It is well known that the prognosis is relatively good in patients on dialysis for end-stage renal disease with renal cell carcinoma (RCC). In patients on long-term dialysis, especially those with a history of more than twenty years, however, it is uncertain whether similar results could be obtained. To investigate tumor characteristics in long-term hemodialysis patients, we retrospectively examined the histopathological findings and prognose of 125 hemodialysis patients who underwent radical nephrectomy for RCC at our hospital between 1982 and 2004. Patients were divided into two groups ; (1) patients who received dialysis for 3 to 20 years before surgery (group 1, N=92) and (2) patients who received dialysis for more than 20 years before surgery (group 2, N=33). Acquired renal cystic disease was found in all group 2 patients. The cancer grade was significantly higher in group 2 than in group 1 (group 1 with cancer grade 3 : 5.4% vs group 2 with cancer grade 3 : 21.2%, p=0.01). Furthermore, the clinical tumor stage was also higher in group 2 than in group 1 (group 1 with stage III+IV : 19.6% vs group 2 with stage III+IV : 30.3%). There was no significant difference in overall 5-year patient survival between the two groups (group 1 : 70.4% vs group 2 : 68.2%). In contrast, cancer-specific 5-year patient survival was significantly lower in group 2 than in group 1 (group 1 : 91.9% vs group 2 : 68.2%, p<0.001). On multivariate analysis, long-term hemodialysis (≥20 years), cancer grade (grade 3), and clinical tumor stage (stage III+IV) showed a significant correlation with cancer-specific death (relative risks were 3.34, 5.14, and 16.55, respectively). Our study suggests that long-term hemodialysis (≥20 years) itself has a negative impact on prognosis in patients on dialysis who develop RCC.

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We manufactured a new device, a belt equipped with an alarm, to facilitate monitoring of patients in danger of or with a history of intentional self-removal of the needle during hemodialysis. The device, a belt integrated with an alarm, is wound gently around the wrist of the patient after fixing the blood tube. The fixation system of the belt has two steps using a Velcro and snap fastener. When the snap fastener is detached, an alarm system is tripped.
We evaluated the clinical efficacy of this device during hemodialysis for an 86 year-old male patient with a slight degree of dementia, memory disturbances and disorientation. The patient had a history of intentional self-removal of the needle during dialysis twice before.
The warning system was activated 20 times, when the patient tried to detach the device, and 5 times after the snap fastener was detached during 11 hemodialysis sessions using the device. We compared the effects of the device in preventing self-removal of the needle with those using a conventional hemostasis belt without an alarm as a control. Such patients are at risk of severe accident during self-removal of the needle if medical staff detect the action too late. Because the device activates an alarm before the belt is detached by the patient, it increases the safety more than the conventional belt.
In conclusion, the device can be easily attached to the patient and is a useful method of preventing intentional self-removal of the needle during dialysis.

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We describe a 38-y-old female with chronic renal failure who was diagnosed with thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS), and thereafter developed posterior reversible encephalopathy syndrome (PRES). She was admitted to our hospital because of high fever and a neck lymphnode swelling. After the infection, she demonstrated five typical signs of TTP except neurological abnormalities, that is, high fever, severe thrombocytopenia, hemolytic anemia and renal failure. Therefore, we initiated plasma exchange with steroid therapy for TTP. Shortly after blood transfusion for severe hemolytic anemia, she was complicated by accelerated high blood pressure and epilepsy. Plasma exchange therapy was performed 29 times till these symptoms of TTP/HUS were controlled. Reversible findings on brain magnetic resonance imaging (MRI) as well as the reversible neurological signs were consistent with PRES.
Blood transfusion may have contributed to the pathogenesis of PRES through altered vascular dynamics.

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A 54-year-old patient on chronic hemodialysis was admitted to our hospital because of respiratory distress and pancytopenia. Laboratory data and radiographic examinations suggested acute lung injury and disseminated intravascular coagulation due to hemophagocytic syndrome (HPS). However, there were no causative pathogens detected by serological tests or cultures of blood, sputa and pleural effusion. Further testing by bone marrow examination showed hemophagocytotic cells, non-caseating granuloma formations and positive acidbacilli staining, which were highly suggestive of mycobacterium infection. The final diagnosis was determined as miliary tuberculosis by PCR and immune chromatography of bone marrow aspirate, and positive bronchoalveolar lavage fluid culture. Although tuberculosis still remains a life-threatening infectious disease for chronic hemodialysis patients, diagnosis is often difficult because atypical presentations such as extrapulmonary involvement are not uncommon. Tuberculosis should be considered early in the differential diagnosis of infectious aetiologies associated with HPS, since appropriate treatment can cure the disease.

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The patient was a 71-year-old woman who started hemodialysis on July 5, 2002.
Around the same time, she developed black stool and severe anemia was detected (Hb 4.2 g/dL). She had no etiology for bleeding identified on routine endoscopy of the upper and lower gastrointestinal tracts. Between initiation of hemodialysis and February 2005, she had four episodes of gastrointestinal bleeding that required blood transfusion support. The source of bleeding could not be identified by conventional radiological or endoscopic evaluation. Since we suspected small bowel bleeding, Wireless capsule endoscopy was performed. Unfortunately the source of bleeding was not identified. During hospital stay (Department of Ophthalmology) on July 22, 2005, she developed hypotension during hemodialysis. Severe anemia and black stool were detected. After blood transfusion support, she underwent double-balloon endoscopy which showed red spots at the middle portion of the jejunum. We considered these lesions to be angiodysplasia or solitary varix. The lesions disappeared without treatment. After prescription of carbazochrome sodium sulfonate, there were no further episodes of gastrointestinal bleeding.

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