Home-based exercise and bone mineral density in peritoneal dialysis patients: a randomized pilot study.

BACKGROUND: The prevalence of osteopenia and osteoporosis is higher in patients with chronic kidney disease than that in the general population. Although physical exercise prevents bone loss in hemodialysis (HD) patients, previous studies have not focused on peritoneal dialysis (PD) patients. Therefore, we aimed to evaluate the effects of home-based exercise on bone mineral density (BMD) in patients with PD. METHODS: Stable outpatients undergoing PD were randomly assigned to the intervention group (n = 26; male, 20; median age, 66 years) or usual-care group (n = 27; male, 21; median age, 64 years). Patients in the intervention group performed home-based exercises (resistance exercise, stretching, and aerobic exercise such as walking) for 6 months, whereas those in the usual-care group performed stretching and their usual physical activity. Based on dual X-ray absorptiometry, the primary outcomes were the BMD data of the lumbar spine and proximal femoral neck. Secondary outcomes included physical function and physical activity. Pre- and post-intervention values were compared. RESULTS: There was no significant within-group change in the BMD of the lumbar spine, femoral neck, and hip after 6 months of the exercise program. The intervention group had significantly improved 30-s chair-stand test, 6-min walk test, and physical activity results. CONCLUSIONS: Home-based exercises in patients with PD did not improve BMD at any of the sites evaluated. Improvement in physical function and physical activity may reduce the risk of falls in patients with PD. TRIAL REGISTRATION: UMIN Clinical Trials Registry, UMIN000041678 . Registered September 4, 2020; retrospectively registered.

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.

Long-term peritoneal dialysis followed by kidney transplantation for Takayasu arteritis: a case report.

BACKGROUND: Takayasu arteritis (TA) is a chronic vasculitis of unknown etiology that primarily affects large vessels. Although renal involvement is frequent in TA, patients with TA undergoing renal replacement therapy, especially long-term peritoneal dialysis (PD) and kidney transplantation (KTx), are rarely reported. We herein present the case of an elderly patient with TA treated by PD for more than 5 years and underwent KTx thereafter. CASE PRESENTATION: A 69-year-old female diagnosed with TA at the age of 19 was treated by PD for seven and a half years for end-stage renal disease due to TA. Dialysate-to-plasma ratio of creatinine, which was well maintained during this period, reflected the efficacy of long-term PD. However, her residual renal function declined; she developed malnutrition, inflammation, and atherosclerosis syndrome and underwent living-related KTx from her husband. Due to the total occlusion of the external iliac arteries with compensatory development of the internal iliac arteries, the right internal iliac artery was used as the anastomosis site. After KTx, the patient developed chronic active antibody-mediated rejection; however, the graft function was maintained throughout the follow-up period. Despite severe aortic calcification and intermittent claudication in the legs, her condition did not worsen, and the blood flow of the graft was preserved. CONCLUSIONS: The current case illustrating the success of long-term PD and living-related KTx in maintaining kidney function in an elderly patient with TA is the first to demonstrate the potential of PD and KTx as feasible options for renal replacement therapy in TA accompanied by severe cardiac involvement.

Continuous monitoring of blood pressure by analyzing the blood flow sound of arteriovenous fistula in hemodialysis patients.

BACKGROUND: Patients with end-stage renal disease undergoing hemodialysis (HD) have an elevated risk of cardiovascular disease-related morbidity and mortality. To prevent from such a life-threatening event, the continuous blood pressure (BP) monitoring system may contribute to detect BP decline in early stages and may help to do appropriate disposal. Our research team has introduced an electronic stethoscope (Asahi Kasei Co, Ltd., Tokyo, Japan), which translates sound intensity of Arteriovenous Fistula (AVF) to BP data using the technique of Fourier transformation that can predict continuous BP non-invasively. This study, we investigated whether electronic stethoscope-guided estimated BP (e-BP) would actually reflect systolic BP measured by sphygmomanometer (s-BP), and whether e-BP could predict fall of BP during HD. METHODS: Twenty-six patients who underwent HD treatment in our hospital were evaluated prospectively. We obtained sound intensity data from the electronic stethoscope which was equipped with the return line of HD. Then, the data were translated into e-BP data to be compared with s-BP. Correlation of total of 315 data sets obtained from each method was examined. An accuracy of diagnosis of intra-dialytic hypotension (IDH) was evaluated. RESULTS: Total of 315 data sets were obtained. A close correlation was observed between e-BP and s-BP (r = 0.887, p < 0.0001). Sensitivity and positive predictive value of predicted-BP for detection of IDH was 90 and 81.3%, respectively. CONCLUSIONS: Electronic stethoscope-guided BP measurement would be helpful for real-time diagnosis of BP fall in HD patients. Further investigations are needed.

