Kyoko Hirano

高齢かつ低心機能患者に腹膜透析(PD)を導入し、生活の質(QOL)のみならず心機能が改善した87歳男性の症例を報告した。10年前より腎硬化症による慢性腎不全にて加療中、心エコーでの所見で高度の低心機能を認めていたが、腎機能が不良のため心カテーテル検査による心精査を施行できなかった。うっ血性心不全を発症し入退院を繰り返していた。腎機能は緩徐に増悪したため、PDカテーテルを挿入し、体液量コントロールを目的にPD導入とした。導入後1年の時点で、心機能、SF-36v2によるQOL評価ともに改善を認めた。下腿の浮腫が消失し、経口摂取が改善し体重は増加した。本症例のように重度の低心機能例では、残腎機能が十分に保たれているうちからPD導入が望ましいと考えられた。本症例ではPDによって心機能が改善したが、心機能改善には血液透析(HD)にはない緩徐な除水に加え、さまざまな物質の除去が関与している可能性があり、今後HDと比較した検討が必要であることを指摘した。

Substitution therapy using levocarnitine chloride (L-carnitine 600 mg/day, 12 weeks) was carried out in 13 cases of hemodialysis patients requiring high-capacity (9,000 IU/week or more upon rHuEpo conversion) ESA, and its effect against anemia was investigated along with the ESA requirement. The TC and FC values were very low in all patients before levocarnitine administration, and increased to a normal range 4 weeks after the administration and continued to increase over the following 12 weeks. The hemoglobin value increased by 1.0 g/dL or more in 7 of the 13 cases due to levocarnitine administration, while ESA was reduced by 25% or more in 4 cases, and was effective in a total of 9 cases (2 cases satisfying both standards). There were no significant differences between the effective example and ineffective example regarding the TC, FC, and acylcarnitine (AC) values as well as FC/AC ratio prior to levocarnitine administration. The TC and FC values 4 and 12 weeks after administration in the effective example were significantly higher than those in the ineffective example. The FC/AC ratio significantly increased in the effective example 4 and 8 weeks after administration compared with the prior value. Although red blood cell survival was shortened in 3 effective examples prior to administration, this improved following administration. Red blood cell survival in 2 ineffective examples did not improve, even after administration. As a result, levocarnitine substitution therapy appears to be highly effective in anemic hemodialysis patients without complicated diseases requiring high-quantity ESA, and its mechanism of action is mainly the improvement of shortened red blood cell survival.

In this clinical study, the reduction rate of FLCs by hemodiafiltration (HDF) using protein leaking dialyzer and hemodialysis using PMMA membrane were measured. The removal rates of κFLC were 20.8-71.6% by HDF and 54.7% by PMMA hemodialysis (HD). The removal rates of λFLC were 48.5-60.2% by HDF and 39.4% by PMMA HD. In an in vitro study, high cut-off membrane Theralite2100^<TM>, protein leaking dialyzer PES210Dα^<TM>, plasma separator Evacure1A20^<TM> and β2 microglobulin adsorption column LixelleS-35 were compared in their FLC removal rate. Dialysis using Theralite2100^<TM> or Evacure1A20^<TM>, diafiltration using PES210Dα^<TM> and adsorption using LixelleS-35^<TM> were performed in an in vitro circuit. The highest removal rate was obtained by Theralite2100 dialysis among the four blood purification methods. PES210Da^<TM> diafiltration has the second best removal rate. In conclusion, Theralite2100^<TM> dialysis was the best in removal of FLCs. In countries where Theralite2100^<TM> is not available, HDF using protein leaking dialyzer could become an alternative option.

通院中の血液透析患者でダルベポエチンα(DA)を週1回投与されている32例を対象とし、静注用鉄剤の投与方法別に、DAと同日に投与する群(9例)、DA投与の次の透析日に投与する群(11例)、DA投与の前の透析日に投与する群(12例)に無作為に分け、「赤血球造血」「鉄代謝」「酸化ストレス」に関わる諸指標の推移を群間比較した。結果、いずれの指標にも有意な群間差は認められなかった。このことから、DA週1回投与下にある透析患者において静注用鉄剤の投与日の違いは赤血球造血や酸化ストレスに影響を及ぼさず、どのタイミングで投与しても問題なく使用できると考えられた。

