Renal infiltration of peripheral T-cell lymphoma, not otherwise specified, mimicking drug-induced acute interstitial nephritis.

Renal invasion of T-cell lymphoma does not usually occur. The renal infiltration of peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS), is rare. Therefore, the detailed pathology, clinical features, and effective therapy of this type of extranodal disease remain uncovered. Here, we report the rare case of acute kidney injury (AKI) caused by the renal infiltration of PTCL-NOS with no evidence of lymphadenopathy and extranodal lesions, except for the kidney. We mistakenly diagnosed our patient with drug-induced acute interstitial nephritis (AIN) at first, because his clinical features were similar to those of drug-induced AIN; however, we reached the correct diagnosis by detecting atypical T-cells in his urine. After the introduction of cyclophosphamide, doxorubicin, vincristine, and prednisone therapy his general condition improved rapidly. When suspecting drug-induced AIN as the cause of AKI, PTCL-NOS should also be recognized as one of the causes, and urine cytology may be useful to noninvasively distinguish between the two diseases.

Atypical familial Mediterranean fever developed in a long-term hemodialysis patient.

Familial Mediterranean Fever (FMF) is usually an autosomal recessive autoinflammatory disease characterized by recurrent attacks of fever and serositis. FMF develops before the age of 20 years in 90% of patients. It has intervals of 1 week to several years between attacks, which leads to renal dysfunction-amyloidosis. We report a case of atypical FMF that developed in a long-term hemodialysis patient. A 65-year-old Japanese female undergoing hemodialysis for 32 years was referred to our hospital with a fever of unknown origin (FUO) following cervical laminoplasty. The fever occurred as recurrent attacks accompanied by oligoarthralgia of the left hip and knee. We suspected FMF because of recurrent self-limited febrile attacks, although the patient showed atypical clinical features such as late-onset and highly frequent attacks. After receiving treatment, she achieved a complete response to colchicine. Therefore, a diagnosis of FMF was made based on the Tel-Hashomer criteria, which was confirmed by genetic testing. The case suggests that FMF may be of note in long-term hemodialysis patients developing FUO.

Infective endocarditis in a patient with lupus nephritis who was undergoing immunosuppressive therapy: A case of survival.

Systemic lupus erythematosus is an autoimmune disease associated with mild valvular regurgitation. However, there have been no detailed reports of infective endocarditis in patients with systemic lupus erythematosus. Here, we describe a case of a 55-year-old woman without any cardiac abnormalities who was diagnosed with lupus nephritis by renal biopsy; she contracted infective endocarditis while receiving immunosuppressive therapy. Our case emphasizes that special consideration of the occurrence of infective endocarditis, and its early diagnosis and treatment are mandatory for patient survival. We propose that echocardiography should be performed before treating patients with systemic lupus erythematosus who have an uncertain cardiac status.

Combination of low body mass index and serum albumin level is associated with chronic kidney disease progression: the chronic kidney disease-research of outcomes in treatment and epidemiology (CKD-ROUTE) study.

BACKGROUND: The relationship between protein-energy wasting and chronic kidney disease (CKD) progression is unknown. In the present prospective cohort study, we evaluated the hypothesis that a combination of low body mass index (BMI) and serum albumin level is associated with rapid CKD progression. METHODS: The study cohort comprised 728 predialysis Japanese patients with CKD (stages 2-5) enrolled from 2010 to 2011. Patients were categorized into four groups according to their serum albumin levels and BMI: group 1, low serum albumin level (<4 g/dL) and low BMI (<23.5 kg/m2); group 2, high serum albumin level (≥4 g/dL) and low BMI; group 3, low serum albumin level and high BMI (≥23.5 kg/m2); and group 4, high serum albumin level and high BMI. The primary outcome was a 30 % decline in estimated glomerular filtration rate (eGFR) or start of dialysis within 2 years. The secondary outcome was an annual GFR decline (mL/min/1.73 m2/year). RESULTS: Logistic regression analysis adjusted for baseline characteristics (reference, group 4) showed that only group 1 was associated with a significant risk of CKD progression, with adjusted odds ratio of 3.51 [95 % confidence interval (CI) (1.63, 7.56)]. A multivariate linear regression analysis adjusted for baseline characteristics showed a significant difference in annual eGFR decline between groups 1 and 4 [coefficients ß (standard error) -2.62 (0.75), p = 0.001]. CONCLUSION: This study suggests that combined effects of low BMI (<23.5 kg/m2) and serum albumin level (<4 g/dL) are associated with CKD progression.

