The Association between High-Dose Allopurinol and Erythropoietin Hyporesponsiveness in Advanced Chronic Kidney Disease: JOINT-KD Study.

INTRODUCTION: The aim of the study was to explore the association between urate-lowering agents and reduced response to erythropoietin-stimulating agents in patients suffering from chronic kidney disease G5. METHODS: We conducted a cross-sectional, multicenter study in Japan between April and June 2013, enrolling patients aged 20 years or older with an estimated glomerular filtration rate of ≤15 mL/min/1.73 m2. Exclusion criteria encompassed patients with a history of hemodialysis, peritoneal dialysis, or organ transplantation. The patients were categorized into four groups based on the use of urate-lowering drugs: high-dose allopurinol (>50 mg/day), low-dose allopurinol (≤50 mg/day), febuxostat, and no-treatment groups. We used a multivariable logistic regression model, adjusted for covariates, to determine the odds ratio (OR) for erythropoietin hyporesponsiveness, defined by an erythropoietin resistance index (ERI) of ≥10, associated with urate-lowering drugs. RESULTS: A total of 542 patients were included in the analysis, with 105, 36, 165, and 236 patients in the high-dose allopurinol, low-dose allopurinol, febuxostat, and no-treatment groups, respectively. The median and quartiles of ERIs were 6.3 (0, 12.2), 3.8 (0, 11.2), 3.4 (0, 9.8), and 4.8 (0, 11.2) in the high-dose allopurinol, low-dose allopurinol, febuxostat, and no-treatment groups, respectively. The multivariate regression model showed a statistically significant association between the high-dose allopurinol group and erythropoietin hyporesponsiveness, compared to the no-treatment group (OR = 1.98, 95% confidence interval: 1.10-3.57). CONCLUSIONS: Our study suggests that the use of high-dose allopurinol exceeding the optimal dose may lead to hyporesponsiveness to erythropoiesis-stimulating agents.

Perspectives on the optimal timing of advance care planning among Japanese patients undergoing dialysis and clinicians: a cross-sectional study.

KEY MESSAGES: The majority of dialysis patients and clinicians favor early advance care planning in our sample. Yet, there is a disconnect: only 11% of patients discussed future care with their clinicians. Our findings indicate Japanese dialysis patients and clinicians support proactive advance care planning at or before dialysis initiation. BACKGROUND: Little is known about the optimal timing of discussions about advance care planning among dialysis patients and clinicians engaged in dialysis care. We aimed to explore the preferred timing for advance care planning and assess actual participation in advance care planning among dialysis patients and their clinicians. METHODS: A scenario-based survey on Japanese patients aged ≥65 years on dialysis and clinicians involved in their dialysis care was performed. Participants were asked if they would feel prepared to engage in advance care planning with their clinicians, offering a choice among four hypothetical stages within the illness trajectory, extending from the initiation of dialysis to a later phase characterized by the patient's extreme frailty. RESULTS: Overall, 181 patients and 128 clinicians participated in the study. Among these, 131 (72%) patients, and 84 (66%) clinicians indicated that they would prefer to initiate advance care planning around the time of dialysis initiation. Only 20 patients (11%) indicated that they had participated in advance care planning with at least one clinician, including 11 (6%) who indicated that they had discussed their preferences around life-sustaining treatments and 8 (4%) who had discussed their preferences around dialysis continuation. CONCLUSIONS: While fewer than 11% of patients undergoing dialysis and their clinicians enrolled in our study had participated in advance care planning, most indicated that they would be comfortable initiating the discussion around the time of dialysis initiation. These findings suggest untapped opportunities to engage patients in advance care planning early in the course of their dialysis.

A multi-institutional, observational study of outcomes after catheter placement for peritoneal dialysis in Japan.

