Warfarin-related nephropathy with acute kidney injury in a patient with immunoglobulin A nephropathy.

A 55-year-old man with Marfan syndrome taking warfarin for anticoagulant therapy after aortic valve replacement developed acute kidney injury (serum creatinine level of 9.01 mg/dL) and gross macrohematuria. Renal biopsy showed red cell casts in the renal tubules, glomerular crescent formation in the glomeruli with immunoglobulin A deposition, and global sclerosis. Based on these findings, the patient was diagnosed with warfarin-related nephropathy with acute kidney injury characterized by immunoglobulin A nephropathy with crescents. The warfarin was withdrawn, and his hematuria and renal function improved without immunosuppressive agents.

Efficacy and safety of adding mizoribine to standard treatment in patients with immunoglobulin A nephropathy: A randomized controlled trial.

BACKGROUND: Mizoribine (MZR) is an immunosuppressive drug used in Japan for treating patients with lupus nephritis and nephrotic syndrome and has been also reportedly effective in patients with immunoglobulin A (IgA) nephropathy. However, to date, few randomized control studies of MZR are performed in patients with IgA nephropathy. Therefore, this prospective, open-label, randomized, controlled trial aimed to investigate the efficacy and safety of adding MZR to standard treatment in these patients, and was conducted between April 1, 2009, and March 31, 2016, as a multicenter study. METHODS: Patients were randomly assigned (1:1) to receiving standard treatment plus MZR (MZR group) or standard treatment (control group). MZR was administered orally at a dose of 150 mg once daily for 12 months. RESULTS: Primary outcomes were the percentage reduction in urinary protein excretion from baseline and the rate of patients with hematuria disappearance 36 months after study initiation. Secondary outcomes were the rate of patients with proteinuria disappearance, clinical remission rate, absolute changes in estimated glomerular filtration rate from baseline, and the change in daily dose of prednisolone. Forty-two patients were randomly assigned to MZR (n = 21) and control groups (n = 21). Nine patients in MZR group and 15 patients in the control group completed the study. No significant differences were observed between the two groups with respect to primary and secondary outcomes. CONCLUSION: The addition of MZR to standard treatment has no beneficial effect on reducing urinary protein excretion and hematuria when treating patients with IgA nephropathy.

Pathological interstitial vascular proliferation adjacent to glomeruli in immunoglobulin a nephropathy.

We detected an increase in small arterioles around glomeruli, particularly adjacent to tuft adhesive lesions in immunoglobulin A nephropathy (IgAN), for the 1 st time, as far as we know. We labeled these as periglomerular microarterioles (PGMAs). This study aimed to clarify the pathological significance of PGMAs. Sixty-two patients with IgAN and 19 controls with minor glomerular abnormalities without proteinuria were evaluated in this study. The number of PGMAs located between the Bowman's capsule and the adjoining tubules was counted for each glomerulus. The mean number of PGMAs per glomerulus in cases of IgAN was significantly higher than those of the controls (0.530 ± 0.477 vs. 0.240 ± 0.182, P <0.05). Serial sections showed that most of the PGMAs were in contact with adjacent glomeruli (71.8%), through tuft adhesive lesions (52.1%), or the vascular pole (19.7%). By single regression analysis, the number of PGMAs was found to be positively correlated with the incidence of glomerular tuft adhesion, glomerular sclerosis, or the area of interstitial fibrosis in IgAN. By multiple regression analysis, the incidence of glomerular tuft adhesion was found to be the only independent pathological feature to correlate with the number of PGMAs (P = 0.0006). We have noticed the existence of PGMAs around glomeruli as a pathological finding of IgAN. Furthermore, the number of PGMAs was associated with the incidence of tuft adhesive lesion in glomeruli of IgAN although there was no relationship between the presence of PGMAs and clinical parameters including urinary protein excretion or creatinine clearance in the present study.

Effects and Safety of Linagliptin as an Add-on Therapy in Advanced-Stage Diabetic Nephropathy Patients Taking Renin-Angiotensin-Aldosterone System Blockers.