Spot Urine-guided Salt Reduction in Chronic Kidney Disease Patients.

OBJECTIVE: Dietary salt restriction is important in patients with chronic kidney disease (CKD) to reduce hypertension, cardiovascular events, progression of CKD, and mortality. However, recommending salt reduction for patients is difficult without knowing their actual sodium intake. This study evaluated the effectiveness of spot urine-guided salt reduction in CKD outpatients. DESIGN: A prospective cohort study was used. SUBJECTS: This study included a total of 127 adult outpatients (aged 60 ± 18 years, 80 males) with CKD. Their baseline estimated glomerular filtration rate was 51.4 ± 25.1 (mL/minute/1.73 m2), and 64 (50%) of them were with CKD stage 3a or 3b (both 32 [25%]). INTERVENTION: We informed the patients of their individual spot urine-estimated salt intake every time they visited the outpatient clinic. Based on the data, the nephrologist encouraged the patients to achieve their salt restriction goal. MAIN OUTCOME MEASURE: The primary outcome was the estimated salt excretion, and the secondary outcome was the urinary protein-to-Cr ratio (UPCR). Multiple regression analyses were performed to clarify the contributing factors of changes in both outcomes. RESULTS: Over a follow-up of 12 months, the median number of patients' visits was 7 (5-8). The estimated salt intake was significantly reduced from 7.98 ± 2.49 g/day to 6.77 ± 1.77 g/day (P < .0001). The median UPCR was also reduced from 0.20 (0.10-0.80) to 0.10 (0.10-0.48) (P < .0001). On multiple regression analysis, a reduction in UPCR was positively associated with the baseline UPCR and a reduction in systolic blood pressure significantly (P < .0001 and P < .01, respectively) as well as positively correlated with a reduction in the estimated salt intake, with borderline significance (P = .08). CONCLUSIONS: Providing spot urine-estimated salt intake feedback effectively motivated CKD patients to reduce their salt intake. Spot urine-guided salt reduction may slow CKD progression through decreased urinary protein excretion.

Computed tomography for the management of exit-site and tunnel infections in peritoneal dialysis patients
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PURPOSE: To evaluate the effectiveness of computed tomography (CT) for detection of exit-site and tunnel infections with a Tenckhoff catheter. MATERIALS AND METHODS: The study enrolled patients with exit-site or tunnel infections who underwent ultrasonography (US), CT scans, and subsequent catheter removal or partial catheter reimplantation from 2010 to 2014. Control cases on peritoneal dialysis who underwent abdominal CT scans for other reasons were randomly selected. Attenuation of the soft tissue around the Tenckhoff catheter was measured in Hounsfield units (HU). RESULTS: 9 infected cases and 15 control cases were identified. CT showed increased attenuation around the catheter in all cases, while ultrasonography detected a hypoechoic area only in one case with abscess formation. Maximal attenuation of the inflamed soft tissue was high (median, 36 HU) compared with normal fatty tissue (median, -75 HU). In all cases, one or two sites with increased fat density were observed focally along the catheter, and these areas did not always extend directly from the exit site. CONCLUSIONS: In this retrospective study comprising a small number of cases, increased attenuation of fatty tissue around the Tenckhoff catheter correlated with exit-site or tunnel infections. CT might be an auxiliary tool for diagnosis, although CT costs much more than US and is not always available in general practice. Further prospective studies are needed.
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Increased peritoneal permeability at peritoneal dialysis initiation is a potential cardiovascular risk in patients using biocompatible peritoneal dialysis solution.

