Nafamostat mesilate has been widely used as an anticoagulant in hemodialysis patients with hemorrhagic diathesis. We compared brand-name and generic versions of the anticoagulant, nafamostat mesilate, with regard to the quantity of precipitate and the effect as an anticoagulant in twelve patients. By the cross-over method, there was no significant difference in the effects as an anticoagulant between the two versions of the drug. However, the quantity of precipitate was larger for the generic version than for the brand-name drug. The difference in the quantity of precipitate might be due to differences in additives or the level of impurities. When introducing the generic medicines, it must be considered that these versions might not be completely identical to the brand-name drug.

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We analyzed the long-term results of endoscopic carpal tunnel release surgery using the Universal Subcutaneous Endoscope (USE) system for haemodialysis-associated carpal tunnel syndrome. A total of 388 hands/279 cases [mean age 52.3 years, mean dialysis duration 16.3 years, mean follow up period 7.4 years (5-15.5)] were followed for more than 5 years. We analyzed the clinical symptoms, tingling sensation, pain and touch sensation, recovery of abductor pollicis brevis (APB) muscle power, complications, and recurrence rate. There were no complications during our procedure. Recovery rates for tingling sensation (93%), pain sensation using a 3 gm. algesiometer (92%), and touch sensation using a 2gm. von Frey hair (90%) were recorded at 6 months postoperatively. Five-year recovery rates were 98%, 98%, and 97%, respectively. APB muscle grading at final follow up showed recovery to grades [4] or [5] on manual muscle testing in 85% of hands with preoperative grading levels of [0], [1], [2], or [3]. Twenty hands (5%) developed recurrence. The mean interval until recurrence was 7.6 years.
We compared the recovery rates of clinical symptoms (tingling, pain and touch sensations) between the recurrence group (20 hands) and the non-recurrence group (368 hands). We found no significant differences between the two groups. Endoscopic carpal canal release surgery using the USE system is safe and effective for treatment of long-term haemodialysis-related carpal tunnel syndrome patients.

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The effects of the specially-programmed exercise load on the AVF growth was investigated in 19 (16 males and 3 females) hemodialysis (HD) patients (66±12 [SD] years old). They had been created the new AVF for initiation of maintenance HD. They were randomly subdivided into the following groups; Group I was composed of 10 patients who underwent a traditional exercise of squeezing a ball, and Group II was composed of 9 patients who were trained with a specially-programmed exercise using a sphygmomanometer, by increasing pressure to the level of 10mmHg above their systolic blood pressure for 30 seconds, and they were asked to squeeze a ball for a designated number of times, 3 times a day. The exercise duration of each group was 4 months. The growth of AVF was evaluated by calculating the lumen area at the venous side of 4cm proximal to the anastomosis site of AVF by using Doppler ultrasonography before, 2 months and 4 months after starting the exercise treatment, and the data were compared between groups at each time. There was a significant difference in the growth rate of increasing area of the venous side of AVF between groups at the 2 nd month, being 134.7±26.1% in Group I and 206.6±86.6% in Group II (p<0.05). It is, thus, concluded that the specially-programmed exercise load by using sphygmomanometer is effective in the earlier achievement of adequate AVF growth for HD.

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We used vitamin E-coated membranes to treat of chronic haemodialysis patients, examining the effects during dialysis (Protocol 1) and those of long-term use for 3 years (Protocol 2), and studied changes in lipid peroxide (oxidized LDL, MDA-LDL) in plasma. During dialysis, the vitamin E-coated membrane significantly reduced changes in oxidized LDL compared to those using polysulfone membrane and regenerated cellulose membrane (7 patients for each group). In the examination of long-term use for 3 years (11 chronic dialysis patients), oxidized LDL and MDA-LDL were both reduced. In comparison between DM (patients with diabetic mellitus) and Non-DM groups, there was no significant difference. Vitamin E-coated membranes might suppress the development of arterial sclerosis in dialysis patients, because it was shown that vitamin E-coated membranes lowered lipid peroxide levels in blood both during dialysis and in long-term use.

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A 77-year-old man was referred to our hospital in December 2002 with a diagnosis of chronic renal failure due to diabetic nephropathy. Initial examination showed blood urea nitrogen of 48mg/dL and serum creatinine of 3.3mg/dL, respectively. His renal function gradually decreased. On January, 2004, he complained flu-like symptoms, and his condition abruptly worsened, and anasarca and bilateral pleural effusion developed. He was admitted for starting hemodialysis treatment and further evaluation. During hospitalization, clinical and laboratory findings revealed fever, macrohematuria, and high titers of CRP. Although various detailed examinations failed to find any definitive diagnosis, his condition was improved by administration of antibiotics. He was transferred to an outpatient maintenance hemodialysis unit. Although fever and CRP-positive reaction had been frequently noted, his condition was ameliorated by antibiotic therapy. In June of the same year, chest pain and pleural effusion on the right side developed, and was admitted again for the further examination. Since sustained fever, high CRP level, and general malaise were resistant to several antibiotics or anti-tuberculous agents. A further investigations with respect to malignancy, collagen disease, and other forms of vasculitis revealed a high titer of MPO-ANCA (503 EU). High-dose steroid therapy was initiated, then fever was subsided, CRP decreased, and pleural effusion disappered. His clinical course and laboratory date strongly suggested pleuritis due to MPA.

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We report a hemodialysis patient presenting with fever of unknown origin (FUO) that was eventually diagnosed as infected pseudoaneurysm of the renal artery and successfully treated by surgery. A 47-year-old Japanese man who had been undergoing hemodialysis for twenty years was referred to our hospital with a twomonth history of fever and left flank pain. Computed tomography demonstrated an aneurysm measuring 2cm in diameter at the proximal left renal artery. Treatment with intravenous infusion of broad-spectrum antibiotics, including fungal coverage, failed to definitively eradicate the infection. We judged that infected aneurysm of the renal artery was the cause of FUO and flank pain, although the repetitive blood cultures were negative. Accordingly, the aneurysm and left kidney were resected simultaneously to avoid rupture of the infected aneurysm. Histological examination showed inflammatory change around the aneurysm of the renal artery and atypical cysts with papillary cell carcinoma in the left kidney. As the mechanism of infection to the renal artery in this patient, two pathways were considered. The first was the infection secondary into a pre-existing pseudoaneurysm complicated by blunt trauma. The second was due to necrosis of the tunica intima as a result of septic invasion of the vasa vasorum. infected aneurysm should be considered to be a case of FUO in patients undergoing hemodialysis.

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The patient was a 50-year-old woman. Proteinuria had been detected when she was 28 years old. In May 2004, renal failure was diagnosed and she was referred to our institution. On May 25 th, polyurethane vascular graft (Thoratec^®) was implanted in her left antebrachium. On June 10 th, exudative erythema with small bulla appeared around the vascular graft and systemic edematous erythema appeared. Patch test was performed, and Thoratec^® was positive 72 hours later. Skin biopsy from the tissue both around the vascular graft and back skin revealed findings compatible with contact dermatitis, and a diagnosis of systemic contact dermatitis was made. Eosinophilia was very mild. Intravenous corticosteroid was given. On June 22 nd, Thoratec^® was removed surgically. Because the allergen must be removed completely, we were careful to avoid leaving any fragment of Thoratec^®. Postoperatively, abscess occurred under the wound and drainage was required. After removing Thoratec^®, eosinophilia worsened remarkably. We treated the patient with systemic corticosteroid therapy, and her symptom improved in two months. There is no previous report of allergy of Thoratec^®.

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