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.

Risk Factors and Utility of Intraoperative Arteriovenous Fistula Blood Flow Level as a Surrogate Marker of Arteriovenous Fistula Failure in Patients with End-stage Renal Disease.

An arteriovenous fistula (AVF) can fail for different reasons at each stage after its creation. The study aimed to analyze the associations of the clinical and laboratory parameters, including the intraoperative AVF blood flow, with AVF failure at different periods (3 weeks and 3, 6, 9, 12, 24, and 36 months) after the AVF's creation and to evaluate the usefulness of the intraoperative AVF blood flow as a surrogate marker of AVF failure in patients with end-stage renal disease (ESRD). This was a single-center, retrospective cohort study that included 130 patients with ESRD who underwent the creation of new radiocephalic AVFs. The associations of the preoperative clinical and laboratory parameters and intraoperative flow with AVF failure in the different observation periods were investigated. Intraoperative AVF blood flow was significantly associated with AVF failure from 3 weeks to 24 months (P <0.05). Hemoglobin level and the size of the anastomosis were significantly associated with AVF failure at 6 months (P <0.05). In the analysis of the receiver operating characteristic curve, intraoperative AVF blood flow was significant from 3 weeks to 24 months (P <0.05). The intraoperative blood flow with the greatest sensitivity and specificity was 205-225 mL/min. Intraoperative blood flow was independently associated with AVF failure from 3 weeks to 24 months after the AVF's creation. An intraoperative AVF blood flow of >225 mL/min is crucial for long-term AVF patency. The intraoperative AVF blood flow level could be a surrogate marker of AVF failure in ESRD patients.

Clinical factors affecting cerebral oxygenation in patients undergoing peritoneal dialysis.

BACKGROUND: Although cerebral regional oxygen saturation (rSO2) is significantly lower in hemodialysis (HD) patients than that in healthy controls, investigations on cerebral oxygenation in peritoneal dialysis (PD) patients are limited. We aimed to confirm the cerebral oxygenation status and identify the factors affecting cerebral rSO2 in PD patients. METHODS: Thirty-six PD patients (21 men and 15 women; mean age, 62.8 ± 12.7 years) were recruited. In addition, 27 healthy volunteers (17 men and 10 women; mean age, 43.5 ± 18.8 years) were recruited as a control group. Cerebral rSO2 was monitored at the forehead using an INVOS 5100c oxygen saturation monitor. RESULTS: Cerebral rSO2 was significantly lower in PD patients than that in healthy controls (57.0 ± 7.3% vs 68.9 ± 8.6%, p < 0.001); moreover, cerebral rSO2 was significantly correlated with natural logarithm (Ln)-PD duration (r = -0.389, p = 0.019) and serum albumin concentration (r = 0.370, p = 0.026) in a simple linear regression analysis. Multivariable linear regression analysis was performed using variables that showed a significant correlation and p < 0.20 (serum creatinine, serum sodium, Ln-C-reactive protein, and dosage of erythropoiesis-stimulating agent) with the cerebral rSO2. Cerebral rSO2 was independently associated with Ln-PD duration (standardized coefficient: -0.339) and serum albumin concentration (standardized coefficient: 0.316). CONCLUSIONS: Cerebral rSO2 was significantly affected by the PD duration and serum albumin concentration. Further prospective studies are needed to clarify whether preventing a decrease in serum albumin concentration leads to the maintenance of cerebral oxygenation in patients undergoing PD.

Cerebral oxygenation improvement is associated with hemoglobin increase after hemodialysis initiation.

INTRODUCTION: Near-infrared spectroscopy has been used to measure the regional oxygen saturation (rSO2) of the brain, and decreases in cerebral rSO2 have been reported to lead to cognitive impairment in patients undergoing hemodialysis. However, reports about the association between changes in cerebral oxygenation and clinical parameters at hemodialysis initiation, including hemoglobin level, are lacking. METHODS: This study included 33 patients at the hemodialysis initiation phase. Cerebral rSO2 was monitored using an INVOS 5100C. Included patients were assessed twice (at hemodialysis initiation and 42.7 ± 20.8 days after the first measurement), and changes in cerebral rSO2 were compared with changes in clinical parameters. RESULTS: Cerebral rSO2 at the second measurement significantly increased compared with that at hemodialysis initiation (57.2 ± 6.8% vs 54.4 ± 8.8%, p < 0.05). Changes in cerebral rSO2 represented a significant correlation with changes in hemoglobin level, pulse rate, and serum albumin level. Multivariate linear regression analysis was performed using significant factors in simple linear regression analysis. Changes in hemoglobin (standardized coefficient: 0.37) and serum albumin (standardized coefficient: 0.45) levels were identified as independent factors influencing the changes in cerebral rSO2. CONCLUSION: Cerebral rSO2 was low in the presence of low hemoglobin levels at hemodialysis initiation and improved in response to hemoglobin increase in addition to changes in serum albumin levels. Attention should be paid to changes in hemoglobin levels even at hemodialysis initiation to prevent the deterioration of cerebral oxygenation, and this might contribute to the maintenance of cognitive function in patients undergoing hemodialysis.