BACKGROUND: Cardiovascular disease is a frequent cause of death in peritoneal dialysis patients. Biocompatible peritoneal dialysis solutions with neutral pH have been anticipated to reduce cardiovascular disease more than conventional peritoneal dialysis solutions with low pH, but it remains unclear which factors at peritoneal dialysis initiation increase cardiovascular risk in patients using biocompatible peritoneal dialysis solutions. This study was undertaken to investigate which clinical factors at peritoneal dialysis initiation, including peritoneal transport status, are associated with cardiovascular event in patients using biocompatible peritoneal dialysis solution. METHODS: This retrospective cohort study of peritoneal dialysis patients using biocompatible solutions with neutral pH assessed relations of clinical parameters at peritoneal dialysis initiation to cardiovascular event during the subsequent five years. RESULTS: Of 102 patients who started peritoneal dialysis, cardiovascular event occurred in 18. Age, history of cardiovascular disease before peritoneal dialysis initiation, hemoglobin, serum albumin, C-reactive protein, peritoneal permeability defined by the ratio of dialysate to plasma creatinine concentration at 4 hr (D/Pcre) in peritoneal equilibration test (PET), number of patients in each PET category defined by D/Pcre, and peritoneal protein clearance significantly differed between patients with and without cardiovascular event. For patients divided according to PET category using Kaplan-Meier method, the group of high average to high peritoneal transporters exhibited significantly high incidence of cardiovascular event and mortality compared with the groups of low and low-average peritoneal transporters (Log rank; p=0.0003 and 0.005, respectively). A Cox proportional hazards model showed independent association of PET category classification with cardiovascular event. CONCLUSIONS: Peritoneal permeability expressed as PET category at peritoneal dialysis initiation is an independent cardiovascular risk factor in peritoneal dialysis patients using biocompatible peritoneal dialysis solution with neutral pH. Greater peritoneal permeability at peritoneal dialysis initiation might reflect subclinical vascular disorders.

Impact of compliance with salt management guidelines before dialysis introduction on peritoneal dialysis technique survival: The importance of pre-dialysis care and education.

INTRODUCTION: Peritoneal dialysis (PD) is a mode of therapy in which the patients themselves actively participate in the care of their own disease. We examined a possible association of salt reduction before starting dialysis with PD technique survival. METHODS: This retrospective cohort study included 42 patients who started PD between April 2014 and March 2018. Participants were allocated to two groups based on their estimated daily salt intake before the initiation of dialysis: patients with an estimated daily salt intake <6 g/day were allocated to the appropriate salt intake group (AS group), while the rest were assigned to the high salt intake group (HS group). RESULTS: During a median follow-up of 47 months, PD technique survival, defined by death or transition to hemodialysis, was significantly lower in the HS group compared to the AS group. CONCLUSION: Successful salt reduction before dialysis introduction is associated with better PD technique survival.

A case of de novo focal segmental glomerulosclerosis occurred one and half years after kidney transplantation supposed to be caused by calcineurin inhibitor.

A 64-yr-old man with end-stage kidney disease caused by hypertensive nephrosclerosis underwent living-unrelated ABO-identical kidney transplantation (KTx) at the age of 60 yr from his 60-yr-old wife. Maintenance trough concentration of cyclosporine A (CsA) was 100 ± 30 ng/mL. Five months after KTx, proteinuria gradually increased to around 1 g/d. TRBx at eight months after KTx revealed the new-onset alteration of mild arteriolosclerosis with intimal hyalinosis, which might reflect calcineurin inhibitor (CNI)-associated arteriopathy (CAA). Nearly one and half years after KTx, urinary protein excretion became nearly 2 g/d. TRBx revealed the advanced CAA and findings of focal segmental glomerulosclerosis (FSGS). Then, CNI was switched from CsA to tacrolimus (TAC). TRBx at two and half years after KTx revealed progressed arteriolar transmural thickening and striped fibrosis, which were supposed to be induced by an increase in serum TAC concentration because of acute enterocolitis. Then, TAC dose was reduced to serum trough concentration 5-8 ng/mL, but urinary protein excretion was increased up to 10 g/d. Reduction of TAC to trough concentration 2.0 ± 0.5 ng/mL reduced urinary protein excretion. Attempts to elevate TAC trough concentration within normal range (4-8 ng/mL) reproducibly induced the recurrence of an increase in sCr or urinary protein excretion. All these findings supported the etiology of graft dysfunction, and proteinuria of this case was FSGS.

