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.

Evaluation of serological diagnosis tests for tuberculosis in hemodialysis patients.

Patients receiving hemodialysis are generally considered to be at increased risk of developing tuberculosis. In the current study, in order to evaluate the usefulness of serological tests in dialysis patients, serum antibodies for tuberculous glycolipids antigen (TBGL) and for lipoarabinomannan (LAM) were measured in hemodialysis patients. The present study included 243 hemodialysis patients. Serum antibodies for TBGL and LAM were measured. Tuberculin skin tests were carried out and chest X-rays evaluated at the same time. There were no patients with active tuberculosis at the time of blood sampling. Thirty-six patients (14.8%) and 25 patients (10.3%) were positive for anti-TBGL antibody and anti-LAM antibody, respectively. One hundred and fifty-five patients (63.8%) were positive for tuberculin skin testing and 123 patients (50.6%) had old pulmonary tuberculosis on their chest X-ray. There was no significant correlation between the results of anti-TBGL antibody and anti-LAM antibody. There were no relationships among the results of tuberculin skin test and the two serological tests. However, positivity of anti-TBGL antibody and anti-LAM antibody was significantly higher in patients with findings of old tuberculosis on the chest X-ray than those without findings. The current results show that these serological tests are positive more frequently in hemodialysis patients without any proof of active tuberculosis than in healthy subjects (2%) and careful interpretation is necessary for relevant results.

An overview of regular dialysis treatment in Japan (as of 31 December 2004).

A statistical survey of 3932 nationwide hemodialysis (hereafter, dialysis) facilities was carried out at the end of 2004, and 3882 facilities (98.73%) responded. The population undergoing dialysis at the end of 2004 was 248 166, an increase of 10 456 patients (4.4%) from that at the end of 2003. The number of dialysis patients per million people was 1943.5. The crude death rate of dialysis patients from the end of 2003 to the end of 2004 was 9.4%. The mean age of patients who underwent dialysis in 2004 was 65.8 years, and that of the total dialysis population was 63.3 years. The percentage distribution of patients who underwent dialysis according to a newly underlying disease showed that 41.3% of patients had diabetic nephropathy and 28.1% had chronic glomerulonephritis. The frequency of calcium carbonate use for dialysis patients was 75.1% and that of sevelamer hydrochloride use was 26.2%. The frequency of sevelamer hydrochloride use does not necessarily have a strong correlation with the dose of calcium carbonate. Patients who received high doses of sevelamer hydrochloride tended to have a low concentration of arterial blood HCO(3-). Approximately 15% of dialysis patients used an intravenous vitamin D preparation, generally maxacalcitol. The longer the patients had been on dialysis, the higher the frequency of use of an intravenous vitamin D preparation. When the concentration of serum intact parathyroid hormone (PTH) was more than 200 pg/mL, the frequency of use of an orally administered vitamin D preparation decreased; but that of intravenous vitamin D preparation increased. The percentage of dialysis patients who received percutaneous ethanol injection therapy (PEIT) was 1.4%. The percentage was more than 50% in the patients who had been on dialysis for more than 10 years. The percentage of patients who received PEIT again was 35.0%. The percentage of patients who had been on hemodialysis for more than 10 years and received PEIT again was more than 50%.

Increasing gender difference in the incidence of chronic dialysis therapy in Japan.

The incidence of chronic kidney disease and its progression to end-stage renal disease (ESRD) differs between genders, so it can be surmised that the incidence of ESRD is different between men and women. We analyzed the annual incidence of ESRD by gender for a 20 year period, from 1983 to 2002, using Japanese Society for Dialysis Therapy (JSDT) registration data. The annual incidence of ESRD was calculated as the number of incident dialysis patients divided by the census population of the previous year in each gender, and expressed per million of each population (male and female). In men, the incidence of ESRD increased from 99.9 in 1983 to 330.2 in 2002, whereas it was 66.6 in 1983 and 184.9 in 2002 in women. The difference of incidence of ESRD from men to women increased from 33.3 in 1983 to 145.3 in 2002. The mean age at the start of dialysis was 51.5 years (men) and 52.5 years (women) in 1983, it increased to 63.8 years (men) and 66.1 years (women) in 2002. The difference in mean age increased from 0.9 years in 1983 to 2.3 years in 2002. There was no clear relationship between the available dialysis station per 100,000 population and the men to women ratio in the prevalent dialysis patients among the 47 prefectures. The acceptance of dialysis therapy might not be strong enough to explain the increasing difference in ESRD incidence between men and women in Japan. Differences in the socioeconomic conditions and lifestyles between men and women, which might be related to the gender difference in incidence in ESRD, should be studied further.

