Care for patients carrying out dialysis therapy at home.

The goal of home dialysis is to more successfully reintegrate dialysis patients with high activities in daily life (ADL) into society as compared to hemodialysis (HD), which is carried out at a dialysis facility. By achieving this goal, this therapy can prove to be more effective than renal plantation, which has been carried out only in a few cases in Japan. Since self-management forms the basis of home dialysis, dialysis complications can be reduced by arranging meals, fluid management and dialysis schedule according to the lifestyle of the patient himself. In addition, long-term survival rate with health conditions similar to that of a healthy person can be increased. On the other hand, the goal of home dialysis for dialysis patients with a lower ADL is to strengthen the family bond, and improve quality of life and life prognosis, since nursing and support from family members are essential to ensure a long-term survival rate and ADL. For safe operation of home dialysis, which can be more effective than HD carried out in dialysis facilities, it is important for doctors, nurses, clinical engineers, social workers and all other members of the dialysis staff to work together as a united team. The type of nursing varies depending on period (during conservative treatment of end-stage renal disease, during the introduction and maintenance of dialysis, and when changing to end-stage renal disease replacement therapy). It also varies depending on whether continuous ambulatory peritoneal dialysis or home hemodialysis is implemented. The important points of nursing in home dialysis for each treatment period, depending on whether by continuous ambulatory peritoneal dialysis and home hemodialysis, are summarized here.

[Significance of serum calcium and phosphorus control for the cardiac function in patients with long term hemodialysis].

We evaluated how serum calcium and phosphorus will effect a cardiomegaly of hemodialysis patients. The cardiac valve of hemodialysis patients have a high incidence of calcification. Forty four percent of mitral valve and seventy five percent of aortic valve occurred the calcification, and the progress of calcification involve with increasing LVMI. The consequence of this results was that we consider prevent calcification is important to inhibiting factor of cardiomegaly, but serum calcium and phosphorus wasn't effect a cardiomegaly. On the other hand, we detected a significant negative correlation between serum calcium and LVMI (P = 0.0008) and a significant positive correlation between serum phosphorus and LVMI (P = 0.0105) . Consequently we thought that to control the serum phosphorus is important factor to inhibit the cardiomegaly.

Encapsulating peritoneal sclerosis in Japan: a prospective, controlled, multicenter study.

BACKGROUND: Encapsulating peritoneal sclerosis (EPS) is recognized as a rare but serious complication of peritoneal dialysis (PD). The aim of this study was to determine the incidence, clinical features, and mortality rate of EPS. METHODS: The authors requested the registration of all PD patients in facilities across Japan where more than 10 patients were treated with PD in this prospective multicenter study. During the 4-year study, the incidence of EPS was observed in the enrolled patients. RESULTS: A total of 1,958 patients who were treated with PD in 57 facilities were followed up from April 1999 through March 2003. EPS occurred in 48 patients, corresponding to an overall incidence of 2.5%. In 33 of the 48 (68.8%) patients, EPS was found after discontinuation of PD. The incidence (and mortality rate) of EPS was 0%, 0.7% (0%), 2.1% (8.3%), 5.9% (28.6%), 5.8% (61.5%), and 17.2% (100%) in patients who had undergone PD for 3, 5, 8, 10, 15, and more than 15 years, respectively. The recovery ratio with total parenteral nutrition, corticosteroids and surgical treatment were 0%, 38.5%, and 58.3%, respectively. Eighteen patients (37.5%) died, 22 (45.8%) recovered, and the status of the other 8 (16.7%) remained unchanged. CONCLUSION: The results of this prospective multicenter study showed that the incidence of EPS was 2.5% within a 4-year observation period and that two thirds of the cases were diagnosed after discontinuation of PD. Because of the current progress in diagnostic technology and therapeutic methodology, it appears that PD can be continued successfully with an acceptable, low risk for EPS for at least 8 years, whereas stricter caution is required for patients receiving PD for longer periods.

Searching for the reasons for drop-out from peritoneal dialysis: a nationwide survey in Japan.

