Blood access problems are one of the most common complications in the management of hemodialysis patients. We performed arteriovenous fistula angiography in 318 cases between January 1997 and April 2002 to determine an appropriate therapeutic strategy. The reasons for angiography examination were insufficient blood flow (131 cases, 41.2%) and high venous pressure (44 cases, 13.8%). As a result, 318 cases showed 380 abnormal findings in the vein adjacent to the anastomosis (230 regions 60.5%), in the arteriovenous anastomosis (67 regions, 17.6%), in the artificial vessel (50 regions, 13.2%), in the central portion of vein (24 regions, 6.3%), and in the artery (4 regions, 1.1%). Overall, 263 regions (69.2%) exhibited stenoses in arteriovenous fistulae. We performed surgery in 132 patients including shunt reconstruction (82 cases, 25.9%) for arteriovenous anastomosis problems, new blood access (31 cases, 9.7%) or graft transplantation (19 cases, 6.0%) for problems in the central portion of the vein. We chose intervention therapy such as percutaneous transluminal angioplasty (PTA) for 79 cases (24.8%) comprising nearly half of the cases showing problems in the vein adjacent to the anastomosis. Since some blood access trouble exhibited multiple abnormal findings, comprehensive angiography from the anastomosis to the central portion of vein is necessary to reduce the number of additional surgeries required. It is also preferable that possible reconstruction surgery be performed on existing blood access. In multiple surgery patients and graft recipients, interventional procedures should be considered. These results suggest that angiography is helpful for determining the optimal therapeutic strategy for blood access problems.

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We evaluated the efficacy of sevelamer hydrochloride (sevelamer) in hemodialysis patients. Twenty patients (male 15, female 5) with a serum phosphate (Pi) level above 5.5mg/dL and corrected serum calcium (Ca) above 9.5mg/dL on chronic maintenance hemodialysis (more than 4 hours, 3 times/week) for over 1 year were enrolled. Calcium carbonate and other phosphate binders were all discontinued, and sevelamer was given for eight weeks. The dosage was determined in accordance with the appended paper, considering side effects such as digestive system disorder.
During the 12-week study period that included 4 weeks before the change in phosphate binder, hemodialysis conditions and dosages of medicines that can effect calcium and phosphate metabolism, such as vitamin D analogues, were left unchanged. During the study period, 4 patients dropped out due to side effects. We analysed blood chemical data consisting of serum phosphate (Pi), calcium (Ca), ALP, intact PTH (i-PTH), total cholesterol (TC), LDL-cholesterol (LDL-C), HDL-cholesterol (HDL-C), and HCO₃^- in 16 patients who completed 8 weeks of therapy. There were no significant changes observed in Pi, or Ca×Pi product, while HDL-C, Ca, TC, LDL-C, and HCO₃^- all decreased significantly and ALP and HCO₃^- both increased significantly.
Sevelamer alone can control serum Pi as well as calcium carbonate can, but in some cases, side effects prevented administration of a sufficient dose of sevelamer. Controlling side effects in order to administer an adequate dose of sevelamer, and how to use in combination with other phosphate binders are problems that remain to be resolved.

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Objective: We examined the usefulness of the glycated albumin(GA)/HbA1c ratio as a nutritional parameter in diabetic patients on hemodialysis.
Patients and methods: Twenty diabetic patients on hemodialysis (13 male and 7 female) treated by our affiliated hospitals underwent various clinical and laboratory tests to determine body mass index (BMI), desirable protein catabolic ratio (dPCR), KT/V, and time averaged concentration of urea (TACurea). Serum levels of total protein, albumin, total cholesterol, triglyceride, calcium, phosphorus, glycated albumin, and HbA1c were also examined.
Results: The patients were subdivided into two groups according to the GA/HbA1c ratio (3.37). (Low GA/HbA1c ratio group, GA/HbA1c ratio<3.37; High GA/HbA1c ratio group, GA/HbA1c ratio>3.37). The high GA/HbA1c ratio group showed significantly lower BMI, dPCR, and serum phosphorus compared to those in the low GA/HbA1c ratio group. In addition, GA/HbA1c ratio in all patients correlated significantly with BMI, dPCR and serum phosphorus.
Conclusions: These findings indicate that the GA/HbA1c ratio may be useful as a nutritional parameter in diabetic patients on hemodialysis.

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It has been pointed out that before initiating peritoneal dialysis, it is necessary to provide short-term stabilization of the exit site after catheter implantation. For systematic initiation of peritoneal dialysis, we designed a method of peritoneal dialysis initiation, called the Short-term Peritoneal dialysis Induction and Education (SPIED) technique, and examined the effectiveness of this method. The study included twelve patients who started peritoneal dialysis from July 2000 to December 2002. There were nine males and three females. The mean patient age was 61.4±12.7 years. Three patients had diabetic nephropathy and four chronic glomerulonephritis, three nephrosclerosis, and two polycystic kidney. The catheter was not embedded and its tip was exteriorized as usual. The exit-site was draped with a sheet of film and gauze. After surgery, patients stayed at home without dressing the exit-site by themselves. Patients were readmitted to our hospital about ten days later and an education program was started using a critical path. Duration of hospitalization was 2.3±0.8 days for catheter implantation, and 11.5±2.4 days for education. There was no initial complication such as dialysate leak and exit-site infection. During the observation period of 21.6±9.9 months, the incidence of exit-site infection was 1/65.0 patient-months, and that of peritonitis was 1/260.0 patient-months. There were no cases of tunnel infection. We concluded that this method caused little physical and mental stress because there was only one surgery and stabilization of not only the cuff but also the exit-site of catheter was achieved by fixing the exit-site for ten days, leading to a lowered incidence of catheter-related infection.

