Peritoneal dialysis (PD)-related infections (PDIs) such as peritonitis, exit-site infection, and tunnel infection are serious complications affecting patients on PD. Because patients with diabetes (DM) and of older age have increased in number in Japan, the number of patients with visual impairment is estimated also to have increased. Near vision is necessary for performing proper PD daily care. However, no studies have reported whether visual impairment is likely to increase the risk of PDIs.Our study included 31 PD patients (16 men, 15 women; mean age: 61.5 ± 11.8 years; mean PD duration: 27.3 ± 20.3 months; 38.7% with DM; 54.8% wearing glasses) who performed their own PD care. At our facility and related facilities, we used a standard near-vision test chart, which classifies vision into 12 grades, from 0.1 (poor) to 1.5 (clear), to assess near-vision binocular visual acuity in those patients between March 2015 and September 2015. In addition, we retrospectively examined the medical records of the patients to determine their history of PDIs. We then evaluated the correlation between near-vision acuity and the incidence of PDIs.Mean measured near-vision acuity was 0.61 ± 0.29, and we observed no significant difference in the visual acuity of patients with and without DM (0.55 ± 0.31 vs. 0.63 ± 0.26 respectively, p = 0.477). In addition, we observed no significant difference in the incidence of PDIs between patients with and without DM (1.298 ± 1.609 per year vs. 1.164 ± 0.908 per year respectively, p = 0.804). We did not find a correlation between near-vision acuity and the incidence of PDIs (r = -0.071, p = 0.795).

CASE PRESENTATION:A 62-year-old man was diagnosed with peritoneal dialysis (PD)-related peritonitis following diarrhea and determination of a dialysate leukocyte count of 10,224/μL. We cultured peritoneal effluent and started intraperitoneal antibiotic therapy. Peritonitis immediately improved. Peritoneal effluent culture yielded Aeromonas hydrophila. The medical interview revealed that the patient kept goldfish as pets. We suspected that the fish tank water was the source of the infection, considering the association of A. hydrophila with aquatic environments. Culturing of tank water confirmed the presence of Aeromonas. Furthermore, we observed that one of the goldfish was suffering from lepidorthosis, which is commonly caused by Aeromonas, and we then confirmed that the fish's infection was caused by an aeromonad.CONCLUSION:Aeromonas species have rarely been identified as the pathogens in PD-related peritonitis; to our knowledge, there hitherto have been no reports identifying the source of this organism. We present here the process of this infection as elucidated through investigation of the living environment of the patient.

Few studies have attempted to evaluate the relationship between peritoneal permeability and fluid status in peritoneal dialysis (PD). The aim of the present study was to clarify the relationship between change in the dialysate-to-plasma ratio of creatinine (D/P Cr) and change in fluid status as evaluated by natriuretic peptides. We studied 49 PD patients (29 men, 62 ± 11 years, 36.7% with diabetes) who underwent a peritoneal equilibration test at least twice after PD initiation. We evaluated correlations between the rate of change in the D/P Cr (R C-D/P Cr), the rate of change in a human atrial natriuretic polypeptide (RC-αhANP), and the rate of change in brain natriuretic peptide (RC-BNP). The RC-αhANP was strongly correlated with RC-BNP (r = 0.637, p < 0.001). In contrast, the RC-D/P Cr was not correlated with RC-αhANP (r = 0.041, p = 0.781) or with RC-BNP (r = 0.114, p = 0.435). However, positive correlations between RC-D/P Cr and RC-αhANP (r = 0.530, p = 0.006) and between RC-D/P Cr and RC-BNP (r = 0.625, p = 0.001) were observed in patients with increased D/P Cr The present study showed a positive correlation between change in peritoneal transport characteristics and change influid status in patients whose D/P Cr increased.

Chronic kidney disease is an important risk factor for cardiovascular disease and mortality [ [1] Go A.S. Chertow G.M. Fan D. McCulloch C.E. Hsu C.Y. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N. Engl. J. Med. 2004; 351: 1296-1305 Crossref PubMed Scopus (8842) Google Scholar ]. In hemodialysis (HD) patients, habitual physical activity (PA) among outpatients undergoing maintenance hemodialysis is associated with decreased mortality risk [ [2] Matsuzawa R. Matsunaga A. Wang G. et al. Habitual physical activity measured by accelerometer and survival in maintenance hemodialysis patients. Clin. J. Am. Soc. Nephrol. 2012; 7: 2010-2016 Crossref PubMed Scopus (93) Google Scholar ]. Sarcopenia is defined as the loss of skeletal muscle mass and strength that occurs with advancing age [ [3] Cruz-Jentoft A.J. Baeyens J.P. Bauer J.M. et al. Sarcopenia: European consensus on definition and diagnosis: report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010; 39: 412-423 Crossref PubMed Scopus (7175) Google Scholar ]. It also related to physical function, activities of daily living, and mortality in elderly people [ [3] Cruz-Jentoft A.J. Baeyens J.P. Bauer J.M. et al. Sarcopenia: European consensus on definition and diagnosis: report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010; 39: 412-423 Crossref PubMed Scopus (7175) Google Scholar ].

