End-stage Renal Disease In Japan Research Articles

Kidney lesions in diabetic patients with normoalbuminuric renal insufficiency

Diabetic nephropathy is a leading cause of end-stage renal disease in Japan. Microalbuminuria has been considered as the first clinical sign of diabetic nephropathy. However, recent studies demonstrated that normoalbuminuric renal insufficiency is not uncommon for diabetic patients, especially in type 2 diabetes. Although the pathogenesis of normoalbuminuric renal insufficiency in diabetic nephropathy remains to be fully elucidated, distinct clinical and pathological features of diabetic patients with this finding have been reported as compared to those in diabetic patients with a typical clinical course. In type 1 diabetes, more advanced glomerular lesions were found in patients with normoalbuminuric renal insufficiency than in patients with normoalbuminuric preserved renal function. In contrast, disproportionately advanced tubulointerstitial and vascular lesions, despite minor diabetic glomerular lesions, which denote the presence of diabetic kidney lesions as well as nephrosclerosis, were likely to be related to the development of normoalbuminuric renal insufficiency in some type 2 diabetic patients. In addition, long-term outcomes of diabetic patients with normoalbuminuric renal insufficiency remain controversial. Further studies to gain a better understanding of the structural-functional relationships and natural history of diabetic patients with normoalbuminuric renal insufficiency may improve the benefits of therapeutic interventions for diabetic nephropathy.

Diabetic Nephropathy Remission and Regression Team Trial in Japan (DNETT-Japan): Rationale and study design

The prevalence of end-stage renal disease (ESRD) is uprising in the paralleled with the increase of chronic kidney disease (CKD) patients. Diabetic nephropathy (DN) is the most important underlying disease of CKD and a leading cause of ESRD in Japan. Intensified multifactorial intervention in patients with type 2 diabetes with microalbuminuria slows the progression to nephropathy, and progression of retinopathy and autonomic neuropathy. However, further studies are needed to establish the effect of intensified multifactorial treatment on DN with overt proteinuria. In this trial, doctors and co-medicals collaborate to treat the DN patients to prevent the deterioration of DN by multifactorial intensive therapy. Diabetic Nephropathy Remission and Regression Team Trial in Japan (DNETT-Japan) is an open, randomized controlled trial to evaluate the efficacy of renal protection of multifactorial intensive therapy in type 2 diabetes patients with overt proteinuria (urinary albumin-to-creatinine ratio ≥300 mg/g creatinine). The study has a targeted enrollment of 600 Japanese patients, and divided into two protocols by renal insufficiency (protocol A: serum creatinine: <1.2 mg/dl in male and <1.0 mg/dl in female, and protocol B: serum creatinine: 1.2–2.5 mg/dl in male and 1.0–2.5 mg/dl in female). The patients were allocated standard treatment or intensive multifactorial treatment. Intensive treatment was a stepwise implementation of behavior modification, pharmacological therapy targeting hyperglycaemia, hypertension, dyslipidaemia, and proteinuria. The primary outcome is the proteinuria in protocol A and the composite endpoint of time to the first occurrence of doubling of serum creatinine, ESRD (the need for chronic dialysis, or renal transplantation) or death in protocol B. The follow-up period is 5 years and the study ends in 2014.

Kidney Disease Screening Program in Japan

In the early 1970s, mandatory kidney disease screening was started with urinalysis in the Japanese health examination program for all workers and school-age children. In 1983, nationwide urinalysis screening in adults aged > or = 40 yr was mandated in the community-based health examination program. Because glomerulonephritis was an endemic disease and the leading cause of end-stage renal disease in Japan until 1997, the urinalysis in the annual health examination program aimed for early detection of glomerulonephritis and early referral of patients to physicians. To the programs, measurement of serum creatinine was added for detection of chronic kidney disease in 1992 for adults aged > or = 40 yr. Kidney disease screening and early intervention brought reduction of progressive glomerulonephritis or an increase in remission. Thus, in children and adults aged < or = 45 yr, the number of patients with end-stage renal disease from glomerulonephritis has declined, and the mean age of patients with new end-stage renal disease has increased significantly. In 1998, the leading cause of end-stage renal disease was shifted from glomerulonephritis to diabetic nephropathy as a result of lifestyle changes in the Japanese population; however, the present comprehensive kidney disease screening in the health examination program for detection of glomerulonephritis must be continued, because even in 2005, 27.3% of newly developed end-stage renal disease was from glomerulonephritis. An additional kidney disease screening program should also be established to target patients with high risk for diabetes, hypertension, and metabolic syndrome, because 42% of newly introduced renal replacement cases were from diabetic nephropathy in 2005.