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A questionnaire survey was conducted to investigate the relation between attitudes and consumption of health food among dialysis patients. In 2001, 108 patients were surveyed and an additional 116 patients were surveyed in 2003. Patients with an interest in health foods comprised 38.9% in 2001 and 44.8% in 2003. Then, patients consuming health foods before or at the time of investigation comprised 24.1% in 2001, and 42.2% in 2003, showing an inxcrease within 2 years. However, patients who consulted a dietitian before consuming any health food decreased, from 10.2% in 2001 to 4.2% in 2003. Patients who regarded health food as medicine comprised 13.8%, the food were 62.9%, likewise, in the supplement, the medicine were 37.1% and the food were 31.9%. In 2003, there are rather more patients who began to consume health foods compared with patients who stopped consuming health foods compared to those in 2001. Even when a product changed, there were patient who continued to consume that product. They are affected by information received daily. Health food products, supplements and so on are introduced through mass media and sold to a wide audience. However, as for dialysis patient's using these products easily, there are concerns that there may be accompanying risks. Physicians often know that these products are being consumed by the blood test result and or weight increase in patients who do not consult before consuming the product. Because these products sometimes are not reflected in test result, however, we should carefully monitor the mass media information presented in daily life and to be able to advise the dialysis patient regarding their safety.

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Between September and November 2004, idiopathic acute encephalopathy occurred in many patients mainly living in Niigata, Yamagata, and Akita area in Japan. Almost all patients had end-stage renal disease (ESRD) and/or had eaten a kind of mushroom (botanical name: Pluerocybella porringens). Twenty-four cases of idiopathic acute encephalopathy were diagnosed in Akita Prefecture. Of these 24 cases, 17 patients were treated with maintenance dialysis and three patients with ESRD were in the pre-dialysis stage. The present study analyzed the clinical backgrounds and dialysis conditions of 17 dialysis patients to identify factors related to the occurrence of acute encephalopathy. The mean patient age was 64.2 years, nine patients were men, the mean dialysis duration was 56.8 months, the main underlying diseases causing ESRD were diabetic nephropathy and chronic glomerulonephritis. Patients who consumed the mushroom and underwent hemodialysis in common. There were no other common factors in the clinical backgrounds of these patients involving drugs or dialysis conditions, such as dialysates, anticoagulants, and dialysis membrane. Furthermore, we investigated the incidence of mushroom consumption and development of acute encephalopathy in 102 dialysis patients at 2 two dialysis centers. Of 102 patients, 57 (55.8%) had eaten the mushroom, 5 of 57 patients (8.7%) developed acute encephalopathy, and 2 of these 5 (40%) died of acute encephalopathy. We failed to find any common factors in the clinical backgrounds or dialysis conditions related to the occurrence of acute encephalopathy other than undergoing hemodialysis and consuming the mushroom. Further investigations are needed to identify the cause of this acute encephalopathy epidemic.

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A problem regarding the puncture order of patients at the start of hemodialysis is commonly experienced in most maintenance dialysis facilities. Various strategies have been used, but an overall approach has not yet been established. We began using a time-fixed puncture system 20 years ago and continue to successfully carry out this approach. In this study, we report practical methods for using the time-fixed puncture system (TFPS) and compared our experience with other various puncture order systems. Patients were also surveyed by questionnaire.
The basic rule of TFPS is as follows. (1) Time interval of the puncture procedure is settled within a 5-minute frame. (2) Two staff are always engaged for the puncture procedure of one patient. (3) Patients are given precedence, by the following criteria: long-term hemodialysis history, long-time hemodialysis per session, travelling a far distance from home, a history of difficulty in being punctured, requiring additional care. (4) Time of puncture and patient names are posted in a prominent place.
Analysis of characteristics of other puncture systems: when puncture is performed in order of the time of arrival to the clinic, patients compete with each other for puncture turn. As a result, many patients come to the clinic off-schedule in the early morning in order to get an early turn. Using the bed placement order system, a simple line of work flow is effective for the staff, but patients usually complain about the simple fixed puncture order by bed number. However, TFPS improves off-schedule arrival at the clinic in the early morning and efficiently shortens the interval until puncture. Staff can concentrate on puncture procedures. The ending procedure can be also smoothly performed. The satisfaction rate (total % of satisfied and rather satisfied patients) using TFPS was 97% on a patient questionnaire survey. However, rather dissatisfied patients comprised 10% on a questionnaire regarding fixed time frame among patients with a hemodialysis durations less than 10 years. Limited choice of a time frame for new patients is a disadvantage of TFPS. We have to consider changes in the time frame appropriately. In conclusion, it is very important to select a suitable puncture order system for each condition.

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