Eosinophilic peritonitis induced by sucroferric oxyhydroxide.

A 49-year-old woman developed eosinophilic peritonitis 2 months after starting continuous ambulatory peritoneal dialysis because of congenital right kidney hypoplasia and chronic glomerulonephritis. This was shown to have been induced by sucroferric oxyhydroxide, an iron-based phosphate binder, using a drug-induced lymphocyte stimulation test. Her eosinophilic peritonitis was improved after stopping the administration of sucroferric oxyhydroxide without providing any immunosuppressive agents.

Induction of hemodialysis with an arteriovenous fistula in a patient with hemophilia A.

An 88-year-old man with congenital hemophilia A developed end-stage renal disease due to microscopic polyangiitis. He was at risk for catheter-related infection because he was taking immunosuppressive agents for the treatment of polyangiitis. He was also unable to manipulate the peritoneal dialysis device. Therefore, hemodialysis using an arteriovenous fistula was induced for renal replacement therapy. Recombinant coagulation factor VIII (1000 IU) was administered via the venous chamber of the hemodialysis circuit 10 min before the end of each hemodialysis session, and nafamostat mesylate (25 mg/h) was employed as an anticoagulant during hemodialysis. His clotting factor VIII activity level increased to > 50% and activated partial thromboplastin time decreased to 50 s at the end of each hemodialysis session. This method allowed him to achieve hemostasis at the puncture site of the arteriovenous fistula and undergo stable hemodialysis with no complications, including bleeding. This case suggests that hemodialysis using an arteriovenous fistula with coagulation factor replacement and nafamostat mesylate in each hemodialysis session is a therapeutic option for end-stage renal disease in patients of advanced age with hemophilia at high risk of bleeding.

Factors Associated with Uremic Pruritus in Patients Undergoing Peritoneal Dialysis.

AIM: The aim of this study was to investigate different intensities of uremic pruritus in the daytime and nighttime, as well as contributing factors, in patients undergoing peritoneal dialysis (PD). METHODS: A total of 46 patients (31 males, 15 females) with a mean age of 59.4±14.7 years and mean PD vintage of 29.2±25.2 months were enrolled in this single-center, prospective, cross-sectional study. The intensity of uremic pruritus in the daytime and nighttime was assessed using a visual analog scale (VAS). The relationships between intensity and various clinical and laboratory parameters were analyzed using multiple linear regression analyses. RESULTS: The most common site of uremic pruritus was on the back (70%), followed by lower limbs (67%), chest and abdomen (59%), upper limbs (28%), and head and neck (22%). Mean VAS scores were higher in the nighttime compared with the daytime (4.5±3.3 vs. 3.5±2.7, P=0.02). Only male sex was correlated with higher uremic pruritus intensity in the daytime (standard coefficient [ß]=0.310, P=0.036). PD vintage (ß=0.415, P=0.004) and topical medicines, including moisturizer and topical corticosteroid use (ß=0.345, P=0.019), were independently correlated with higher uremic pruritus intensity in the nighttime. CONCLUSION: Uremic pruritus intensity was greater in the nighttime than in the daytime in PD patients. Male sex was associated with higher uremic pruritus intensity in the daytime, whereas PD vintage and topical medicine use were associated with higher uremic pruritus intensity in the nighttime.

Changes in tissue oxygenation in response to sudden intradialytic hypotension.

