Objective: Living wills, written types of advanced directives, are now widespread in western countries, but in Japan, their recognition still remains restricted to a small part of the population. As an initial step to introduction of such patient-oriented medicine, we surveyed present recognition and acceptance patterns concerning living wills in a main regional hospital located in a suburban area of Tokyo.
Methods: Without any preceding guidance on living wills, the questionnaire on living wills was distributed to all the staff working at JA Toride Medical Center in September 2013, and their responses were collected for analysis within one month.
Results: Questionnaires were distributed to all hospital staff, 843 in total, and 674 responses (80.0% of distributed) were obtained. The term of living will was known by 304 (45.1%) of the respondents, and introduction of living wills to patients was accepted in 373 (55.3%) of the respondents, meanwhile, 286 (42.4%) respondents did not indicate their attitude toward living wills. As to styles of document form, 332 respondents (49.3%) supported selection of wanted or unwanted medical treatments and care from a prepared list, and 102 respondents (15.1%) supported description of living wills in free form. As preferred treatment options that should be provided as a checklist, cardiac massage (chest compression) and a ventilator were selected by more than half of the respondents. Based on their responses, we developed an original type of living wills available to patients visiting the hospital.
Conclusions: Although not all the respondents were aware of living wills even in this main regional hospital, introduction of living wills to patients was accepted by many of the hospital staff. Awareness programs or information campaigns are needed to introduce living wills to support patient-centered medicine.

Objective: The usefulness of estimated glomerular filtration rate may not be restricted to pre-dialysis patients, since we reported that estimated glomerular filtration rate was well correlated with measured total creatinine clearance in peritoneal dialysis patients. To clarify the clinical usefulness of estimated glomerular filtration rate as a parameter for peritoneal dialysis adequacy, we retrospectively surveyed estimated glomerular filtration rate and total creatinine clearance in peritoneal dialysis patients treated at JA Toride Medical Center.
Patients and Methods: A total of 114 data sets of estimated glomerular filtration rate and total creatinine clearance from 21 PD patients treated at JA Toride Medical Center were collected from November 2010 to October 2011. The patients consisted of 15 men and six women with an average age of 66.6 ± 12.6 years (46-95 years old). The average number of samples was 5.4 ± 1.5 (2 to 7) per patient.
Results: The collected data showed less correlation of estimated glomerular filtration rate and total creatinine clearance (r. = 0.435) than that of a previous cross-sectional study (r. = 0.836). As reported in pre-dialysis patients, the differences between estimated glomerular filtration rate and total creatinine clearance were correlated with total creatinine excretion in urine and PD effluent (r. = 0.821). The differences were also correlated with normalized protein catabolic rate, which was one of the main determinant factors for total creatinine excretion (r. = 0.636). A similar tendency was apparently observed in one patient with poor compliance to diet therapy and fluctuating dietary intake. From the analysis of these data, serum creatinine seemed to fluctuate less possibly due to compensatory capacity of the residual renal function in small solute clearance.
Conclusions: Consequently, estimated glomerular filtration rate was turned out to be a more stable parameter than total creatinine clearance, which might be a desirable feature in long-term follow-up of peritoneal dialysis patients.

Objective: A direct renin-inhibitor (DRI), aliskiren, was administered to anuric patients to investigate whether it can be a new optional therapy against hypertension in hemodialysis (HD) patients. Patients: The patients that received aliskiren comprised 8 males and 2 females with a mean ± SD age of 63 ± 8 years (43-72 years). They were exposed to dialysis therapy for 118 ± 73 months (8-251 months), with diabetes mellitus in 4 cases, chronic glomerulonephritis in 4 cases, and other diagnoses in 2 cases. Methods: After the plasma renin activity (PRA) and plasma aldosterone concentration (PAC) were measured before an HD session, aliskiren, 150 mg as an initial dose, was administered to the patients. PRA and PAC were also examined a week after initiating aliskiren. The blood pressure (BP) levels at the start of each HD session for a period of 2 weeks (6 HD sessions) were compared between before and after administration of aliskiren. The change of doses in other antihypertensive agents was also counted. Results: The averaged reduction of mean blood pressure was 4 ± 5 mmHg, and doses of antihypertensives other than aliskiren were reduced in 4 patients. Of the examined parameters, only the reduction rate of PRA x PAC seemed correlated with the BP lowering effect of aliskiren, which was calculated as the sum of the mean BP reduction in mmHg and drug reduction with 1 tablet (capsule)/day considered to be 10 mmHg. Conclusion: A DRI, aliskiren, was effective even in anuric dialysis patients, and monitoring of PRA and PAC was valuable for selecting cases responsive to aliskiren.