Integrated therapies including erythropoietin decrease the incidence of dialysis: lessons from mapping the incidence of end-stage renal disease in Japan

Erythropoietin (EPO) has been reported to slow the decline of renal function in predialysis chronic kidney disease (CKD) patients. On the contrary, in the recent large-scale randomized controlled trial (RCT), CREATE and CHOIR, which aimed to keep a higher haemoglobin (Hb) level than former trials, the renoprotective effect of EPO was not observed. Today, the renoprotective effect of EPO has become controversial. In order to test the hypothesis that the usage of EPO in predialysis CKD patients may ameliorate the progression of renal disease, we conducted a macro-level observational study dealing with all Japanese predialysis CKD patients. Annually since 1982, the Japanese Society for Dialysis Therapy reports the number of patients that have entered maintenance dialysis in each prefecture of Japan. Based on the 2002-2004 data, we calculated the annual incidence of end-stage renal disease (ESRD) in each of the 47 prefectures. The annual amounts paid for EPO by each prefecture, presumably corresponding to the amounts used, corrected for the estimated predialysis CKD patients, were calculated. We examined the relationship between the incidence of new dialysis and the usage of EPO in each prefecture. Furthermore, the usage of EPO was compared with that of antihypertensive agents including angiotensin converting enzyme inhibitor (ACE-I), and that of statin. There were prefectural differences in the annual incidence of ESRD from 2002 to 2004. We also found prefectural differences in the usage of EPO for the three consecutive years. The usage of EPO in predialysis patients was negatively correlated with the incidence of ESRD on linear and multiple regression analyses. At the same time, the usage of EPO had strong positive correlations with the usage of antihypertensive agents including ACE-I and with that of statin. Our nationwide epidemiologic study revealed that a higher use of EPO was associated with a decreased incidence of new dialysis in daily clinical practice. In addition, there were strong correlations among the usage of EPO, antihypertensive agents and statin. These data are supportive of, but do not prove, the hypothesis that EPO may be renoprotective, when used in combination with other strategies.

The Enigma of Hypertensive ESRD: Observations on Incidence and Trends in 18 European, Canadian, and Asian-Pacific Populations, 1998 to 2002

Despite improved treatment of hypertension and decreasing rates of stroke and coronary heart disease, the reported incidence of hypertensive end-stage renal disease (ESRD) increased during the 1990s. However, bias, particularly from variations in acceptance into ESRD treatment (ascertainment) and diagnosis (classification), has been a major source of error when comparing ESRD incidences or estimating trends. Age-standardized rates were calculated in persons aged 30 to 44, 45 to 64, and 65 to 74 years for 15 countries or regions (separately for the Europid and non-Europid populations of Canada, Australia, and New Zealand), and temporal trends were estimated by means of Poisson regression. For 10 countries or regions, population-based estimates of mean systolic blood pressures and prevalences of hypertension were extracted from published sources. Hypertensive ESRD, comprising ESRD attributed to essential hypertension or renal artery occlusion, was least common in Finland, non-Aboriginal Australians, and non-Polynesian New Zealanders; intermediate in most European and Canadian populations; and most common in Aboriginal Australians and New Zealand Maori and Pacific Island people. Rates correlated with the incidence of all other nondiabetic ESRD, but not with diabetic ESRD or community rates of hypertension. Between 1998 and 2002, hypertensive ESRD did not increase in Northwestern Europe or non-Aboriginal Canadians, although it did so in Australia. Despite the likelihood of classification bias, the probability remains of significant variation in incidence of hypertensive ESRD within the group of Europid populations. These between-population differences are not explained by community rates of hypertension or ascertainment bias.

