Introduction Of Hemodialysis Research Articles

Development of a prognostic risk score to predict early mortality in incident elderly Japanese hemodialysis patients.

Information of short-term prognosis after hemodialysis (HD) introduction is important for elderly patients with chronic kidney disease (CKD) and their families choosing a modality of renal replacement therapy. Therefore, we developed a risk score to predict early mortality in incident elderly Japanese hemodialysis patients. We analyzed data of incident elderly HD patients from a nationwide cohort study of the Japanese Society for Dialysis Therapy Renal Data Registry (JRDR) to develop a prognostic risk score. Candidate risk factors for early death within 1 year was evaluated using multivariate logistic regression analysis. The risk score was developed by summing up points derived from parameter estimate values of independent risk factors. The association between risk score and early death was tested using Cox proportional hazards models. This risk score was validated twice by using an internal validation cohort derived from the JRDR and an external validation cohort collected for this study. Using the development cohort (n = 2,000), nine risk factors were retained in the risk score: older age (>85), yes = 2, no = 0; sex, male = 2, female = 0; lower body mass index (<20), yes = 2, no = 0; cancer, yes = 1, no = 0; dementia, yes = 3, no = 0; lower creatinine (<6.5 mg/dL), yes = 1, no = 0; lower albumin (<3.0 g/dL), yes = 3, no = 0; normal or high calcium (≥8.5 mg/dL), yes = 1, no = 0; and higher C reactive protein (>2.0 mg/dL), yes = 2, no = 0. In the internal and external validation cohorts (n = 739, 140, respectively), the medium- and high-risk groups (total score, 6 to 10 and 11 or more, respectively) showed significantly higher risk of early death than the low-risk group (total score, 0 to 5) (p<0.001). We developed a prognostic risk score predicting early death within 1 year in incident elderly Japanese HD patients, which may help detect elderly patients with a high-risk of early death after HD introduction.

Poor glycemic control attributable to insulin antibody in a fulminant type 1 diabetes patient under hemodialysis: successful treatment with double filtration plasmapheresis and prednisolone

BackgroundInsulin antibody appears in approximately 40% of insulin users using human insulin and insulin analog formulations. Insulin antibody, characterized by high affinity and low insulin antibody binding capacity (% bound), rarely causes clinical problems including poor glycemic control. Recently, the insulin antibody against human insulin causing deterioration of glycemic control, characterized by low affinity and high insulin antibody binding capacity similar to those observed in insulin autoimmune syndrome, has been reported.Case presentationA 62-year-old male developing fulminant type 1 diabetes showing rapid hyperglycemia (602 mg/dL) and normal range of glycoalbumin (GA) (18.4%) in the introductory stage of hemodialysis (HD) was transferred to our hospital 3 weeks after the onset of diabetes. He had been administered insulin intensification therapy in other medical clinic; however, his glycemic control remained poor, showing ketoacidosis. After hospitalization, he was initially administered intravenous insulin for 2 days and then switched to subcutaneous intensification therapy (24 U/day); the dose was gradually increased maximum of 72 U/day within 2 months. His glycemic control deteriorated despite high-dose insulin administration and change in the insulin type. Insulin antibody was detected, insulin antibody binding capacity (% bound) was of a high value (89.5%), GA was 32.9%, and casual blood glucose widely changed in continuous glucose monitor, suggesting that unstable blood glucose fluctuations caused by insulin antibody; therefore, treatment with double filtration plasmapheresis (DFPP) and prednisolone (PSL) was performed. The insulin dose reduced, and glycemic control improved from 1 month after the commencement of treatment. Subsequently, insulin antibody level remained high; however, after 6 months, % bound declined (20.9%), and glycemic control improved (GA 23.7%) by PSL (gradually reduced to 5 mg/day). The Scatchard plots also indicated the effectiveness with DFPP and PSL therapy.ConclusionsThe authors present a unique case of fulminant type 1 diabetes developing during the HD introduction period. Although this is a rare complication, physicians specializing in dialysis therapy should also keep in mind that this is a life-threatening complication if the treatment is delayed and that concomitant therapy with apheresis such as DFPP and long-term steroids is effective in some cases when glycemic control deteriorates attributable to insulin antibody.

Helicobacter pylori status and esophagogastroduodenal mucosal lesions in patients with end-stage renal failure on maintenance hemodialysis

The aim of this study was to elucidate the impact of Helicobacter pylori infection on esophagogastroduodenal mucosal lesions in patients with end-stage renal failure on maintenance hemodialysis (HD). An upper endoscopy and the (13)C-urea breath test were performed in 198 patients on maintenance HD. Clinical features, serum pepsinogen levels and esophagogastroduodenal mucosal lesions were compared between H. pylori-positive and H. pylori-negative patients. Risk factors associated with esophagogastroduodenal mucosal lesion were determined by multivariate analyses. The upper endoscopy revealed that gastric erosion was the most frequent (58%) type of esophagogastroduodenal mucosal lesion, followed by duodenal erosion (18%), gastric ulcer (14%), gastroesophageal reflux disease (10%), and duodenal ulcer (7%). Of the 198 patients enrolled in the study, 81 were positive and 117 patients were negative for H. pylori infection. The time duration after the introduction of HD was significantly longer and serum pepsinogen I/II ratio was significantly higher in H. pylori-negative patients than in H. pylori-positive patients. Multivariate analyses revealed that the H. pylori infection was an independent, protective factor for gastric erosion (odds ratio 0.38; 95% confidence interval 0.21-0.70), while the infection was unrelated to other mucosal lesions. The most common mucosal lesion observed in our study cohort, all of whom were patients on maintenance HD, was gastric erosion. The high prevalence of this type of lesion may be explained partly by the cure of H. pylori infection during the clinical course of maintenance HD.