The influences of method of calcium correction and the timing of blood collection on application of the K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Japan.

We investigated the treatment of renal osteodystrophy (ROD) in Japan and problems concerning the K/DOQI Guidelines. The subjects were 3698 hemodialysis patients (2328 males and 1370 females) with a mean age of 61.4 years. On average, they had been on hemodialysis for 8.34 years. The serum phosphorus level was <3.5 mg/dL in 5% of the subjects, 3.5-5.5 mg/dL in 49%, 5.6-7.0 mg/dL in 33%, and >7.0 mg/dL in 13%. The serum calcium level was <8.4 mg/dL in 16% of the subjects, 8.4-9.5 mg/dL in 47%, 9.5-10.2 mg/dL in 22%, and >10.2 mg/dL in 15%. The intact PTH level was <150 pg/mL in 57%, 150-300 pg/mL in 27%, and >300 pg/mL in 16% of the patients. The first problem is that correcting Ca is not always performed in clinical fields. The uncorrected calcium level was 9.14+/-0.92 mg/dL, while the corrected calcium level [Ca = Ca + 0.8 x (4-Alb)] was 9.26+/-0.93 mg/dL (P < 0.05). The second problem is that the timing of blood collection is not described in the K/DOQI Guidelines. Subjects with a serum phosphorus level >7.0 mg/dL at 3 days after the previous dialysis were selected for assessment. In these patients, the midweek serum phosphorus level (7.13+/-0.15 mg/dL) at was significantly lower than that (8.11+/-0.15 mg/dL) at the beginning of the next week (P < 0.001). These results suggest that it is necessary to specify the timing of measurement and the method of Ca correction when guidelines for management of ROD are established in the future.

Risk factors for encapsulating peritoneal sclerosis in patients who have experienced peritoneal dialysis treatment.

BACKGROUND: The present study was conducted to clarify the clinical risk factors related to the development of encapsulating peritoneal sclerosis (EPS), which is one of the most serious complications in patients undergoing peritoneal dialysis (PD). METHODS: The records of 78 patients with a history of PD treatment, including 18 with EPS, were retrospectively analyzed (male/female, 51:27; age, 51.8 +/- 11.0 years; PD treatment, 94.1 +/- 42.7 months). The inclusion criteria were: duration of PD more than 24 months; 36-month follow up after discontinuation of PD; available data for dialysate-to-plasma creatinine ratio (D/P Cr), by fast peritoneal equilibration test within 3 months before PD discontinuation; and absence of EPS at PD discontinuation. Analytical parameters included age, sex, underlying renal disease, duration of PD, membrane transport state (higher transporter or lower transporter: D/P cr ratio more than or less than 0.75), number of episodes of peritonitis during PD treatment, performance of peritoneal lavage after PD discontinuation, and reasons for PD withdrawal (ultrafiltration failure, acute peritonitis, social matters). RESULTS: Significant differences were noted regarding the PD duration, D/P cr, higher membrane transport state, and number of peritonitis episodes during PD. On receiver operating characteristic curves, the cutoff points for EPS were: D/P cr ratio, 0.74; number of peritonitis episodes, 2; and PD duration (months), 115.2. Multivariate analysis, employing the factors age, PD duration, higher membrane transport state, and number of peritonitis episodes, which were selected by stepwise analysis, identified the latter two factors as significant for the development of EPS (odds ratio [OR], 4.0; P = 0.046 and OR, 12.0; P = 0.049, respectively). CONCLUSIONS: A higher transporter membrane state and the number of peritonitis episodes are factors contributing to the occurrence of EPS in patients who have experienced PD treatment.

Surgical verification of percutaneous maxacalcitol injection therapy on enlarged parathyroid glands in chronic dialysis patients.

Selective percutaneous ethanol injection therapy (PEIT) has been used to control parathyroid function in patients with secondary hyperparathyroidism (2HPT) when one or more parathyroid gland (PTG) progresses to the nodular hyperplasia stage. However, PEIT can have adverse side effects, such as nerve paralysis and adhesion, because the ethanol is destructive. Intraparathyroid injection of a vitamin D analogue has been designed as a treatment to control parathyroid function without destruction of the PTG or causing adhesions to the surrounding tissue, and the present study aimed to verify the effect of percutaneous maxacalcitol (22-oxacalcitriol) as the vitamin D analogue. The study group comprised two haemodialysis patients who needed parathyroidectomy for uncontrolled 2HPT with a maximal PTG diameter >20 mm. The treatment began with an ultrasonographically guided injection of 10 microg of maxacalcitol solution into the largest PTG and, 1 week later, parathyroidectomy was performed to examine the effect of the maxacalcitol injection both macroscopically and microscopically. The injected glands were swollen and inflamed, and adhesions made it difficult to remove them. There was macroscopic and microscopic evidence of haemorrhagic necrosis and adhesions to the surrounding tissue. Direct vitamin D analogue injection should not be performed as a primary treatment option because the adverse side effects are not overcome by this technique.