Frequency of Gouty Arthritis in Patients with End-stage Renal Disease in Japan

The purpose of this study was to investigate gouty arthritis in Japanese patients with end-stage renal disease (ESRD). Questionnaires plus patient interviews and reviews of medical records were used to investigate gouty arthritis in 493 Japanese patients with ESRD receiving maintenance dialysis. The frequency of gouty arthritis was 4.1% for female patients and 15.4% for male patients greater than 2 years before the start of dialysis, and 0.6% for female patients and 7.7% for male patients less than 2 years before the start of dialysis. After the start of dialysis the frequency was 3.4% for the first 2 years and 1.2% thereafter in male patients, but no gouty arthritis appeared in female patients. Although the annual number of gouty attacks was 2.0+/-4.2 greater than 2 years before the start of dialysis, and 1.9+/-6.6 less than 2 years before the start of dialysis, the annual number of attacks decreased significantly after the start of dialysis to 0.2+/-0.7 in the first 2 years and 0.1+/-0.6 thereafter. The frequency of gouty arthritis in Japanese patients with ESRD is similar to that of patients with hyperuricemia in the general population and it is decreased slightly before dialysis; however, the frequency decreases markedly after dialysis.

ESTABLISHING NEPHROLOGY NURSING SPECIALIZATION IN JAPAN: A MATTER OF URGENCY

This paper explores the current situation regarding the provision of renal services to patients with end-stage renal disease in Japan. The statistical data reveal that Japan is in a predicament regarding the current rate of incidence of end-stage renal disease in the population. The discussion highlights the fact that nephrology nursing practice is as yet not recognised as a speciality in its own right in Japan. Therefore Japanese nurses who work in the field of nephrology are still struggling to establish their own professional identity and to improve the professional level of their practice. This situation persists in Japan despite support from the literature, which confirms that appropriately qualified nephrology nurses are well equipped to provide specialised care. The recent decision by the Japanese Association of Nephrology Nurses is to establish the position of the specialised dialysis nurse, which does not cover the area of kidney transplantation and will start in 2004. It is expected that it will be an important challenge to improve professional skills and nephrology nursing status in Japan.

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

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. 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. 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. The present study shows changes in the epidemiological features of the incidence of ESRD in Japan from 1983 to 2000.

Age distribution and yearly changes in the incidence of ESRD in Japan

Background: Although several treatment and screening methods have been tried, the incidence of patients with end-stage renal disease (ESRD) on renal replacement therapy (RRT) continues to increase worldwide. By making a detailed analysis of the major primary renal diseases, we found there have been some favorable effects in the incidence rate of ESRD recently in Japan. Methods: A total of 339,478 patients in Japan and 909,591 patients in the United States started RRT between 1983 and 1999. We compared trends of average age and incidence rate in each age group with major primary renal diseases and in racial groups after adjusting for general population aging by using a linear regression analysis. Results: All trends in ESRD incidence rates among Japanese, US total, US white, and US black patients showed significant increases (P < 0.001). A significant positive linear relationship between year and mean age at start of RRT also was observed (P < 0.001). After adjustment for general population aging, the mean age increment in Japanese patients with glomerulonephritis was increased significantly, and the proportion of Japanese patients who had glomerulonephritis and were younger than 45 years was decreased, but this decrement was not observed in US patients with glomerulonephritis. Conclusion: The reduced number of new patients with ESRD with glomerulonephritis might be caused by early detection and early referral to nephrologists as a result of the Japanese urinalysis-screening program. To reduce the ESRD population, it will be necessary to establish more effective treatment methods to delay exacerbation of progressive renal diseases.

Impact of a Pharmacist-Implemented Anemia Management in Outpatients with End-Stage Renal Disease in Japan

Given the absence of standard guidelines for use of recombinant human erythropoietin in patients with end-stage renal disease in Japan, in the present study, pharmacists actively managed the erythropoietin therapy, and the therapeutic and pharmacoeconomic outcome was evaluated. We compiled in-hospital guidelines for proper use of erythropoietin for outpatients with renal anemia under hemodialysis, and made recommendations, particularly about changes in the doses of erythropoietin and administration of iron preparations, to physicians. The clinical test values and the dosages of erythropoietin were monitored for 9 months and analyzed. As results of our participation, the number of renal anemia patients with over 30% of the hematocrit value as a therapeutic target increased from 7 to 32 among 41 patients. Twenty three of the 41 patients could decrease the dose of erythropoietin, and 5 patients could cease receiving the drug. Monthly total units of erythropoietin used for the 41 patients could also be decreased from 915000 units to 642000 units, resulting in considerable improvement of cost performance. Thus, active participation of pharmacists in management of renal anemia had great therapeutic and pharmacoecomic impact in Japan, as in North America.

