A survey of environmental sustainability in Japanese dialysis facilities.

BACKGROUND: Dialysis practice has a particularly high environmental impact, including responsible for carbon emissions and climate change. Insufficient research has been conducted on environmental sustainability activities in dialysis therapy in Japan. METHODS: We conducted an online Green Survey comprising 30 question items based on a previously conducted survey in Australia. Between August and September 2023, this was sent to members of the Japanese Association of Dialysis Physicians, including hospital and clinic physicians, working across 885 dialysis facilities in Japan. RESULTS: In total, 255 (29%) facilities responded to the survey. More than half of the facilities (n = 157; 61.6%) responded that they did not have a strategy, policy, or action plan for environmental sustainability. In four-fifths of the facilities (n = 208; 81.6%), no "green team" or committee had been formed to promote environmental protection. By contrast, most of the surveyed facilities had emergency strategies for natural disasters, such as covering for patient visits and staff commuting during extreme weather conditions (n = 169; 66.3%), water shortages (n = 159; 62.4%), and power outages (n = 188; 73.7%). CONCLUSIONS: Following the UK, Australia and New Zealand, and Portugal, this is the fourth Green Survey to be conducted, and the first on environmental sustainability among kidney health-care providers in Japan. The results indicated that daily activities for environmental protection are still lacking at many facilities, even though the management of dialysis treatment during a natural disaster is well conducted.

Randomized controlled open-label trial of vitamin E-bonded polysulfone dialyzer and erythropoiesis-stimulating agent response.

BACKGROUND AND OBJECTIVES: A 1-year multicenter prospective randomized controlled study was conducted on the effects of vitamin E-bonded polysulfone dialyzers on erythropoiesis-stimulating agent response in hemodialysis patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Major inclusion criteria were use of high-flux polysulfone dialyzers with 50-70 ml/min ß2-microglobulin clearance over 3 months, transferrin saturation over 20%, same erythropoiesis-stimulating agent for over 3 months, and hemoglobin at 10-12 g/dl. Hemodialysis patients were placed in four interventional groups: two hemoglobin ranges (10.0-10.9 or 11.0-11.9 g/dl) and two dialyzers. Patients were randomly assigned by central registration to a vitamin E-bonded polysulfone dialyzers or polysulfone control group. Primary end point was relative erythropoiesis resistance index at baseline between groups at 12 months. Erythropoiesis resistance index was defined as total weekly erythropoiesis-stimulating agent dose divided by hemoglobin. RESULTS: There were no statistically significant differences in age or sex. There was no significant difference in relative erythropoiesis resistance index between vitamin E-bonded polysulfone dialyzers and control groups at 12 months (vitamin E-bonded polysulfone dialyzers: 1.1, control: 1.3). The vitamin E-bonded polysulfone dialyzers group showed better relative erythropoiesis resistance index than the control group at 11.0-11.9 g/dl hemoglobin (vitamin E-bonded polysulfone dialyzers: 1.0, control: 1.4 at 12 months, significant difference) but no difference at 10.0-10.9 g/dl hemoglobin. CONCLUSIONS: The overall relative erythropoiesis resistance index showed no difference between the vitamin E-bonded polysulfone dialyzers and control groups, although the change in relative erythropoiesis resistance index differed according to hemoglobin level.

Impact of the Fukushima Daiichi Nuclear Power Plant accident on hemodialysis facilities: an evaluation of radioactive contaminants in water used for hemodialysis.

Following the crisis at the Fukushima Daiichi Nuclear Power Plant caused by the 2011 Tohoku earthquake and tsunami, radioactive substances ((131) I, (134) Cs, (137) Cs) were detected in tap water throughout eastern Japan. There is now concern that internal exposure to radioactive substances in the dialysate could pose a danger to hemodialysis patients. Radioactive substances were measured in three hemodialysis facilities before and after purification of tap water for use in hemodialysis. Radioactive iodine was detected at levels between 13 and 15 Bq/kg in tap water from the three facilities, but was not detected by reverse osmosis membrane at any of the facilities. We confirmed that the amount of radioactive substances in dialysate fell below the limit of detection (7-8 Bq/kg) by reverse osmosis membrane. It is now necessary to clarify the maximum safe level of radiation in dialysate for chronic hemodialysis patients.

Who needs acetate-free biofiltration?

Acetate-free biofiltration (AFB) is a hemodiafiltration (HDF) technique that is performed with a base-free dialysate and simultaneous infusion of sodium bicarbonate solution. In Japan 3 years ago, a new form of acetate-free dialysate containing 2.0 mEq/l citric acid was approved. Recently, we have had a 76-year-old male subject who switched from AFHD to AFB, mainly because of cardiovascular stability. Several factors may contribute to hemodynamic adaptation during AFB. One theory is that an increase in peripheral vascular tone and vascular refilling rate is caused by the high sodium concentration of the substitution fluid. AFB has all the premises for being a perfectly biocompatible technique capable of satisfying even the demands of critical patients laden with comorbidities.