Is encapsulating peritoneal sclerosis a threatening issue in continuous ambulatory peritoneal dialysis? The Japanese experience.

Encapsulating peritoneal sclerosis (EPS) is undoubtedly the most serious complication of continuous ambulatory peritoneal dialysis treatment in Japan, with a mortality rate ranging from about 39% to 49% in reported series. Cases of EPS have been linked to long-term peritoneal dialysis, and limitations on renal transplantation in Japan mean that most Japanese patients have to accept long-term dialysis therapy, which is a critical problem. Treatment alternatives for EPS include total parenteral nutrition, prednisolone administration, and surgical approaches, all of which have varying success rates. Additional therapeutic and new preventive measures have to be established for EPS.

[Effect of angiotensin II receptor antagonist (losartan) on renal function, serum potassium and blood pressure in patients with advanced renal failure: differences between patients with a serum creatinine (SCr) level higher than 3 mg/dl and those with a lower SCr level].

The administration of angiotensin II receptor antagonist(AIIA) to patients with advanced chronic renal failure(CRF) is not actively recommended. This study was performed to verify the appropriateness of this situation and to determine if there are any substantial differences between patients with a serum creatinine(SCr) level higher than 3 mg/dl and those with a lower SCr level in terms of the clinical effects such as renal function, serum potassium level and systemic blood pressure(BP) after the administration of AIIA. Sixteen patients with advanced CRF who were admitted to the out-patient clinic in Jikei University Hospital(1998/1-1999/12) were enrolled(average age: 65 years, underlying renal disease: diabetic nephropathy 6, CGN 5, and other 1). They had never been administered AIIA before. The patients were classified into two groups in accordance with their level of SCr: group A(SCr lower than 3.0 mg/dl; n = 11), and Group B(SCr higher than 3.0 mg/dl; n = 5). Losartan(50 mg/day) administration was started in order to examine parameters such as the SCr, potassium, BP at the out-patient clinic, and urinary protein excretion at the 0, 1, 3, 6, 9, and 12 month time points. Although the 1/SCr values provided negative slopes with time in both groups, no significant difference was found between the two slopes. There were no changes in the serum potassium levels or urinary protein excretion during the study period in either group, and no statistical difference was found between the two groups. Although the serum potassium level exceeded 5.5 mEq/l in two patients each in both groups, the level was controlled by diet therapy with restricted potassium. BP was reduced significantly in both groups during the study period, and no statistical difference in BP reduction was observed between the two groups. In conclusion, the results indicate there were no differences in the effect on renal function, serum potassium levels or systemic BP between the patients with a SCr level higher than 3.0 mg/dl and those with a lower level. The results also support the notion that patients with advanced renal dysfunction are not precluded from AIIA administration.

[Long-standing high-transport membrane as a risk factor for EPS development after PD withdrawal: an analysis based on changes in peritoneal function during and after CAPD withdrawal].

The pathophysiology of encapsulating peritoneal sclerosis (EPS) that develops after withdrawal from long-standing dependence on CAPD remains unclear. The aim of this study was to clarify the risk factors for EPS as expressed in the peritoneal function. Fourteen patients who had shifted to standard hemodialysis after long-term CAPD (average, 105 months) were studied: 3 developed EPS after PD withdrawal while 11 did not. Analysis of the data obtained from the peritoneal equilibration test (PET) revealed that: (1) the dialysate/plasma creatinine ratio (D/Pcr) was significantly higher in the EPS group than in the non-EPS group during the course of PD as well as after PD withdrawal; and (2) eight patients, including the 3 with EPS, were classified as being in a high-transport membrane state (HTS) at PD withdrawal. The duration of HTS during PD was longer in those patients with EPS. During the periods after PD withdrawal, none of these EPS patients recovered from HTS, whereas 4 of the 5 non-EPS patients did. These data suggest that long-standing HTS during the course of PD as well as post-withdrawal, may be risk factors for EPS development. For this reason, it is indicated that PET has clinical relevance in examining sequential changes in peritoneal function and in detecting those patients at risk of EPS.