A 76-year-old woman on hemodialysis (HD) for diabetic nephropathy was admitted to our hospital with occasional intradialytic hypotension (IDH). We continuously monitored the regional oxygen saturation (rSO2) in the brain, liver, and lower limb muscle during HD. The time course of changes in rSO2 ratios in each region was evaluated throughout HD. The rSO2 ratio was defined as the ratio of rSO2 value at t (min) during HD to the rSO2 value before HD. During the early phase of HD, blood pressure (BP) gradually decreased and both hepatic and lower limb muscle rSO2 ratios decreased with changes in BP, whereas the cerebral rSO2 ratio was relatively maintained. At around 90 min after HD initiation, the BP decreased to 71/46 mmHg (mean BP, 54 mmHg) and the previously maintained cerebral rSO2 ratio also suddenly decreased. Soon after the onset of IDH, ultrafiltration was stopped, normal saline was infused, and intravenous noradrenaline infusion was started. After the BP recovered, cerebral and hepatic rSO2 ratios improved, but the lower limb muscle rSO2 ratio remained low. After restarting ultrafiltration, improvement in the lower limb muscle rSO2 ratio was delayed, although cerebral and hepatic oxygenation were maintained. This observation aids in our understanding of the effect of IDH on regional tissue oxygenation.

Continuous monitoring of changes in cerebral oxygenation during hemodialysis in a patient with acute congestive heart failure.

A 71-year-old man undergoing hemodialysis (HD) was admitted to our hospital with congestive heart failure (CHF) and pneumonia. After admission, ultrafiltration with HD was urgently performed because of a lack of respiratory improvement despite the use of noninvasive positive pressure ventilation. During HD, cerebral regional saturation of oxygen (rSO2) was monitored by INVOS 5100c oxygen saturation monitor (Covidien Japan, Japan) to evaluate changes in tissue oxygenation. At HD initiation, cerebral rSO2 was very low at 34% under the fraction of inspiratory oxygen (FiO2) of 0.4. Ultrafiltration was performed at the rate of 0.5 L/h thereafter, cerebral rSO2 gradually improved even as inhaling oxygen concentration decreased. At the end of HD, cerebral rSO2 improved at 40% under a FiO2 of 0.28 as excess body fluid was removed. After pneumonia and CHF improved, he was discharged. Reports of the association between cerebral oxygenation and acute CHF status in patients undergoing HD are limited; therefore, in our experience with this case, cerebral oxygenation deteriorated with the CHF status but was improved by adequate body-fluid management during HD.

Changes in Serum and Urinary Potassium Handling Associated with Renin-Angiotensin-Aldosterone System Inhibitors in Advanced Chronic Kidney Disease Patients.

Objective This study aimed to (i) compare the extent of urinary potassium (K+) excretion in addition to the changes in serum K+ concentration: and (ii) clarify the association between changes in serum K+ concentration, urinary K+ excretion, and acid-base status with or without renin-angiotensin-aldosterone system (RAAS) inhibitors in patients with advanced chronic kidney disease (CKD) stages. Methods Six hundred and ninety-one patients with advanced CKD (CKD G3b, 161; G4, 271; G5, 259) were retrospectively evaluated. Differences in serum K+ concentration, urinary K+ excretion, and serum sodium and chloride differences (Na+-Cl-) were compared among patients with RAAS inhibitors, RAAS inhibitors and diuretic agents, and without either medication in each CKD stage. Results Serum K+ concentrations in patients with RAAS inhibitors were significantly higher than in those with RAAS inhibitors and diuretics in CKD stage G3b and the other two treatment groups in CKD stage G4. Urinary K+ excretion among the three groups did not differ significantly in each CKD stage. Serum Na+-Cl- differences in patients with RAAS inhibitors were significantly smaller than in those with RAAS inhibitors and diuretics in CKD stages G3b (p = 0.006) and the other two groups in CKD stage G4 (vs. RAAS inhibitors and diuretics, p <0.001; vs. without either medication, p = 0.008). Conclusion Our study demonstrated that RAAS inhibitor use might be associated with hyperkalemia via not decreased urinary K+ excretion but rather K+ redistribution from intracellular to extracellular fluid induced by the progression of metabolic acidosis in patients with advanced CKD, particularly stages G3b and G4.

Effects of dietary intake and nutritional status on cerebral oxygenation in patients with chronic kidney disease not undergoing dialysis: A cross-sectional study.

