestational age equal to or exceeding 32 weeks corresponded to BUN levels of 48-49 mg/dl or less. Whether the low BUN is the direct cause of the improved outcome remains to be examined.

Characteristics of dialysis-related amyloidosis in patients on haemodialysis therapy for more than 30 years.

BACKGROUND: Dialysis-related amyloidosis is one of the chronic the complications of haemodialysis. We conducted an investigation of dialysis-associated amyloidosis in extremely long-term survivors. METHODS: Twenty-one patients on haemodialysis for more than 30 years ('30+' group) and 13 patients on haemodialysis for 20-30 years ('20-30' group) at Sangenjaya Hospital were enrolled in this study. The frequencies of operations for conditions related to haemodialysis-related amyloidosis were examined. RESULTS: The mean age at the start of haemodialysis was younger in the '30+' group (29.1 +/- 7.3 years) than in the '20-30' group (40.5 +/- 8.2 years, P = 0.0003). Eighteen (85.7%) patients had undergone surgery for CTS, six (28.6%) had undergone surgery for trigger finger and six (28.6%) had undergone surgery for cervical destructive spondyloarthropathy (DSA) at 30 years after the start of haemodialysis therapy. Patients who were over the age of 30 years at the start of dialysis therapy more frequently underwent CTS operations (100%) than those who were under 30 years of age at the start of dialysis (76.9%; P = 0.025) in the '30+' group at 30 years after the start of haemodialysis. The frequencies of operations for CTS did not differ significantly between the '20-30' group and the '30+' group. CONCLUSIONS: Haemodialysis-associated amyloidosis was common in extremely long-term survivors. Even though the mean age at the start of haemodialysis was younger in the '30+' group than in the '20-30' group, the frequency of operations for CTS did not differ. This may be attributable to the recent advances in haemodialysis technologies.

Clinical assessment of tacrolimus therapy in lupus nephritis: one-year follow-up study in a single center.

BACKGROUND/AIMS: The purpose of this study was to examine whether tacrolimus is effective and safe, and to determine the optimal dose of tacrolimus for maintenance treatment in patients with lupus nephritis (LN). METHODS: A total of 17 adult patients (1 man and 16 women) with LN were enrolled. Tacrolimus was initiated at a dose of 3 mg/day which was administered once per day after the evening meal. Prospective data on renal response and serologic lupus activity were collected and followed for a year. RESULTS: Mean age at baseline was 48.8 +/- 12.6 years (range 31-72 years). The mean urinary protein/creatinine ratio significantly decreased from 1.14 +/- 1.74 at baseline to 0.23 +/- 0.47 at 1 year (p < 0.05). Mean serum C3 significantly increased from 73.0 +/- 12.3 mg/dl at baseline to 84.7 +/- 12.2 mg/dl at 1 year (p < 0.01). Mean serum creatinine levels were unchanged after tacrolimus treatment. The mean blood concentration of tacrolimus was 3.9 +/- 2.1 ng/ml. There was no relationship between the incidence of adverse effects and blood tacrolimus level. CONCLUSION: Our results suggest tacrolimus to be potentially effective and safe for maintenance treatment in patients with LN.

Adding High-Dose Spironolactone to Tolvaptan Improves Acute Decompensated Heart Failure Due to Obstructive Hypertrophic Cardiomyopathy and Aortic Stenosis: A Case Report.

BACKGROUND In the setting of acute decompensated heart failure (ADHF), tolvaptan, a selective V2 receptor antagonist, did not alter plasma renin activity or angiotensin II level, but significantly increased plasma aldosterone by the activation of V1ₐ receptor, suggesting that a high-dose mineralocorticoid receptor antagonist (MRA) combined with a V2 receptor antagonist might be of interest, especially in ADHF patients. However, in the setting of ADHF, the short-term and long-term efficacy of a high-dose MRA combined with tolvaptan remains unclear. CASE REPORT An 86-year-old woman with a history of chronic HF with a preserved ejection fraction due to obstructive hypertrophic cardiomyopathy and severe aortic stenosis was transferred to our hospital complaining of persistent dyspnea (New York Heart Association class IV). She did not respond to standard therapy with tolvaptan (15.0 mg/day). However, the present case demonstrated that adding high-dose spironolactone (100 mg/day) to low-dose tolvaptan (15.0 mg/day) is safe and well tolerated, resulting in an increase in urine output and improvement of the symptoms or signs of ADHF in a patient who was refractory to loop diuretics and tolvaptan. CONCLUSIONS The short- and long-term efficacy of high-dose spironolactone combined with low-dose tolvaptan may be associated with an attenuation of the aldosterone level, which is increased through V1ₐ activation by vasopressin during tolvaptan administration.