BACKGROUND: We investigated the effects and safety of linagliptin as an add-on therapy in patients with advanced-stage diabetic nephropathy (DMN) taking renin-angiotensin-aldosterone system (RAAS) blockers. METHOD: Twenty advanced-stage DMN patients (estimated glomerular filtration rate (eGFR): 24.5 ± 13.4 mL/min/1.73 m(2)) taking RAAS blockers were administered 5 mg/day linagliptin for 52 weeks. Changes in glucose and lipid metabolism and renal function were evaluated. RESULTS: Linagliptin decreased glycosylated hemoglobin levels (from 7.32 ± 0.77% to 6.85 ± 0.87%, P < 0.05) without changing fasting blood glucose levels, and significantly decreased total cholesterol levels (from 189.6 ± 49.0 to 170.2 ± 39.2 mg/dL, P < 0.05) and low-density lipoprotein cholesterol levels (from 107.1 ± 32.4 to 90.2 ± 31.0 mg/dL, P < 0.05) without changing high-density lipoprotein cholesterol and triglyceride levels. Urine protein/creatinine ratio and annual change in eGFR remained unchanged. No adverse effects were observed. CONCLUSION: Linagliptin as an add-on therapy had beneficial effects on glucose and lipid metabolism without impairment of renal function, and did not have any adverse effects in this population of patients with advanced-stage DMN taking RAAS blockers.

[A case of rapidly progressive glomerulonephritis exhibiting granulomatosis with polyangiitis (GPA) and extremely high level of PR3-ANCA with improvement of renal dysfunction after plasma exchange therapy].

A 68-year-old Japanese man was diagnosed with left otitis media with effusion and left uveitis more than 5 months before admission. He was urgently admitted to our hospital for progressive deterioration of his renal function [serum creatinine(Cr) 7.59 mg/dL] with proteinuria and urinary red blood cell casts, inflammation, and anemia. Additionally, his serum proteinase 3 antinuclear antibody (PR3-ANCA) level, determined by using the chemiluminescence enzyme immunoassay method, had increased to more than 3,500 U/mL. Hemodialysis (HD) was initiated on the third day after admission and renal biopsy was performed on the eighth day. The histological findings showed necrotic cellar crescents, hence, he was diagnosed as granulomatosis with polyangiitis on the basis of the clinical criteria. Methylprednisolone pulse therapy was administered from the 11th day. Thereafter, the administration of oral prednisolone (PSL) was started, and plasma exchange was initiated for the purpose of RP3-ANCA removal. In his clinical course, PSL was tapered as soon as possible because of the development of steroid psychosis, and we started intravenous cyclophosphamide on the 25th day instead of tapering the PSL. Subsequently, his renal function improved even without HD, and he was discharged on the 49th day. Although his PR3-ANCA level was still high after discharge, the administration of azathioprine led to a decrease in the PR-3 ANCA levels. About 2 years after discharge, the PR3-ANCA level decreased to 10.0 U/mL, and there has been no sign of GPA recurrence.

Effects of a new bicarbonate/lactate-buffered neutral peritoneal dialysis fluid for peritoneal failure in patients undergoing peritoneal dialysis.

BACKGROUND: The highly concentrated lactate in peritoneal dialysis fluid (PDF) has been considered to contribute to peritoneal failure in patients undergoing PD. A new PDF containing a lower lactate concentration, physiological bicarbonate concentration, and neutral pH (bicarbonate/lactate-buffered neutral PDF) was recently developed. We compared the clinical effects of this bicarbonate/lactate-buffered neutral PDF and a lactate-buffered neutral PDF. METHODS AND DESIGN: Patients undergoing PD were changed from a lactate-buffered neutral PDF to a bicarbonate/lactate-buffered neutral PDF. We then investigated the changes in peritoneal functions as estimated by a peritoneal equilibration test (PET) and the following surrogate markers of peritoneal membrane failure in the drained dialysate: fibrin degradation products (FDP), vascular endothelial growth factor (VEGF), cancer antigen 125 (CA125), interleukin-6 (IL-6), and transforming growth factor beta 1 (TGF-ß1). RESULTS: Fourteen patients undergoing PD were enrolled. The PET results were not different before and after use of the bicarbonate/lactate-buffered neutral PDF. The FDP concentration significantly decreased from 15.60 ± 13.90 to 6.04 ± 3.49 µg/mL (p = 0.02) and the VEGF concentration significantly decreased from 37.83 ± 15.82 to 27.70 ± 3.80 pg/mL (p = 0.02), while the CA125 and IL-6 concentrations remained unchanged before and after use of the bicarbonate/lactate-buffered neutral PDF. TGF-ß1 was not detected in most patients. CONCLUSION: The bicarbonate/lactate-buffered neutral PDF decreased the FDP and VEGF concentrations in the drained dialysate. These results suggest that the decreased lactate level achieved by administration of bicarbonate with a neutral pH in PDF may contribute to decreased peritoneal membrane failure in patients undergoing PD.