BACKGROUND: This multi-institutional, observational study examined whether the outcomes after peritoneal dialysis (PD) catheter placement in Japan meet the audit criteria of the International Society for Peritoneal Dialysis (ISPD) guideline and identified factors affecting technique survival and perioperative complications. METHODS: Adult patients who underwent first PD catheter placement for end-stage kidney disease between April 2019 and March 2021 were followed until PD withdrawal, kidney transplantation, transfer to other facilities, death, 1 year after PD start or March 2022, whichever came first. Primary outcomes were time to catheter patency failure and technique failure, and perioperative infectious complications within 30 days of catheter placement. Secondary outcomes were perioperative complications. Appropriate statistical analyses were performed to identify factors associated with the outcomes of interest. RESULTS: Of the total 409 patients, 8 who underwent the embedded catheter technique did not have externalised catheters. Of the 401 remaining patients, catheter patency failure occurred in 25 (6.2%). Technical failure at 12 months after PD catheter placement calculated from cumulative incidence function was 15.3%. On Cox proportional hazards model analysis, serum albumin (hazard ratio (HR) 0.44; 95% confidence interval (CI) 0.27-0.70) and straight type catheter (HR 2.14; 95% CI 1.24-3.69) were the independent risk factors for technique failure. On logistic regression analysis, diabetes mellitus was the only independent risk factor for perioperative infectious complications (odds ratio 2.70, 95% CI 1.30-5.58). The occurrence rate of perioperative complications generally met the audit criteria of the ISPD guidelines. CONCLUSION: PD catheter placement in Japan was proven to be safe and appropriate.

Association between pill burden and interdialytic weight gain in patients with hemodialysis: A multi-center cross-sectional study.

High daily pill burden affects quality of life and mortality. High interdialytic weight gain (IDWG) is associated with increased mortality. We examined the association between pill burden and IDWG in hemodialysis patients. This cross-sectional study was conducted in six dialysis centers in Japan in June 2017. The exposure was the number of daily tablets, and outcome was defined as 1 day of relative IDWG divided by post-dialysis weight from the previous session. Among 188 outpatients (mean age, 68.7 [SD, 10.3] years; men, 67.0%; median dialysis vintage, 76.0 [interquartile range, 36.5, 131.5] months), the mean number of daily tablets was 19.7 ± 9.9, and mean relative weight gain was 3.5 ± 1.2%. Multiple linear regression analysis showed a regression coefficient of 0.021 (95% confidence interval: 0.004-0.039), indicating that one additional tablet prescription increased the IDWG by 0.021%. In hemodialysis patients, the daily pill burden was a significant, independent risk for increased relative IDWG.

Psychological Flexibility and Depression in Advanced CKD and Dialysis.

RATIONALE & OBJECTIVE: Depression is prevalent and highly associated with mortality among patients with chronic kidney disease (CKD). Psychological flexibility can be captured as acceptance in psychology, and its improvement by behavioral therapy is associated with reduced depression in some clinical settings. However, no study has been reported on patients with CKD. This study aimed to examine the association between psychological flexibility and depression in patients with CKD. STUDY DESIGN: Cohort study. SETTING & PARTICIPANTS: This multicenter study of 5 hospitals in Japan included patients with nondialysis stage 3-5 CKD or stage 5D CKD receiving hemodialysis or peritoneal dialysis. PREDICTOR: Psychological flexibility measured using the 7-item Acceptance and Action Questionnaire (AAQ-II). OUTCOMES: The prevalence and incidence of depression after 1 year, which was defined by a score ≥ 16 points on the Center for Epidemiologic Studies Depression (CES-D) questionnaire. ANALYTICAL APPROACH: Gamma regression was used in the examination of correlates of the psychological flexibility value. Modified Poisson regression models were fit for the prevalence and incidence of depression. RESULTS: The cross-sectional and longitudinal analyses included 433 and 191 patients, respectively. Lower (ie, worse) psychological flexibility levels were associated with hemodialysis and peritoneal dialysis. Higher (ie, better) psychological flexibility levels were associated with lower prevalence of depression (per 5-point increase; adjusted prevalence ratio, 0.75; 95% CI, 0.70-0.80) and lower incidence of depression (per 5-point increase; adjusted risk ratio, 0.72; 95% CI, 0.61-0.85). LIMITATIONS: Depression was assessed using the CES-D questionnaire. Cultural differences may exist in the interpretation of AAQ-II scores. CONCLUSIONS: Better psychological flexibility was associated with lower prevalence and incidence of depression in patients with CKD. Further studies are warranted to determine the possible prevention and treatment of depression by the development of behavioral interventions to improve psychological flexibility.