Successful Kidney and Hematopoietic Stem Cell Transplantation for Malignant Lymphoma from Different Donors: A Case Report and Literature Review.

There are particularly few reports on kidney transplantation after hematopoietic stem cell transplantation (HSCT) for malignant lymphoma, and none of the cases reported a favorable outcome in patients who received kidney transplantation from a different donor to HSCT. In this report, we describe the first case of kidney transplantation from a different donor to HSCT with a successful outcome. Furthermore, we reviewed the previously reported cases. A 59-year-old female patient received an HSCT from her younger brother after chemotherapy for malignant lymphoma. After HSCT, she did not have graft-versus-host disease (GVHD) requiring maintenance treatment. The patient developed chronic kidney disease requiring kidney replacement therapy, probably due to drug toxicity or cardio-renal syndrome. At age 65, she underwent an ABO-compatible, HLA-A, -B, -DR 5/6 mismatched kidney transplantation from her husband. Immunosuppressive therapy with tacrolimus, mycophenolate mofetil, methylprednisolone, and basiliximab was administered. The patient had urinary tract infections at 7 days, 9 weeks, and 4 months after kidney transplantation, and cytomegalovirus antigenemia at 9 weeks after kidney transplantation, which improved with antibiotic and valganciclovir, respectively. When each infection occurred, we weakened immunosuppressive therapy. Four years after kidney transplantation, the patient is in good clinical condition with a serum creatinine of 1.2 mg/dL, without critical infection or malignancy. In this case, we believe that it was important to optimize the immunosuppressive therapy. In addition, from a review of previous cases, it seemed important that there was no GVHD requiring maintenance therapy in order to prevent excessive immunosuppression.

Pregnancy-onset thrombotic thrombocytopenic purpura with nephrotic syndrome: a case report.

Pregnancy-onset thrombotic thrombocytopenic purpura (TTP) was reported by many obstetricians and hematologists, but less by nephrologists, and the detailed clinical course of its renal complication is not known. Here, we report a case of a 33-year-old pregnant woman who suffered from pregnancy-onset TTP with nephrotic syndrome which was controlled by the termination of pregnancy. On admission, she had periorbital and lower leg edema at 32 weeks of gestation. Her serum albumin level was 2.8 g/dL and the urine protein/creatinine ratio was 4.1 g/g Cr. Besides those, she had thrombocytopenia, hemolytic anemia, and severe deficiency of A Disintegrin-like and Metalloproteinase with Thrombospondin type 1 motifs 13 (ADAMTS-13) activity. Thus, she was diagnosed with nephrotic syndrome due to pregnancy-onset TTP. A cesarean section was performed without complications for the patient and her baby. Then, all her symptoms improved shortly. She was suspected of congenital TTP because of no ADAMTS-13 inhibitor results and the persistent deficiency of ADAMTS-13 activity even after her condition improved. Pregnancy-onset TTP can cause nephrotic syndrome. Termination of pregnancy should be considered in cases with pregnancy-onset TTP to protect kidney function.

Culturally Adapted Consensus Definition and Action Guideline: Japan's Advance Care Planning.