Dialyzability of gadodiamide in hemodialysis patients.

PURPOSE: The aim of this study was to evaluate the contrast enhancement, pharmacokinetics, dialyzability, and safety of gadodiamide in patients on hemodialysis. MATERIALS AND METHODS: Thirteen hemodialysis patients with abdominal disease were examined after receiving intravenous gadodiamide (0.1 mmol/kg body weight) by magnetic resonance imaging (MRI) and were dialyzed at l, 3, 5, and 8 days. Blood samples were obtained immediately before, during, and at the end of the first hemodialysis session and immediately before and at the end of the next three sessions. The complete blood count, blood biochemistry, beta2-microglobulin, and gadolinium were measured. Dialysis of urea, creatinine, and gadolinium during the first hemodialysis session was assessed. Precontrast and postcontrast MRI and Gd-enhanced MR angiography (MRA) images were reviewed and visually evaluated by two radiologists; their evaluation was based on consensus. RESULTS: Gadodiamide did not cause any changes in renal function. An average of 73.8%, 92.4%, and 98.9% of the gadodiamide dose was eliminated by the end of the first, second, and third hemodialysis sessions, respectively. The average half-time of gadodiamide was 1.93 h (SD 0.55). The mean clearance of gadodiamide during hemodialysis was 63.5 ml/min (SD 21.9). There were no side effects related to the injection of gadodiamide. In all cases, diagnosable MRI and MRA images were obtained after gadodiamide injection in the hemodialysis patients. CONCLUSION: In hemodialysis patients, gadodiamide achieves diagnosable images. It is dialyzable and can be used safely without measures to increase excretion.

The salvage of graft occlusion in a maintenace hemodialysis patient with tuberous sclerosis by percutaneous transluminal angioplasty using intravascular ultrasound: case report.

End-stage renal failure due to tuberous sclerosis is rare and there is no previous report of a patient with tuberous sclerosis undergoing long-term hemodialysis for over 18 years. The patency rate for a dialysis prosthetic graft is low, however, our patient's graft survived over 16 years. For thrombotic occlusion of a graft, we performed percutaneous thrombectomy and balloon angioplasty and salvaged graft occlusion. Moreover, this case is the first report in which the interventional procedure (mechanical thrombectomy and balloon angioplasty) could be observed by intravascular ultrasound in addition to angiography.

A comparison of bicarbonate hemodialysis, hemodiafiltration, and acetate-free biofiltration on cytokine production.

Acetate-free biofiltration (AFB) is a special hemodiafiltration (HDF) modality performed with a base-free dialysate and simultaneous injection of non-pyrogenic sodium bicarbonate solution. The purpose of this study was to investigate the difference of cytokine production by conventional bicarbonate hemodialysis (BCD), standard HDF and AFB in the same patients. Eight stable hemodialysis patients were treated in random order with BCD, HDF and AFB every 4 weeks. The production of interleukin-1 beta (IL-1 beta) and interleukin-1 receptor antagonist (IL-1Ra) by peripheral blood mononuclear cells (PBMC) was investigated without stimulation and with stimulation by a small amount of endotoxin (ET)-contaminated beta 2-microglobulin (beta 2M) and lipopolysaccharide (LPS) before and after dialysis treatment in the last sessions during all periods. To serve as controls, 14 healthy volunteers participated in this study. In spontaneous IL-1Ra production, the values of before and after AFB were not significantly different from that of the controls, and the values of before and after BCD and before HDF were significantly higher than that of the controls. In LPS-stimulated PBMC, IL-1 beta production before and after AFB was not significantly different from that of the controls, and before and after BCD and HDF was significantly higher than that of the controls. In ET-contaminated beta 2M-stimulated PBMC, IL-1 beta production before and after AFB was not significantly different compared to the controls, and the production was significantly lower than that before and after BCD and HDF. In addition, IL-1Ra production after AFB was not significantly different from the controls, and the production was significantly lower than that before and after BCD and HDF. It was concluded that a lower cytokine production by AFB may have the effect of preventing dialysis-related complications.

Clinical benefit of preserving residual renal function in patients after initiation of dialysis.

Preserving residual renal function (RRF) after initiation of dialysis therapy is desirable for improving quality of life in ESRD patients. It has been believed that RRF declines more slowly in patients receiving continuous ambulatory peritoneal dialysis (CAPD) than in patients treated with other forms of maintenance dialysis. Episodes of intravascular volume depletion might be expected to cause more rapid loss of RRF, and are more frequent in patients on hemodialysis, which is intermittent therapy. However, recently it was demonstrated that in hemodialysis using high-flux biocompatible membrane and ultrapure water, RRF declines at a rate indistinguishable from that in CAPD. The HDF using ultrapure dialysate and the substitution fluid may show to preserve RRF as well as CAPD patients. In future, it might be a major concern for the assessment of the HDF by a multicenter clinical study for preserving RRF.

