Cryofiltration (CF) is a technique in which separated plasma is chilled before being subjected to a plasma fractionator (PF), leading to cryoglobulin precipitation or cryogel formation. In CF using ...the Evaflux‐5A as the PF, there is no consensus on the necessity of albumin supplementation, and when or how often the PF column should be washed. We analyzed the sieving effects of various solutes (albumin, IgG, IgM, LDL, HCV‐RNA, and cryoglobulin) depending on transmembrane pressure (TMPPF) during CF using the Evaflux‐5A in a patient with hepatitis C virus‐associated cryoglobulinemic glomerulonephritis. Five CF treatments were initially performed and a sixth one later, at disease recurrence. Quantitative detection of cryoglobulin and a marked rise in TMPPF to 400 mm Hg were observed only at the first and sixth treatment, and albumin losses during these treatments were very high, at 16.8 g, and 14.6 g, respectively, while those of others (from the second to fifth) were 6.7 g, 6.4 g, 5.9 g, and 7.0 g, respectively. The sieving coefficients (SCs) of both albumin and IgG were stable (0.8–1.0) at TMPPF < 200 mm Hg, but significantly decreased at TMPPF ≥ 200 mm Hg (P < 0.01). The SC of IgM tended to decrease at TMPPF ≥ 200 mm Hg, but not significantly, while that of LDL was zero regardless of the TMPPF. Albumin loss per treatment likely depends on degree of TMPPF rise, which is mainly affected by the patient's cryoglobulinemic status. In CF using Evaflux‐5A, washing the PF column to keep TMPPF < 200 mm Hg during treatment may be a recommended for selective removal and albumin salvage.
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•A novel organic–inorganic hybrid layered aluminosilicate KCS-11 has been obtained.•It inhales ethanol vapor in its interlayer like breathing even at a low pressure.•Its interlayer ...shows strong affinity selectively to amphiphilic guest molecules.•This material can even extract ethanol from the aqueous solution.
A novel crystalline organic–inorganic hybrid aluminosilicate material was successfully synthesized using methyltrimethoxysilane as a silicon source. Ab initio crystal structure analysis using powder X-ray diffraction data elucidated that this material was composed of the ordered stacking of layered aluminosilicates similar to sodalite-type zeolites and that methyl groups bonded to silicon atoms were arrayed on the inner surface of the interlayer. This material selectively inhaled amphiphilic molecules such as alcohols to open its interlayer distance. It could even breathe ethanol vapor at quite a low pressure and extract ethanol from the aqueous solution.
Routine examination of bone mineral density(BMD)by DXA(dual energy X-ray absorptiometry)is useful to predict bone fracture in both CKD nondialysis and dialysis patients. The cutoff value of BMD to ...predict bone fracture is different between genders and its predictive power is better in patients with lower serum PTH levels than higher counterpart. Increase in serum bone specific alkaline phosphatase is a better predictor of the bone fracture than serum PTH levels.
Introduction
Anemia is a common complication of patients with chronic kidney disease (CKD), which not only lowers their quality of life but also potentially causes cardiovascular diseases such as ...congestive heart failure and coronary heart disease, and accelerates the progression of renal dysfunction.
Methods
Pre-dialysis patients were assigned to groups A, B, C or D based on hemoglobin levels of ≤8.9 (
n
= 48), 9.0–9.9 (
n
= 63), 10–10.9 (
n
= 53), and ≥11.0 g/dL (
n
= 39), respectively. Cardiac function was estimated using echocardiography to clarify the relationship between anemia and cardiac disorders in patients with CKD immediately before starting hemodialysis.
Results
Left ventricular ejection fraction (LVEF) was significantly higher in group D than in groups A and B. The fractions with an LVEF of less than 50% were 16.7, 4.8, 1.9, and 0% in groups A, B, C, and D, respectively. Posterior wall thickness was statistically thicker and the deceleration time of the early diastolic wave was longer in groups A and B, respectively, than in groups C and D. The left ventricular mass index in group D was significantly lower than in any other groups.
Conclusion
Anemia in pre-dialysis patients with CKD is a probable cause of impaired left ventricular systolic function and progressive left ventricular hypertrophy. Our results suggest that Hb levels should be maintained at >11 g/dL by EPO administration from the perspective of protecting cardiac function, although the upper limit of the target Hb level was undetermined.