New Method for the Approximation of Corrected Calcium Concentrations in Chronic Kidney Disease Patients.

The following conventional calcium correction formula (Payne) is broadly applied for serum calcium estimation: corrected total calcium (TCa) (mg/dL) = TCa (mg/dL) + (4 - albumin (g/dL)); however, it is inapplicable to chronic kidney disease (CKD) patients. A total of 2503 venous samples were collected from 942 all-stage CKD patients, and levels of TCa (mg/dL), ionized calcium ([iCa(2+) ] mmol/L), phosphate (mg/dL), albumin (g/dL), and pH, and other clinical parameters were measured. We assumed corrected TCa (the gold standard) to be equal to eight times the iCa(2+) value (measured corrected TCa). Then, we performed stepwise multiple linear regression analysis by using the clinical parameters and derived a simple formula for corrected TCa approximation. The following formula was devised from multiple linear regression analysis: Approximated  corrected TCa (mg/dL) = TCa + 0.25 × (4 - albumin) + 4 × (7.4 - p H) + 0.1 × (6 - phosphate) + 0.3. Receiver operating characteristic curves analysis illustrated that area under the curve of approximated corrected TCa for detection of measured corrected TCa ≥ 8.4 mg/dL and ≤ 10.4 mg/dL were 0.994 and 0.919, respectively. The intraclass correlation coefficient demonstrated superior agreement using this new formula compared to other formulas (new formula: 0.826, Payne: 0.537, Jain: 0.312, Portale: 0.582, Ferrari: 0.362). In CKD patients, TCa correction should include not only albumin but also pH and phosphate. The approximated corrected TCa from this formula demonstrates superior agreement with the measured corrected TCa in comparison to other formulas.

Blood Volume Changes Induced By Low-Intensity Intradialytic Exercise in Long-Term Hemodialysis Patients.

Intradialytic exercise-induced blood volume (BV) reduction may cause intradialytic hypotension in hemodialysis (HD) patients. However, BV recovery time after intradialytic exercise remains unknown. Hemodialysis patients were recruited, and their relative BV change (%ΔBV) were measured with intradialytic exercise (n = 12). After confirming the linearity of %ΔBV for 30 min, patients exercised using a stationary cycle in the supine position. The target exercise intensity was a 10% increase in heart rate (HR), corresponding to relatively low-intensity exercise. Baseline %ΔBV (assumed baseline) were calculated for the 30 min before exercise using linear regression analysis. The mean intradialytic exercise start and end times after HD initiation were 93.0 ± 8.4 and 116.4 ± 8.3 min, respectively, a mean exercise duration of 23.5 ± 2.6 min. Percentage change in blood volume declined rapidly upon exercise initiation and gradually increased above the assumed baseline throughout HD. At the end of HD, %ΔBV in the exercise group was significantly higher than the assumed baseline (measured - assumed baseline %ΔBV: 2.17 ± 0.62%; p = 0.02). Intradialytic exercise with low intensity in the supine position attenuated ultrafiltration-induced BV reduction at the end of HD. Therefore, intradialytic exercise may prevent intradialytic hypotension during later HD, although its intensity was relatively low level.

Approximation of Corrected Calcium Concentrations in Advanced Chronic Kidney Disease Patients with or without Dialysis Therapy.

