日本人血液透析患者におけるProtein-Energy Wasting（PEW）と高リン血症が予後に及ぼす影響 : 5年間の観察研究

Background & aims: In dialysis patients, malnutrition is a poor prognostic factor. In patients with chronic kidney disease (CKD), malnutrition is qualitatively different from general malnutrition, which is defined as “Protein-Energy Wasting (PEW).” Dietary therapy for the enhancement of PEW requires the aggressive intake of protein. Conversely, as protein intake and phosphorus intake correlate positively, increasing the protein intake increases the phosphorus intake, which is a poor prognostic factor in dialysis patients. One of the treatments for hyperphosphatemia in dialysis patients is the intake restriction of phosphorus by dietary counseling. However, protein uptake to maintain and augment the nutritional status and the protein intake restriction to correct hyperphosphatemia are contradictory treatments. Hence, this study aims to investigate the effects of PEW and hyperphosphatemia on the prognosis in hemodialysis patients. Methods: We enrolled 60 outpatients who underwent maintenance hemodialysis for 6 months (May–November 2012) at Iga City General Hospital (Mie, Japan). In November 2012, we assessed the presence or absence of PEW and hyperphosphatemia in patients and evaluated the survival rate over the next 5 years. Results: Overall, 10 patients (17%) were diagnosed as PEW. While 17 patients (28%) exhibited average phosphorus level >6.0 mg/dL (hyperphosphatemia). The 5-year survival rate was 30% in the PEW group, 66% in the non-PEW group, 57% in the hyperphosphatemia group, and 61% in the non-hyperphosphatemia group. A statistically significant difference existed between the PEW and non-PEW groups (P = 0.021). However, we observed no significant difference between the hyperphosphatemia and non-hyperphosphatemia groups. Conclusions: This study suggests that PEW affects the prognosis more than hyperphosphatemia in maintenance hemodialysis patients. The normalization of the serum phosphorus level by the protein intake restriction could prevent secondary hyperparathyroidism and vascular calcification. Conversely, restricting the protein intake poses a risk of malnutrition. In fact, early death occurred in patients with PEW in this study. Perhaps, patients with PEW should prioritize improving their nutritional status rather than controlling the serum phosphorus level

日本维持性血液透析患者蛋白质能量消耗的患病率和诊断标准评估

Background and Objectives: The International Society of Renal Nutrition and Metabolism (ISRNM) has recently recommended the use of the term “protein-energy wasting” (PEW). PEW is a state of malnutrition with decreased body stores of protein and energy fuel in hemodialysis patients and is known as a risk factor for morbidity and mortality. We examined the prevalence of PEW and the characteristics of PEW patients in a hemodialysis center in Japan. Methods and Study Design: Fifty-nine outpatients undergoing maintenance hemodialysis at Iga City General Hospital were evaluated. We observed their biochemical data, body composition, dietary intake, and the number of steps prospectively. PEW was defined according to ISRNM criteria. Results: Nine patients (15% of total) were diagnosed as having PEW. Among indicators of PEW criteria, the relevance ratios of “reduced muscle mass” and “unintentional low dietary energy intake” were significantly higher in PEW than in non-PEW. The number of steps was lower, and serum levels of glucose and C-reactive protein were higher in PEW. Conclusion: About 15% of Japanese hemodialysis patients are estimated to have PEW. Our results suggested that major contributing factors to PEW were reduced muscle mass, unintentional low dietary energy intake, lower amount of exercise, insulin resistance, and chronic inflammation.背景与目的：国际肾营养与代谢协会（ISRNM）最近推荐使用术语“蛋白质能量消耗（PEW）”。PEW 是血液透析患者体内蛋白质和能量储存减少的一种营养不良状态，并且被认为是患病率和死亡率的危险因素。我们在日本的一个血液透析中心研究了PEW 的患病率和PEW 患者的特征。方法与研究设计：我们评估了58 名在伊贺市综合医院做维持性血液透析的门诊患者，并观察了他们的生化数据、体成分、膳食摄入量和行走的步数。根据ISRNM 标准诊断PEW。结果：9 名（占总数的15%）患者被诊断为PEW。在PEW 诊断标准指标中，PEW 患者“肌肉量减少”和“无意识的低膳食能量摄入”的比例高于非PEW 患者。PEW 患者中行走的步数较低，而血清葡萄糖和C-反应蛋白水平较高。结论：约有15%的日本血液透析患者患有PEW。我们的研究结果表明：引起PEW 的主要因素是肌肉量减少、无意识的低膳食能量摄入、运动量低、胰岛素抵抗和慢性炎症

Body fat mass is correlated with serum transthyretin levels in maintenance hemodialysis patients