A 77-year-old man was admitted to our hospital for a right femoral neck fracture. He had been prescribed lamivudine for chronic hepatitis B infection for 11 years, and adefovir was added 5 years ago. ...After hospitalization, a right femoral head prosthesis was performed successfully, but an unknown hypokalemia was revealed. Hypophosphatemia, hypouricemia, glucosuria, and panaminoaciduria were also revealed, and multiple microfractures were detected by bone scintigraphy. We diagnosed him as ‘osteomalacia associated with Fanconi syndrome,’ which was likely due to the adefovir. Moreover, a monoclonal IgG-kappa and a kappa Bence-Jones protein were detected in his serum and urine, respectively. We switched from adefovir plus lamivudine to entecavir and started calcitriol. His excessive urinary β2-microglobulin excretion and glucosuria had decreased dramatically at 10 weeks after the modification of drugs; those of the phosphate, uric acid and total protein, however, continued. Renal biopsy specimens obtained at 10 weeks after discontinuation of adefovir revealed focal tubular atrophic changes with/without inflammatory cells, which were predominantly observed next to glomeruli. Kappa-dominant staining was not observed in either glomeruli or tubules with immunostaining by the enzyme-labeled antibody method. Electron microscopy revealed neither crystalline structures in the cytoplasm of proximal tubules nor electron-dense deposits. Because of the remarkable proportional reduction of other urinary protein fractions, urinary M-peak appeared 26 weeks after discontinuation of adefovir, but the net amounts of the fraction decreased gradually.
Abstract Background and Aims Renin-angiotensin-aldosterone system inhibitors (RAASi) are well-established renoprotective agents, but can induce serum potassium (K) elevation and metabolic acidosis ...(MA). MA contributes to the progression of chronic kidney disease (CKD), thus the renoprotective potential of RAASi is unknown in advanced CKD with MA due to the use of RAASi. MA with elevated serum K may discourage the use of RAASi. In highly advanced CKD, besides factors such as age, proteinuria, and diabetes, it is still debatable under what conditions the continued use of RAASi is favorable for renal prognosis. Furthermore, no studies have focused on the relationship between the response to alkalizing therapy for MA and renal prognosis in advanced CKD with MA and serum K elevation under RAASi use. Method In this single-center retrospective observational study, CKDG4 or G5 outpatients with MA (HCO3− < 22 mM) and elevated K (serum K≥5.0 mEq/L) at our center and who had started alkalinizing therapy (i.e., sodium bicarbonate and/or low-dose trichlormethiazide plus fludrocortisone) for MA were included. A total of 45 patients were selected, excluding those who had already been prepared for renal replacement therapy at the start of treatment. The RAASi group (Ri group, N = 39) and the non-RAASi group (non-Ri group, N = 16) were divided by the presence or absence of continued RAASi use prior to alkalizing therapy for MA, and the two groups were followed and compared up to 2 years after treatment. Background factors including age, sex, cause of CKD, estimated glomerular filtration rate (eGFR), CKD stage, diabetes, urinary protein (g/gCr), serum K/ HCO3−/Na/CL/albumin/phosphate, hemoglobin levels, and the use of K binders, diuretics were investigated. The endpoints were rapid response to alkalizing therapy (i.e., changes in serum HCO3−, K, Na-CL levels 2 months after the start of alkalinizing therapy, and percentage of patients achieving HCO3− ≥22 mM at 2 months after the start of alkalizing therapy) and incidence of renal events (>30% reduction in eGFR or renal replacement therapy). Results In all 45 subjects, the mean age was 71.3±11.8 years, 84% were male, mean eGFR was 18.3 ± 5.6 mL/min/1.73 m2, G4 67%/G5 33%, primary disease was diabetic nephropathy 31%, nephrosclerosis 40%, K binders and diuretics use was 25% and 24%, respectively. Mean serum HCO3− was 17.9 ± 2.3 mM and mean serum K was 5.5 ± 0.4 mEq/L. Comparison of background factors showed no significant difference between the two groups. The changes in serum K, HCO3−, Na-CL 2 months after the start of alkalinizing therapy and the percentage of patients achieving HCO3− ≥22 mM after 2 months of starting alkalizing therapy did not differ at all between the Ri and non-Ri groups (Table 1). Cumulative renal survival (non-renal events) was significantly higher in the Ri group than in the non-Ri group(p = 0.010) (Figure 1). None of the rapid responses to alkalizing therapy (i.e., changes in serumHCO3−, K, Na-CL, and the percentage of patients achieving HCO3− ≥22 mM) were significantly associated with cumulative renal survival (p = 0.186, p = 0.266, p = 0.65, p = 0.114). In a Cox proportional hazards multivariate model adjusted for age, sex, eGFR, cause of CKD, diabetes, urinary protein(g/gCr), method of alkalizing therapy, and rapid response to alkalizing therapy, the risk of renal events without RAASi use was significantly higher (Table 2). Conclusion In CKDG4/5 with MA with elevated serum K under RAASi use, renal function declines more slowly than with non-RAASi use, ensuring a rapid response to alkalizing therapy for MA.