Association of admission and discharge anemia status with outcomes in patients hospitalized for acute decompensated heart failure: Differences between patients with preserved and reduced ejection fraction.

BACKGROUND: In acute decompensated heart failure patients with a preserved or reduced ejection fraction, the association of admission and discharge anemia status with outcomes remains unclear. METHODS AND RESULTS: Of the 4842 patients enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry, 4433 patients (2017 with a preserved and 2416 with a reduced ejection fraction) were examined to investigate associations among the anemia status at admission and discharge (no anemia, developed anemia, resolved anemia, or persistent anemia), a preserved or reduced ejection fraction and the primary endpoint (all-cause death and readmission for heart failure). In the preserved ejection fraction group, adjusted analysis showed that either developed or persistent anemia was associated with a significantly higher risk of the primary endpoint relative to no anemia (hazard ratio: 1.53; 95% confidence interval (CI): 1.11-2.11; p=0.009 and hazard ratio: 1.60; 95% CI: 1.26-2.04; p<0.001, respectively), but there was no association between resolved anemia and the primary endpoint (hazard ratio: 0.98; 95% CI: 0.67-1.45; p=0.937). In the reduced ejection fraction group, either developed or resolved anemia was associated with a tendency toward higher risk of the primary endpoint relative to no anemia (hazard ratio: 1.29; 95% CI: 0.95-1.62; p=0.089, and hazard ratio: 1.31; 95% CI: 0.96-1.77; p=0.085, respectively), while persistent anemia was associated with a significantly higher risk of the primary endpoint relative to no anemia (hazard ratio: 1.36; 95% CI: 1.12-1.65; p=0.002). CONCLUSIONS: In acute decompensated heart failure patients, the association of admission and discharge anemia status with outcomes differs markedly between patients with a preserved or reduced ejection fraction.

Influence of serum high-molecular-weight and total adiponectin on arteriosclerosis in IgA nephropathy patients.

BACKGROUND/AIM: Adiponectin has attracted a great deal of attention because of its antiatherogenic properties. Previous studies have reported that high-molecular-weight (HMW) adiponectin may be the active form of this protein, but there have been no reports on the relationship between serum adiponectin and arteriosclerosis. The aim of our study was to determine whether HMW or total adiponectin levels are associated with arteriosclerosis in patients with IgA nephropathy. METHODS: We enrolled 72 patients aged 34.3 +/- 12.7 years, from whom interlobular arteries were obtained by renal biopsy in our hospital between 2003 and 2006 and who were confirmed to have IgA nephropathy. We assessed them in relation to age, gender, body mass index, presence of hypertension, serum total cholesterol, triglyceride, uric acid, high-sensitive C-reactive protein and HMW adiponectin and total adiponectin levels, creatinine clearance, and urinary protein excretion. The severity of arteriosclerosis was semiquantitatively evaluated and classified into the following four grades: 0 = none; 1 = mild; 2 = moderate, and 3 = severe. RESULTS: Multiple stepwise regression analysis showed associations between arteriosclerosis grade and age [standard regression coefficient (st beta) = 0.560, p < 0.001], total adiponectin (st beta = -0.218, p = 0.026), triglyceride (st beta = 0.222, p = 0.033), and presence of hypertension (yes = 1, no = 0; st beta = 0.182, p = 0.036) in the IgA nephropathy patients as a whole and associations between arteriosclerosis grade and age (st beta = 0.708, p < 0.001), HMW adiponectin (st beta = -0.321, p = 0.035), and triglyceride (st beta = 0.292, p = 0.038) in the male IgA nephropathy patients. CONCLUSIONS: Serum total adiponectin levels are an independent determinant of arteriosclerosis in IgA nephropathy patients. It was noteworthy that in males the serum HMW adiponectin levels correlated more strongly with arteriosclerosis grade than the total adiponectin levels did. Adiponectin may prevent renal arteriosclerosis.