[A case of chronic renal failure complicated with tuberculous meningitis successfully diagnosed by nested polymerase chain reaction (PCR)].

A 44 year-old woman was diagnosed as having chronic renal failure due to rapidly progressive glomerulonephritis (RPGN) from one year earlier. She has been managed with steroid therapy and hemodialysis. The patient was admitted to our hospital because of fever and sudden disturbance of consciousness with generalized convulsion on October 30, 2003. She showed mild meningeal irritation. Cerebrospinal fluid (CSF) examination demonstrated a cell count of 60/microl, protein level of 70 mg/dl, glucose level of 52 mg/dl, and chloride (Cl) level of 116 mEq/l. Both the CSF culture for Mycobacterium (M.) tuberculosis and the conventional single polymerase chain reaction (PCR) for M. tuberculosis DNA in CSF were negative results on admission. In contrast, nested PCR of preserved CSF samples obtained at admission demonstrated positive results. We diagnosed her conditions as tuberculous meningitis (TBM) and administered a total of 3 anti-tuberculosis agents over a period of about 2 months. Her clinical condition and CSF examinations improved immediately in response to anti-tuberculosis treatment. Serial CSF cultures for M. tuberculosis and the serial single PCRs for M. tuberculosis DNA in CSF were all negative during the course of anti-tuberculosis treatment. However, serial nested PCR results gradually converted from positive to negative, correlating with the improvement in clinical conditions during the course of anti-tuberculosis treatment. Therefore, nested PCRs were much more useful for the rapid and accurate diagnosis of TBM and for assessment of the clinical course and anti-tuberculosis treatment response of TBM than conventional CSF cultures and single PCRs. To the best of our knowledge, there have been few previous reports of diachronic study in which the serial nested PCR was used to test CSF samples obtained earlier in the clinical course of TBM. In conclusion, our findings suggest that nested PCR for M. tuberculosis DNA in CSF was highly useful not only for rapid and accurate diagnosis of TBM, but also for assessment of the antituberculous treatment response in cases highly suspected of TBM despite negative results on conventional cultures and single PCRs.

Factors influencing long-term survival in patients on chronic dialysis.

Japan has the highest prevalence of dialysis patients in the world. According to the Annual Report of the Japanese Society for Dialysis Therapy (JSDT; 2002), the total dialysis population was 229 538 (1801.5 patients per million population) at the end of 2002. The annual crude mortality rate has been less than 10%. Survival rates in the incident dialysis patients were 0.874 for 1 year, 0.609 for 5 years, and 0.391 for 10 years. Despite the increased acceptance for dialysis of elderly patients, those with comorbid conditions, and those with diabetes mellitus, the adjusted hazard ratios for death have been improving since 1983. This improvement was obtained by delivering a dialysis dose of Kt/V 1.33 and dialysis sessions of 4 h. Independently of the JSDT registry, there exists a local dialysis registry in Okinawa, the Okinawa Dialysis Study (OKIDS) registry, in which are filed the records of every chronic dialysis patient from the beginning of dialysis therapy in 1971 to the end of 2000. Several outcome studies have been conducted to determine the factors related to survival, using the data in that registry. There are distinct differences in environmental and socioeconomic conditions and lifestyles within a given country, and between countries and ethnic groups, that may affect the survival of dialysis patients. In this article, both the JSDT registry and OKIDS data are reviewed in order to identify factors related to the survival of chronic dialysis patients.

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.

Trends in incidence of end-stage renal disease in Japan, 1983-2000: age-adjusted and age-specific rates by gender and cause.