[Evaluation of the elimination and safety of gadodiamide injection in patients with hemodialysis].

We performed this study to evaluate the safety and elimination of gadodiamide injection in patients with hemodialysis (HD). The subjects were 10 patients on maintenance HD therapy, after receiving gadodiamide injection for magnetic resonance imaging (MRI) examination. The patients' mean age was 59.4 +/- 3.5 years, and their mean hemodialysis period was 70.6 +/- 20.4 months. Diseases for MRI examination were liver tumor (n=2), gallbladder tumor (n=1), renal tumor (n=3), pancreas tumor (n=1), abdominal aortic aneurysm (n=1), and arteriosclerosis obliterans (n=2). HD was performed routinely three times a week for 4 hours. Cellulose triacetate (CTA) membranes were used for 5 patients, polysulphone (PS) for 3 patients and polyester-polymer alloy (PEPA) for 2 patients. Serum levels of gadodiamide were analyzed before and after the first and second HD, and before the third and fourth HD. At the first HD, the concentration of gadodiamide in dialysate was analyzed every hour. Gadodiamide was eventually eliminated over time; 74.1% of the gadodiamide was dialyzed after the first HD and 98.8% after the third HD. There were no significant changes in the removal rate and laboratory parameters between each membrane. The present study suggests that gadodiamide could be removed by HD therapy efficiently thereby indicating that gadodiamide injection is possible in patients with HD.

The impact of visceral fat on multiple risk factors and carotid atherosclerosis in chronic haemodialysis patients.

BACKGROUND: There has been recent interest in the importance of visceral fat (VF) for the development of atherosclerosis. The purpose of this study was to examine associations between VF and multiple risk factors as well as the prevalence of carotid atherosclerosis in chronic haemodialysis patients. METHODS: We classified 77 non-diabetic haemodialysis patients into 'low VF', 'middle VF' and 'high VF' groups after determining VF area using computed tomography. Systemic atherosclerosis was assessed from intima-media thickness (IMT), plaque score (PS) and stiffness parameter beta (stiffness-beta) measured by high-resolution B-mode ultrasonography. RESULTS: Compared with the low VF group, the high VF group exhibited (i) significantly higher fasting plasma insulin (11.0 +/- 6.8 vs 7.1 +/- 2.9 micro U/ml, P = 0.0061); (ii) significantly higher plasma triglycerides (141.8 +/- 94.0 vs 86.5 +/- 32.5 mg/dl, P = 0.0032); and (iii) significantly lower plasma high-density lipoprotein cholesterol (42.1 +/- 14.5 vs 53.0 +/- 15.7mg/dl, P = 0.0134). Moreover, the high VF group had a higher prevalence and extent of carotid atherosclerosis: IMT was 0.69 +/- 0.13 vs 0.61 +/- 0.12 mm (P = 0.0239), PS was 4.8 +/- 3.2 vs 2.4 +/- 3.6 (P = 0.0236) and stiffness-beta was 11.4 +/- 3.1 vs 8.5 +/- 3.0 (P = 0.0082) in the high and low VF groups, respectively. CONCLUSION: We show that VF is associated with the prevalence of carotid atherosclerosis as well as with hyperinsulinaemia and lipid abnormalities in chronic haemodialysis patients.

Comparison of the effects of cellulose triacetate and polysulfone membrane on GPIIb/IIIa and platelet activation.

BACKGROUND: During hemodialysis session, several adverse reactions can occur on platelets, which are attributable to bioincompatibility of the dialysis membrane. Glycoprotein IIb/IIIa (GPIIb/IIIa) is the receptor for fibrinogen, which mediates platelet aggregation and adhesion. Accordingly, we compared the influence of a cellulose triacetate (CTA) and polysulfone (PS) membrane on GPIIb/IIIa and platelet activation. METHODS: Blood samples from 5 patients on hemodialysis were taken at 0 time, 15 min, 30 min, 60 min and 240 min, during a single hemodialysis session, by a crossover design using CTA or PS. Platelet count and plasma concentration of GPIIb/IIIa, beta-thromboglobulin (beta-TG) and platelet factor 4 (PF-4) were measured. GPIIb/IIIa was measured by flow cytometry. beta-TG and PF-4 were measured by ELISA. RESULTS: There was no significant change in the total amount of GPIIb/IIIa during dialysis session between the CTA and PS. However, the level of bound GPIIb/IIIa was significantly (p < 0.0002) increased from 1,426 +/- 435 to 40,446 +/- 2,777 mol/PLT with PS. In contrast, there was no significant change with CTA (3,258 +/- 1,469 to 4,301 +/- 1,422 mol/PLT). The platelet counts and beta-TG and PF-4 behavior during the dialysis session did not show significant change between the PS and CTA. CONCLUSION: The characterization of changes in platelet membrane receptor (GPIIb/IIIa) may be a useful marker for studying the biocompatibility of dialysis membranes. On platelet aggregation, CTA might be more biocompatible membrane than PS.