BACKGROUND: The following calcium (Ca) correction formula (Payne) is conventionally used for serum Ca estimation: corrected total Ca (TCa) (mg/dl) = TCa (mg/dl) + [4 - albumin (g/dl)]; however, it is inapplicable to advanced chronic kidney disease (CKD) patients. METHODS: 1,922 samples in CKD G4 + G5 patients and 341 samples in CKD G5D patients were collected. Levels of TCa (mg/day), ionized Ca(2+) (iCa(2+)) (mmol/l) and other clinical parameters were measured. We assumed the corrected TCa to be equal to eight times the iCa(2+) value (measured corrected TCa). We subsequently performed stepwise multiple linear regression analysis using the clinical parameters. RESULTS: The following formula was devised from multiple linear regression analysis. For CKD G4 + G5 patients: approximated corrected TCa (mg/dl) = TCa + 0.25 × (4 - albumin) + 4 × (7.4 - pH) + 0.1 × (6 - P) + 0.22. For CKD G5D patients: approximated corrected TCa (mg/dl) = TCa + 0.25 × (4 - albumin) + 0.1 × (6 - P) + 0.05 × (24 - HCO3 (-)) + 0.35. Receiver operating characteristic analysis showed the high values of the area under the curve of approximated corrected TCa for the detection of measured corrected TCa ≥8.4 mg/dl and ≤10.4 mg/dl for each CKD sample. Both intraclass correlation coefficients for each CKD sample demonstrated superior agreement using the new formula compared to the previously reported formulas. CONCLUSION: Compared to other formulas, the approximated corrected TCa values calculated from the new formula for patients with CKD G4 + G5 and CKD G5D demonstrates superior agreement with the measured corrected TCa.

Factors affecting cerebral oxygenation in hemodialysis patients: cerebral oxygenation associates with pH, hemodialysis duration, serum albumin concentration, and diabetes mellitus.

BACKGROUND: Patients undergoing hemodialysis (HD) often develop cerebral disease complications. Furthermore, cerebral regional saturation of oxygen (rSO2) was previously reported to be significantly lower in HD patients than in healthy subjects. We aimed to identify the factors affecting the cerebral rSO2 in HD patients. METHODS: Fifty-four HD patients (38 men and 16 women; mean age, 67.7 ± 1.2 years, HD duration, 6.5 ± 1.9 years) were recruited. Cerebral rSO2 was monitored at the forehead before HD using an INVOS 5100C (Covidien Japan, Tokyo, Japan). RESULTS: The rSO2 levels were significantly lower in HD patients compared with healthy controls (49.5 ± 1.7% vs. 68.9 ± 1.6%, p <0.001). Multiple regression analysis showed that cerebral rSO2 independently associated with pH (standardized coefficient: -0.35), HD duration (standardized coefficient: -0.33), and serum albumin concentration (standardized coefficient: 0.28). Furthermore, the rSO2 was significantly lower in HD patients with diabetes mellitus (DM), compared with patients without DM (46.8 ± 1.7% vs. 52.1 ± 1.8%, p <0.05). CONCLUSIONS: In HD patients, cerebral rSO2 was affected by multiple factors, including pH, HD duration, and serum albumin concentration. Furthermore, this is the first report describing significantly lower levels of rSO2 in HD patients with DM than in those without DM.

A Higher Cardiothoracic Ratio Is Associated with 2-Year Mortality after Hemodialysis Initiation.