Association of serum chloride level with mortality and cardiovascular events in chronic kidney disease: the CKD-ROUTE study.

BACKGROUND: Electrolyte abnormalities, particularly dysnatremia, are independent predictors of adverse outcome in individuals with and without renal failure. However, the association of serum chloride level (Cl-) with mortality or risk of cardiovascular (CV) events in chronic kidney disease (CKD) remains unclear. METHODS: This prospective cohort study included 923 pre-dialysis CKD G2-G5 patients among the participants of the CKD Research of Outcomes in Treatment and Epidemiology (CKD-ROUTE) study, who newly visited 16 nephrology centers. The primary outcome was a composite of overall death and CV events, and the secondary outcome was overall death. Data were analyzed using the Cox hazards model with adjustment for potential confounders. RESULTS: Median Cl- was 106.0 mEq/L at enrollment [quartile (Q) 1: ≤103.9, n =  207; Q2: 104.0-105.9, n =  207; Q3: 106.0-108.0, n =  289; Q4: ≥108.1, n = 220]. During a median follow-up of 33 months, there were 98 CV events, 66 deaths, and 154 composite outcomes. The hazard ratio (HR) for the composite outcome was higher for Q1 than Q3 [HR 1.72; 95 % confidence interval (CI) 1.08-2.72; P =  0.022]. As a continuous variable in a subset of patients whose Cl- was ≤106.0 mEq/L, higher Cl- was associated with lower risk of the composite outcome (HR 0.93; 95 % CI 0.87-0.99; P = 0.023). HR for all-cause mortality was also higher for Q1 than Q3 (HR 2.48; 95 % CI 1.22-5.03; P =  0.012). CONCLUSION: Low Cl- was associated with increased mortality and risk of CV events in pre-dialysis CKD patients. Cl- may be an additional prognostic indicator in CKD.

Successful recovery from an acute kidney injury due to amniotic fluid embolism.

A 33-year-old Japanese woman at 40 weeks gestation visited the maternity hospital after imminent labor had begun. After the delivery, persistent bleeding developed resulting in hemorrhagic shock. Although the hemorrhage was eventually controlled, hepatic and renal dysfunction occurred, leading to acute kidney injury (AKI). The patient's clinical presentation was suggestive of amniotic fluid embolism (AFE). We subsequently initiated continuous renal replacement therapy (RRT) for AKI. The patient's condition improved, she discontinued RRT, and her renal function recovered. We herein report a patient who successfully recovered from AKI caused by AFE.

Hepatic cyst infection in an autosomal dominant polycystic kidney disease patient diagnosed by right pleural effusion.

A 64-year-old Japanese man with renal dysfunction caused by autosomal dominant polycystic kidney disease (ADPKD) was admitted to our hospital for evaluation of right back pain, fever, inflammation, and pleural effusion. Diagnostic investigations for tuberculous pleuritis were all negative. Although no radiographic abnormality suggesting hepatic cyst infection was detected by computed tomography, hepatic cyst drainage demonstrated purulent contents indicative of cyst infection. Conglutination of the cyst by minocycline 100 mg was performed five times in addition to drainage. After drainage, the symptoms of inflammation, right back pain and right pleural effusion subsided. Renal function and anemia, which had been resistant to darbepoetin treatment, also improved after the procedure. These results suggested that the infected hepatic cyst was associated with the patient's symptoms, exacerbation of renal dysfunction and anemia. The pleural effusion was due to the propagation of inflammation from the cyst infection. This is the first report of an infected hepatic cyst in an ADPKD patient presenting with and diagnosed by right pleural effusion.

Baseline characteristics and prevalence of cardiovascular disease in newly visiting or referred chronic kidney disease patients to nephrology centers in Japan: a prospective cohort study.

