We, the Risk management Committee of Hyogo Dialysis Association, report data obtained from questionnaire surveys of infection control and risk management in dialysis facilities in our prefecture conducted in 2003 and 2006. The collection rate in each survey was over 60 percent. There was no further report of hepatitis virus infection during the recent survey in 2006. The rate of adoption of erythropoietin injection syringe improved from 74% to 93%. The rate of adoption of the luer lock tube also improved from 62% to 96%. The method of returning the patient's blood from extracorporeal circuit using saline, which was used by 37% in 2003, improved to 57% in 2006. Otherwise, both the rates of facilities with an infection control committee or risk management committee were slightly decreased, from 91% to 88% and 88% to 84%, respectively. Fifteen cases involved in accidents related to dementia were reported. The 2006 survey showed high motivation for disaster planning, and a total of 31 physicians, 98 nurses, and 62 clinical engineering technologists in our prefecture can be dispatched in case of disasters.

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There are few reports evaluating the relationship between autonomic nervous dysfunction and hypotension occurring during maintenance hemodialysis (HD), although impaired vasoconstriction induced by an imbalance of autonomic nervous activity is one of major factors causing excessive decrease in blood pressure during HD. The present study investigated the relationship between autonomic nervous dysfunction characterized by arteriosclerosis and hypotension observed during HD. Fifty-six patients with chronic renal failure who regularly received HD treatment were enrolled in this study. The subjects were divided into two groups according to the severity of decrease in systolic blood pressure (SBP) during HD ; hypotension and non-hypotension groups showing an SBP decrease during HD of 30 mmHg or more, and less than 30 mmHg, respectively, compared with the SBP value before HD. Clinical characteristics including age, sex, body mass index, complication by diabetes mellitus, dry weight, left ventricular ejection fraction and brain natriuretic peptide were assessed and arteriosclerosis was evaluated using pulse wave velocity (PWV). Physical activity was assessed using the international physical activity questionnaire. High frequency (HF : 0.15-0.4 Hz) and low frequency components (LF : 0.04-0.15 Hz) and entropy were analyzed on 24-hour Holter ECG recording using the maximal entropy method. HF and LF/HF indicated parasympathetic nervous activity and the dominancy of the sympathovagal balance, respectively. Clinical characteristics did not show any significant differences between the two groups. PWV was significantly higher in the hypotension group than in the non-hypotension group (p<0.05). Physical activity were significantly lower in the hypotension group than in the non-hypotension group (p<0.01). HF, LF/HF and entropy increased significantly during HD in the non-hypotension group as compared with baselines before HD (p<0.01, p<0.01 and p<0.05, respectively). Although HF and LF/HF remained unchanged in the hypotension group, entropy decreased significantly compared with the baseline before HD (p<0.05). These findings suggested that arteriosclerosis characterized by the imbalance of autonomic nervous activity induced an excessive decrease in blood pressure during HD.

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To investigate changes in blood glucose levels (BG) during hemodialysis (HD), we examined BG in 233 patients without diabetes (N ; 154) and with diabetes (without medication : DM-Diet ; 25 and with medication : DM-Drug ; 54). When patients did not consume a snack during HD, the BG after HD was significantly lower (p<0.0001) than that before HD in both N and DM-Diet. In N, BG after HD fell below 100 mg/dL in 80% and below 70 mg/dL in 12% of patients, and in DM-Diet, BG fell below 100 mg/dL in 75% of patients, when they did not consume a snack during HD.
To clarify the causes of decreased BG, we examined the serum insulin level (Ins) and renal parenchymal volume (V) in the following groups. 1A : BG after HD≥70 mg/dL and decrement in BG<25 mg/dL (n=31), 1B : BG after HD≥70 mg/dL and decrement in BG≥25 mg/dL (n=20), 2A : BG after HD<70 mg/dL and decrement in BG<25 mg/dL (n=2), and 2B : BG after HD<70 mg/dL and decrement in BG≥25 mg/dL (n=6). Ins fell significantly after dialysis in all groups, and Ins before HD were significantly correlated with decrement in BG. Ins before HD was also significantly higher in group 1B than in group 1A. There was no significant difference in V among all groups.
These findings indicate that we need to monitor patients for hypoglycemia during and at the end of hemodialysis even if glucose is added to the dialysate. Furthermore, these data suggest that a high level of Ins before HD is one of the causes in dialysis-induced BG decrease.

