Background : Advances in hemodialysis (HD) therapy and medical treatment have increased the life expectancy of patients with chronic renal failure, and attempt to enhance activities of daily living (ADL) and quality of life (QOL) with the prolongation of HD duration. Purpose : The present study investigated the relation between physical function and the duration of HD treatment in patients with chronic renal failure. Methods : Seventy-three patients with chronic renal failure (62±11 y) who have regularly received HD therapy entered the present study, and were classified into three groups ; group A (HD duration<5 y), group B (5 y≤HD duration<15 y) and group C (15 y≤HD duration). Clinical characteristics including age, dry weight, body mass index, blood hematocrit and hemoglobin, serum albumin, and physical activity were assessed and symptoms concerning QOL and ADL score were investigated using KDQOL-SF™ version 1.3. Straight leg raising, isomeric knee extension strength, handgrip strength, functional reach and maximal gait speed were measured as the parameters of physical function. Statistical analysis was performed using the analysis of covariance, and P value <0.05 was considered significant. Results : The handgrip strength was significantly lower in group C than that in group A (p<0.05). The maximal gait speed was significantly lower in group C than that in groups A and B (p<0.05, respectively), when it was corrected by age and physical activity as a covariate value. Conclusion : These findings suggested that the physical function of HD patients gradually declines with the prolongation of HD duration.

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Though a variety of bone joint complications are widely recognized in long-term dialysis patients, myelopathy caused by ectopic calcification surrounding the cervical spinal dura has not been reported. We encountered seven patients with the cervical peridural calcification (CPC) and performed surgery on four.
The present study investigated the clinical features of this condition. All seven had a dialysis history over 20 years, and the Ca×P product was high. Plain cervical CT scan was the most useful diagnostic tool for CPC, though was quite difficult to establish the diagnosis by plain X-ray, MRI or myelography. Clinical symptoms of CPC resembled those of spinal canal stenosis caused by thickening or ossification of the ligament. The spinal cord in the area of CPC was comppressed with calcified fibrous membrane surrounding the cervical dura mater, swelling and pulsation of spinal cord was obtained after not only excising the vertebral arch but also opening and removing the calcified membrane from the dura. Clinical improvement was obtained only in two patients with a short symptomatic period.

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We conducted a multi-center cooperative prospective survey of the technique and patient survival focusing on Japanese PD patients older than 65 years.
Four-hundred ten PD patients from twenty-five PD centers, were enrolled in the survey (mean 75 years old, max : 92 years old), and factors influencing the outcome were determined using the Cox proportional hazards model adjusted for possible confounding factors at the baseline. Variables examined in this study were ; patients' clinical background such as age, body mass index(BMI), comobidity determined by Charlson's Comobidity Index(CCI), residual renal function, blood parameters, principal person who selected PD treatment, and persons who actually performed PD bag exchange.
The 50% technical and patient survivals were 30.3 and more than 48 months, respectively. Those factors such as CCI, patient intention to select PD, bag exchange by patients, in addition to BMI and positive CRP levels, were demonstrated to be independent factors for both outcomes.
Conclusion : Less comobidity, independent life, absence of poor nutrition and inflammation could be predictive factors for better patient outcomes in elderly Japanese PD patients.

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Our study was to elucidate the feature of dialysis patients with atrial fibrillation (AF). We examined patients with (AF group ; n=29) and without AF (control group ; n=30) who underwent dialysis therapy in our institution. The duration of dialysis was comparable between the two groups. We evaluated their clinical characteristics, laboratory data and echocardiographic parameters. Age (p=0.040), left atrial diameter (LAD) (p=0.001), presence of valvular disease (p=0.023) and old cerebral infarction (OCI) (p=0.003) were significantly greater and the number of patients prescribed angiotensin converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB) was significantly smaller in the AF group. Furthermore, the duration of dialysis (p=0.049), LAD (p=0.019) and presence of valvular disease (p=0.001) were significantly greater in patients with chronic AF (n=12) than in those with paroxysmal AF (n=17). In the AF group, anticoagulant therapy was insufficient in patients with OCI. In addition, rhythm control was poor in patients with paroxysmal AF despite the administration of antiarrhythmic drugs.
These findings suggest that age, the duration of dialysis therapy and presence of valvular disease contribute to the occurrence of AF in dialysis patients. We consider that it is difficult for patients with AF to undergo rhythm control therapy. Furthermore, we suggest that ACE-I and ARB might be associated with the prevention of AF in dialysis patients.

