Superficialized arterio-venous fistulas using brachial arteries and brachial veins were constructed in 28 patients between 1997 and 2002. The mean age and duration of hemodialysis were 67.2 years old and 7.5 years. The previous number of blood access procedures was 4.9 on average. All fistulas were successfully constructed, and the first puncture for hemodialysis was performed an average of 25.8 days post operatively. Complications during the follow-up period included 8 occlusions, 2 stenoses, 3 arm swellings at the access site, 2 lymphoceles, and 2 patients with poor wound healing. Patency rates were 80.8% after 6 months and 75.4% after a year. Superficialized brachio-brachial A-V fistula is a useful technique for secondary or tertiary blood access, because the cumulative patency rate is by no means inferior to vascular access grafts in the upper arm at our hospital during almost the same period.

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The influence of age, gender, original disease and the region of internal shunt placement on cumulative patency rate and surgical time was investigated in 140 patients who were newly introduced to hemodialysis and received the first internal shunt procedure between 1992 and 2001 at our hospital. The mean patients age was 60.2 years, and there were 86 males and 54 females. Sixty-seven patients had diabetic nephropathy and 56 chronic glomerulonephritis. The internal shunt was placed in the snuff-box (tabatiere) in 80 patients, and in the cephalic vein of the forearm in 60 patients. The cumulative patency rate of internal shunt 1, 3, 5 and 10 years after surgery was 75.7%, 71.0%, 69.0%, and 60.5%, respectively. When comparing the cumulative patency rate by age, gender, region of internal shunt placement, and presence of diabetes mellitus, there was a significant difference in patency between patients aged 60 years or older and those younger than 6 years, and between males and females. The mean surgical time was 96.3 minutes. The surgical time for the snuff-box (88.8 minutes) was significantly shorter than that for the forearm (107.8 minutes). There was no difference in the patency period between the snuff-box procedure and that for the forearm. Intra- and post- operative management should be performed carefully for females and elderly patients, since the risk of shunt occlusion was higher in these patients compared with that in males and younger patients, respectively. Shunt surgery by the snuffbox technique required a shorter surgical time, and might have an advantage in conserving the forearm vessels.

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We have previously reported that prognostic nutritional index (PNI) is a comprehensive assessment and variable of nutritional conditions at the measuring point by analyzing several factors that comprise PNI. By comparison of PNI between a healthy group and a hemodialysis group, we established a new nutritional assessment index. According to the new index, PNI in poor nutrition is over 40, that in intermediate nutrition is between 20 to 40, and that in good nutrition is under 20. Furthermore, we compared changes of PNI with the clinical course of dialysis patients. To quantify the risk that hemodialysis patients might develop cancer cachexia, we examined the maximal increasing range of PNI. The maximum actual measurement value was 9.4±4.7[SD]%, being the maximum rate 51.2±48.0% in percent in the non-cancer group, while they were 17.9±1.0%, 161.6±116.6%, respectively, in the cancer group. The maximum percent rate of PNI increase in the cancer group was significantly higher then that in the non-cancer group (p<0.001) value. According to the changes in PNI in both groups, the patients were subdivided into three groups, being the higher risk group (actual value≥20% and percent rate≥100%), the intermediate risk group (20<actual value<10 and 50<percent rate<100), the lower risk group (actual measurement value≤10 and percent rate≤50). Accordingly, if we cannot find any definitive cause of PNI increment other than shortage of food intake in hemodialysis patients, it should be suspected that they are developing cancer cachexia. Therefore, it would be recommended to search malignant tumor in these patients.