Serum troponin T levels using a highly sensitive assay (hsTnT) in patients with chronic kidney disease (CKD) not on dialysis have not been examined. The aim of this prospective cohort study was to investigate the association of hsTnT with cardiac events in ambulatory CKD patients not on dialysis. The serum hsTnT level was measured in 442 ambulatory CKD patients not on dialysis whose estimated glomerular filtration rate was &lt; 60 ml/min/1.73 m(2). Patients were divided into quartiles according to hsTnT levels, and were followed up for 3 years. Cardiac events were defined as a cardiac death, acute myocardial infarction, unstable angina pectoris that required emergency coronary revascularization, or hospitalization for worsening heart failure. During the follow-up period (median 22 months), 63 cardiac events occurred. Kaplan-Meier incidence rates of cardiac events for 3 years were 0.88 %, 11.5 %, 19.0 %, and 41.4 % among quartiles of hsTnT levels (P &lt; 0.0001). After adjusting for other confounders, elevated hsTnT level was an independent predictor for cardiac events (hazard ratio 6.18, 95 % confidence interval 1.38-27.7, P = 0.0080 for highest quartile vs lowest quartile). In addition, C-index for receiver-operating characteristic curves for cardiac events was greater in an established risks plus hsTnT model than in the established risk alone model (0.857 vs 0.844, P = 0.026). Using a highly sensitive assay, serum hsTnT level was shown to be an independent predictor of cardiac events and a promising risk stratification tool in patients with CKD not on dialysis.

Serum troponin T levels using a highly sensitive assay (hsTnT) in patients with chronic kidney disease (CKD) not on dialysis have not been examined. The aim of this prospective cohort study was to investigate the association of hsTnT with cardiac events in ambulatory CKD patients not on dialysis. The serum hsTnT level was measured in 442 ambulatory CKD patients not on dialysis whose estimated glomerular filtration rate was &lt; 60 ml/min/1.73 m(2). Patients were divided into quartiles according to hsTnT levels, and were followed up for 3 years. Cardiac events were defined as a cardiac death, acute myocardial infarction, unstable angina pectoris that required emergency coronary revascularization, or hospitalization for worsening heart failure. During the follow-up period (median 22 months), 63 cardiac events occurred. Kaplan-Meier incidence rates of cardiac events for 3 years were 0.88 %, 11.5 %, 19.0 %, and 41.4 % among quartiles of hsTnT levels (P &lt; 0.0001). After adjusting for other confounders, elevated hsTnT level was an independent predictor for cardiac events (hazard ratio 6.18, 95 % confidence interval 1.38-27.7, P = 0.0080 for highest quartile vs lowest quartile). In addition, C-index for receiver-operating characteristic curves for cardiac events was greater in an established risks plus hsTnT model than in the established risk alone model (0.857 vs 0.844, P = 0.026). Using a highly sensitive assay, serum hsTnT level was shown to be an independent predictor of cardiac events and a promising risk stratification tool in patients with CKD not on dialysis.

Renal failure is a frequent complication in patients with multiple myeloma. Immunoglobulin free light chains (FLCs) form casts in the distal tubules, resulting in renal obstruction, and are also directly toxic to proximal renal tubules. Removal of FLCs contributes to renal recovery. High cut-off (HCO) membrane Theralite2100, protein leaking dialyzer PES210D alpha, plasma separator Evacure1A20 and beta(2) microglobulin adsorption column LixelleS-35 were compared in their FLC removal rate. Dialysis using Theralite2100 or Evacure1A20, diafiltration using PES210D alpha and adsorption using LixelleS-35 were performed in an in vitro circuit. The highest removal rate was obtained by Theralite2100 dialysis among the four blood purification methods. Albumin loss was also the greatest in Theralite2100 dialysis. The removal content of FLCs per 1 g albumin loss was better in PES210D alpha diafiltration. The removal rate of FLCs by Evacure EC1A-20 dialysis was the third highest. Adsorption of FLCs by the beta(2) microglobulin adsorption column Lixelle S-35 was confirmed. In conclusion, Theralite2100 dialysis was the best in removal of FLCs. PES210D alpha diafiltration can remove FLCs with smaller loss of albumin.

42歳男性。患者は関節痛および皮疹を主訴に近医を受診、アレルギー性紫斑病を疑われ、著者らの施設へ紹介となった。入院時、体幹および両下腿に散在する紫斑がみられ、あわせて頸部、両肩、腰、左膝、左示指、右環指に関節痛が認められた。また、尿蛋白は陽性で、血液検査では肝・胆道系酵素の上昇がみられ、ウイルス検査を行ったところ、HBs抗原陽性、HBc-IgM陽性、HBe抗原陽性が判明し、急性B型肝炎と診断された。以後、入院第4病日より黄疸が出現し、AST/ALT値はピークとなったが、紫斑は第3病日まで、関節炎は第11病日までに消失し、第18病日目には退院となった。

76歳女。4年前にRS3PE症候群に対してステロイド投与が開始され、同時に骨粗鬆症予防のためにビスホスホネート(BP)投与が開始された。今回、右側下唇の痺れを主訴に当科受診した。諸検査の結果から、右側下顎骨の壊死によって下歯槽神経が傷害されたことで下唇に知覚異常をきたしたものと考えられた。下顎骨壊死を生じた原因については「BP投与」に加え、「ステロイド投与」「糖尿病」「口腔衛生の不良」なども増悪因子になっていたと思われた。