Background : Dialysis patients have bleeding tendency and we sometimes encounter cases with a significant amount of spontaneous hemorrhage. Method and result : Between January 1987 and August 2007, 11 dialysis patients (9 men and 2 women) were diagnosed as having spontaneous bleeding on admission or during hospitalization. There were 13 events in these 11 patients ; 5 in the perirenal space, 3 in the lower extremities, 2 in the retroperitonium, 1 each in the abdominal cavity, omentum, and rectus abdominis. We did not include gastrointestinal, cerebrovascular, ophthalmic or vascular access-related hemorrhages. Ten patients were on hemodialysis, and 1 patient was on peritoneal dialysis. The average age and dialysis period were 59±12 (36～81) and 14±10 (5～32) years, respectively. Nine patients demonstrated chronic glomerulonephritis, whereas 2 were diagnosed as nephrosclerosis. Two patients used anti-platelet drugs, and 4 patients were under anticoagulant treatment. Eight patients had hypertension. Transcatheter arterial embolization was needed in 7 events, and surgical repair was performed in 1 event. The remaining 5 events were followed conservatively. Among these 11 patients 10 patients were discharged after recovery, but one patient died of myocardial infarction during hospitalization. Discussion : Spontaneous bleeding can be affected by factors such as platelet dysfunction, drug use and blood pressure. Spontaneous hemorrhage should be considered when acute anemia or hypotension is noted in dialysis patients.

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The effectiveness of renin-angiotensin system inhibitors (RA inhibitors) in chronic systolic heart failure (HF) was established. In dialysis therapy, an appropriate dry weight (DW) must be maintained, especially for HF patients. The numbers of diabetic patients have been increasing among patients starting dialysis. In diabetics, especially those with HF, blood pressure (BP) can be unstable during dialysis, which may make it difficult to maintain DW. RA inhibitors may be helpful in diabetic dialysis patients with chronic HF (CHF). RA inhibitors have not been sufficiently studied in dialysis patients, to date. We studied the effectiveness of RA inhibitors in diabetic CHF patients on maintenance dialysis therapy, with a left ventricular ejection fraction (LVEF) less than 50%. The cohort included seven male patients with an average age of 64.4±8.7 years and a BMI of 22.0±2.9 kg/m². The average duration of diabetes was 10.9±11.4 years, and HbA1c was 6.5±1.6%. Two patients used diet therapy ; four patients, oral hypoglycemic agents ; and one patient was treated with insulin. The average duration of dialysis was 49.7±44.3 months. Six patients had ischemic heart disease, and one patient had dilated cardiomyopathy. One patient was prescribed enalapril ; one, losartan ; three, valsartan ; and two, telmisartan. RA inhibitors were gradually increased to 82.1±24.9% of the target dose. Duration of treatment and observation was 12.6±8.8 months. DW increased from 57.6±7.6 to 61.5±8.3 kg after treatment. CTR decreased from 52.3±4.5 to 48.9±5.3%. LAD decreased from 45.7±6.4 to 39.7±6.7mm. LVDd decreased from 60.9±3.2 to 52.2±5.5 mm. LVEF showed a notable improvement from 39.8±8.0 to 55.0±8.6%. BP and pulse rate did not show any significant change. Following treatment with RA inhibitors, despite a DW increment, CTR decreased and LV function improved in diabetic dialysis patients with CHF.

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A 44-year-old male patient with tetralogy of Fallot (TOF) who had not undergone radical surgery, developed chronic renal failure that necessitated the initiation of hemodialysis. Cyanosis was observed in the patient three months after the birth. At seven months, he was diagnosed as having TOF. At the age of 17 years, ascending aorticopulmonary shunt surgery was performed. At the age of 41 years, laboratory data demonstrated an elevated serum creatinine level, and he was suspected of having chronic renal failure due to cyanotic nephropathy. At the age of 43 years, the patient caught a cold, followed by the appearance of generalized fatigue, oliguria and numbness of the feet. The BUN, serum creatinine and serum potassium levels were 10.1 mg/dL, 3.38 mg/dL and 8.0 mEq/L, respectively. Acute chronic renal failure was diagnosed based on these findings. Therefore, hemodialysis was performed three times. The patient subsequently showed diuresis, with improvement in his general condition. However, only 4 months later, he caught a cold again, followed by the development of oliguria, and edema of the legs and eyelids. Chest X-ray demonstrated massive pleural effusion, associated with hypoxia. The urinary volume failed to improve, despite the initiation of hemodialysis. However, the general condition improved and the patient was continued on stable maintenance hemodialysis. The rate of survival to 40 years of age in cases of TOF without radical surgery has been reported to be only 3%. In this article, we report a rare patient with TOF who survived until the age of 44 years without radical surgery. The subsequent clinical course of this patient was complicated by the development of chronic renal failure due to cyanotic nephropathy necessitating hemodialysis.