Objective: Since the conventional drip-infusion method for measuring inulin clearance (Cin) has problems related to its accuracy and performance, we explored a more accurate and concise method by rapid intravenous injection of a newly developed inulin fraction (Inulead^®), in which spot urine sampling was omitted and the administration period of inulin was shortened from 120 to 5 minutes. Patients and Methods: Twenty seven patients (M/F: 15/12, 67.8 ± 12.9 years old) admitted to the Nephrology ward were enrolled in this study. Inulead^®, 1500 mg dissolved in 150 mL of saline, was intravenously administered in 5 minutes. Then, sequential blood samplings and urine collection were performed for 24 hours. Cins were calculated by the following three formulae: (1) a pharmacokinetic analysis using a two compartments model based on the plasma inulin concentration to determine Cin, which was the administered dose divided by the area under the curve (AUC) from 0 to ∞, (2) urinary inulin excretion divided by the AUC for 24 hours and (3) the Bayesian method using a three-point set of plasma inulin concentrations to predict the change of inulin concentration to determine Cin as in 1. These Cins were compared with levels of estimated GFR (eGFR), creatinine clearance (Ccr), serum β2 microglobulin (β2MG) and serum cystatin C (Cys C). Results: Cins obtained by the above three methods were well correlated with each other (r. = 0.9088 – 0.9998) and with eGFR (r. = 0.8286 – 0.8650), Ccr (r. = 0.821 – 0.864), 1/β2MG (r. = 0.631 –0.752) and 1/CysC (r. = 0.830 – 0.857). The averaged differences of each Cin from eGFR were distributed between –4.4 and –4.5 mL/min. Conclusion: Since the Cins by rapid inulin injection showed satisfactory correlation and differences with other GFR parameters, this method will be a good alternative to the drip infusion method, and may reduce the burden of patients and medical staff.

  The number of dialysis patients in Japan is increasing every year. The medical expense for dialysis patients has now surpassed well over 7 per cent of all medical costs. This has become a great burden on national finance. The D3-30 project was started in April 2006 for Toride city residents. The purpose of this project was a 30% reduction of the yearly number of new dialysis patients in three years. Toride city is located in southern Ibaraki prefecture; it had a population of 112, 152 in fiscal 2006, and 19% of the residents were over 65 years of age. The treatment procedure for chronic kidney disease (CKD) patients at the predialysis stage comprised the following four parts: 1. control of blood pressure, 2. mild restiction of protein and sodium intake, 3. administration of antiproteinuric drugs (angiotensin receptor blocker, angiotensin converting enzyme inhibitor, some calcium channel blocker, etc.), and 4. multifactorial treatment.  CKD patients were recruited through introductions from hospital registered doctors and public health nurses. Some patients entered voluntarily. The number of patients that started dialysis was counted by inquiring at the dialysis center of Toride Kyodo General Hospital and eighteen neighboring dialysis centers. In 2005, before intervention, 36 patients started dialysis; subsequently, the number of patients was 30 in 2006, 33 in 2007, 22 in 2008, and 23 in 2009. The rate of decrease was 39% in 2008 and, 36% in 2009, so the aim of the project was achieved.  If this treatment becomes widespread, it will contribute greatly to the curtailment of medical expenses. However, the difficulty of the treatment may hamper its spread. For it to spread, it is necessary to add the new medical fee for guidance and management for CKD patients.