BACKGROUND: About 39,000 patients were newly prescribed renal replacement therapy in Japan in 2011, resulting in a total of more than 300,000 patients being treated with dialysis. This high prevalence of treated end stage kidney disease (ESKD) patients is an emergent problem that requires immediate attention. We launched a prospective cohort study to evaluate population specific characteristics of the progression of chronic kidney disease (CKD). In this report, we describe the baseline characteristics and risk factors for cardiovascular disease (CVD) prevalence among this cohort. METHODS: New patients from 16 nephrology centers who were older than 20 years of age and who visited or were referred for the treatment of CKD stage 2-5, but were not on dialysis therapy, were recruited in this study. At enrollment, medical history, lifestyle behaviors, functional status and current medications were recorded, and blood and urine samples were collected. Estimated glomerular filtration rate (eGFR) was calculated by a modified three-variable equation. RESULTS: We enrolled 1138 patients, 69.6% of whom were male, with a mean age of 68 years. Compared with Western cohorts, patients in this study had a lower body mass index (BMI) and higher proteinuria. The prevalence of CVD was 26.8%, which was lower than that in Western cohorts but higher than that in the general Japanese population. Multivariate analysis demonstrated the following association with CVD prevalence: hypertension (adjusted odds ratio (aOR) 3.57; 95% confidence interval (CI) 1.82-7.02); diabetes (aOR 2.45; 95% CI 1.86-3.23); hemoglobin level less than 11 g/dl (aOR 1.61; 95% CI 1.21-2.15); receiving anti-hypertensive agents (aOR 3.54; 95% CI 2.27-5.53); and statin therapy (aOR 2.73; 95% CI 2.04-3.66). The combination of decreased eGFR and increased proteinuria was also associated with a higher prevalence of CVD. CONCLUSIONS: The participants in this cohort had a lower BMI, higher proteinuria and lower prevalence of CVD compared with Western cohorts. Lower eGFR and high proteinuria were associated with CVD prevalence. Prospective follow up of these study patients will contribute to establishment of individual population-based treatment of CKD.

[A case of combination therapy with MMF and steroids for idiopathic membranoproliferative glomerulonephritis].

A 26-year-old man diagnosed with nephrotic syndrome was administered steroid monotherapy. Urinary protein excretion was 2-3 g/day despite the therapy. Percutaneous renal biopsy revealed Type I idiopathic membranoproliferative glomerulonephritis (IMPGN). Although intravenous steroid therapy at the dose of 1,000 mg/day for 3 days was administered, proteinuria persisted at the level of 1 g/day. Renal dysfunction (cystatin C, 1.33 mg/L) was evident. Strong inflammation was suggested by occult blood (3+) and urinary (red blood cells: 30-50/high power field) sediment. We considered steroid monotherapy to be ineffective, and initiated combina-tion therapy with mycophenolate mofetil (MMF) and steroids. Consequently, urinary protein excretion moderately decreased to 0.34 g/day without adverse events or worsening of the renal function. The steroid quantity could be reduced without relapse. Subsequently, we were able to reduce the dose of MMF gradually, then terminated the medication. IMPGN is a rare disease with a poor renal prognosis. Recently, MMF therapies for IMPGN have been attempted, but there are few cases in Japan. Our case suggests that combination therapy with MMF and steroids is effective and safe for treating IMPGN.

Focal segmental glomerulosclerosis as a complication of hepatitis B virus infection.

Human hepatitis B virus (HBV) is well known as a cause of membranous nephropathy (MN). While the association of HBV infection with MN is strong, data regarding its association with other glomerular diseases are conflicting. Here, we report a case of focal segmental glomerulosclerosis (FSGS) with HBV infection. In this case, we have found HBV-DNA in urinary podocytes by real-time PCR methods. After the administration of anti-viral therapy, FSGS improved, paralleling the decreased level of HBV-DNA in podocytes. The refractory FSGS induced by HBV could be effectively treated with appropriate anti-viral agents.

[Adult male with tubulointerstitial nephritis and uveitis syndrome complicated with thyroiditis].