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Bone fractures occurred during treatment with long-term high-dose administration of etidronate (EHDP) in two hemodialysis patients, despite regression of giant ectopic soft tissue calcinosis. Case 1 : A 61-year-old woman with diabetes had undergone hemodialysis treatment since 1993. In 1997, she developed severe pain in the shoulders and pubic joint due to tumoral calcinosis. X-ray and computer tomography (CT) image showed extensive tumoral calcifications in the soft tissues around these joints. Oral administration of EHDP 300 mg/day was started in August 1998, and the dose was decreased to 200 mg every 2 days in 3 years. The pain was improved, and the size of calcinosis decreased. Because joint pain recurred with an increase of CRP in 2003, the dose of EHDP was increased to 400 mg/day for three months following a three-month off period, which was repeated. In 2004~2005, rib and metatarsal fractures occured in association with decreased bone density. Case 2 : A 60-year-old man suspected of chronic glomerulonephritis had been receiving hemodialysis therapy since 1991. In 1995, he developed severe shoulder and hip pain associated with tumoral calcinosis. Since oral therapy of EHDP 200 mg/day for 4~8 weeks followed by an off-period could not reduce the size of calcinosis, the duration of oral EHDP (200~400 mg) therapy was elongated to 9 months, followed by repeated cycles of 200 mg for three months with a three-month off-period. The pain and size of the calcification were improved. However, in 2002 asymptomatic rib fracture occurred due to decreased bone density. EHDP, which is supposed to be effective for reduction of ectopic calcinosis in soft tissue, not only has a suppressive effect on bone absorption but also has a strong suppressive effect on bone calcification. That might account for fractures following long-term treatment of EHDP in our cases.

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We encountered a hemodialysis patient complicated by idiopathic thrombocytopenic purpura (ITP). A 60-year-old man had been on hemodialysis due to diabetic nephropathy until May 1999. We administered alprostadil from November 2002 when arteriosclerosis obliterans worsened. Thrombocytes decreased to 0.6×10⁴/μL on February 2003. Although alprostadil and other drugs were discontinued thrombocytopenia did not abate and bone marrow assessment showed ITP. He started oral steroid therapy for ITP but there was no response. Thereafter, developed a he perianal abscess. Secondly, oral danazol was initiated and three days later, thrombocytes rose to 2.6×10⁴/μL. Low-dose danazol was very effective and did not cause any harmful aftereffects. There have not been any recurrences while the patient continued on tapered doses of danazol for 15 months or after discontinuation of danazol for 33 months. Therefore, we concluded low dose danazol was an optional rescue procedure for treating ITP developing in a patient on maintenance hemodialysis.

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Case 1, a 68-year-old female on hemodialysis for 18 years underwent resection of anal canal tumor. Histopathological findings of the tumor showed tubular carcinoma, and deposits of β₂-microglobulin amyloid were found in the small arteries of the submucosa and muscular layers. Case 2, a 75-year-old female on hemodialysis for 18 years underwent anterior cervical reconstruction. Eight days after surgery, she developed panperitonitis due to perforation of diverticulum in the sigmoid colon. The resected colon showed deposits of β₂-microglobulin amyloid in the subserosal vein. Both cases were long-term hemodialysis patients, and demonstrated amyloid deposits in the colon, but there had not been any symptoms due to gastrointestinal amyloidosis. Moreover, there were differences in the distribution of amyloid deposits between the two cases.

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We report a case of spontaneous splenic rupture in a 71-year-old man receiving maintenance hemodialysis. Hemodialysis was started 5 months earlier due to chronic renal failure caused by diabetic nephropathy. Medical history included non-Hodgkin lymphoma and surgery for colon cancer, along with the presence of hypothyroidism, C virus-induced hepatitis and arteriosclerosis obliterans. Before admission, the patient had been given heparin at each hemodialysis session. Erythropoietin and antiplatelet therapy had also been administered. He developed mild splenomegaly after chemotherapy for malignant lymphoma, but had not shown massive splenomegaly at that time. He arrived at the emergency room of Nagoya Memorial Hospital complaining of partial numbness in both legs and abdominal fullness. He had no history of trauma. Blood pressure was 85/47 mmHg, heart rate was 116 beats/min and hemoglobin was 6.4 g/dL. Computed tomography showed rupture of an enlarged spleen with hematoma. Blood transfusion was provided and he was closely observed in the Intensive Care Unit. After 3 days, since anemia progressed rapidly, emergent splenectomy was performed. A total of 1,100 mL of hemorrhage and blood clots were removed from the abdominal cavity. The enlarged spleen had ruptured near the hilum. Postoperatively, the patient recovered and was discharged on hospital day 28. Histological studies showed congestion of the spleen, but there were no tumorous lesions, broken vessels, amyloid angiopathy or peliosis lesion. Spontaneous splenic rupture was thus diagnosed. Spontaneous splenic rupture is a rare but potentially life-threatening condition. Patients on hemodialysis receiving anti-coagulants and frequent anti-platelet therapy are at particular risk. This case suggests that early diagnosis and therapy for spontaneous splenic rupture is very important.

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