UNLABELLED: A high cardiothoracic ratio (CTR) is indicative of a cardiac disorder. However, few reports have revealed an association between the CTR and mortality in patients starting hemodialysis (HD). METHODS: Patients with HD initiation (n = 387; mean age, 66.7 ± 12.7 years) were divided into the following three groups according to their CTR at HD initiation: CTR <50%, 50% ≤ CTR < 55%, and CTR ≥55%. Kaplan-Meier analysis was performed to compare 2-year all-cause mortality among these groups. Furthermore, we investigated the factors affecting their 2-year mortality using a Cox proportional hazard regression analysis. RESULTS: Sixty-five patients (17%) died within 2 years after HD initiation. Kaplan-Meier analysis showed that patients with CTR ≥55% had a higher mortality rate than those in the other groups. Cox proportional hazard regression analysis was performed using parameters with p values <0.1 among these three groups [sex, age, presence or absence of ischemic heart disease, hemoglobin levels, serum albumin levels, CTR, body mass index (BMI)] and confounding factors [presence or absence of diabetes mellitus, and estimated glomerular filtration rate (eGFR)]. Age, eGFR, BMI, and CTR ≥55% at HD initiation were identified as factors influencing 2-year mortality. CONCLUSION: CTR >55% is one of the most important independent factors to affect 2-year all-cause mortality. Thus, confirming the cardiac condition of patients at HD initiation with a CTR >55% may improve their survival.

Effectiveness of plasma exchange for acquired type A hemophilia.

An 80-year-old man was treated at our hospital for chronic kidney disease, diabetes mellitus and hypertension. He presented a bleeding tendency over the past several weeks. When he was admitted to our hospital with a consciousness disturbance, he had irregular 10-20 cm patches of subcutaneous bleeding. Laboratory findings showed prolonged activated partial thromboplastin time (APTT) but normal platelet count and prothrombin time. The administration of fresh frozen plasma did not control the bleeding tendency and the result of APTT cross-mixing test suggested the presence of factor VIII inhibitor. The diagnosis of acquired hemophilia A was made by a marked decrease in factor VIII activity levels (<1 %) and a high titer of factor VIII inhibitor (11 Bethesda units). To remove the factor VIII inhibitor and suppress its production, plasma exchange was performed and methylprednisolone was administered. Thereafter, the bleeding tendency could be controlled with APTT measurement normalization. Plasma exchange does not have a first priority in the treatment but our case findings suggested that plasma exchange is an effective method for eliminating factor VIII inhibitor and alleviating acquired hemophilia A severity.

Renoprotective effects of thiazides combined with loop diuretics in patients with type 2 diabetic kidney disease.

BACKGROUND/AIMS: Type 2 diabetic kidney disease (DKD) is frequently accompanied by uncontrollable hypertension due to the sodium sensitivity inherent in DKD and to diuretic-resistant edema. In general, diuretics are effective in treating this condition, but thiazide diuretics are thought to be innocuous in advanced chronic kidney disease (CKD). We examined the renoprotective effects of combination therapy with thiazides and loop diuretics in type 2 DKD patients with CKD stage G4 or G5. METHODS: This study included 11 patients with type 2 DKD and an estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m(2) who were suffering from severe edema even with loop diuretics. Each patient received additional hydrochlorothiazide (HCTZ) therapy, which was continued for more than 12 months. We examined clinical parameters including blood pressure (BP), proteinuria, and eGFR before and after the addition of HCTZ. RESULTS: Patients received a 13.6 ± 3.8 mg/day dose of HCTZ in addition to loop diuretics (azosemide: 120 mg/day in 6 cases, 60 mg/day in 3 cases and furosemide: 80 mg/day in 1 case, 120 mg/day in 1 case). Side effects of HCTZ were not observed in all patients. After the addition of HCTZ therapy, systolic and diastolic blood pressures (S-BP, D-BP) as well as proteinuria significantly decreased (S-BP: at 6 months, p < 0.05 and 12 months, p < 0.01 vs. 0 month, D-BP: at 12 months, p < 0.05 vs. 0 month, proteinuria: at 6 months, p < 0.05 and 12 months, p < 0.01 vs. 0 month). The annual decline in eGFR was not significantly different before and after HCTZ therapy (-7.7 ± 8.5 and -8.4 ± 4.8 mL/min/1.73 m(2)/year, respectively). CONCLUSION: Our findings suggest that the combination of HCTZ and loop diuretics improves BP levels, and decreases proteinuria even in advanced stage type 2 DKD patients with severe edema. The addition of HCTZ therapy was not found to negatively affect the change in eGFR in the present study.

Evaluation of cerebral oxygenation in patients undergoing long-term hemodialysis.