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A 77-year-old woman developed chronic renal failure and became dialysis-dependent. Her uremic syndrome was in remission after dialysis had started, but she became drowsy, accompanied by delirium and dementia. Computed tomography and magnetic resonance imaging of the brain showed diffuse brain atrophy and chronic ischemia, which seemed to involve age-related changes in the brain. However, her patterns of electroencephalographic activity showed slow-waves, which was suggestive of metabolic brain disease or autoimmune brain diseases. Although she was in euthyroid state, antithyroglobulin test was highly positive. In addition, anti N-terminal enolase antibody specific for autoimmune Hashimoto's encephalopathy was positive. Based on these results, the diagnosis of Hashimoto's encephalopathy was obtained. Oral prednisolone 30 mg per day was prescribed and her neuropsychiatric symptoms were ameliorated. In conclusion, as a cause of consciousness disorder and dementia with psychotic manifestations in dialysis-dependent patients, autoimmune Hashimoto's encephalopathy should be considered.

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A 72-years-old man with hypertension and ischemic heart disease underwent coronary angiography on September 7, 2000. The findings demonstrated triple vessel stenosis. As a result, he underwent percutaneous transluminal coronary angioplasty (PTCA) and stent placement on September 14, 2000. Since purple toes and painful necrotizing lesions on the toes were demonstrated, he was re-hospitalized about four weeks after undergoing PTCA. Skin biopsy demonstrated CE. Though the serum creatinine (s-Cr) level was 1.1 mg/dL at the first admission to our hospital, s-Cr level was found to have deteriorated to 13.6 mg/dL, and he was therefore transferred to another hospital for advanced therapy.
The patient was placed on hemodialysis using heparin sodium as an anticoagulant. However, painful necrotizing lesions on the toes and livedo reticularis thereafter became worse than before. Therefore, the anticoagulant was changed to nafamostat mesilate. Livedo reticularis improved thereafter, but eosinophilia did not. After the administration of prednisolone (PSL) at a dose of 40 mg/day (0.6 mg/kg/day), the eosinophilia improved immediately. He improved after the amputation of the bilateral 5 th toe on December 12, 2000. PSL was tapered gradually at a dose of 10 mg/day, and he was discharged from the hospital on January 19, 2001.
We carried out ambulatory maintenance hemodialysis using low-molecular-weight heparin (LMWH) as the anticoagulant and administration of PSL at a dose of 10 mg every day in our hospital from January 20, 2001. Thereafter, the patient survived for about 5 years.
The prognosis of ESRD with CE has been reported to be very poor. According to our better than usual patient-survival, it is suggested that the prognosis of ESRD with CE may show improvement with administration of PSL and use of LMWH as the anticoagulant during hemodialysis.

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A 62-year-old Japanese man with a one-year history of hemodialysis was transferred because of the development of foot gangrene. He was also complicated by cerebral infraction and abdominal aortic aneurysm. The patient complained of painful digital cyanosis and ulcer on the left foot. Computed tomographic angiography and magnetic resonance angiography demonstrated a completely occluded left femoral artery and right popliteal artery ; thus, he was diagnosed as having severe arteriosclerosis obliterans in the bilateral lower extremities, and this arteriosclerosis obliterans was thought to be the cause of foot gangrene. Below-the-knee amputation of the left lower limb was performed. However, cholesterol crystals were found in the small artery obtained from the ulcer on the amputated foot specimen, indicating cholesterol crystal embolism had also occurred and might have contributed to the development of foot symptoms. As systemic anticoagulation therapy, i.e., administration of heparin and low-molecular-weight heparin in hemodialysis, is one of the risk factors for the occurrence of cholesterol crystal embolism, we used nafamostat mesilate as hemodialysis-associated anticoagulation. This study suggests that physicians should consider cholesterol crystal embolism in the differential diagnosis for foot gangrene in maintenance hemodialysis patients.

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In this paper, we report a patient in whom residual renal graft function was successfully preserved using continuous ambulatory peritoneal dialysis (CAPD) with Icodextrin solution at reintroduction of dialysis after deterioration of graft function. A 70-year-old female underwent cadaver renal transplantation in 2001 after two years of hemodialysis due to end stage renal disease. Renal graft function deteriorated gradually over several years, and CAPD was reintroduced in June 2004. However, we encountered difficulty in controling her water balance and she developed edema and cardiac enlargement. In September 2004, we changed the CAPD prescription from 1.5% dextrose to Icodextrin solution at night. CAPD with Icodextrin solution increased her urine volume and corrected her body fluid status, CTR (cardiothracic ratio) and improved lipid metabolism and nutritional status. In this case, CAPD with Icodextrin solution contributed markedly to preserving residual renal graft function and finally improved her quality of life as evaluated by SF-36 (short form 36).

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