CONTEXT: A conceptual framework for advance care planning is lacking in societies like Japan's valuing family-centered decision-making. OBJECTIVES: A consensus definition of advance care planning with action guideline adapted to Japanese society. METHODS: We conducted a multidisciplinary modified Delphi study 2020-2022. Thirty physicians, 10 healthcare and bioethics researchers, six nurses, three patient care managers, three medical social workers, three law experts, and a chaplain evaluated, in 7 rounds (including two web-based surveys where the consensus level was defined as ratings by ≥70% of panelists of 7-9 on a nine-point Likert scale), brief sentences delineating the definition, scope, subjects, and action guideline for advance care planning in Japan. RESULTS: The resulting 29-item set attained the target consensus level, with 72%-96% of item ratings 7-9. Advance care planning was defined as "an individual's thinking about and discussing with their family and other people close to them, with the support as necessary of healthcare providers who have established a trusting relationship with them, preparations for the future, including the way of life and medical treatment and care that they wish to have in the future." This definition/action guideline specifically included support for individuals hesitant to express opinions to develop and express preparations for the future. CONCLUSION: Adaptation of advance care planning to Japanese culture by consciously enhancing and supporting individuals' autonomous decision-making may facilitate its spread and establishment in Japan and other societies with family-centered decision-making cultures.

The effect of trichlormethiazide in autosomal dominant polycystic kidney disease patients receiving tolvaptan: a randomized crossover controlled trial.

The vasopressin V2 receptor antagonist tolvaptan delays the progression of autosomal dominant polycystic kidney disease (ADPKD). However, some patients discontinue tolvaptan because of severe adverse aquaretic events. This open-label, randomized, controlled, counterbalanced, crossover trial investigated the effects of trichlormethiazide, a thiazide diuretic, in patients with ADPKD receiving tolvaptan (n = 10) who randomly received antihypertensive therapy with or without trichlormethiazide for 12 weeks. The primary and secondary outcomes included amount and osmolarity of 24-h urine and health-related quality-of-life (HRQOL) parameters assessed by the Kidney Disease Quality of Life-Short Form questionnaire, renal function slope, and plasma/urinary biomarkers associated with disease progression. There was a significant reduction in urine volume (3348 ± 584 vs. 4255 ± 739 mL; P < 0.001) and a significant increase in urinary osmolarity (182.5 ± 38.1 vs. 141.5 ± 38.1 mOsm; P = 0.001) in patients treated with trichlormethiazide. Moreover, trichlormethiazide improved the following HRQOL subscales: effects of kidney disease, sleep, emotional role functioning, social functioning, and role/social component summary. No significant differences were noted in renal function slope or plasma/urinary biomarkers between patients treated with and without trichlormethiazide. In patients with ADPKD treated with tolvaptan, trichlormethiazide may improve tolvaptan tolerability and HRQOL parameters.

Successful treatment of two Japanese ESRD cases with severe COVID-19 pneumonia.

Novel coronavirus disease 2019 (COVID-19) is a highly infectious and deadly disease, spreading worldwide. There are limited data about the clinical course of end-stage renal disease (ESRD) patients infected with COVID-19. However, previous cohort studies showed a high mortality rate of ESRD patients infected with COVID-19. We report here two Japanese ESRD patients confirmed with severe COVID-19 pneumonia. Case 1 was a 60-year-old man with ESRD due to diabetic nephropathy who were infected with COVID-19 and exhibited acute respiratory distress syndrome (ARDS) requiring mechanical ventilation and intensive care unit (ICU) admission. He was treated with tocilizumab and intravenous immunoglobulin (IVIG). After 6 days of treatment in ICU, he was extubated. Case 2 was a 68-year-old woman undergoing maintenance hemodialysis for 17 years who also exhibited ARDS due to COVID-19. Her clinical course resembles case 1. Our experience of these two cases indicates that anti-cytokine therapy might be effective for severe COVID-19 pneumonia in ESRD patients.

Sarcomatoid renal cell carcinoma with autosomal dominant polycystic kidney disease: a case report and literature review.