Chronic kidney disease (CKD) is an important risk factor for cardiovascular disease and mortality [ [1] Go A.S. Chertow G.M. Fan D. McCulloch C.E. Hsu C.Y. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N. Engl. J. Med. 2004; 351: 1296-1305 Crossref PubMed Scopus (9368) Google Scholar ]. In patients undergoing dialysis, malnutrition and low physical activity (PA) are common complications that are independent predictors of hospitalization, morbidity and mortality [ 2 Kalantar-Zadeh K. Block G. McAllister C.J. Humphreys M.H. Kopple J.D. Appetite and inflammation, nutrition, anemia, and clinical outcome in hemodialysis patients. Am. J. Clin. Nutr. 2004; 80: 299-307 PubMed Scopus (506) Google Scholar , 3 Cupisti A. Capitanini A. Betti G. D'Alessandro C. Barsotti G. Assessment of habitual physical activity and energy expenditure in dialysis patients and relationships to nutritional parameters. Clin. Nephrol. 2011; 75: 218-225 Crossref PubMed Scopus (48) Google Scholar , 4 Ikizler T.A. A patient with CKD and poor nutritional status. Clin. J. Am. Soc. Nephrol. 2013; 8: 2174-2182 Crossref PubMed Scopus (37) Google Scholar ]. However, these are modifiable risk factors that may affect the development and course of CKD. Previous studies have established the benefits of increased PA on mortality in the general population and in patients with CKD [ 5 Paffenbarger Jr., R.S. Hyde R.T. Wing A.L. Hsieh C.C. Physical activity, all-cause mortality, and longevity of college alumni. N. Engl. J. Med. 1986; 314: 605-613 Crossref PubMed Scopus (2062) Google Scholar , 6 Leon A.S. Myers M.J. Connett J. Leisure time physical activity and the 16-year risks of mortality from coronary heart disease and all-causes in the Multiple Risk Factor Intervention Trial (MRFIT). Int. J. Sports Med. 1997; 18: S208-S215 Crossref PubMed Google Scholar , 7 Beddhu S. Baird B.C. Zitterkoph J. Neilson J. Greene T. Physical activity and mortality in chronic kidney disease (NHANES III). Clin. J. Am. Soc. Nephrol. 2009; 4: 1901-1906 Crossref PubMed Scopus (203) Google Scholar ]. Pupim et al. reported that PA may facilitate the anabolic effects of nutritional interventions [ [8] Pupim L.B. Flakoll P.J. Levenhagen D.K. Ikizler T.A. Exercise augments the acute anabolic effects of intradialytic parenteral nutrition in chronic hemodialysis patients. Am. J. Physiol. Endocrinol. Metab. 2004; 286: 589-597 Crossref PubMed Scopus (73) Google Scholar ]. We previously reported that the PA of peritoneal dialysis (PD) patients was significantly lower than that of healthy people [ [9] Wakamiya A. Hiraki K. Hotta C. Izawa K.P. Watanabe S. Oishi D. et al. Physical activity in peritoneal dialysis patients. Rigakuryouhougaku. 2013; 40 (in Japanese with English abstract): 473-479 Google Scholar ]. Oishi et al. also reported that serum albumin, age and C-reactive protein (CRP) are associated with a decline in the PA of PD patients [ [10] Oishi D. Koitabashi K. Hiraki K. Imai N. Sakurada T. Konno Y. et al. Physical activity is associated with serum albumin in peritoneal dialysis patients. Adv. Perit. Dial. 2012; 28: 148-152 PubMed Google Scholar ].

The removal of a peritoneal dialysis catheter (PDC) is an important procedure, much like the placement of a PDC. In our institution, the removal of a PDC was always performed under spinal or general anesthesia. However, we might hesitate to remove a PDC in some patients under such anesthesia when their general condition is too poor due to severe cerebrovascular and/or cardiac disease. Therefore, we attempted a re-embedding catheter technique in 4 patients. In this report, we review the advantages and disadvantages of this technique and compare it with traditional techniques.

