It has been reported that sevelamer hydrochloride, which is often used as a polymer phosphorus (P) binder for managing serum P concentration in dialysis patients, causes gastrointestinal adverse effects such as constipation, etc. The reason for this is thought to be that sevelamer hydrochloride has high water absorption, causing it to absorb water and swell in the gastrointestinal tract. In June 2012, the new polymer P binder bixalomer was launched in Japan. Since bixalomer has low swelling due to water absorption, it can be expected to alleviate adverse effects in the gastrointestinal system. In our study, for 21 cases of maintenance hemodialysis patients undergoing treatment with sevelamer hydrochloride at our hospital, the P binder was switched from sevelamer hydrochloride to the same dosage of bixalomer, and the concentrations of serum P, corrected calcium (Ca) and whole parathyroid hormone (PTH) before and one month after the switch were compared. In addition, gastrointestinal symptoms (acid reflux, abdominal pain, indigestion, diarrhea and constipation) were evaluated before and after the switch using a questionnaire based on the Japanese version of the Gastrointestinal Symptom Rating Scale (GSRS). By switching to bixalomer, serum P concentration was significantly reduced (P=0.024), but there were no significant changes observed for serum corrected Ca and whole PTH. Furthermore, there were no significant changes observed for all five of the evaluation items of the GSRS, before and after the switch. These results suggest that although bixalomer can more potently reduce the serum P concentration than sevelamer hydrochloride, there were no significant differences in the effects of both P binders on the gastrointestinal symptoms.

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Keywords： adrenal insufficiency, isolated ACTH deficiency, hypercalcemia, vitamin D analogue, hemodialysis 〈Abstract〉 A 62 year old male, who had been undergoing hemodialysis for 19 years and 3 months, experienced a loss of appetite and diarrhea for one month. He developed a fever and low blood pressure during dialysis and was admitted to our hospital, Saitama Sekishinkai Hospital. Hypercalcemia (corrected calcium＝11.8 mg/dL), hypoglycemia, and eosinophilia were observed. He stopped taking precipitated calcium carbonate and maxacalcitol (a vitamin D derivative) and was administered antibiotics due to a suspected infection. The antibiotics did not alleviate his symptoms, and there was no improvement in his laboratory test results. A subsequent examination revealed that his serum basal cortisol (0.4 µg/dL) and adrenocorticotropic hormone ( ＜1.5 pg/mL) levels were low, which resulted in him being diagnosed with secondary adrenal insufficiency. He was treated with hydrocortisone, after which his symptoms, hypercalcemia, hypoglycemia, and eosinophilia were ameliorated. Calcium containing phosphate binders and vitamin D analogues are often used for the management of chronic kidney disease mineral bone disorder in patients undergoing long term hemodialysis. We eventually diagnosed our patient with adrenal insufficiency, after excluding iatrogenic hypercalcemia.

Purpose To determine the location of coronary atherosclerosis distribution observed in patients with chronic kidney disease (CKD). Methods A cross-sectional study was conducted using the database of cardiovascular medicine data from Saitama Sekishinkai Hospital to clarify the association between renal function and angiographic characteristics of coronary atherosclerosis. In total, 3268 patients who underwent percutaneous coronary intervention were included. Propensity score matching revised the total to 1772. The association of renal function with the location and/or distribution of coronary atherosclerosis lesions was then examined. Results Overall, coronary lesion was observed in the left anterior descending coronary artery (LAD) in 56% patients, whereas 28% and 22% were in the right coronary artery (RCA) and left circumflex coronary artery (LCX), respectively. LAD was most affected and observed in 57% patients with stage 1 CKD. RCA was second-most affected, at 26% CKD stage 1, but it increased to 31%, 38%, and 59% in CKD 3, 4, and 5, respectively. In CKD 5 patients, the RCA was the most affected artery (59%), with 41% LAD lesions. Logistic regression analysis after propensity score matching showed that the odds ratios for an RCA lesion was 3.658 in CKD 5 ( p = .025) compared with CKD 1 after adjusting for traditional risk factors. Conclusion The prevalence of RCA lesions, but not LAD or LCX lesions, increased with increasing CKD stage. The pathophysiology of coronary atherosclerosis may differ by lesion location. Deterioration of renal function may affect progression of atherosclerosis more in the RCA than in the LAD or LCX.