BACKGROUND: Trends in age-adjusted or age-specific incidence rates of end-stage renal disease (ESRD) have never been examined in Japan, a major ESRD epidemic area. METHODS: A nationwide registry has provided the number of ESRD patients commencing maintenance renal replacement therapy for time period from 1983 to 2000. We computed gender- and age-specific incidence rates of ESRD over 2-year periods, in total or by cause. Age-adjusted incidence rates were calculated using the 1985 Model Population of Japan as the standard. RESULTS: Causes of ESRD in 1999-2000 were, in order of decreasing frequency, diabetic nephropathy, chronic glomerulonephritis, unknown causes, nephrosclerosis and polycystic kidney disease in men, and chronic glomerulonephritis, diabetic nephropathy, unknown causes, nephrosclerosis and polycystic kidney disease in women. The age-adjusted all-cause incidence of ESRD increased until 1995-1996, but has since levelled off in both genders. The age-adjusted rate for diabetic nephropathy has been rapidly increasing, while that for chronic glomerulonephritis has decreased since 1995-1996. The former rate exceeded the latter in 1997-1998 in men. All-cause ESRD has rapidly increased in the eighties age group, whereas the increase slowed down in younger age groups in the late 1990s. The rate for diabetic nephropathy has linearly risen in almost every age group in men, whereas it began to level off in women aged 40-59 years at about 1995. For chronic glomerulonephritis, the rate had already started to decline in the mid-1980s in those aged <45 years. The rate of nephrosclerosis has been increasing independently of age. CONCLUSIONS: The present study shows changes in the epidemiological features of the incidence of ESRD in Japan from 1983 to 2000.

An overview of regular dialysis treatment in Japan (as of 31 December 2001).

Questionnaire forms for an annual survey conducted at the end of 2001 were sent out to 3520 institutions, and 3485 replies were received (response rate, 99.00%). According to the survey, the dialysis population of Japan at year end was 219 183 patients, up 6.3% (13 049) over the year before. This equals 1721.9 dialysis patients per million population. The gross mortality rate was 9.3% for the year extending from the end of 2000 to the end of 2001. The mean age of patients beginning dialysis was 64.2 years (+/- 13.7 SD). The mean age of the overall dialysis population in the study year was 61.6 years (+/- 13.1 SD), which was also a higher age than the year before. Among dialysis patients, the primary disease was diabetic nephropathy in 38.1% of patients, slightly down from 39.1% the previous year. Chronic glomerulonephritis was the primary disease in 32.4% of cases, a decrease from 34.7% the previous year. This survey included for the first time the items of the lowest blood pressure during hemodialysis session, vasopressor therapy before dialysis and vasopressor therapy during dialysis session. An analysis of the relationship between the type of vascular access used at the initiation of dialysis and the survival prognosis revealed a significantly higher risk of death in patients undergoing dialysis with synthetic arterio-venous (AV) fistula, AV shunt, or catheter implantation into a central vein than in those receiving dialysis treatments with a native fistula. There was a significantly lower risk of death in the patient group in whom the vascular access was created at 3-6 months before initiation of dialysis than in those in whom such access was created at the time of initiation or within 3 months before the initiation of dialysis. An analysis of the risk factors affecting survival prognosis in maintenance hemodialysis patients showed that risk factors for death are post-dialysis systolic blood pressure over 180 mm Hg and lower than 120 mm Hg, blood pressure elevating progressively from the start to the end of dialysis, serum high density lipoprotein cholesterol concentration of less than 30 mg/dL, and a higher ultrafiltration rate. In comparisons of the death risk between the patient group with a history of intervention for ischemic heart disease and the patient group with a history of myocardial infarction or heart failure but without such intervention, among diabetes patients, those who underwent percutaneous transluminal coronary angioplasty had a significantly lower risk of death than those in whom no intervention was made.

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.

[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.

Sclerosing encapsulating peritonitis: regional changes of peritoneum.

Sclerosing encapsulating peritonitis (SEP) is characterized by the diffuse appearance of marked sclerotic thickening of the peritoneal membrane. We experienced a case with SEP accompanied by regional changes of peritoneum. A 37-year-old woman with end-stage renal failure was started on continuous ambulatory peritoneal dialysis in 1985 and was transferred to hemodialysis in 1997. She was admitted because of ileus in 1998 with SEP and died of septicemia. The diagnosis of SEP was confirmed via the autopsy. The root of the mesentery was retracted and shortened. Since the peritoneal change was marked in the regions with free margin of mesentery and was less apparent in the regions not adhered to mesentery, it is indicated that mechanical stress also contributes to the occurrence of SEP. Since calcification and ossification were only seen in a free margin of small bowel from mesentery, it is suggested that there is a close relationship between calcification and ossification. Since fibrosis invaded into the muscle layer, dysfunction of bowel movement as well as bowel obstruction contributed to the appearance of ileus. It is suggested that mechanical stress by the root of mesentery which is retracted and shortened also contributes to the appearance of SEP.