Peritoneal dialysis (PD) catheter-related infection is still is the most troublesome problem for continuation of PD without the need to switch to hemodialysis. We have been performing subcutaneous pathway diversion (SPD) as a surgical treatment for refractory exit-site and tunnel infection (ESTI). To clarify the efficacy and safety of SPD, we conducted a retrospective study. From August 2008 to August 2013, 30 SPDs were performed in 26 patients (16 men, 10 women; mean age: 58 +/- 13 years; 54% with diabetes; mean body mass index: 23.9 +/- 3.5 kg/ m2). The reasons for the SPDs were ESTI in 25 patients, and outer cuff extrusion in 1 patient. All patients resumed PD immediately after SPD, and the duration of hospitalization was 11.7 +/- 10.1 days. After SPD, one patient experienced a dialysate leak, and another patient experienced a mild subcutaneous hematoma. Another 4 patients developed exit-site infection (ESI) and underwent a second SPD. Of those 4 patients, 3 presented with another ESI unrelated to the first episode, and all developed an ESI after 6 months or more. The remaining 20 patients experienced no such complications. Furthermore, catheter survival after SPD was 17.4 +/- 13.4 months. To eradicate ESTTI we suggest that SPD, which does not require catheter removal or interruption of PD, is useful compared with the unroofing technique or catheter removal.

The proportion of elderly people requiring renal replacement therapy has been increasing in Japan. Although several studies have shown the benefits of peritoneal dialysis (PD) in the elderly, few have reported on outcomes, including prognosis, in elderly PD patients, especially those more than 80 years of age. The purpose of the present study was to evaluate clinical outcomes in elderly (more than 80 years of age) PD patients. We retrospectively evaluated the medical records of elderly PD patients who commenced PD between 2007 and 2011. The frequency of perioperative complications, rate of PD-associated peritonitis, technique survival, overall survival, and utilization of nursing-care insurance systems were investigated as clinical outcomes. The 12 patients eligible for this study (7 men, 5 women; mean age: 85 +/- 3 years) had a median duration of follow-up of 1.2 years (interquartile range: 0.65-1.74 years). Perioperative complications were not observed in any of the patients. The frequency of PD-associated peritonitis was 1 episode in 56 months. During follow-up, 6 patients died, and 3 patients switched to hemodialysis because of tunnel infection or lack of family support. The overall survival rate at 12 months was 83%. Nursing-care insurance was used by 63% of patients. In elderly patients, it is important to predict the potential short-term issues at the initiation of PD to facilitate implementation of social services, such as home-visit nursing-care services, at the time of worsening general condition.

The incidence of metabolic syndrome is about 50% in peritoneal dialysis (PD) patients. The positive association of metabolic syndrome with lower physical activity (PA) has been reported in the general population, but the effect of PA in PD patients has not been clarified. The purpose of the present study was to evaluate PA in PD patients and to clarify the correlations between PA and various clinical parameters in PD patients. We assessed 38 PD patients (22 men; age: 63.9 +/- 10.8 years; body mass index: 24.0 +/- 3.9; 15 with diabetes) who had been treated with PD at least for 3 months. We defined PA as the average number of steps per day measured using a pedometer for 1 month. Blood biochemical findings and dialysis adequacy were measured as clinical parameters. Of the 38 patients, only 11 (29%) reached the steps per day of healthy individuals. In addition, steps per day were significantly correlated with serum albumin (r = 0.45, p = 0.01), C-reactive protein (r = -0.33, p = 0.04), and age (r = -0.34, p = 0.04). Multiple regression analysis showed that serum albumin was the only variable that significantly correlated with steps per day (beta = 0.42, p = 0.01). Our study showed that PA declines significantly in PD patients, which might correlate with malnutrition-inflammation-atherosclerosis syndrome.

