The mean age of overall dialysis population and the incidence of diabetic patients has been increasing. With these changes, we have sometimes encountered hemodialysis patients with difficulty in creating blood access. In these patients, we try to construct an arteriovenous fistula (AVF) utilizing brachial artery and brachial vein following superficial repositioning, before deciding whether to implant an artificial graft or to puncture an artery directly. We describe our surgical procedure and the results.
Between January 1996 and December 2000, fifteen blood access routes were established by this technique in 11 patients without suitable veins for standard AVF in the upper extremities. Our procedure involves two steps, one is constructing the AVF and the other is superficial repositioning of these vessels. Four blood access routes were created in one stage in which the two steps were performed at the same time. Eleven blood access routes were created in two stages in which the two steps were separated into two operations. The mean duration of the superficialized veins remaining patent was greater in the two-stage group than in the one-stage group (15.2 months in the two-stage group, 2.8 months in the one-stage group). Of 11 fistulae constructed in two stages, 8 fistulae were patent after 1 year. Arterial rupture, steal syndrome, formation of aneurysm and the excessive blood flow in the AVF were observed as complications. Therefore this procedure requires care and the superficialized brachial artery should be used as backup access.
This technique facilitated the establishment of blood access in patients with vascular access complications to avoid using an artificial graft or puncturing an artery directly. We conclude that this procedure is useful for establishing secondary blood access.

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To compare the effect of maxacalcitol and of intravenous calcitriol on secondary hyperparathyroidism, we conducted a 24-week prospective study for 20 chronic hemodialysis patients. Five or ten μg of maxacalcitol (5μg for patients with intact parathyroid hormone (PTH) less than 500pg/mL and 10μg for those with intact PTH higher than 500pg/mL) was administered intravenously to 10 patients, and 0.5 or 1.0μg of calcitriol (0.5μg for patients with intact PTH less than 500pg/mL and 1.0μg for those with intact PTH higher than 500pg/mL) was administered intravenously to 10 patients, at the end of every hemodialysis session. Dosage was changed according to PTH and serum calcium. We compared whole PTH, a new immunoradiometric assay exclusively for biologically active PTH (1-84), carboxy-terminal fragment (7-84) of PTH, intact PTH, bone-specific alkaline phosphatase (BAP), intact osteocalcin (iOC), amino-terminal propeptide of type I procollagen (PINP), serum calcium ajusted for albumin (Ca) and phosphorus (P).
Both maxacalcitol and calcitriol suppressed whole PTH 4 weeks after the start of administration. Calcitriol had less suppressing effect on whole PTH from 8 to 12 weeks of the study. From 16 to 24 weeks of the study, maxacalcitol and calcitriol showed almost equal whole PTH-suppressing effects. Intact PTH, 7-84 PTH, BAP, iOC and PINP showed almost similar changes as in whole PTH. However, the changes in BAP, iOC and PINP in patients treated with calcitriol were comparable. Ca increased and P showed no significant change. At the end of the study, there was no significant difference in these parameters between maxacalcitol and calcitriol. The effect of maxacalcitol was found to be 7 times higher than that of calcitriol.
In conclusion, maxacalcitol and calcitriol had almost equal effects on PTH, calcium and phosphorus, if dosages of these drugs are adjusted. The efficacy ratio of maxacalcitol to calcitriol was considered about 1:7.

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Hemodialysis patients often have severely calcified coronary artery lesions. Rotational atherectomy (RA) is now more frequently indicated for calcified coronary lesions. This study investigated the usefulness of rotational atherectomy for calcified coronary artery disease in patients on hemodialysis (HD). The early and intermediate-term outcome of revascularization therapy was compared between two groups, rotational atherectomy plus adjunct scent (RA-stent group) and balloon angioplasty adjunct stent (BA-stent group). RA-stent was performed for 49 lesions in 42 HD patients between July 1997 and June 2000, and BA-stent was performed for 20 lesions in 17 HD patients between July 1994 and February 1997. The incidence of diabetes mellitus was significantly higher in the RA-stent group them in the BA-stent group. The RA-stent group had more complex lesions (type B2 or C) than in the BA-stent group. The initial success rates for both groups were favorable (RA-stent; 95% vs. BA-stent; 100%), and neither Q-wave infarction nor emergency coronary artery bypass grafting was required in either group. In the RA-stent group, however, two patients died from arrhythmic event and non-cardiac cause during hospitalization. Target lesion revascularization was 10% lower in the RA-stent group than in the BA-stent (25% vs. 35.3%; NS), despite complex lesions showing a higher rate in the RA stent group 6 months after revascularization. These results demonstrate that RA may be a safe and effective revascularization therapy for HD patients with calcified and complex coronary lesions.