Association between health-related hope and adherence to prescribed treatment in CKD patients: multicenter cross-sectional study.

BACKGROUND: In chronic kidney disease (CKD), patients' adherence to prescriptions for diet and for medications might depend on the degree to which they have hope that they will enjoy life, and that hope could vary with the stage of CKD. The aims of this study were to quantify both the association of CKD stage with health-related hope (HR-Hope), and the association of that hope with psychological and physiological manifestations of adherence. METHODS: This was a cross-sectional study involving 461 adult CKD patients, some of whom were receiving dialysis. The main exposure was HR-Hope, measured using a recently-developed 18-item scale. The outcomes were perceived burden of fluid restriction and of diet restriction, measured using the KDQOL, and physiological manifestations of adherence (systolic and diastolic blood pressure [BP], and serum phosphorus and potassium levels). General linear models and generalized ordered logit models were fit. RESULTS: Participants at non-dialysis stage 4 and those at stage 5 had lower HR-Hope scores than did those at stage 2 or 3 (combined). Those at non-dialysis stage 5 had the lowest scores. HR-Hope scores of participants at stage 5D were similar to those of participants at stage 4, but they were lower than the scores of participants at stage 2 or 3 (combined). Higher HR-Hope scores were associated with lower perceived burdens of fluid restriction and of diet restriction (adjusted ORs per ten-point difference were 0.82 and 0.84, respectively). Higher HR-Hope scores were associated with lower systolic BP (adjusted mean difference in systolic BP per ten-point difference in HR-Hope scores was - 1.87 mmHg). In contrast, HR-Hope scores were not associated with diastolic BP, serum phosphorus levels, or serum potassium levels. CONCLUSIONS: Among CKD patients, HR-Hope is associated with disease stage, with psychological burden, and with some physiological manifestations of adherence.

A questionnaire on prescription patterns of proton pump inhibitors for hemodialysis patients in Japan.

BACKGROUND: Proton pump inhibitors (PPIs) are widely used in the general population often without an endpoint. The practice of prescribing PPIs in the hemodialysis (HD) population is unknown. Thus, we aimed to identify the practice pattern related to PPI prescription for HD patients in Japan through a questionnaire survey. METHODS: We conducted a questionnaire survey for physicians engaged in dialysis practice through email. An email was sent to physicians listed in the Japanese Society of Nephrology (JSN) and iHOPE International registry. RESULTS: We received 187 physicians' answers. One-hundred twelve (60%) physicians would prefer to continuously prescribe PPIs after 8 weeks of treatment for peptic ulcer (PU) or gastroesophageal reflux disease (GERD). The main reason for continuous PPI prescription was the concern for recurrence of PU or GERD. Approximately 20% of physicians responded that they were not accustomed to de-prescribing PPIs for PU or GERD. The reason for PPI de-prescription was the concern for side effects or insurance adaptation period. Even in cases wherein PPIs were prescribed for uncertain reasons, 42% physicians would continuously prescribe PPIs. Most physicians (82%) who answered about stopping PPIs regarded HD patients as a high-risk group for PU. CONCLUSIONS: PPI prescription is often continued in HD patients. De-prescription is not a common practice in Japan. It remains unclear whether discontinuation of PPIs should be recommended in hemodialysis patients who have a high risk of gastrointestinal ulcer. Yet, considering the side effects and polypharmacy in the HD population, more discussions on preferable de-prescription of PPIs are needed.