Accumulating evidence has shown that diabetic patients are increasing in number, and renal and cardiovascular complications are the most common cause of death in diabetic patients. Thus, it would be of considerable value to identify the mechanisms involved in the progression of renal impairment and cardiovascular injury associated with diabetes. Recent evidence also indicated that multifactorial intervention is able to reduce the risk of cardiovascular disease and death among patients with diabetes and microalbuninuria. In this pilot study, we examined the effects of intensified multifactorial intervention, with tight glucose regulation and the use of valsartan and fluvastatin on ambulatory blood pressure (BP) profile, estimated glomerular filtration rate (eGFR), and urinary albumin to creatinine ratio (UACR), in 20 hypertensive patients (16 male and 4 female) with type 2 diabetes mellitus and overt nephropathy. After 12 months of intensified treatment, office BP, fasting plasma glucose (FPG), and low-density lipoprotein cholesterol (LDLC) were significantly decreased compared to baseline (systolic blood pressure (SBP), 130 ± 2 vs. 150 ± 1 mmHg; diastolic blood pressure (DBP), 76 ± 1 vs. 86 ± 1 mmHg; FPG, 117 ± 5 vs. 153 ± 7 mg/dl; LDLC, 116 ± 8 vs. 162 ± 5 mg/dl, P < 0.0001). Also, compared to the baseline values, the daytime and nighttime ambulatory BP and short-term BP variability were significantly decreased after 12 months. Furthermore, while eGFR was not altered (44.3 ± 5.1 vs. 44.3 ± 6.5 ml/min/1.73 m(2), not significant (NS)), UACR showed a significant reduction after 12 months of intensified treatment (1228 ± 355 vs. 2340 ± 381 mg/g-cr, P < 0.05). These results suggest that the intensified multifactorial intervention is able to improve ambulatory BP profile, preserve renal function, and reduce urinary albumin excretion in type 2 diabetic hypertensive patients with overt nephropathy.

The present study evaluated the clinical efficacy and pharmacokinetics of microemulsion cyclosporine A (ME-CyA) with modification from postprandial to preprandial administration in adult patients with refractory nephrotic syndrome.

A 53-year-old man with end-stage kidney disease on haemodialysis thrice weekly for 32 years due to purpura nephritis presented with exertional dyspnoea and fever. Chest radiograph revealed nodular shadows in the periphery of lung areas, especially bilateral upper lung areas (Fig- ure ​ure1),1), and computed tomography of the chest revealed high dense foci of a ground-glass appearance in bilateral upper lung areas (Figure ​(Figure2A).2A). At first, he was suspected to have infectious pneumonitis, because of opportunistic condition due to long-lasting steroid use and immunosuppressive therapy for recurrent episodes of purpura. However, the symmetrical and upper lung distribution of the lesions raised the possibility of metastatic pulmonary calcification (MPC). A Technetium 99 methylene diphosphonate (Tc-99m-MDP) bone scan was then performed and an increased uptake in the upper lobe lesions (Figure ​(Figure2B)2B) confirmed the diagnosis of MPC. Indeed, respiratory function tests noted a restrictive pattern. Fig. 1 Chest radiograph showing nodular shadows in the bilateral upper lung. Fig. 2 (A) Computed tomography showing diffuse ground-glass opacities in the bilateral upper lung. (B) 99mTc-MDP bone scan showing prominent uptake of the bilateral upper lung. The review of the medical history revealed that he had undergone a total parathyroidectomy for secondary hyperparathyroidism 17 years ago and, subsequently, developed adynamic bone disease. For hypocalcaemia, he had been taking large doses of calcium carbonate and alfacalcidol for a long term. His recent intact parathyroid hormone level was 15 pg/ml, serum calcium 9.0 mg/dl, serum phosphate 2.2 mg/dl, and calcium phosphate product 19.8 mg2/dl2. Doses of calcium carbonate and vitamin D were reduced to a minimum to maintain normocalcaemia. MPC was found to be common (60–80%) by bone scan or autopsy among dialysis patients and can cause restrictive lung disease, however, rarely manifests overt symptoms and is often overlooked. Pathogenesis of MPC still remains to be determined but is suspected to be associated with bone and mineral disorders as in other ectopic calcification. Therefore, reduction of calcium-containing medication, vitamin D or its analogues is a mainstay for the management of MPC. Conflict of interest statement. None declared.