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Cardiovascular disease is the predominant cause of death in the patients with end-stage renal disease (ESRD). This study sought to define the value of dobutamine stress echocardiography (DSE) for detecting ischemic heart disease in patients with ESRD. Forty patients (serum creatinine>2.5mg/dL) who underwent DSE were studied. Standard dobutamine stress was administered until attainment of the peak dose, the development of ischemia or the occurrence of side effects. Electrocardiogram, echocardiogram and blood pressure were obtained before, at a low dose of dobutamine and at the peak dose. Ischemia was identified by new or worsening wall motion abnormalities with stress. DSE demonstrated ischemia in 10 (group A), a normal study in 14 (group M) and side effects in 16 patients (group S). Coronary angiography was performed in 9 of group A, 8 of group M and 9 of group S and demonstrated coronary artery disease in 7 of group A (p<0.05), and 1 of group M and 4 of group S. In patients with ESRD, identification of ischemia with DSE is a valuable diagnostic tool for detecting the presence of coronary artery disease.

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The authors report an uncommon case of cerebral nocardiosis in a 59-year-old man, who was admitted because of progressive muscle weakness. On complete physical examination, bilateral muscle weakness was revealed on upper extremities. Brain abscesses were found on head CT and MRI.
After draining the abscesses, he was treated with antibiotics and sulfamethoxazole-trimethoprim.
Cerebral nocardiosis is a life-threatening disease, and this case was successfully treated by drainage of the abscesses and postoperative chemotherapy with adequate antibiotics.

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It is well known that various malignancies are frequently encountered in patients receiving maintenance hemodialysis. Although the incidence of non-Hodgkin lymphoma has increased recently, only seven cases of lymphoma in hemodialysis patients have been reported in Japan. Here we report four additional cases of non-Hodgkin lymphoma in hemodialysis patients.
Case 1: The patient was a 63-year-old woman who had been receiving hemodialysis for 5 years. She developed left leg pain, high fever and consciousness disturbance. Several antibiotics showed no effect, and the appearance of atypical lymphocytes in peripheral blood smears, and an increase in LDH suggested malignant lymphoma, although there were no enlarged lymph nodes detected on computed tomography. The patient died of pulmonary hemorrhage, and autopsy demonstrated non-Hodgkin lymphoma in various organs. Case 2: The patient was an 80-year-old man who had been receiving hemodialysis for 3 months. He developed high fever and right thigh pain, and a skin biopsy of the right thigh revealed diffuse large B-cell type non-Hodgkin lymphoma. Radiation therapy effectively relieved his symptoms. Case 3: The patient was a 72-year-old man who had been receiving hemodialysis for 6 months. He developed high fever and swelling of the axillar and inguinal lymph nodes. Lymph node biopsy demonstrated T-cell-rich B cell non-Hodgkin lymphoma. Half-dose THP-COP chemotherapy achieved partial remission. Case 4: The patient was a 53-year-old man who had been receiving hemodialysis for 38 months. He developed a neck tumor and dysphagia, and biopsy of the neck mass demonstrated diffuse large B cell non-Hodgkin lymphoma. Reduced-dose CHOP therapy relieved the symptoms, but the patient died after 18 months.
As cases of malignant lymphoma may be increasing among hemodialysis patients, a standard chemotherapy regimen for such patients should be considered.

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Secondary hyperparathyroidism (II HPT) is a major complication in chronic dialysis patients, and percutaneous ethanol injection therapy (PEIT) has become a useful alternative treatment for II HPT. However, recurrent nerve paralysis by ethanol is a major problem in performing PEIT. Recently, percutaneous calcitriol injection therapy was reported as a useful treatment for severe II HPT without recurrent nerve paralysis.
We report here a 48-year-old female who was successfully controlled intact-PTH by percutaneous calcitriol injection therapy. High intact-PTH and parathyroid gland in both sides were detected by ultrasonography. After percutaneous calcitriol injection therapy was administered three times to each side of the parathyroid gland, successful control of intact-PTH was eventually achieved. The levels of Ca×Pi and parathyroid gland volume were both decreased after percutaneous calcitriol injection therapy.
In this case, it was suggested that percutaneous calcitriol injection therapy for II HPT was a useful treatment to control the levels of intact-PTH, Ca×Pi and parathyroid gland volume.

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The patient was a 53-year-old woman undergoing hemodialysis due to diabetic nephropathy since 1998. She presented with high grade fever on November 11, 2000. Two days later, pain, flare and swelling appeared at the left flank, hip and left femoral regions. We diagnosed this case as gas gangrene based on the presence of subcutaneous gases in these regions on X-ray and CT. She was immediately transferred to our hospital and extensive incision, drainage and debridement were carried out. Perirectal abscess was recognized at surgery, and this was considered to be the cause of gas gangrene. Postoperatively, she developed serious infection, disseminated intravascular coagulation and shock. Continuous hemodiafiltration and hyperbaric oxygenation exposure of the whole body were started in combination with intensive antibiotics treatment. Gas-producing Bacteroides was identified on culture of the resected tissue. Inflammation disappeared after about one-month, and skin grafting was finally carried out. Her general condition improved and she was discharged from our hospital on February 17, 2001.

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