Cardiac arrest during hemodialysis: a survey of five Japanese hospitals.

AIM: Intraprocedural cardiac arrest is a serious complication among patients receiving hemodialysis. However, the frequency and reaction to these events remain unclear. This study aimed to explore the clinical picture of cardiac arrest during hemodialysis. METHODS: Ten cardiac arrests that had occurred during 217,984 hemodialysis treatments in five Japanese hospitals, between 2008 and 2017, were reviewed. We investigated the underlying disease, vital signs, emergency responses, and outcomes using patient medical records. RESULTS: The cardiac arrest rate ranged from 1.1 to 7.5 per 100,000 hemodialysis sessions. All included cases of cardiac arrest occurred in a hemodialysis unit and had been witnessed and reported by supervising clinicians. The initial rhythm was ventricular fibrillation/ventricular tachycardia in six patients (60%) and pulseless electrical activity/asystole in four patients (40%). Seven (70%) patients showed a return of spontaneous circulation (ROSC), and two (20%) patients were discharged with a cerebral performance category score of 1. There was a statistically significant difference in the ROSC rate (P = 0.048) only in the event of an emergency call. The SpO2 and respiratory rates had not been recorded in six patients. There was no significant difference in ROSC between initial rhythms of ventricular fibrillation/ventricular tachycardia and pulseless electrical activity/asystole. CONCLUSION: We evaluated the frequency of cardiac arrest during hemodialysis. Overall assessment including respiratory status is needed at initiation of hemodialysis. In case of a sudden change in a patient's status, high-quality resuscitation treatment that includes an emergency call can improve prognosis.

Lower Diastolic Blood Pressure was Associated with Higher Incidence of Chronic Kidney Disease in the General Population Only in those Using Antihypertensive Medications.

BACKGROUND/AIMS: The association of diastolic blood pressure (DBP) with incidence of chronic kidney disease (CKD) in the general population is not well examined. METHODS: Using national health check-up database from 2008 to 2011 in the general Japanese population aged 39-74 years, we evaluated the association between DBP and incidence of CKD 2 years later in 127,954 participants without CKD. DBP was categorized by every 5 mm Hg from the lowest (<60 mm Hg) to the highest category (>100 mm Hg) and was further stratified into those with and without antihypertensive medications (BP meds). We calculated the OR for estimating adjusted risk of incident CKD using logistic regression model. RESULTS: Participants were 62% female and 25.9% with BP meds, mean age of 76 years with estimated glomerular filtration rate of 78.2 ± 13.4 and DBP of 76 ± 11 mm Hg. Two years later, 12,379 (9.7%) developed CKD. Compared to DBP 60-64 mm Hg without BP meds as reference, multivariate analysis showed no difference in CKD risk at any DBP category among those without BP meds. However, in those with BP meds, risk increased according to lower DBP from 95 to 60 mm Hg (p for trend 0.05) with OR 1.51 (95% CI 1.14-1.99) in DBP <60 mm Hg. In subgroup analysis within those with or without BP meds, CKD risk was lower at higher DBP (p for trend 0.02) only in those without BP meds. CONCLUSION: Lower DBP was associated with higher risk of incident CKD only in the general population taking antihypertensive medication.

External validation of the quick Sequential Organ Failure Assessment score for mortality and bacteraemia risk evaluation in Japanese patients undergoing haemodialysis: a retrospective multicentre cohort study.