Effects of sevelamer on the progression of vascular calcification in patients on chronic haemodialysis.

BACKGROUND/AIM: Vascular calcification is thought to be associated with a high cardiovascular mortality rate in patients with end-stage renal disease. Control of hyperphosphataemia is important for the treatment of the vascular calcification. The aim of the present study was to evaluate the effects of sevelamer hydrochloride on the progression of aortic calcification in haemodialysis (HD) patients. METHODS: 42 HD patients were studied in this study and divided into two groups (sevelamer vs. calcium). Sevelamer was added and titrated up to achieve serum P control for 6 months. The estimations of aortic calcification index (ACI) by abdominal computed tomography scans were performed twice in each patient. We compared the changes in serum calcium, phosphorus, intact parathyroid hormone, and lipids in two groups. RESULTS: Serum phosphorus levels decreased significantly from 6.7 +/- 0.7 to 6.2 +/- 0.5 mg/dl with no changes in serum intact parathyroid hormone levels in the sevelamer group (p < 0.01), and increased from 6.5 +/- 1.0 to 6.7 +/- 1.1 mg/dl in the calcium group (p < 0.05). Serum calcium levels did not change in the sevelamer group and calcium group. The serum levels of total cholesterol decreased significantly from 158.5 +/- 20.7 to 146.2 +/- 24.1 mg/dl (p = 0.024) and the low-density lipoprotein cholesterol level from 65.3 +/- 14.4 to 54.7 +/- 11.6 mg/dl (p = 0.014) in the sevelamer group. Serum C-reactive protein decreased significantly from 0.14 +/- 0.13 to 0.08 +/- 0.11 mg/dl in the sevelamer group (p = 0.038) and significantly increased (0.18 +/- 0.09 vs. 0.22 +/- 0.12 mg/dl) in the calcium group (p = 0.042). The mean changes in ACI (DeltaACI) were 3.6 +/- 1.5% in the sevelamer group and 8.2 +/- 3.1% in the calcium group. CONCLUSIONS: Sevelamer allows a better serum phosphorus control compared with calcium-based phosphate binder and suppresses the progression of aortic calcification in HD patients.

Sex Differences in Left Ventricular Cavity Dilation and Outcomes in Acute Heart Failure Patients With Left Ventricular Systolic Dysfunction.

BACKGROUND: In this study we evaluated the influence of sex on the left ventricular end-diastolic dimension (LVEDD) and adverse outcomes in patients hospitalized for acute decompensated heart failure (HF) with a reduced ejection fraction (EF). METHODS: Among the 4842 patients enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry, 2367 patients (1607 men and 760 women) discharged alive after hospitalization for acute decompensated HF with a reduced EF (defined as a left ventricular EF < 50%) were investigated to assess the association of sex and LVEDD with the primary end point (all-cause death and readmission for HF after discharge). Men and women were separately divided into LVEDD quartiles at discharge (men: LVEDD ≤ 54, 55-60, 61-65, and ≥ 66 mm; women: LVEDD ≤ 48, 49-54, 55-60, and ≥ 61 mm). The median follow-up period after discharge was 524 (range, 385-785) days. RESULTS: Occurrence of the primary end point did not differ between men and women (37.0% vs 37.2%; P = 0.921). After adjustment for multiple comorbidities including left ventricular EF, men with an LVEDD of 61-65 and ≥ 66 mm had a significantly higher risk of the primary end point than men with an LVEDD ≤ 54 mm, indicating a positive association between a larger LVEDD and adverse outcomes. In contrast, in women, the adjusted risk of the primary end point was comparable among the LVEDD quartiles. CONCLUSIONS: Men and women with acute decompensated HF and a reduced EF might show important differences in relation to the association between left ventricular cavity dilation and outcomes.

Achievement of the Japanese Society for Dialysis Therapy guideline targets for mineral metabolism measures: one Japanese university center result.