BACKGROUND: Dietary management is highly important for the maintenance of renal function in patients with chronic kidney disease (CKD). Cerebral oxygen saturation (rSO2) was reportedly associated with the estimated glomerular filtration rate (eGFR) and cognitive function. However, data concerning the association between cerebral rSO2 and dietary intake of CKD patients is limited. METHODS: This was a single-center observational study. We recruited 67 CKD patients not undergoing dialysis. Cerebral rSO2 was monitored using the INVOS 5100c oxygen saturation monitor. Energy intake was evaluated by dietitians based on 3-day meal records. Daily protein and salt intakes were calculated from 24-h urine collection. RESULTS: Multivariable regression analysis showed that cerebral rSO2 was independently associated with energy intake (standardized coefficient: 0.370) and serum albumin concentration (standardized coefficient: 0.236) in Model 1 using parameters with p < 0.10 in simple linear regression analysis (body mass index, Hb level, serum albumin concentration, salt and energy intake) and confounding factors (eGFR, serum sodium concentration, protein intake), and the energy/salt index (standardized coefficient: 0.343) and Hb level (standardized coefficient: 0.284) in Model 2 using energy/protein index as indicated by energy intake/protein intake and energy/salt index by energy intake/salt intake in place of salt, protein and energy intake. CONCLUSIONS: Cerebral rSO2 is affected by energy intake, energy/salt index, serum albumin concentration and Hb level. Sufficient energy intake and adequate salt restriction is important to prevent deterioration of cerebral oxygenation, which might contribute to the maintenance of cognitive function in addition to the prevention of renal dysfunction in CKD patients.

Approximation of bicarbonate concentration using serum total carbon dioxide concentration in patients with non-dialysis chronic kidney disease.

BACKGROUND: We investigated the relationship between serum total carbon dioxide (CO2) and bicarbonate ion (HCO3-) concentrations in pre-dialysis chronic kidney disease (CKD) patients and devised a formula for predicting low bicarbonate (HCO3- < 24 mmol/L) and high bicarbonate (HCO3- ≥ 24 mmol/L) using clinical parameters. METHODS: In total, 305 samples of venous blood collected from 207 pre-dialysis patients assessed by CKD stage (G1 + G2, 46; G3, 50; G4, 51; G5, 60) were investigated. The relationship between serum total CO2 and HCO3- concentrations was analyzed using Pearson's correlation coefficient. An approximation formula was developed using clinical parameters correlated independently with HCO3- concentration. Diagnostic accuracy of serum total CO2 and the approximation formula was evaluated by receiver operating characteristic curve analysis and a 2 × 2 table. RESULTS: Serum total CO2 correlated strongly with HCO3- concentration (r = 0.91; P < 0.001). The following approximation formula was obtained by a multiple linear regression analysis: HCO3- (mmol/L) = total CO2 - 0.5 × albumin - 0.1 × chloride - 0.01 × (estimated glomerular filtration rate + blood glucose) + 15. The areas under the curves of serum total CO2 and the approximation formula for detection of low bicarbonate and high bicarbonate were 0.981, 0.996, 0.993, and 1.000, respectively. This formula had superior diagnostic accuracy compared with that of serum total CO2 (86.6% vs. 81.3%). CONCLUSION: Serum total CO2 correlated strongly with HCO3- concentration in pre-dialysis CKD patients. An approximation formula including serum total CO2 showed superior diagnostic accuracy for low and high bicarbonate compared with serum total CO2.

Differences in cerebral and hepatic oxygenation in response to intradialytic blood transfusion in patients undergoing hemodialysis.

Hemodialysis (HD) patients frequently experience severe anemia, requiring intradialytic blood transfusion. Severe anemia leads to deterioration of systemic tissue oxygenation. However, few reports have examined the effect of intradialytic blood transfusion on tissue oxygenation changes. This study aimed to (i) monitor the differences in tissue oxygenation in the brain and liver during intradialytic blood transfusion, and (ii) elucidate the clinical factors affecting cerebral and hepatic oxygenation. Thirty-eight HD patients with severe anemia requiring intradialytic blood transfusion were included (27 men, 11 women; mean age, 70.2 ± 1.6 years). Cerebral and hepatic regional oxygen saturation (rSO2) values were monitored using near-infrared spectroscopy (INVOS 5100c oxygen saturation monitor). Cerebral and hepatic rSO2 were significantly higher after than before blood transfusion (p < 0.001, both). Furthermore, hepatic rSO2 was significantly higher than cerebral rSO2 after transfusion (p = 0.004). In multivariable linear regression analysis, cerebral rSO2 changes were independently associated with the natural logarithm of hemoglobin (Hb) ratio (Hb after/before transfusion) (standardized coefficient: 0.367, p = 0.023), whereas hepatic rSO2 changes were independently associated with the natural logarithm of [Hb ratio/colloid osmotic pressure ratio (colloid osmotic pressure after/before transfusion)] (standardized coefficient: 0.378, p = 0.019). In conclusion, throughout intradialytic blood transfusion, brain and liver tissue oxygenation improved. Hepatic rSO2 was significantly higher than cerebral rSO2 at the end of HD. Furthermore, cerebral oxygenation changes were associated with only transfusion-induced Hb increase, whereas hepatic oxygenation changes were associated with both transfusion-induced Hb increase (positive changes) and ultrafiltration-induced colloid osmotic pressure increase (negative changes).