Renal dysfunction was detected by routine medical examination in a 46-year-old man (blood urea nitrogen : 26 mg/dL, creatinine : 2.4 mg/dL and moderate proteinuria). A few weeks later, he visited a local ophthalmologist complaining of left eye pain and red eye. He was diagnosed as left uveitis, prescribed eye-drops and referred to our hospital for further examination. At the first visit, test results pointed to renal dysfunction and a high level of thyroid hormones (creatinine : 1.8 mg/dL, free T3 : 7.41 microg/mL, free T4 : 3.18 ng/dL, thyroid stimulating hormone : 0.010micro IU/mL). Gallium scintigraphy showed an increased uptake of the tracer in bilateral thyroid glands, parotid glands and kidneys. No autoantibodies to thyroid gland were detected. Ultrasonography of the thyroid gland revealed no abnormal findings. Renal biopsy showed interstitial nephritis with minor glomerular abnormalities except for a few sclerotic changes. As no improvement was observed after stopping all drugs, and no disease causing uveitis was detected, he was diagnosed as tubulointerstitial nephritis and uveitis syndrome (TINU syndrome). After oral glucocorticoid was prescribed (prednisolone 15 mg/day), both renal function and thyroid abnormalities were normalized gradually. TINU syndrome with hyperthyroidism is rare. Although the precise etiology is not known, the same mechanism might occur in the thyroid gland as in TINU syndrome where abnormal cellular immunity, especially in helper T cell is said to play a role. In conclusion, in cases of TINU syndrome, systemic investigation, including the thyroid gland should be mandatory.

No evidence for patient-to-patient transmission of hepatitis C virus during upper gastrointestinal endoscopy: molecular studies on three acute hepatitis C patients.

BACKGROUND: The risk of patient-to-patient transmission of hepatitis C virus (HCV) during endoscopy remains controversial. Using molecular approaches, we examined the possibility of patient-to-patient transmission of HCV in three patients who developed acute hepatitis C 1-6 months after examination by upper gastrointestinal endoscopy (UGIE) in a hospital endoscopy unit in Japan. METHODS: For the source of HCV infection, we used frozen sera obtained from potential candidates who underwent UGIE earlier than three index patients on the same days in the same unit. HCV genotype was determined by multiplex polymerase chain reaction (PCR) with genotype-specific primers. The 1087-nucleotide (nt) sequence of the NS5B region of the HCV genome was compared between index patients and their HCV-viremic candidates. RESULTS: The three index patients were exclusively infected with HCV of genotype 1b. Among a total of 60 candidate patients who underwent UGIE earlier than the index patients, 14 were positive for anti-HCV, of whom 12 had detectable HCV-RNA (1b, n = 9; 2a, n = 1; 2b, n = 2) on sera collected during each UGIE. Shared identity within the 1087-nt NS5B sequence was less than 95.0% between index patients and HCV/1b-infected candidates (n = 3, 1 and 5, respectively). None of the remaining 46 candidates who were negative for anti-HCV at UGIE examination tested positive for HCV-RNA, nor seroconverted to anti-HCV on their sera, which most likely excludes the possibility of HCV viremia despite the anti-HCV-negative serology at UGIE examination. CONCLUSION: The present study suggests that patient-to-patient transmission of HCV during UGIE is infrequent.

Molecular analysis of transmission of hepatitis C virus in a nurse who acquired acute hepatitis C after caring for a viremic patient with epistaxis.

A 23-year-old nurse (HC-IP) developed acute hepatitis C. Intrafamilial transmission of hepatitis C virus (HCV) was suspected initially because her parents were carriers of HCV of the same genotype (1b) as that of Patient HC-IP. However, the HCV isolate from Patient HC-IP and those from her parents shared identities of only 92.4-92.7% in the 1,087-nucleotide (nt) sequence within the NS5B region. It was then suspected that she contracted HCV infection during medical practice. Sixteen patients with antibodies to HCV (anti-HCV) were hospitalized 1-3 months before she became positive for anti-HCV. Upon analysis of stored serum samples, 14 of the 16 patients were found to be positive for HCV RNA, and 9 of the 14 viremic patients had genotype 1b HCV. Although the shared identities between the HCV isolate from Patient HC-IP and those from eight of the nine patients were merely 90.6-93.9% within the 1,087-nt NS5B sequence, the HCV isolate from the remaining one patient (HC-P12) was 99.7% identical to that from Patient HC-IP. Upon analysis of the E1 and E2 junctional region including hypervariable region 1 (283 nt), there was a close relationship (99.3-100%) between clones obtained from Patients HC-IP and HC-P12. Although the nurse HC-IP had a finger injury, she took care of Patient HC-P12, a 70-year-old man with HCV-related cirrhosis and recurrent epistaxis, occasionally without wearing protective gloves. This study indicates the occurrence of HCV transmission by exposure of nonintact skin to blood in health care settings.

