Although the qualifications for the specialty of nursing have been improved by the Japanese Nursing Association, they are still backward in the nephrology nursing field. We investigated the qualifications for 1) Japanese Nephrology Clinical Nurse Specialist and Certified Dialysis Nurse, 2) Japanese Clinical Nurse Specialist other than for nephrology, 3) Japanese Certified Nurse other than for dialysis, and 4) nephrology nurse specialist in the U.S. We compared the qualifications for these four categories by referring to the literature, in terms of necessity, purpose for system, definition, education, role, organization for authorization, and problems in the future and the clinical practice of dialysis nurse specialists in the U.S.
Concerning Japanese Nephrology Clinical Nurse Specialist and Japanese Certified Dialysis Nurse, there was no literature suitable for the purpose of this research. The role of a Japanese Clinical Nurse Specialist other than for nephrology, were defined as practice, education, consultation, coordination, and research and those of a Japanese Certified Nurse were defined as practice, advice, and consultation. Nephrology nurse specialists in the U.S. were dirided into two categories; one was Advanced Practice Nurse (APN) and the other was Certified Nephrology Nurse (CNN). The role of an APN was considered as, direct caregiver, educator, coordinator, researcher, consultant, and administrator, and that of a CNN as direct caregiver, educator, coordinator, consultant, and researcher.

View full abstract

To evaluate the AABI as a marker of arteriosclerotic disease in hemodialysis (HD) patients, we measured AABI in 101 patients on HD once a month for about 1 year. The AABI was compared in patients with or without coronary artery disease (CAD), cerebrovascular disease (CVD) and peripheral vascular disease (PVD). The AABI was significantly lower in patients with disease than in those without disease (CAD: 0.99±0.16 vs 1.17±0.10; CVD: 1.02±0.18 vs 1.13±0.13; PVD: 0.95±0.15 vs 1.13±0.13). The mean AABI decreased as the number of vascular diseases decreased (0: 1.18±0.09; 1: 1.09±0.13; 2: 0.91±0.14). In patients with or without DM, the mean AABI was respectively 0.98±0.16 and 1.16±0.11. For HT, it was 1.08±0.17 and 1.15±0.10. In all patients, the absolute magnitude of the AABI correlated with age, but not with the duration of HD. The correlation between the AABI and age was seen in non-DM patients, but not in DM patients. These data suggest that, in DM patients, arteriosclerotic disease was strongly influenced by factors other than age, namely the degree of the diabetic complications. Of the patients with vascular disease 31.3% showed an AABI value above 1.0, of whom 88.0% had calcification of the arteries of the lower extremities, and if the patients with calcification were excluded, only 3.8% had sclerotic diseases. One should be aware of this phenomenon, when evaluating the AABI. In patients with an AABI of less than 1.0, 95.2% had overt vascular disease. We concluded that the AABI serves as a powerful marker for the presence and intensity of systemic arteriosclerotic vascular disease of HD patients.

View full abstract

A 27-year-old woman undergoing regular hemodialysis had been treated with sufficient prednisolone orally for the complication of idiopathic thrombocytopenic purpura. On 11th July 1995, she was admitted to our hospital with purpura due to severe thrombocytopenia. Despite an increased dose of prednisolone to 60mg/day for 6 weeks, the effect was transient and limited. Therefore the dose of prednisolone began to be tapered off. Since the middle of September, she had complained of fever up to over 38°C with a dry cough. Findings of intensive examinations including repeated culture and chest X-ray were negative except for mild hypoxia found by arterial blood gas analysis. Thoracic computed tomography detected unhomogeneous interstitial lesions in both lung fields. A diagnosis of Pneumocystis carinii was made by detection of carinii cysts in the BAL samples obtained by bronchofiberscopy. Immediately, combination therapy consisting of pentamidine inspiration (300mg/day) and sulfamethoxazole (2000mg/day)-trimethoprim (400mg/day) taken orally was started. Furthermore, intravenous injection of fluconazole (50mg/day) and ganciclovir (100mg every 48 hours after hemodialysis) were added to prevent fungus and cytomegalovirus infection, respectively. Although Pneumocystis carinii was eliminated by the intensive therapy, she suddenly exhibited severe nausea, bilateral leg tremors and night time emotional instabilitys. These symtoms completely disappeared after discontinuation or reduction of the therapy. To rule out toxicity, plasma concentrations of the drugs were measured. More than two/thirds of the administered doses of sulfamethoxazole-trimethoprim and ganciclovir had disappeared after hemodialysis. However, a high plasma concentration of ganciclovir (2.91μg/l) was noted even 53 hours after the last injection, suggesting an extensive prolonged plasma half-life of ganciclovir on non-hemodialysis days. A previous study suggested that ganciclovir was able to cross the blood-brain barrier and to cause encepalopathy when the blood level was 1.2μg/l. From these findings taken together, ganciclovir-induced encephalopathy was suspected in this case. Pneumocystis carinii pneumonia is a fatal pulmonary disease because of its early progression and the presence of a mixed infection of fungus and cytomegalovirus. Because of early diagnosis and intensive therapy, this case was successfully treated for Pneumocystis carinii. An appropriate manual on ganciclovir administration should be written for preventing the encephalopathy by this medicine in hemodialysis patients.