A consensus conference for the Guidelines for the Management of Secondary Hyperparathyroidism in Chronic Dialysis Patients was conducted in the general meeting of the Japanese Society for Dialysis Therapy (JSDT) in June 2006, and the guidelines were proposed in the Journal of JSDT in 4 months later. The aim of this study was performed on the status of observance with the data, based on 6 months later proposal of the guidelines. Only 48.9% stayed within the range specified by the calcium and phosphorus guideline. Moreover, only 12% of patients were able to remain within the ranges specified by all three guidelines (calcium, phosphorus, and PTH), 6 months later proposal of the guidelines. In our institution, compliance with the JSDT guidelines was inadequate. Major reasons were the special characteristics of the medical care system and patients in our institution as a university hospital. Further improvement in the contents and method of the use of the guidelines is necessary alongside observation of the present situation in Japan.

Characteristics of patients on hemodialysis therapy for more than 30 years.

Since its experimental introduction in 1960, hemodialysis has become a widely performed and relatively safe procedure. Therapeutic strategies have been developed, and the numbers of long-term survivors of hemodialysis therapy have been increasing. Hemodialysis therapy was introduced at Sangenjaya Hospital in October 1970, and the 16 patients who have survived for more than 30 years on hemodialysis therapy since its introduction at the hospital were enrolled in this study to investigate the characteristics of long-term hemodialysis patients. For comparison, 50 patients on hemodialysis for less than 30 years were also studied (21 patients with <10 years hemodialysis, 13 with 10-20 years hemodialysis and 16 with 20-30 years hemodialysis). Background information (age, gender, and cause of renal disease), dialysis dose (single pool [sp.] Kt/V), mineral metabolism (serum phosphate), anemia management (serum hemoglobin), and nutrition (serum albumin and reduced interdialytic weight gain) were assessed. Hemodialysis was instituted at 28.7 +/- 6.4 years of age. The primary cause of end-stage renal disease was chronic glomerulonephritis in all of the patients except one, and in that patient it was polycystic kidney disease. As an index of the dialysis dose, sp. Kt/V was 1.2 +/- 0.11. As an index of mineral metabolism, serum phosphate was 5.4 +/- 0.9 mg/dL. As an index of anemia management, serum hemoglobin was 10.2 +/- 1.2 g/dL. As indexes of nutrition, serum albumin was 4.0 +/- 0.2 g/dL and interdialytic weight gain was 4.43 +/- 1.36%. The sp. Kt/V-value, serum phosphate, serum hemoglobin and interdialytic weight gain did not differ between the four different hemodialysis duration groups. Serum albumin was lower in the >30 group (4.0 +/- 0.2 g/dL) than in the <10 group (4.2 +/- 0.3 g/dL) (P = 0.046). As the duration of hemodialysis has increased, the age at hemodialysis induction has become younger. The cause of the renal failure was chronic glomerulonephritis in most of the cases. None had diabetic nephropathy. Improvement of the prognosis of patients with diabetic nephropathy is required. Most of the indexes of these patients nearly satisfied the recommended values.

Ischemic or Nonischemic Functional Mitral Regurgitation and Outcomes in Patients With Acute Decompensated Heart Failure With Preserved or Reduced Ejection Fraction.

The aim of this study was to evaluate the association of functional mitral regurgitation (FMR), preserved or reduced ejection fraction (EF), and ischemic or nonischemic origin with outcomes in patients discharged alive after hospitalization for acute decompensated heart failure (HF). Of the 4,842 patients enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry, 3,357 patients were evaluated to assess the association of FMR, preserved or reduced EF, and ischemic or nonischemic origin with the primary end point (all-cause death and readmission for HF after discharge). At the time of discharge, FMR was assessed semiquantitatively (classified as none, mild, or moderate to severe) by color Doppler analysis of the regurgitant jet area. According to multivariable analysis, in the ischemic group, either mild or moderate to severe FMR in patients with a preserved EF had a significantly higher risk of the primary end point than patients without FMR (hazard ratio [HR] 1.60; 95% confidence interval [CI] 1.12 to 2.29; p = 0.010 and HR 1.98; 95% CI 1.30 to 3.01; p = 0.001, respectively). In patients with reduced EF with an ischemic origin, only moderate to severe FMR was associated with a significantly higher risk of the primary end point (HR 1.67; 95% CI 1.11 to 2.50; p = 0.014). In the nonischemic group, there was no significant association between FMR and the primary end point in patients with either a preserved or reduced EF. In conclusion, among patients with acute decompensated HF with a preserved or reduced EF, the association of FMR with adverse outcomes may differ between patients who had an ischemic or nonischemic origin of HF.