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A 70-year-old man underwent left nephroureterctomy due to left renal pelvic tumor (Transitional cell carcinoma (TCC), non-invasive, G2, pTa) in 1995 and transurethral resection of bladder tumor (TCC, non-invasive, G2>3, pTa-pT1a) in Oct 1996 and Apr 1999.
In Mar 2003, he noticed asymptomatic macrohematuria. Right hyronephrosis was found on ultrasonograhy and a 3cm filling defect was found in the right ureter by retrograde pyelograhy (RP). Urine cytological diagnosis of the locus was class V, and we diagnosed the as a lesion right ureteral tumor. There was no finding of obvious metastasis.
We construted an arteriovenous fistula utilizing the left radial artery and vein at April 28, 2003. At May 8, 2003 we performed laparoscopic right nephroureterectomy via the retroperitoneal approach, laparoscopic total cystectomy via the peritoneal approach, and urethrectomy. Surgical duration was 8 hours 30 minutes; blood loss was 535g and volume of blood transfusion was 850mL. We resected the total urinary tract en bloc. On the first postoperative day, he hemodialysis wasinitiated. The pathological finding was TCC, papillary, non-invasive, G2, pTa and we have not recognized recurrence or metastasis to date.
We sometimes find patients in whom hemodialysis was initiated due to surgery for urological malignant tumor, but we could not find a case in which the total urinary tract was resected en bloc by laparoscopic surgery and then received initiation of hemodialysis. Laparoscopic surgery is useful due to its the lower invasiveness.

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The patient was a 44-year-old woman who had undergone maintenance hemodialysis since February 1985 due to chronic glomerulneritis. In Octorber 2002, she developed fever, general arthralgia, lumbago and rightsided gluteal pain. Laboratory test demonstrated severe inflammation and MSSA (methicifin sensitive Stapylococcus aureus) was isolated by blood culture. Echocardiogram disclosed calcification and vegetation on the posterior mitral leaflet. The patient was transferred to our hospital for further evaluation of infective endocarditis. Computed tomography showed systemic multiple abscesses. She underwent urgent surgery (mitral valve replacement) on October 23 because of worsening of left-sided heart failure, a large vegetation (1.5-2.0cm) and multiple embolic events. Thereafter, inflammatory data declined, but 9 days later, cardiac tamponade developed due to perforation of the right ventricle. The perforated portion was obliterated by mattress suture using pericardium. Thereafter, her general condition gradually improved. However, cardiac tamponade occurred again 51 days after the valve replacement therapy. Computed tomography demonstrated ruptured ventricular aneurysm under the prosthetic valve and she died on the same day.
We report a rare case that developed an infected ventricular aneurysm during maintenance hemodialysis. If patients on long-term hemodialysis become complicated by cardiac valvular diseases due to metastatic calcification, we need to pay attention to the onset of infective endocarditis in these patients.

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We report here 3 cases of abdominal angina in patients with chronic renal failure, and they were successfully treated with intravenous administration of prostaglandin E₁ (PGE₁). Abdominal angina is a disease with a classical triad of abdominal pain after food intake, weight loss, and fear of eating due to the abdominal pain. The cause of this syndrome is mainly stricture of the main abdominal arteries and chronic intestinal ischemia. Progression of abdominal angina triggers main abdominal arterial obstruction, extensive bowel necrosis, and is sometimes fatal. In addition to its poor prognosis, the frequent appearance of abdominal pain and discomfort seriously diminishes the patient's QOL. Atherosclerosis is the cause of about 50% of the cases of stricture of the main abdominal arteries. However, chronic renal failure patients with or without dialysis who often have concomitant disease-induced atherosclerosis, might become complicated by abdominal angina. The first choice of treatment for this syndrome is usually surgical bypass or revascularization of the main arteries. However, patients with chronic renal failure possess concomitant diseases, such as obstructive arteriosclerosis, ischemic heart disease, etc., resulting in a high risk for surgical procedures. Medical treatment without any surgery may be preferable for abdominal angina, especially as a complication of chronic renal failure, however, there is still no commonly acceptable medical treatment.
We treated 3 cases of abdominal angina with chronic renal failure by intravenous administration of PGE₁. PGE₁ successfully reduced the degree and the frequency of patients' symptoms. These patients, who had renal failure with several complications, were not considered to be able to tolerate surgical treatment. PGE₁, which is a potent vasodilator, was effective for their symptoms. Our experience with these cases suggested that drip infusion of PGE₁ could e one of the choices for non-surgical treatment of abdominal angina as a complication in patients with chronic renal failure.

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