BACKGROUND/AIMS: Patients undergoing hemodialysis (HD) have higher occurrence rates of cerebral diseases, including uremic encephalopathy, cognitive impairment, dementia, and cerebrovascular disease, than the general population. During HD, ultrafiltration is performed to maintain an adequate fluid condition and is associated with subsequent blood volume (BV) reduction. We aimed to (1) monitor changes in cerebral oxygenation and BV reduction during HD, and (2) clarify the mechanism that influences cerebral oxygenation in HD patients. METHODS: Eighteen HD patients and 12 healthy controls were recruited. Regional saturation of oxygen (rSO2) was continuously monitored in the frontal cortex using INVOS 5100C before, during, and after HD, and in healthy controls. Relative change in BV (%ΔBV) was simultaneously monitored during HD using a BV monitor. RESULTS: Before HD, patients had significantly lower rSO2 values than controls (56.1 ± 1.4 vs. 70.4 ± 2.5%, p < 0.001). Although %ΔBV significantly decreased from 20 min to the end of HD (20 min: -3.3 ± 0.3%, p < 0.05; end of HD: -12.0 ± 1.0%, p < 0.01), changes in rSO2 values during HD were not significant. No relationship existed between rSO2 values and blood pressure levels, hemoglobin levels, oxygen pressure, HCO3(- ), oxygen saturation, and arterial O2 content before and after HD. Furthermore, changes in rSO2 were not correlated with changes in these parameters. CONCLUSION: rSO2 values before HD were significantly lower in HD patients than in healthy controls. rSO2 values were maintained during HD and were not influenced by BV reduction.

Acute severe liver dysfunction induced by febuxostat in a patient undergoing hemodialysis.

A 58-year-old man with chronic kidney disease (CKD) was admitted to our hospital for hemodialysis (HD) therapy. He had been administered allopurinol (100 mg/day) before hospitalization, and we replaced it with febuxostat (10 mg/day), a new xanthine oxidase inhibitor. Levels of aspartate aminotransferase, alanine transaminase (ALT), and lactate dehydrogenase were within the normal ranges in the morning before febuxostat administration, but 6 h after administration, these parameters increased markedly to approximately 10 times the levels before administration. Although we stopped administering febuxostat, his serum potassium levels increased at a rate of 1 mmol/L every 12 h, and he had to undergo HD daily to lower the serum potassium levels. The levels of liver function test parameters peaked on the fourth hospital day (ALT, 1134 IU/L; AST, 1485 IU/L; and LDH, 1869 IU/L) and recovered to normal ranges on the 13th hospital day. In this case, febuxostat appeared to have a relationship with acute liver dysfunction in the clinical course. Therefore, it would be important to check liver function test parameters frequently after febuxostat initiation and also to initiate a lower than usual dose of febuxostat, especially in patients with CKD and those who are undergoing HD.

An adult case of fulminant Epstein-Barr virus infection with acute tubulointerstitial nephritis.

Epstein-Barr virus (EBV) infection is common in adolescence, but fulminant infection is very rare. A 40-year-old man presented with high fever and sore throat. Symptoms, including cervical lymphadenopathy, jaundice, atypical lymphocytosis, respiratory distress and oliguria, suggested infectious mononucleosis with multiple organ failure that required mechanical ventilation and renal replacement therapy. Virus markers were consistent with primary EBV infection. Renal function was gradually improved by corticosteroid therapy. Renal biopsy revealed acute tubulointerstitial nephritis. In situ hybridizaion EBV-encoded RNA 1 did not show the presence of virus in the kidney, but acute kidney injury may be explained by cytotoxic/suppressor T lymphocyte infiltration.

Evaluation of a new method for measuring vascular access recirculation.

