This study was designed to clarify the clinical significance of plasma vasoactive substances including atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) as a survival predictor in chronic hemodialysis (HD) patients. Cardiothoracic ratio (CTR) and blood pressure were measured and blood samples were collected before the HD session for the measurements of ANP, BNP, plasma renin activity (PRA) and noradrenalin (PNA) in 52 HD patients. During 13-year follow-up period 41 patients died; 18 of either sudden death or cardiac death, 7 strokes, 8 infections, 5 other diseases, 2 accidents, and 1 suicide. Patients were divided into two groups using the median of their age and clinical and laboratory variables. Kaplan-Meier (KM) survival analysis demonstrated that the groups showing older age, lower serum albumin level and higher plasma BNP concentration had significantly lower survival rates as compared with each counterpart (p<0.001, p=0.008, p<0.001, respectively). Univariate and multivariate Cox proportional hazard regression analysis was used to assess the potential association of patient age, and clinical and laboratory variables. Univariate Cox hazard analysis showed that age, CTR, serum albumin level and plasma BNP concentration had a significant relationship with overall mortality (p<0.001, p=0, 010, p<0.001, p=0.011, respectively). However, stepwise multivariate analysis demonstrated that there was a significant relationship with overall mortality for patient age (p<0.001), and serum albumin level (p=0.020). The relationship with overall mortality was not significant for plasma BNP concentration (p=0.062) or CTR (p=0.816). These results demonstrated that age and serum albumin level were independent risk factors for long-term survival and that the plasma BNP concentration was an important risk factor next to age and serum albumin level, though it was not independent. Predialysis plasma ANP level was not significantly associated with overall mortality.

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Guidelines for vascular access were published by the Japanese Society for Dialysis Therapy in September 2005. We have constructed vascular access for chronic hemodialysis following the proposals in this guideline. analyzed the construction of ulnobasilic arteriovenous fistulas before we shifted the construction of fistulas from the forearm to the elbow, thereafter we evaluated the cumulative patency rates of fistula and the management. For 10 years from January 1995 to December 2004, 167 cases of arteriovenous fistulas in 115 patients were constructed using either the ulnar artery and basilic vein or the radial artery and cephalic vein in the distal forearm. All cases were classified into the following two groups, group U (41 cases in 25 patients): ulnaris (ulnobasilic arteriovenous fustula) or group (126 cases in 90 patients): radialis (radiocephalic arteriovenous fistula). The age at first construction of fistula, duration of hemodialysis and cumulative primary and secondary patency rates of fistula by percutaneous transluminal angioplast (PTA) were analyzed. The age at first construction of fistula was slightly higher in group than in group R, and the duration of hemodialysis was longer in group U than in group R. Moreover, the primary patency rate of the fistula in group U was worse than that in group R. In 86 (73 patients) of 167 (115 patients), repeated PTA procedures were performed. They were classified into the two subgroups, subgroup U' (21 cases in 17 patients): ulnaris and subgroup R' (65 cases in 56 patients): radialis. Cumulative secondary patency rate of the fistula was improved in all 86 repeat cases and there was no significant difference of cumulative secondary patency rates of fistulas between subgroup U' and subgroup R'. There was a correlation between the frequency of PTA and the secondary patency rate. The interval until repeat PTA was 2.55 months in subgroup U' and 3.28 months in subgroup R', respectively. Therefore, PTA attempts were more frequent in subgroup U' and the intervals were shorter in subgroup U'. These findings suggest that repeated PTA procedures ameliorate the secondary patency rate in cases of ulnobasilic arteriovenous fistula. As a result, the secondary patency rate of the ulnobasilic arteriovenous fistula is equal to that of riocehlic arteriovenous fistula. In conclusion, we do recommend the construction of an ulnobasilic arteriovenous fistula at the forearm before fistula construction is shifted from the forearm to the elbow.

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A 46-year-old female patient, who had been on chronic hemodialysis since 43 years old, was complicated by catamenial pneumothorax. She had previously been diagnosed when endometriosis when she delivered. She had regular menstruation from menarche till end-stage renal disease. She developed pneumothorax in April 2002, which recurred with menstruation despite being treated twice with GnRH therapy. She under went video-assisted thoracoscopy and blueberry spots were detected on the visceral pleura and diaphragm along with bulla. These blueberry spots and bulla were resected. Endmetrium was detected in the blueberry spots by histology. She did not develop further recurrence of pneumothorax postoperatively. This is a rare patient receiving hemodialysis, in whom endometriosis in the thorax was confirmed by histology.

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We report here a peritoneal dialysis (PD) patient complicated by diaphragmatic hernia, inguinal hernia and diaphragmatic communication. The patient was a 20-year-old man with IgA nephropathy who was treated with steroid therapy for over 6 months. Thereafter, he started PD in November 2003 due to end stage renal failure. He had dislocation of the PD catheter several times. In June 2004, an abnormal shadow was noted on chest X-ray and mediastinal tumor was suggested by CT and MRI. He was diagnosed by thoracotomy as having diaphragmatic hernia. During treatment he complained of a hydrocele of the scrotum and was diagnosed as inguinal hernia by abdominal CT with injection of contrast medium into the abdominal cavity and herniorrhaphy was performed. Two months later, he complained dyspnea, increasing body weight and loss of ultrafiltration. Diaphragmatic communication was diagnosed since the glucose concentration of the pleural effluent was higher than that of serum. Hemodialysis (HD) was performed until renal transplantation in September 2005. A history of malnutrition and/or steroid therapy tends to promote diaphragmatic hernia or hydrocele by inducing weakness of the connective tissue in PD patient. It appears that the attention to the PD prescription might be important to prevent these complications.

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