A 71-year-old man was admitted to our hospital because of fever and rapidly progressive renal insufficiency over a month. He had depression and Alzheimer's disease as complications. On admission, his serum creatinine was 5.4 mg/dL, and the serum CRP and MPO-ANCA were 18.2 mg/dL and 285 EU, respectively. A computed tomographic chest scan showed pericardiac effusion and fibrosis in both lower lung fields. Although microscopic polyangiitis(MPA)was inferred from a positive MPO-ANCA, renal biopsy could not be carried out. The initial therapy was started with pulse methylprednisolone therapy, followed by oral administration of prednisolone at the dose of 1 mg/kg(60 mg/day). As a result, his fever and inflammatory findings disappeared, and renal insufficiency was ameliorated with a smooth recovery and the pericardial effusion was markedly diminished. However, on the 18th hospital day, chest radiography revealed a nodular shadow in the right lung. Fungus infection was suspected because his serum beta-D-glucan level was extremely high (above 999 pg/mL). Mikafungin, therefore, was started at a dose of 75 mg/day and then, the dose was increased up to 300 mg/day. Nevertheless, he finally died of respiratory failure on the 26th hospital day. The autopsy findings revealed a cavity of 4.0 x 3.0 x 3.0 centimeters in size in the upper lobe of the right lung. There was a great number of fungal threads with a septal wall branched in a Y-shaped figure around the cavity, thus indicating pulmonary aspergilloma. Intranuclear inclusion bodies staining positive for cytomegalovirus were observed in all the lung fields, suggestive of a cytomegalovirus infection. In the kidney, a cellular crescent formation was noted in the majority of glomeruli showing crescentic glomeluronephritis, compatible with MPA.

STUDY OBJECTIVE:To compare the absorption profile of cyclosporine after preprandial administration with that after postprandial administration, and to determine which administration time resulted in a more stable absorption profile and the timing of the drug concentration that was the most reliable marker for monitoring drug absorption.DESIGN:Prospective analysis.SETTING:University teaching hospital in Japan.PATIENTS:Sixteen patients with refractory nephrotic syndrome.INTERVENTION:Thirteen patients received cyclosporine after breakfast (postprandial group) and eight received the drug 30 minutes before breakfast (preprandial group).MEASUREMENTS AND MAIN RESULTS:Blood cyclosporine concentration was measured 5 times serially: before administration (C 0 ) and at 1-hour intervals until 4 hours after administration of cyclosporine (C 1 -C 4 ). Also, area under the concentration-time curve from 0-4 hours (AUC 0-4 ) was calculated. Of the 13 patients in the postprandial group, six (46%) showed fair absorption and exhibited a peak concentration at C 1 or C 2 (high-absorption pattern); seven (54%) showed poor absorption and did not reach the peak concentration within the 4-hour period (low-absorption pattern). Five of the seven patients with the low-absorption pattern were switched from postprandial to preprandial administration. All patients in the preprandial administration group showed a high-absorption pattern and reached the peak cyclosporine concentration at C 1 . The C 2 value showed the best correlation with AUC 0-4 in both groups, and the C 0 parameter did not correlate with AUC 0-4 in either group.CONCLUSION:Preprandial administration provided a more stable absorption profile of cyclosporine compared with postprandial administration. From the correlation with AUC 0-4 , we concluded that C 2 , and not C 0 , is a reliable marker for monitoring cyclosporine exposure.

A 65-year-old man was admitted to our hospital for high fever and severe left shoulder pain. He was initiated on maintenance hemodialysis for end-stage renal failure caused by diabetic nephropathy 9 years previously. On admission, the serum CRP level was 29.3 mg/d/l and the white blood cell count was 29,000/mm3. Bacterial examination of blood and spinal fluid revealed MRSA colonization. On the 6th hospital day, a giant negative T wave in the V2-6 leads of an electrocardiogram asymptomatically appeared. Ultracardiogram revealed apical systolic paradoxical centrifugal motion. None of the cardiogenic enzymes, such as creatine kinase, lactate dehydrogenase and glutamic oxaloacetic transaminase was elevated. Cardiac thallium-201-chloride (201Tl-Cl) and I-123 beta-metyl iodophenyl-pentadecanoic acid (123I-BMIPP) scintigraphy revealed a decreased accumulation of isotopes in the apex. From these findings, we diagnosed Takotsubo cardiomyopathy induced by MRSA meningitis. Vancomycin was administrated and the inflammatory signs decreased. On the 46th hospital day, tetraplegia and respiratory suppression occurred. A cervical spinal magnetic resonance image revealed cervical spondylodiscitis and cervical epidural abscess, which compressed the medulla oblongata. Surgical spinal decompression and drainage of the abscess were performed. The giant negative T wave in the electrocardiogram improved after the operation. Two months after the operation, cardiac 201Tl-Cl scintigraphy revealed improvement in the accumulation of isotopes in the apex. Takotsubo cardiomyopathy is secondary cardiomyopathy presenting with apical systolic paradoxical centrifugal motion without coronary stenotic disease. It has been reported to be induced by severe mental stress or intracranial disease. In the present patient, it was predicted that stress on the central nerve system caused by the MRSA meningitis and the cervical epidural abscess induced the Takotsubo cardiomyopathy.