Bedtime administration of long-acting antihypertensive drugs restores normal nocturnal blood pressure fall in nondippers with essential hypertension.

BACKGROUND: Nondipper hypertensive patients have more pronounced target organ injury. We examined whether shifting the time of dosing long-acting antihypertensive drugs from morning to bedtime reduces nocturnal blood pressure (BP) and restores normal nocturnal dipping in nondippers with essential hypertension. METHODS: We studied 71 Japanese hypertensive patients who received long-acting antihypertensive drugs once daily in the morning using 24-h ambulatory BP monitoring. After determination of circadian BP pattern, medication time was changed to bedtime only in nondippers. RESULTS: Among 71 patients, 36 were classified as dippers and 35 as nondippers. After shifting administration time from morning to bedtime in 34 nondippers, the office and 24-h ambulatory BP did not change, but the diurnal BP slightly increased and nocturnal BP markedly decreased. The percentages of nocturnal decline in systolic and diastolic BP increased from 2.6% to 15.5% (P < 0.0001) and 5.6% to 16.9% (P < 0.0001). Morning BP at 7 a.m.-11 a.m. did not increase by bedtime administration. The frequency of dippers increased from 0/34 (0%) to 24/34 (71%). Adding to 50% of dippers on morning administration, 86% of the hypertensive patients became dippers by deciding the medication time according to dipper status. CONCLUSION: Nondippers on morning dosing can be changed to dippers by shifting administration time to bedtime, reducing nocturnal BP but not changing office BP, 24-h ambulatory BP or morning BP. In treating essential hypertensive patients, it is desirable to measure 24-h ambulatory BP as well as office BP and to decide the administration time of long-acting antihypertensive drugs to normalize nocturnal BP fall.

Long-term evolution and changing associations of left ventricular hypertrophy after starting hemodialysis.

BACKGROUND/AIMS: Left ventricular hypertrophy (LVH) is prevalent in dialysis patients and is recognized as a potent risk factor for cardiovascular diseases. We examined the evolution of LVH after starting dialysis and the determinants of changes in LV mass. METHODS: A cohort of 107 patients who had two or more echocardiograms at yearly intervals after starting hemodialysis was studied. RESULTS: At baseline, the mean LV mass index (LVMI) was 145.8 g/m(2) and 73 (68%) patients had LVH. During the mean follow-up period of 34.5 months, LVMI decreased by 3.9 g/m(2). At last follow-up, the mean LVMI was 141.5 g/m(2) and 68 (64%) patients had LVH. For changes in LVMI, a significant correlation was found in changes in systolic blood pressure, LVMI at baseline, changes in serum albumin concentration, and age. The relationship between changes in LVMI and systolic blood pressure was close during the 1st and 2nd intervals, but became weak gradually during the 3rd and 4th intervals. CONCLUSION: Many patients had LVH at starting hemodialysis and continued to have LVH thereafter. The most important determinants of LV mass changes were baseline LV mass and systolic blood pressure control, but the grade of reduction decreased gradually with time. These results suggest that active antihypertensive treatment should be started early to regress LVH and prevent cardiovascular diseases.

Can predialysis hypertension prevent intradialytic hypotension in hemodialysis patients?

BACKGROUND/AIM: Intradialytic hypotension is the most common complication associated with hemodialysis, and its cause is multifactorial. However, the relationship between hypertension and intradialytic hypotension is not clear. We investigated the influence of predialysis blood pressure and antihypertensive drugs on intradialytic hypotension. METHODS: Risk factors for intradialytic hypotension were analyzed in 111 patients undergoing regular hemodialysis treatment and had annual echocardiography performed. The correlation between the addition of antihypertensive medications and the incidence of intradialytic hypotensive episodes was studied in 21 hypertensive patients. RESULTS: Based on multivariate logistic regression analysis, diabetes (odds ratio OR 8.18, 95% confidence interval CI 1.47-45.5; p = 0.016), interdialytic weight gain (OR 2.45, 95% CI 1.24-4.82; p = 0.010), ejection fraction (OR 0.88, 95% CI 0.81-0.95; p = 0.001), and left ventricular volume (OR 0.97, 95% CI 0.94-0.99; p = 0.013) were determined as risk factors for intradialytic hypotension. However, there was no association between predialysis blood pressure and intradialytic hypotension. After additional antihypertensive medications, the predialysis blood pressure fell from 175/85 mm Hg to 154/78 mm Hg (p < 0.0001/p < 0.0001). The mean 24-hour interdialytic blood pressure fell from 165/87 mm Hg to 147/80 mm Hg (p < 0.0001/p = 0.006). However, the frequency of hypotensive episodes was not increased (p = 0.77). CONCLUSIONS: Diabetes, excessive interdialytic weight gain, low ejection fraction, and low left ventricular volume are independent risk factors for intradialytic hypotension. However, no correlation was found between predialysis blood pressure values or addition of antihypertensive medications and the incidence of intradialytic hypotension. Thus, hypertension may be controlled without aggravating intradialytic hypotension in hemodialysis patients.