OBJECTIVES: We aimed to examine the validity of the quick Sequential Organ Failure Assessment (qSOFA) score for mortality and bacteraemia risk assessment in Japanese haemodialysis patients. DESIGN: This is a retrospective multicentre cohort study. SETTING: The six participating hospitals are tertiary-care institutions that receive patients on an emergency basis and provide primary, secondary and tertiary care. The other participating hospital is a secondary-care institution that receives patients on an emergency basis and provides both primary and secondary care. PARTICIPANTS: This study included haemodialysis outpatients admitted for bacteraemia suspicion, who had blood drawn for cultures within 48 hours of their initial admission. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was overall in-hospital mortality. Secondary outcomes included 28-day in-hospital mortality and the incidence of bacteraemia diagnosed based on blood culture findings. The discrimination, calibration and test performance of the qSOFA score were assessed. Missing data were handled using multiple imputation. RESULTS: Among the 507 haemodialysis patients admitted with bacteraemia suspicion between August 2011 and July 2013, the overall in-hospital mortality was 14.6% (74/507), the 28-day in-hospital mortality was 11.1% (56/507) and the incidence of bacteraemia, defined as a positive blood culture, was 13.4% (68/507). For predicting in-hospital mortality among haemodialysis patients, the area under the receiver operating characteristic curve was 0.61 (95% CI 0.56-0.67) for a qSOFA score ≥2. The Hosmer-Lemeshow χ2 statistics for the qSOFA score as a predictor of overall and 28-day in-hospital mortality were 5.72 (p=0.02) and 7.40 (p<0.01), respectively. CONCLUSION: On external validation, the qSOFA score exhibited low diagnostic accuracy and miscalibration for in-hospital mortality and bacteraemia among haemodialysis patients.

Refractory THSD7A membranous nephropathy with severe asthma related to eosinophilia
.

We report a case of a 50-year-old Japanese man with a history of pediatric asthma diagnosed with nephrotic syndrome after 4 years of relapsing asthma with severe eosinophilia. Thrombospondin type-1 domain-containing 7A membranous nephropathy (THSD7A-MN) was diagnosed based on histological evaluation. We started a course of steroid semi-pulse therapy, high-dose oral prednisolone, mizoribine, and cyclosporine. Frequent relapse of asthma was observed after gradual tapering of prednisolone dose to 10 mg/day. After improvement of asthma symptoms and eosinophilia, his serum albumin level increased gradually. Considering the clinical course of refractory MN and asthma, we suggest that THSD7A-MN may be associated with severe asthma and eosinophilia.

Association between post-dialysis hemoglobin level and the survival of vascular access.

INTRODUCTION: Although a few dialysis facilities conduct a complete blood cell count for some patients at post-dialysis, including hemoglobin, clinical findings supporting the interpretation of results are scarce. The aim of this study was to investigate the association between post-dialysis hemoglobin level and vascular access failure with clinical data. METHODS: Study design: Case crossover design. SETTING: Japanese dialysis facilities, which routinely take post-dialysis blood samples, including complete blood cell counts at least once a month. PARTICIPANTS: Hemodialysis patients who experienced vascular access failure in January 2010 until December 2014. EXPOSURE: Post-dialysis hemoglobin level. MAIN OUTCOME: Vascular access failure treated with endovascular treatment or operation. STATISTICAL ANALYSIS: Self-matched odds ratios and 95% confidence intervals were estimated by comparing post-dialysis hemoglobin just before events ("case") with levels at 6 and 12 months before events ("control") using conditional logistic regression, and presented with restricted cubic spline. RESULTS: Two hundred and thirty hemodialysis patients with vascular access failure were identified. Mean post-dialysis hemoglobin level before the failure was 11.8 g/dL (standard deviation 1.7). The spline curve showed that higher post-dialysis hemoglobin levels above 11.8 g/dL had a greater odds ratio for vascular access failure. Post-dialysis hemoglobin levels and odds ratios (95% confidence interval) for vascular access failure relative to the reference value (Hb 11.8 g/dL) were Hb 12.0 g/dL, 1.1 (1.0-1.1); Hb 14.0 g/dL, 1.4 (1.0-2.0); and Hb 16.0 g/dL, 2.1 (1.1-4.3). CONCLUSIONS: A higher post-dialysis hemoglobin level was associated with vascular access failure. Higher post-dialysis Hb could be a factor that triggers vascular access failure.

Correction: Development and Validation of a Clinical Prediction Rule for Bacteremia among Maintenance Hemodialysis Patients in Outpatient Settings.