Together with Nikkiso in Shizuoka, Japan, we developed a new method for measuring the rate of vascular access recirculation by the blood volume monitor. This measurement is performed via a method of dilution that employs a marker produced by rapid ultrafiltration using a dialysis machine. In this paper, we evaluate the reliability and safety of this machine, in vitro and in vivo. The safety of this method was evaluated by investigating hemolysis after rapid ultrafiltration. The measurement of free hemoglobin, potassium and haptoglobin in the circulating blood were performed before and after rapid ultrafiltration. No data was found to indicate hemolysis in vivo, detected by an increase in potassium or a decrease in haptoglobin. Evaluation of reliability in an experimental system was also performed on an in vitro recirculation system at a rate of 0, 10, 25, 50, and 70%. Almost all of the measured rates were within ± 10% of the theoretical rate. We performed 20 hemodialysis experiments with vascular access recirculation applying this monitor and simultaneous urea and creatinine dilution methods, which were the recommended standard measurements for vascular recirculation. In 53 measurements of standard vascular shunts with no postural change, differences of the results between the monitor and both dilution methods were only 4.0% and 3.2%, respectively. Regression analysis showed a significant and positive correlation between them (P < 0.0001). We conclude that this new method for measuring vascular access recirculation is applicable in terms of both accuracy and ease of operation.

A new device to monitor blood volume in hemodialysis patients.

We developed a new optical device (Nikkiso) to assess changes through blood volume monitoring (BVM) during hemodialysis and were able to determine the ideal levels in which changes in blood volume percentage (BV%) occur among hemodialysis patients in one hemodialysis center. We evaluated both the reliability of BVM and these ideal levels in a multicenter group. The purpose of this manuscript is to develop a navigating system to set dry weight in a variety of situations as the final goal. First, based on the obtained BVM (BV%(BVM) ) measurements, the relationships between BV% and hematocrit (BV%(HT) ) and between BV% and CRIT-LINE (BV%(CLM) ; Hema Metrics, Kaysville, UT, USA) were then evaluated. In 30 hemodialysis patients, there was a close correlation between both BV%(BVM) vs. BV%(HT) and BV%(BVM) vs. BV%(CLM) (n=30, r=0.967, P<0.001, and n=36, r=0.7867, P<0.001, respectively). Second, BV% data were obtained from 464 treatment cases performed on 26 subjects in one satellite hemodialysis center on patients whose body weight was deemed clinically suitable. The formulas for the levels of BV% (standardized by the percent change in body weight at the end of hemodialysis treatment: BW%end) were determined. Finally, we revalidated the reliability of the above levels. A total of 1126 measurements were performed on 201 patients whose body weights were deemed suitable in seven hemodialysis centers. New ideal levels were then recalculated. We therefore conclude that BVM is a sufficiently accurate method of monitoring BV% in hemodialysis treatment. Most well-controlled hemodialysis patients display the same pattern of BV%/BW%end. Monitoring BV% during hemodialysis is beneficial for determining dry weight (DW).

[Effect of oral adsorbent AST-120 under standard treatment of care in patients with chronic renal failure].

BACKGROUND: Oral adsorbent AST-120 reduces uremic toxins, such as indoxyl sulfate, and retards the progression of chronic kidney disease (CKD). The present study was conducted to elucidate the association between the progression of CKD and the combined effect of AST-120 and standard care based on diet therapy and medications such as ACE inhibitor and ARB. METHOD: Retrospective analysis was performed using forty-four CKD patients (chronic glomerular nephritis 16, diabetic nephropathy 9, nephrosclerosis 13, and others 6) who were treated by AST-120 during the period from October, 2001 through December, 2004 and followed up for more than 6 months. The selection criteria were an estimated creatinine clearance (eCCr) of 30 mL/min or under at the initiation of treatment and a negative change in eCCr over time (DeltaeCCr (mL/min/year)) before AST-120 treatment. The eCCr was calculated using the Cockcroft-Gault equation and the DeltaeCCr was evaluated as a marker for the progression of chronic renal failure. RESULT: Overall DeltaeCCr before and after AST-120 treatment significantly improved from -7.28 +/- 6.33 to -4.29 +/- 5.09 (paired Wilcoxon test, p < 0.05). AST-120 led to greater improvement of DeltaeCCr in patients with an DeltaeCCr of less than -10 mL/min/year before AST-120 treatment and who had higher blood uric acid, urinary protein, and urinary specific gravity valves. CONCLUSION: This finding suggests that AST-120 treatment is effective in slowing the progression of chronic kidney disease, especially, in patients who exhibit a poor response to standard care.