Discordance of influence of hypertension on mortality and cardiovascular risk in hemodialysis patients.

BACKGROUND: Hemodialysis patients are at significantly increased risk for both morbidity and mortality from cardiovascular disease. However, most recent reports have indicated elevated mortality risk associated with low blood pressure, rather than high blood pressure. We added nonfatal cardiovascular events as an outcome in addition to cardiovascular and all-cause mortality to analyze the risk of hypertension. METHODS: One hundred sixty-four patients receiving regular hemodialysis between January and December 1998 were examined and prospectively followed up until the end of 2003. The primary end point was hospital admission or death from cardiovascular disease. Secondary end points were cardiovascular and all-cause mortality. RESULTS: During the 5-year follow-up period, 52 patients experienced cardiovascular events and 45 patients died (18 patients, from cardiovascular disease). Based on Cox analysis, high systolic blood pressure (relative risk [RR], 1.23; 95% confidence interval [CI], 1.07 to 1.43; P = 0.004) and older age were independently associated with cardiovascular events. Elevated systolic blood pressure (RR, 1.25; 95% CI, 0.99 to 1.59; P = 0.063) was a marginal predictor for cardiovascular mortality. Age, serum albumin level, malignant neoplasm, and diabetes were independent risk factors for all-cause mortality, whereas there was no association between blood pressure and all-cause mortality. The hazard ratio for cardiovascular events after adjustment for age, sex, and diabetes was lowest in patients with systolic blood pressure of 140.1 mm Hg or less and progressively increased with the increase in systolic blood pressure. CONCLUSION: Hypertension is a potent risk factor for cardiovascular disease in hemodialysis patients, as in the general population, whereas there is no association of hypertension with mortality. Active reduction in systolic blood pressure is important to minimize the occurrence of cardiovascular events.

Factors contributing to higher hematocrit levels in hemodialysis patients not receiving recombinant human erythropoietin.

Recombinant human erythropoietin (rHuEPO) is used to correct anemia in the majority of hemodialysis patients, but a few patients can maintain greater hematocrits without the use of rHuEPO. We aim to investigate which factors stimulate erythropoiesis, other than rHuEPO, in hemodialysis patients. One hundred fifty-eight patients undergoing regular hemodialysis treatment participated in a cross-sectional study. To keep the target hematocrit of 30%, 133 patients (84%) were administered rHuEPO, but 25 patients (16%) did not need rHuEPO. Mean hematocrits were 33.4% +/- 4.6% in patients who did not need rHuEPO and 30.9% +/- 4.0% in those administered rHuEPO. In the analysis of factors contributing to the lack of requirement of rHuEPO with multivariate logistic regression analysis, years on dialysis therapy and body mass index (BMI) were determined to be independent factors with odds ratios of 1.12 (95% confidence interval [CI], 1.02 to 1.23; P = 0.02) and 1.36 (95% CI, 1.13 to 1.63; P = 0.001), respectively. Neither serum erythropoietin level, albumin concentration, nor normalized protein catabolic rate contributed to the lack of requirement of rHuEPO. BMI correlated closely with log serum leptin level (r = 0.55; P < 0.0001), and log serum leptin level correlated inversely with rHuEPO dose (r = -0.18; P = 0.03). These results indicate that 16% of hemodialysis patients could maintain greater hematocrits without the administration of rHuEPO, and independently contributing factors were greater BMI and more years on hemodialysis therapy. Regarding nutritional parameters, a relatively greater BMI, possibly through effects of greater leptin levels, may stimulate erythropoiesis in uremic patients even in the absence of sufficient erythropoietin production.