Diagnosis of renal cell carcinoma (RCC) in patients with autosomal dominant polycystic kidney disease (ADPKD) is challenging and often delayed due to accompanying multiple renal cysts. Sometimes, it is difficult to distinguish RCC from cyst infection or hemorrhage. We herein present the case of a patient with ADPKD undergoing long-term hemodialysis whose sarcomatoid RCC was difficult to diagnose and was confirmed via nephrectomy. A 53-year-old male, undergoing hemodialysis since 20 years for end-stage renal disease secondary to ADPKD, was admitted to our hospital with a 3-week history of fever at > 38 °C and right flank pain. Clinical manifestations were compatible with cyst infection. Magnetic resonance images of the lesion identified in the lower right kidney, revealing slightly high signal intensity on T1-weighted images, low signal intensity on T2 weighted images, and restricted diffusion on diffusion-weighted images, were also consistent with those of cyst infection. Therefore, antibiotic therapy with ciprofloxacin, doripenem, and vancomycin was initiated. However, the patient's symptoms did not improve. Consequently, right nephrectomy was performed for both diagnosis and treatment, which revealed a sarcomatoid RCC with metastasis to the regional lymph node. The patient gradually developed cachexia and died on day 106 post-admission. The present case illustrates the difficulty of diagnosing RCC in patients with ADPKD, particularly sarcomatoid RCC, which is a rare and aggressive variant of RCC, even with the use of various types of imaging modalities. An early decision of nephrectomy may be necessary in such cases.

Ultrafiltration volume by once-weekly hemodialysis is a predictor of technique survival of combination therapy with peritoneal dialysis and hemodialysis.

Overhydration is a major cause of technique failure of peritoneal dialysis (PD). Hence, we investigated the impact of ultrafiltration (UF) volume by once-weekly hemodialysis (HD), excess volume beyond their dry weight, on technique survival of PD and HD combination therapy (PD+HD). Forty-six anuric PD+HD patients were divided into three groups according to baseline UF volume by HD: low-UF (

Evaluation of the performance, operability, and safety of Plasauto µ, a new type of machine for cell-free and concentrated ascites reinfusion therapy, in a postmarketing clinical study.

Cell-free and concentrated ascites reinfusion therapy (CART) is performed by collecting the ascites from the patient, followed by filtration and concentration. Thereafter, concentrated cell-free ascites is reinfused into the patient intravenously. The new type of machine, Plasauto µ, for managing the process of CART was launched onto the market. We have evaluated the machine through postmarketing clinical study in 17 patients with malignant ascites. The amounts of original and concentrated ascites were 3673 ± 1920 g and 439 ± 228 g, respectively. Recovery rates were acceptable regarding values of total protein, albumin, and IgG that were 55.6% ± 17.3%, 60.2% ± 20.8%, and 58.2% ± 20.5%, respectively. Recovery rates were positively associated with amounts of original ascites and negatively associated with total protein concentration. No adverse events related to the machine were observed. The new type of machine showed preferable performance in processing malignant ascites.

Bioimpedance Spectroscopy-Based Fluid Status in Combined Dialysis Compared With Hemodialysis and Peritoneal Dialysis: A Cross-Sectional Study.

Combination therapy with peritoneal dialysis and hemodialysis (PD+HD) is widely used in Japan for PD patients with decreased residual renal function. However, fluid status in PD+HD patients has not been well studied. In this cross-sectional study, we compared fluid status in 41 PD+HD patients with that in 103 HD and 92 PD patients using the bioimpedance spectroscopy. Extracellular water normalized to patient height (NECW, kg/m) was the highest in pre-HD (8.3 ± 1.6) followed by PD (7.9 ± 2.7), PD+HD (7.5 ± 2.5), and post-HD patients (6.9 ± 1.5) (P < 0.01). By multiple linear regression analysis, PD+HD was associated with a significantly lower NECW than pre-HD (ß = -0.8, P = 0.03) and similar to PD (ß = -0.5, P = 0.24) and post-HD (ß = 0.6, P = 0.08) after adjustment for age, sex, diabetic nephropathy, ischemic heart disease, dialysis period, and daily urine volume. There was no correlation between NECW and daily urine volume in all dialysis groups. Average daily fluid removal (a sum of urine volume and ultrafiltration volume by dialysis) was positively correlated with NECW in PD+HD and pre-HD, but not in PD and post-HD patients. Our results suggest that fluid status in PD+HD patients with decreased residual renal function is acceptable as compared with that in HD and PD patients.

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.