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Nafamostat mesilate (NM) has often been used as an anticoagulant instead of heparin during extracorporeal circulation under hemorrhagic conditions. However, reports of serious allergic reaction induced by NM have been accumulated. We report two cases of allergic reaction induced by NM during maintenance of hemodialysis. Case 1 was a 54-year-old woman, who had been on chronic hemodialysis for 24 years because of chronic renal failure due to lupus nephritis. After NM was used for hemodialysis prior to surgery for cervical spondylosis, the patient presented with fever. Case 2 was a 64-year-old woman with chronic renal failure due to nephrosclerosis. She had undergone hemodialysis for 9 years. Anaphylaxis appeared just after injection of NM during hemodialysis after vitrectomy. Both patients had histories of NM administration, but had never demonstrated an allergic reaction before. Among 35 cases reported previously, NM allergy was not characterized by the causes of renal failure, duration of maintenance dialysis and the membrane material of dialyser. However, most of these patients had a history of NM administration. Among 37 cases undergoing extracorponeal circulation, the features of NM allergy were classified into three types by the main symptoms, e.g., shock, eruption and fever. Patients demonstrating shock were prone to show less eosinophilia and a high positive rate on drug lymphocyte stimulation test. Patients with fever showed a marked elevation in CRP, and had a significantly longer history of dialysis. The number of hemodialysis patients has continued to increase rapidly, and the number of patients receiving NM during hemodialysis has been increasing. However, there is no currently valid method of predicting an allergic reaction, we should monitor patients for the possibility of an allergic response to NM.

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We report two cases of acute reversible parkinsonism in diabetic uremic patients. “Case 1” A 56-year-old man with diabetes mellitus and undergoing hemodialysis suddenly developed gait disturbance, bradykinesia, dysarthria. These symptoms diminished spontaneously 8 months later. T2-weighted magnetic resonance (MR) images demonstrated symmetrical high signal intensity in the basal ganglia, and these abnormalities regressed remarkably 2 months later. “Case 2” A 66-year-old man with diabetes mellitus and undergoing hemodialysis suddenly developed general fatigue, gait disturbance, dysarthria and dysphagia. These symptoms diminished spontaneously 7 months later. T2-weighted MR images showed symmetrical high signal intensity in the basal ganglia, and these abnormalities had almost disappeared 5 months later. There have been several similar case reports, and many of the patients were both diabetic and Asian. The pathogenesis of this condition is uncertain, but it may be associated with changes in regional blood flow (ischemia or hyperemia), effect of uremic toxins, or metabolic disturbance in the basal ganglia. The acute reversible parkinsonism is usually self-limiting and the prognosis is generally good, however, caution should be taken to prevent fatal infectious complications. Because the MR findings and clinical course resemble those of extrapontine myelinolysis, further study is needed to elucidate whether this condition is caused by extrapontine myelinolysis.

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A 65-year-old man with no previous medical history was admitted to our hospital with sudden onset of pneumococcal bacteremia. Disseminated intravascular coagulation and multiple organ dysfunction developed rapidly. There was no apparent site of infection. An abdominal computed tomography scan showed a very small spleen and Howell-Jolly bodies were present in the blood smear. Therefore, we suspected that hyposplenia was involved with pneumococcal bacteremia. Despite intensive treatment with continuous hemodiafiltration, endotoxin adsorption and plasma exchange, he died on the 14 th hospital day. In general, the spleen plays an important role in immunological function as a filter for bacteria, and produces immunological antibodies specific for a polysaccharide capsule of Gram-positive bacteria such as Streptococcus pneumoniae. Splenic dysfunction has been recognized as a major risk factor for severe overwhelming infections of Streptococcus pneumoniae. There have been some reports describing overwhelming postsplenectomy sepsis (OPSI), but there are few previous reports describing pneumococcal bacteremia in patients with adult hyposplenia. We report here a rare case of pneumococcal bacteremia complicated by adult hyposplenia

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We report here a rare case of bilateral primary adrenal malignant lymphoma with adrenal insufficiency in a patient receiving regular hemodialysis. A 74-year-old man was referred to our hospital from a local clinic because of anorexia and hypoglycemia. Abdominal CT scan demonstrated bilateral adrenal tumors, and the ACTH value was beyond the normal range (328 pg/mL). He was diagnosed as having adrenal insufficiency. After we administered hydrocortisone 20 mg/day, his general condition improved dramatically, and dopamine and noradrenaline levels were improved (96 pg/mL→16 pg/mL, 1,117 pg/mL→216 pg/mL, respectively) simultaneously. A right upper jaw tumor biopsy showed diffuse large B-cell lymphoma, and gallium scintigraphy demonstrated strong uptake in the right upper jaw, mediastinum and bilateral adrenal glands, suggesting that adrenal insufficiency was caused by bilateral adrenal malignant lymphoma.
To our knowledge, primary adrenal malignant lymphoma or adrenal insufficiency in a hemodialysis patient has not been reported previously. In addition to the case report, we discuss catecholamine metabolic disorder in adrenal insufficiency.

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