PURPOSE: We wanted to clarify, in a large population, the reasons that peritoneal dialysis (PD) was interrupted and to propose appropriate strategies that might prolong the use of PD as a renal replacement therapy. PATIENTS AND METHODS: We enrolled 5 391 patients from 439 centers into the study. Each center used a worksheet to report details about patients who either transferred to hemodialysis (HD) or died on continuous ambulatory peritoneal dialysis (CAPD) over a 6-month period from 1 April 2000, to 30 September 2000. RESULTS: We collected 252 drop-out cases from 141 centers. Of the 252 cases, 170 (67.5%) involved transfer to HD, and 82 (32.5%) involved death while on PD. Primary renal diseases were chronic nephritis (CN: 51.6%), diabetic nephropathy (DM: 26.6%), nephrosclerosis (4%), and unspecified or other condition (15.8%). Mean duration on PD in drop-out cases was 4.47 years. The age of patients at transfer to HD was younger (53.7 years) than the age of patients at death on PD (65.2 years). Patients with CN remained on PD significantly longer than did patients with DM (5 years vs 2.4 years). The three main reasons for PD discontinuation were overhydration because of ultrafiltration failure (UFF) or poor compliance with salt and fluid restrictions (34.1%); peritonitis (30.1%); and preference of the physician, patient, or family (6.5%). The proportional share represented by those three major reasons varied with the number of years since PD initiation (from 1 year to more than 8 years). Patients who had been on PD for a longer time were more likely to drop out because of UFF and less likely to drop out because of peritonitis. The three major causes of death on CAPD were cerebrovascular accident (22%), ischemic heart disease (14.6%), and sudden death (9.8%). CONCLUSION: Approximately 10% of patients drop out from PD programs annually in Japan. To prolong PD treatment, new solutions that better preserve peritoneal function need to be developed, and patients and caregivers alike need to receive intensive education in preventing and treating peritonitis.

Effects of L-threo-3,4-dihydroxyphenylserine on orthostatic hypotension in hemodialysis patients.

BACKGROUND: Orthostatic hypotension (OH) is a serious complication observed in hemodialysis (HD) patients after HD as well as during the interdialytic period. L-Threo-3,4-dihydroxyphenylserine (L-DOPS) is a nonphysiological neutral amino acid that is directly converted to the neurotransmitter norepinephrine by aromatic L-amino acid decarboxylase. METHODS: A placebo-controlled double-blind study for 4 consecutive weeks and a long-term study (24-52 weeks) were conducted to evaluate the efficacy of L-DOPS for OH after HD. The drug was administered orally 30 min before the start of each HD period in both studies. Doses of 400 mg of L-DOPS or placebo were given to HD patients with OH (45 and 41 patients, respectively) in the double-blind study, and doses of 200 or 400 mg of L-DOPS were given to 74 HD patients in the long-term study. RESULTS: In the double-blind study, L-DOPS significantly ameliorated subjective symptoms related to OH, including dizziness/light-headed feeling, and malaise, throughout the interdialytic period. For 19 patients with delayed-type OH, hypotension with the lowest blood pressure recorded 10 min after standing, the decrease in blood pressure was suppressed significantly after L-DOPS treatment (10 patients) as compared with the placebo-treated group (9 patients). In the long-term study, the efficacy of L-DOPS was not attenuated, and the marked fluctuations in the plasma L-DOPS and norepinephrine levels were not noted after long-term use, without increases in incidence or severity of adverse reactions. CONCLUSIONS: These results indicate that L-DOPS is effective for improving OH-related interdialytic subjective symptoms in HD patients after short-term as well as after long-term administration.

Clinical effects of L-threo-3,4-dihydroxyphenylserine on orthostatic hypotension in hemodialysis patients.

Orthostatic hypotension is one of the major factors interfering with everyday activities in hemodialysis patients, but there has been no effective agent for treating it. In order to clarify the clinical effects of L-threo-3,4-dihydroxyphenylserine (L-DOPS) on orthostatic hypotension of hemodialysis patients, we conducted a randomized, double-blind comparative trial. 149 regular hemodialysis patients with orthostatic hypotension were randomly allocated to three groups and L-DOPS at doses of 400 mg, 200 mg or placebo was orally administrated to each group 30 min before starting every hemodialysis for 4 weeks. Changes of blood pressure (BP) in orthostatic hypotension immediately after completion of hemodialysis and symptoms related to orthostatic hypotension were compared between the three groups. In the 400-mg group, systolic and diastolic BP after standing increased significantly and the drop of mean BP after standing was also reduced compared with pretreatment levels. No such changes were observed in the placebo group. Fatiguability, malaise/weakness, dizziness and light-headed feeling, the interdialytic symptoms commonly observed in hemodialysis patients who developed orthostatic hypotension, were improved to a significant extent in the L-DOPS group compared with the placebo group. In particular, the improvement was more remarkable for the L-DOPS 400-mg group than the placebo group in patients with diabetic nephropathy, lower systolic BP after standing, and the long duration type of orthostatic hypotension. The incidence of adverse events was comparable between the three groups, and all recovered after discontinuation of L-DOPS or concomitantly administered drugs, or without any treatment. These findings indicate that L-DOPS taken before hemodialysis prevents orthostatic hypotension in patients undergoing hemodialysis, and is also effective for the interdialytic symptoms related to orthostatic hypotension.