[This corrects the article DOI: 10.1371/journal.pone.0169975.].

Association Between Staphylococcus aureus Bacteremia and Hospital Mortality in Hemodialysis Patients With Bloodstream Infection: A Multicenter Cohort From Japanese Tertiary Care Centers.

Multiple studies have shown that Staphylococcus aureus bacteremia (SAB) has been a major cause of death in hemodialysis patients. We examined whether SAB is a risk for mortality among chronic hemodialysis patients in Japan where the standard vascular access is arteriovenous fistula (AVF). This was a multicenter, retrospective study of maintenance hemodialysis patients with bloodstream infection (BSI) from 2011 to 2013 at tertiary care centers in Japan. The endpoint was hospital mortality. Our cohort contained 32 SAB cases (14 MRSA and 18 MSSA) and 42 non-SAB cases. Hospital mortality was higher among SAB cases than non-SAB cases (46.9% vs. 23.8%, P = 0.038). In patients with BSI, SAB was significantly associated with hospital mortality after adjustment for potential confounders, including type of vascular access (OR 3.26). S. aureus was the leading cause of BSI and hospital mortality among this cohort. Therefore, initial empiric treatment should cover for S. aureus.

[Pathophysiology of secondary hyperparathyroidism.]

Secondary hyperparathyroidism(SHPT)is the result of a compensatory response of the calcium phosphate homeostatic mechanism. Vitamin D deficiency and chronic kidney disease, both representative pathophysiological causes of SHPT, have been related not only to skeletal disorders but also cardiovascular diseases, ADL and QOL. This relates the importance of SHPT as a pathological cause or marker of such states.

Development and Validation of a Clinical Prediction Rule for Bacteremia among Maintenance Hemodialysis Patients in Outpatient Settings.

BACKGROUND: To our knowledge, no reliable clinical prediction rule (CPR) for identifying bacteremia in hemodialysis (HD) patients has been established. The aim of this study was to develop a CPR for bacteremia in maintenance HD patients visiting the outpatient department. METHODS: This multicenter cohort study involved consecutive maintenance HD patients who visited the outpatient clinic or emergency room of seven Japanese institutions between August 2011 and July 2013. The outcome measure was bacteremia diagnosed based on the results of blood cultures. The candidate predictors for bacteremia were extracted through a literature review. A CPR for bacteremia was developed using a coefficient-based multivariable logistic regression scoring method, and calibration was performed. The test performance was then assessed for the CPR. RESULTS: Of 507 patients eligible for the study, we analyzed the 293 with a complete dataset for candidate predictors. Of these 293 patients, 48 (16.4%) were diagnosed with bacteremia. At the conclusion of the deviation process, body temperature ≥ 38.3°C, heart rate ≥ 125 /min, C-reactive protein ≥ 10 mg/dL, alkaline phosphatase >360 IU/L, and no prior antibiotics use within the past week were retained and scored. The CPR had a good fit for the model on calibration. The AUC of the CPR was 0.76, and for score CPR ≥ 2, the sensitivity and specificity were 89.6% and 51.4%, respectively. CONCLUSIONS: We established a simple CPR for bacteremia in maintenance HD patients using routinely obtained clinical information in an outpatient setting. This model may facilitate more appropriate clinical decision making.

Anemia and Long-Term Renal Prognosis in Patients with Post-Renal Acute Kidney Injury of Nonmalignant Cause.

