Sarcopenia and frailty are common in patients with peripheral artery disease, and are risk factors for lower limb amputation and death. Therefore, evaluation, prevention, and treatment of sarcopenia and frailty are important. The causes of sarcopenia are aging, activity, nutrition, and disease. Iatrogenic sarcopenia is defined as sarcopenia caused by the activities of medical staff, including doctors, nurses, or other health care professionals in healthcare facilities. Iatrogenic sarcopenia has three categories: 1）activity-related: caused by unnecessary inactivity or unnecessary nil per os, 2）nutrition-related: caused by inappropriate nutritional care management, and 3）disease-related: due to iatrogenic diseases. Types of frailty include physical, psychological, cognitive, and social. The main causes of physical frailty are sarcopenia, malnutrition, and polypharmacy, and polypharmacy is considered iatrogenic frailty. Prevention of iatrogenic sarcopenia and frailty is important. Rehabilitation nutrition is recommended to prevent and treat sarcopenia and frailty. Rehabilitation nutrition elicits the highest body functions, activities, participation, and quality of life by improving nutritional status, sarcopenia, and frailty using‘nutrition care management in consideration of rehabilitation’and‘rehabilitation in consideration of nutrition’. I hope that treatment of peripheral artery disease, and intervention for sarcopenia and frailty are carried out simultaneously from the viewpoint of rehabilitation nutrition.

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Dialysis patients in Japan are becoming older. Elderly patients often have functional deterioration due to age and the presence of multiple complications, and further care and support are required because of sarcopenia, frailty, and dementia. For dialysis treatment for the elderly, consideration is given as to whether dialysis therapy will medically benefit the patient, and hemodialysis or peritoneal dialysis (PD) is selected after careful examination of their respective advantages and disadvantages. In addition to the satisfaction level and quality of life, it is also necessary to consider the burden on caregivers. For patients who need nursing care and support, it is essential to promote the utilization of social resources through collaboration between medical and nursing-care insurance, and to strengthen regional cooperation while constructing community-based integrated care systems. Assisted PD is considered to be one of the important methods to support dialysis for the elderly.

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Japan is an aging society and the number of elderly chronic kidney disease (CKD) patients is increasing. As physiological function declines with age, patients with CKD and dialysis patients often develop sarcopenia and flail due to the decline in renal function and presence of many comorbidities. It is important to prolong the healthy lifespan of elderly people, and we believe that it is essential for the well-being of elderly CKD patients to maintain physical function. As such, approaches from physical function, nutritional, and social aspects are important. Based on the concept and diagnosis of basic sarcopenia and flail, we examined the frequency, prognosis, and characteristics of sarcopenia and flail in CKD patients from prior reports.

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The number of high-age patients with end-stage renal disease who require maintenance hemodialysis continues to increase. The incidence of critical limb ischemia among these patients is high because these patients have multiple risk factors for atherosclerosis. Poly-vascular disease, frailty, high bleeding risk, immune-insufficiency, and delayed wound-healing are characteristics of these patients, and these may limit the therapeutic approaches. As the activities of daily life（ADL）of each patient vary widely, the therapeutic goal setting in each case also varies. Prolonged hospitalization for excessive limb salvage, regardless of baseline ADL, may result in a significant deterioration in ADL. A multidisciplinary approach with allied health professionals, including physical therapists or medical social workers, is necessary to improve the outcome for each patient.

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The presence of chronic kidney disease（CKD）in peripheral artery disease（PAD）patients is associated with higher morbidity and mortality rates. This review focuses on the importance and efficacy of rehabilitation for CKD patients. Patients with CKD on hemodialysis（HD）have a high mortality with cardiovascular diseases, such as chronic heart failure, and a higher mortality risk has been reported for sedentary HD patients. A new systematic review and meta-analysis of randomized controlled trials reported that exercise-based renal rehabilitation improved aerobic capacity, muscular function, cardiovascular function, walking capacity, and health-related quality of life in CKD patients with HD. Moreover, exercise training may have renal protective effects not only in some animal models of pre-HD CKD, but also in pre-HD CKD patients. Exercise therapy may be an effective clinical strategy to improve renal function and reduce the need for renal replacement therapy, such as HD, or renal transplant risk in pre-HD CKD patients. The Japanese Society of Renal Rehabilitation was established to evaluate and promote renal rehabilitation in 2011, and Japan is the only country to offer exercise training that is covered by the national health insurance system for diabetic patients with pre-dialysis CKD（eGFR < 45 mL/min/1.73 m²）

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Plastic surgeons are the gatekeepers of limb salvage and examine patients with foot disease at my hospital. Multidisciplinary care is important for limb salvage; therefore, plastic surgeons, cardiologists, vascular surgeons, dermatologists, nephrologists, nurses and the others work together as the foot team. We examine several diseases such as nail disorders, calluses, corns, foot deformities, diabetic foot ulcers, and critical limb ischemia. The number of dialysis patients with critical limb ischemia is increasing and they are referred by a nearby dialysis clinic. We perform specialized wound therapy and prevent ulcers in cooperation with a specialized hospital and the dialysis clinic. Thus, we carry out limb salvage for dialysis patients at my hospital and in the surrounding area. If wounded patients are hospitalized for a long time, they often have trouble returning home. The Ministry of Health, Labour and Welfare promoted integrated community care systems and comprehensive community care systems that enable individuals to live out their lives in the local community by their own values. Regional cooperation is a challenge for the future.

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Far-infrared therapy is currently used in 10 countries, such as Taiwan and China, to improve the access flow and survival of arteriovenous fistulas in dialysis patients, but its usefulness in foot care is less reported. In this study, we examined the results of 5 cases in which far-infrared therapy was used for patients who were hospitalized at our wound care center. The patients comprised 4 males and 1 female. All patients were diagnosed with critical limb ischemia and underwent minor amputation after end vascular therapy, which did not heal. Far-infrared therapy was carried out, and was effective in four cases, but ineffective in one. This device was mobile, a special setting was not necessary, direct irradiation of the skin at a sufficient distance was possible, device handling was simple, and it was safe to use. It was possible to use this therapy with other adjunctive therapy, but sufficient blood circulation is required.

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The prognosis of critical limb ischemia（CLI）is poor and the restenosis rate is high. Moreover, severe pain due to ulcers in patients with lower leg arterial ischemia reduces the QOL. We report a case of repeated restenosis and refractory ulcers due to CLI that was cured using near-infrared irradiation and endovascular conventional treatment. A 70-year-old male with hypertension and smoking history undergoing hemodialysis received endovascular treatment 6 times for infra-popliteal lesions. As the ulcers and pain remained, we started near-infrared therapy in addition to the provision of modified relief sandals. After irradiation for 5 months, the ulcers disappeared and blood flow in the lower leg artery recovered.

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