View full abstract

The patient, a 44 year-old man had been well until January 1996, when he noticed general malaise and weight loss. He was hospitalized with severe anemia and an increased creatinine level. One month after admission, melena developed. Results of a gastrointestinal tract workup were normal. He was followed up in the outpatient department until June 1996, when he developed general malaise, anorexia and intermittent upper abdominal pain, and was readmitted. At admission his serum creatinine had increased to 10mg/dl, and BUN to 165mg/dl, and renal replacement therapy by hemodialysis was begun. Occult blood was detected in his stool and he had significant anemia. His Hb fell to 3g/dl and Ht to 12%. An upper gastrointestinal series revealed a 3-cm mass in the jejunum. Two days later, severe continuous upper abdominal pain developed. Emergency CT scans showed gaseous distention of the small and large bowels. These findings suggested a diagnosis of intusucception caused by a jejunal tumor. Open laparotomy revealed an invagination of the jejunum about 40-cm in length. Following manual reduction, a hard mass with serosal invasion was palpated. A 90-cm segment of the jejunum and the mesentery, with lymph nodes, was resected. The pathological specimen showed an ulcerated 3 by 3cm circular tumor. Histological diagnosis revealed a well-differentiated adenocarcinoma with lymph node involvement. Generally, tumors of the small intestine are rare and difficult to diagnose. We suggest that a full workup of the gastrointestinal tract including the small intestine be performed for a diagnosis of chronic renal failure with severe anemia and melena, if a routine examination did not detect the lesion.

View full abstract

We report a 53-year-old female hemodialysis patient who presented with resistance of anemia to rHuEPO therapy due to cervical lymph node tuberculosis. She had end-stage renal disease probably due to chronic pyelonephritis and began maintenance hemodialysis in 1986. In 1990, rHuEPO therapy at a dose of 4500U/week, with iron supplementation, was commenced for her renal anemia. In 1991, the rHuEPO dose was increased to 9000U/week. However, her hematocrit was not elevated and was not maintained over 24%. In March 1992, cervical lymph node tuberculosis was diagnosed and antituberculous therapy using 0.4g of isoniazid and 0.45g of rifampicin daily was prescribed. She took her medicine irregularly and her clinical symptoms persisted. In 1993, after the beginning of streptomycin injection 2g/week for 5 weeks, her clinical symptoms and the response to rHuEPO therapy were simultaneously ameliorated and her hematocrit has been maintained at 28 to 30% by rHuEPO therapy at doses of 4500 to 9000U/week. Antituberculous therapy with isoniazid and rifampicin had been performed until May and November in 1993, respectively. Symptoms of recurrence of tuberculosis have not been observed. Poor response to rHuEPO therapy had already existed before the diagnosis of cervical lymph node tuberculosis. This may be attributed to the persistent infection by Mycobacterium tuberculosis. Tuberculosis was considered to cause the resistance of anemia to rHuEPO therapy in hemodialysis patients.

View full abstract

We report a case of bone pain in a chronic hemodialysis patient which is thought to have been caused by erythropoietin. A 64-year-old woman undergoing hemodialysis for eight years was receiving erythropietin in doses of 1500 IU every other day as treatment for renal anemia. After the tenth injection, she felt generalized bone pain starting from the left scalpel bone, which had continued until the erythropoietin was discontinued. She was also suffering from idiopathic thrombocytopenic purpura. Although there are few reports on bone pain caused by erythropoietin, it is speculated that the pain is caused by the same mechanism as that caused by granulocyte colony stimulating factor.

View full abstract

Recently the number of chronic hemodialysis patients presenting difficulty in creating blood access has been increasing. An unsuitable superficial vein for arteriovenous fistula (AVF) and stenosis of the subclavian vein are especially apt to prevent adequate hemodialysis. We experienced a case of subclavian vein stenosis due to previous frequent catheterizations without suitable veins for AVF in the upper extremities. With an artificial vessel we created a bypass for blood access going over the rt clavicle between the rt brachial artery and the rt external jugular vein.
There are several reports indicating how to treat hemodialysis patients with subclavian vein stenosis. All of those patients were treated by bypass surgery, stenting or percutaneous transluminal angioplasty for the stenosis. Our operative method made it possible to create blood access for the patients with subclavian vein stenosis without suitable veins for AVF in the upper extremities which were required by the previous methods.
We concluded that this operative method is indeed worth considering for such a patient.

View full abstract

A 47-year-old woman was referred to our hospital because of a mass in her left forearm. She had been receiving hemodialysis with an internal shunt in the left hand because of chronic renal failure. She reported that after a penetrating trauma at hemodialysis, this mass had gradually increased in size. Arteriography showed an aneurysm of the radial artery. The aneurysmal sac was excised under the diagnosis of a pseudoaneurysm. The wound healed satisfactorily and the internal shunt trouble disappeared.

View full abstract