Non-tubercuous mycobacterial (NTM) infection in peritoneal dialysis (PD) patients has been rarely reported. We report a case of a 55-year-old female on continuous ambulatory peritoneal dialysis (CAPD). After a 2-year-history of recurrent exit-site infection of a PD catheter caused by Mycobacterium abscessus (M. abscessus), the patient was admitted to the hospital with signs of peritonitis. Since the same species, M. abscessus, was isolated from the CAPD effluent, multiple antibiotics were administered. However, the treatments could not relieve the symptoms of her infection. Consequently, the PD catheter was removed. Her condition gradually recovered over the course of subsequent, long-term, empirical antimicrobial therapies. NTMs, especially a rapidly growing NTM infection, have rarely been reported in PD patients and are commonly resistant to a variety of antimicrobial agents. Routine acid-fast staining is most likely helpful in promptly initiating treatment against NTM infection in PD patients. Moreover, an appropriate treatment regimen for a rapidly growing NTM infection should be established by accumulating data from cases as reported here.
Infection as complication of medical care ; PUPILLARY DISTANCE ; Peritoneal Dialysis, Continuous Ambulatory ; Peritonitis ; Patients

Current ; Kidney Diseases ; Japan

Safety management in routine medical practice is one of the important issues that must be addressed by medical staffs, even it is hard to deal with various happenings and problems encountered in medical facilities.Here we present some arrangements in a reporting system of incidents and accidents to motivate each staffer to notice the significance of safely, and quantify the urgency and severity of reports using the originally developed management score at the Toride Kyodo General Hospital.The reports from all sections of the hospital were previously evaluated by five risk managers. This practice was effective in analyzing reports rapidly and appropriately, but was insufficient to motivate all of staffs to give much more heed to safety in routine medical practice. Instead, these reports are now discussed and analyzed by a group of people consiting of representatives of all sections and the departments in the hospital. This innovation evoked more interest and concerns about the safety management among the whole medical staff.We also utilized the management level, which was stratified into three grades from the point of urgency and severity of cases. The first level means the occurrence without urgency or need to change any systems, procedures and organizations. The second level requires some change in systems, but no urgent action. The accident at the third level should be dealt with as soon as possible by any of feasible ways. The total score, obtained by summing up a lisk level multiplied by a management level in each report, decreased between May and August in 2004, despite increases in the total numbers of monthly reports.In conclusion, the incident/accident reporting system became more familiar to medical staffs through the use of group-working. The management score and the derived total score may be available for comparing outcomes of safety management activities among different observation periods or facilities.
Reporting ; Safety ; Accidents ; Analysis ; Management

Dialysis therapies are generally considered to be contraindications in cases with non-curative malignancies. Here we report two cases in which peritoneal dialysis was undertaken to reduce malignancy-related symptoms like abdominal full sensation and anorexia as well as to eliminate uremic toxins. The first case was a 61year-old male with peritonitis carcinomatosa and its related ascites disseminated from pancreas tail cancer. His renal function deteriorated after initiating chemotherapy using 1,000mg/m² of gemcitabine (GEM), and dialysis was required to improve his uremic symptoms. The second case was an 81year-old male who had been receiving maintenance HD therapy for 8years at another clinic. He had been complaining of abdominal distension derived from ascites and had multiple liver tumors of unknown origin. Since the main complaint in these two cases was unbearable abdominal full sensation, continuous ambulatory peritoneal dialysis (CAPD) was initiated to simultaneously control uremia and to relieve the abdominal distension. CAPD was successful in reducing ascites and in controlling the uremia as well as general symptoms. Consequently, we propose “PD terminal” as the rescue treatment for uremic patients with massively retained ascites related to malignancies.
Ascites ; Therapeutic procedure ; Malignant Neoplasms ; PUPILLARY DISTANCE ; symptoms <1>

There is such an opinion that low protein diet (LPD) is unnecessary for preventing progression of renal insufficiency in chronic kidney disease (CKD). However, three randomized control trials of nondiabetic nephropathy (NDN) with CKD, using a metaanalysis method, revealed the usefulness of LPD in preventing progression of renal insufficiency. It is thought that the usefulness of LPD may increase further, if we evaluate randomized control trials one by one and select only what has high quality.
WHO/FAO recommended 0.8 g/kg/day of daily protein intake (DPI) to healthy people from a viewpoint of illness prevention 30 years ago. As, in advanced nations, DPI is 1.1 to 1.3 kg/day/kg in every country, DPI of CKD will become the same level of healthy people if not regulated. It cannot be considered at all that protein restriction is not required for CKD who is more susceptive to cardiovascular diseases than healthy poeple.
In conclusion, we should monitor DPI of patients with CKD, and control DPI between 0.6 and 0.8 g/kg/day. Under the restriction of DPI, we should manage NDN with CKD to prevent progression of renal insufficiency by controlling blood pressure, suppressing rennin-angiotensin system, compensating acidosis and correcting renal anemia.