Regional variations in the incidence of end-stage renal failure in Japan.

Despite recent medical advances, the number of patients beginning dialysis annually is increasing in both the United States and Japan. The ethnically homogeneous population of Japan presents an opportunity to study the presence of factors other than race/ethnicity that might contribute to incidence of end-stage renal disease (ESRD). To determine if and where regional differences exist in ESRD in Japan. Analysis of data reported by the Japanese Society for Dialysis Therapy based on the annual number of patients with ESRD beginning maintenance dialysis therapy in all 47 prefectures of Japan from 1982 to 1998. Mean annual ESRD incidence and increasing rate of ESRD in each of 11 predefined areas making up the entire country. Incidence of ESRD increased approximately 3-fold in Japan during the study years, from 81.3 per 1 million in 1982 to 237.6 per 1 million in 1998. Significant regional differences were found in both measures. The mean (SEM) annual ESRD incidence (P<.01) and increasing rate of ESRD (P<.01), respectively, were significantly different across Japan. Koshinetsu (140 [11] per 1 million and 9.1 [0.6] per 1 million/y) and Hokuriku (141 [12] per 1 million and 9.7 [0.5] per 1 million/y) were the areas with the lowest incidence and increasing rate of incidence, while Okinawa (188 [17] per 1 million and 13.4 [0.6] per 1 million/y) and Kyushu (179 [15] per 1 million and 12.0 [0.6] per 1 million/y) were the areas with the highest incidence and increasing rate of incidence. We found definite and significant regional differences in incidence and increasing rate of incidence of ESRD in Japan. Further analyses are needed to identify factors that contribute to these regional differences and thereby improve strategies for treatment of renal disease. JAMA. 2000;284:2622-2624.

Estimated number of patients with chronic renal failure but not with end-stage renal disease in Japan: comparisons between two estimation methods.

We estimated the number of patients with chronic renal failure (CRF) but not with end-stage renal disease (ESRD) in Japan by two methods: a nationwide survey and an estimation using incidence rates of ESRD among CRF patients as well as the number of incident ESRD. The former estimated the number of patients with CRF but not with ESRD as 154,000 (95% confidence interval 139,000-168,000), while so did the latter as 142,000 (133,000-150,000). It follows that the number of CRF patients including ESRD could amount to more than 300,000, which would give a substantial impact on public health in Japan. Despite some own methodological issues in estimation, the two estimates were reasonably in good agreement: supporting their methodological validity in estimation, since sources of errors appeared to be quite independent of each other.

The Japanese National Registry Data on Pediatric Capd Patients: A Ten-Year Experience a Report of the Study Group of Pediatric Pd Conference

Over the past 10 years, we have collected data on pediatric patients less than 16 years of age from the National Registry of CAPD (continuous ambulatory peritoneal dialysis). We present our experience with this population. The database details the patient number, age, weight, height, outcome, cause of death, reason for terminating CAPD therapy, peritonitis, and catheter survival. Of the 434 patients (239 males, 195 females), 37 patients (8.5%) were under 1 year of age and 164 patients (37.8%) were under 6 years of age. About half of the patients were less than 20 kg in weight, clearly indicating that CAPD was the treatment of choice in young children. The duration on CAPD for these patients was less than 2 years for 233 patients (54%), and was 5 years or more in 48 patients (11%). The outcome of the total patient population of 434 as of May, 1991, is as follows: 229 patients (52.8%) were being successfully treated with CAPD, 47 patients (10.8%) died, and 78 patients (18.0%) received a kidney transplantation. The patient survival rate was 85.6% at 3 years and 81.7% at 5 years. The technique survival rate was 74.9% at 3 years and 63.5% at 5 years. The rate of peritonitis was one episode over 28.6 patient-months. The mean catheter duration was 1.68 years. Peritonitis rate, catheter survival rate, and the rate of tunnel infection were worse in children less than 6 years of age than in older children. The excellent patient and technique survival rates indicate that CAPD is an effective treatment for children with end-stage renal disease in Japan. The high infection rates in younger children indicate that extra careful management is needed for this young age group.