Abstract Background and Aims Advanced chronic kidney disease (CKD) is often complicated by metabolic acidosis(MA) with elevated serum potassium(K). MA is a risk factor for CKD progression, and ...elevated serum K forces dietary K restriction, which is also undesirable in CKD, stalling the use and escalation of renin-angiotensin-aldosterone system inhibitors (RAASi). Sodium bicarbonate(SB) and K binders, which are not well tolerated due to gastrointestinal symptoms, are often used to correct MA and hyperkalemia. On the other hand, the concurrent use of thiazide and fludrocortisone to promote urinary excretion of K and hydrogen ions has been reported in the type IV renal tubular acidosis, but its efficacy and safety in advanced CKD is unclear. Method This single-center, retrospective, observational study included CKDG3b-G5 outpatients with MA(HCO3−<22 mM) and elevated K (serum K≥ 5.0 mEq/L) at our center. A total of 59 patients were selected, excluding those who had already been prepared for renal replacement therapy at the start of treatment. Patients who continued to receive trichlormethiazide (1 mg, at 1-3 day intervals) plus fludrocortisone (0.1 mg, at 1-3 day intervals) (low-T/F group, N = 10) or SB(0.5 g-5 g/day) alone (SB group, N = 49) were followed up until 2 years after the start of treatment and the two groups were compared. Background factors including age, sex, cause of CKD, estimated glomerular filtration rate (eGFR), CKD stage, urinary protein(g/gCr),serum K/ HCO3−/Na/CL/albumin/phosphate, hemoglobin levels, and the use of RAASi/K binders/diuretics were investigated. Efficacy and safety comparisons between the two groups were evaluated based on changes in serum HCO3−and K levels before and after starting of treatment (at 2, 6, 12, 18, and 24 months), percentage of patients achieving HCO3− ≥22 mM, change in eGFR, incidence of renal events (>30% reduction in eGFR or renal replacement therapy), the incidence of cardiovascular events, and the incidence of treatment-modified events such as initiation or increase of antihypertensive, K-binding, and uric acid-lowering agents. Results In all 59 subjects, the mean age was 72.0±11.7 years, 81% were male, mean eGFR was 19.6 ± 7.2 mL/min/1.73 m2, CKDG4/5 account for 92% (G4 60%/G5 32%), primary disease was diabetic nephropathy 30%, nephrosclerosis 43%, RAASi use 68%, mean K was 5.5 ± 0.4 mEq/L and mean HCO3− was 18.1 ± 2.2 mM. The low-T/F group consisted of patients who switched due to prior SB intolerance or in whom SB was ineffective, and included 5 patients who received concomitant SB. Comparison of background factors showed no significant difference between the two groups. The changes in the serum HCO3− and K levels 2 months after starting the treatment were significantly larger in the low-T/F group compared with the SB group (Kafter - Kbefore (mEq/L):median −1.2, IQR-1.6 to −0.48 vs −0.57, −0.80 to −0.10, p = 0.036; {Kafter -Kbefore}×100/Kbefore(%): median −20.3, IQR −26.4 to −9.2 vs −9.3, −14.8 to −1.85, p = 0.032; HCO3−after-HCO3−before (mM):median +5.2, IQR +3.75 to +8.23 vs +3.2, +1.7 to +5.1, p = 0.022) . The percentage of patients achieving HCO3− ≥22 mM at 2 months after treatment was significantly higher in the low-T/F group at 88.9% (SB group 38.8%, p = 0.007). There were no renal events in the low-T/F group, and cumulative renal survival (no renal events) tended to be higher in the low-T/F group than in the SB group in the all conditions such as unadjusted condition, presence of RAASi, CKDG4/5 and matched for age, sex, primary cause of CKD and eGFR (p = 0.06, p = 0.265, p = 0.16, p = 0.14, respectively) (Figure). In patients with no renal events, the low-T/F group had a significantly better mean eGFR change of +4.2% at 6 months (SB group: −11.0%, p = 0.019). There were also no cardiovascular events in the low-T/F group, and there were no significant differences between the two groups in either cardiovascular events or treatment-modified events (Table). Conclusion Even in advanced CKD, the low-dose combination of thiazide and fludrocortisone can rapidly improve K-elevating MA and continue without adverse renal or cardiovascular outcomes.
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