Serum transthyretin (TTR), also known as prealbumin, is a reliable nutritional indicator and an independent prognostic factor for maintenance hemodialysis patients. However, we recently reported that serum TTR levels did not affect protein−energy wasting (PEW). In this study, we investigated factors affecting serum TTR levels in 60 maintenance hemodialysis patients. The patients were divided into High-TTR and Low-TTR groups according to the median serum TTR level. Albumin levels were significantly higher and C-reactive protein (CRP) levels were significantly lower in the High-TTR group than in the Low-TTR group. Although body fat mass was significantly higher in the High-TTR group than in the Low-TTR group, no significant difference in body fat ratio were observed. These findings suggest that body fat mass is related to serum TTR levels, apart from factors such as albumin and CRP levels, which showed correlations with serum TTR levels. Because body fat mass is related to better survival in maintenance hemodialysis patients, it may contribute to the prognostic value of serum TTR levels. In addition, in such patients, it may be important to evaluate body fatmass rather than body fat ratio and to maintain the minimum necessary body fat mass

Infliximab versus intravenous immunoglobulin for refractory Kawasaki disease: a phase 3, randomized, open-label, active-controlled, parallel-group, multicenter trial

Abstract We compared the efficacy and safety of infliximab with intravenous immunoglobulin (IVIG), a standard therapy, in a phase 3 trial (NCT01596335) for Japanese patients with Kawasaki disease (KD) showing persistent fever after initial IVIG. Patients with initial IVIG-refractory KD, aged 1–10 years, received a single dose of IV infliximab 5 mg/kg or IV polyethylene glycol-treated human immunoglobulin (VGIH) 2 g/kg on day 0. Primary outcome was defervescence rate within 48 h after the start of treatment. Safety was evaluated through day 56. Overall, 31 patients were randomized (infliximab, n = 16; VGIH, n = 15); 31.3% and 60.0% patients discontinued due to worsening KD. Defervescence rate within 48 h was greater with infliximab (76.7%) than VGIH (37.0%) (p = 0.023), and defervescence was achieved earlier with infliximab (p = 0.0072). Coronary artery lesions occurred in 1 (6.3%) and 3 (20.0%) patients receiving infliximab and VGIH, respectively, up to day 21. Adverse events occurred in 15 (93.8%) and 15 (100.0%) patients in the infliximab and VGIH groups, respectively. No serious adverse events in the infliximab group and one in the VGIH group were observed. Infliximab improved the defervescence rate within 48 h and time to defervescence versus standard therapy, and was well tolerated in patients with IVIG-refractory KD

フライアッシュ高含有ポーラスコンクリートパネルを用いた能登半島での藻場造成の検討: 輪島市名舟漁港におけるフィールド実験

金沢大学理工研究域機械工学系普通コンクリートパネルやフライアッシュ (FA) を活用したFA高含有ポーラスコンクリートパネルを取り付けた藻場造成材を用い, 能登半島において約4年間のフィールド実験を実施し, 褐藻カジメ属植物を主体とした藻場造成の可能性や課題について検討した。この結果, 4年後には藻場造成材上に14個体のカジメ属植物であるクロメが着生, 生長し, その半数が成熟した。クロメは普通コンクリートパネルよりもFA高含有ポーラスコンクリートパネルに多く着生する傾向があり, 最大24個体m-2の着生密度であった。クロメの着生数は, 藻場造成材の設置環境によって大きく異なり, 波浪等の環境条件が着生に強く影響すると推定された。さらに, 4年を経て藻場造成材にはマクサ等の小型海藻からクロメ等の大型褐藻まで多岐に及ぶ多様な海藻相が形成され, 植食動物による海藻の摂食も見られなかったことから, 能登半島における藻場造成の可能性が示唆された。We conducted a pilot-scale experiment for seaweed bed construction using concrete substrata with newly developed fly-ash (FA) porous concrete panels or conventional concrete panels from November 23, 2013 to October 14, 2017 in a coastal area of Noto Peninsula, Japan. The FA porous concrete panel was manufactured by replacing 20-40% of the cement with coal fly ash produced in a coal power plant. The total number of Ecklonia kurome sporophytes grown on two substrata after four years was 14. The erosion of central lamina began in the third year and the maturing of over 50% of E. kurome sporophytes was observed in the fourth year. A greater number of E. kurome sporophytes tended to grow on FA porous concrete panels than on normal concrete panels; the maximum density of E. kurome sporophytes attached to FA porous concrete panels was 24 individuals per square meter. The final number of E. kurome sporophytes largely differed among the sides of each substratum, which seemed to be strongly affected by waves. No grazing marks of herbivorous fishes and benthic animals were observed during the four years of growth monitoring. These results suggest that E. kurome bed construction using FA porous concrete panels in the coastal area of Noto Peninsula would be possible