Sustained severe intestinal edema after nafamostat mesilate-associated anaphylactic reaction during hemodialysis / Edema intestinal grave y prolongado después de reacción anafiláctica relacionada con nafamostat mesilato durante la hemodiálisis

No disponible

A case of posterior reversible encephalopathy syndrome in a patient undergoing automated peritoneal dialysis.

A 44-year-old man undergoing automated peritoneal dialysis (PD) developed headache and dizziness with truncal ataxia and ataxic gait. Severe hypertension (systolic blood pressure/diastolic pressure: 193/83 mm Hg) and lower extremity edema were present, and his PD efficiency (weekly KT/V: 1.49) was inadequate. Magnetic resonance imaging revealed diffuse hyperintensities in the brain stem and bilateral cerebellar hemispheres on fluid-attenuated inversion recovery and apparent diffusion coefficient mapping imaging. Based on these findings, the patient was diagnosed with posterior reversible encephalopathy syndrome due to hypertension and uremia. He was treated with antihypertensive agents, and we changed the PD prescription to improve PD efficiency. Thereafter, his symptoms gradually improved, and abnormal findings on brain magnetic resonance imaging disappeared in accordance with lowering blood pressure.

Two cases of advanced stage rapidly progressive diabetic nephropathy effectively treated with combination therapy including RAS blocker, GLP-1 receptor agonist and SGLT-2 inhibitor.

We herein report two cases of advanced stage rapidly progressive diabetic nephropathy that were effectively treated with combination therapy including renin-angiotensin-aldosterone system (RAS) blocker [angiotensin II receptor blocker (ARB)], glucagon-like peptide-1 (GLP-1) receptor agonist and sodium glucose transporter-2 (SGLT-2) inhibitor. A 30-year-old woman with advanced stage diabetic nephropathy [estimated glomerular filtration rate (eGFR): 20.7 mL/min/1.73 m2; proteinuria: 13.2 g/gCr], showing a rapidly progressive pattern (annual eGFR change: - 60.0 mL/min/1.73 m2/year), had improvement in proteinuria (5.9 g/gCr) and eGFR change (+ 4.3 mL/min/1.73 m2 over 15 weeks) after administration of ARB (irbesartan 25 mg/day), GLP-1 receptor agonist (liraglutide 0.3 mg/day) and SGLT-2 inhibitor (canagliflozin 50 mg/day). A 59-year-old man with advanced stage diabetic nephropathy (eGFR: 32.4 mL/min/1.73 m2; proteinuria: 8.90 g/gCr), showing a rapidly progressive pattern (annual eGFR change: - 21.2 mL/min/1.73 m2/year), had an improvement in proteinuria (0.02 g/gCr) and annual eGFR change (+ 0.1 mL/min/1.73 m2/year) after combination therapy with ARB (olmesartan 40 mg/day), GLP-1 receptor agonist (liraglutide 0.9 mg/day) and SGLT-2 inhibitor (tofogliflozin 10 mg/day). These results suggest that this triple combination therapy has renoprotective effects on advanced stage rapidly progressive diabetic nephropathy.

A Case of Upper Ureter Rupture With Acute Kidney Injury.

We herein report a case of ureter rupture with severe oliguric acute renal injury due to benign prostatic hypertrophy. After insertion of an indwelling urinary catheter, the patient's urine output immediately increased. His symptoms and renal function also rapidly improved to the normal range without a surgical operation. Clinicians should note this complication in patients with oliguria.