BACKGROUND/AIMS: The renal prognosis of post-renal acute kidney injury (PoR-AKI) has not been verified so far. The objective of this study was to assess the association of baseline anemia with long-term renal prognosis in patients with PoR-AKI. METHODS: We performed a multicenter retrospective cohort study. Consecutive adult patients from December 2006 to February 2010, who met the requirements as mentioned in the definition of PoR-AKI, were included. Patients without data on baseline renal function and at 6 months after PoR-AKI were excluded. We set baseline hemoglobin (Hb) level (g/dl) as the main exposure to be tested. The main outcome measure was long-term renal prognosis as determined by the difference between proximate estimated glomerular filtration rate (eGFR) at 6 months after diagnosis of PoR-AKI and baseline eGFR prior to the occurrence of the present PoR-AKI (ΔeGFR after 6 months) using the general linear model. RESULTS: We included 136 patients with PoR-AKI. The most frequent cause of PoR-AKI was malignancy, accounting for 39.0% (n = 53) of cases. Multivariate analysis adjusted for possible confounders showed that ΔeGFR after 6 months significantly changed by -4.28 ml/min/1.73 m2 for every 1 g/dl lower Hb at diagnosis (95% CI 1.86-6.69, p < 0.01). An additional multivariate analysis that was stratified by the presence or absence of malignancy as the cause of PoR-AKI yielded the same significant result only in the stratum of the nonmalignant cause of PoR-AKI. CONCLUSION: Patients with a nonmalignant cause of PoR-AKI who have baseline anemia may have poor long-term renal prognosis. In these cases, close observation of renal function after renal recovery may be required.

Systemic Inflammatory Response Syndrome Is Not an Indicator of Bacteremia in Hemodialysis Patients With Native Accesses: A Multicenter Study.

Bloodstream infection (BSI) in hemodialysis (HD) patients is often difficult to diagnose. Systemic inflammatory response syndrome (SIRS) is a sensitive predictor of BSI in the general population. We aimed to assess the usefulness of SIRS in predicting BSI in HD patients. We designed a multicenter retrospective observational study of adult (age > 18 years) HD patients who underwent two sets of blood cultures for suspected BSI at first hospital visit from August 2011 to July 2012. Clinical, biological, and microbial data were evaluated to evaluate SIRS as a predictor of BSI upon initial presentation to the hospital. Data were obtained from 279 HD patients. Vascular access other than arteriovenous fistula and subcutaneously fixed superficial artery, and those administered antimicrobial drugs before visit were excluded; thus, a total of 202 patients were finally enrolled. Mean patient age was 71 years, 67.3% were male, 49.3% had diabetes, 28.2% had indwelling hardware, and 18.3% patients had BSI. Endocarditis and vertebral osteomyelitis were common infection sites, and Staphylococcus aureus was the most common pathogen. Of those with SIRS, 25.3% had BSI and 74.7% did not (odds ratio for SIRS, 2.10; 95% confidence interval, 0.90-4.91; p = 0.11). Thus, SIRS had a low sensitivity for predicting BSI in HD patients (sensitivity, 71.9%; specificity, 45.2%; positive likelihood ratio, 1.31; negative likelihood ratio, 0.62). Systemic inflammatory response syndrome has low sensitivity in identifying BSI in HD patients. A low threshold for drawing blood cultures and initiating antibiotic treatment should be considered for HD patients.

Validity of low-efficacy continuous renal replacement therapy in critically ill patients.

The 1980s saw the use of continuous arteriovenous hemofiltration whose intensity hemofiltration rate was only 3 or 4 mL kg⁻¹ h⁻¹. With the installation of a blood pump, this dose went up to 8 or 10 mL kg⁻¹ h⁻1, and continued to increase, reaching about 20 mL kg⁻¹ h⁻¹ by the year 2000. Some studies found that a higher dose could be beneficial, and the world rapidly followed the trend, increasing the dose up to 35 mL kg⁻¹ h⁻¹. Then, two randomized control trials, namely the VA/NIH Acute Renal Failure Trial Network study and the RENAL study, came along in succession which changed the Kidney Disease: Improving Global Outcomes (KDIGO) recommendation to 20 to 25 mL kg⁻¹ h⁻¹. However, no good evidence exists to support this. Our recent multicenter retrospective studies from the JSEPTIC CRRT database show that the Japanese continuous renal replacement therapy dose of (14.3 mL kg⁻¹ h⁻¹) does not seem to have worse outcomes when compared with a higher dose.