It is commonly thought that the use of vascular access systems (native arterio-venous fistula or vascular grafts) within the early postoperative period should be avoided. In “Guidelines for vascular access construction and repair for chronic hemodialysis”, the use of native arterio-venous fistula is recommended to begin two weeks postoperatively and that of vascular grafts three to four weeks postoperatively.
In emergencies, if it becomes necessary to start hemodialysis, we have to catheterize the patients. As a result, infection and a decline in the patient's activities of daily living reduce the patient's overall quality of life. Upon reviewing three years of data from 95 patients who received hemodialysis (68 graft cases) between April 2001 and March 2003, we found that the complications that occurred within one month postoperatively were due to exposure of the vascular graft by diastasis (1 case) and thrombosis (5 cases).
The primary patency rates of native arterio-venous fistula at 1, 2, and 3 years were 72.1%, 64.7%, and 60.3%, respectively. The secondary patency rates of native arterio-venous fistula at 1, 2, and 3 years were 72.1%, 64.7%, and 60.3%, respectively. The primary patency rates of vascular grafts at 1, 2, and 3 years were 70.4%, 48.1%, and 44.4%, respectively. The secondary patency rates of vascular grafts at 1, 2, and 3 years were 85.2%, 81.5%, and 74.1% respectively. Based on these findings, we conclude that use of the blood access systems in the early postoperative period reduces the need for hospitalization due to hemodialysis and blood access complications. Thus, this method contributes not only to the patient's quality of life, but also relieves some of the financial burden due to medical expenses.

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The current status of patients requiring daily life assistance, among hemodialysis patients managed at hemodialysis centers in Ishikawa Prefecture, was surveyed. A questionnaire was filled out by the chief nurse responsible for the care of hemodialysis patients at each of the 36 hemodialysis centers in Ishikawa Prefecture. Responses to the questionnaire were analyzed to clarify the current status of nursing for hemodialysis patients. Of all hemodialysis patients requiring daily life assistance, 30.0∼42.6% were rated as requiring Level 1 assistance (the lowest level) and 23.7∼40.7% were rated as requiring Level 2∼5 assistance (progressively higher levels of assistance with various aspects of daily life). Of all the hemodialysis patients managed at these centers, 11.4∼19.1% had difficulties moving. Symptoms of dementia and/or disorders of communication were noted in about 5∼10% of all the hemodialysis patients. Approximately 81.0∼90.5% were patients who went to the hospital from home. Only about 2% of the patients were treated at hemodialysis centers outside the facilities or hospitals in which they were accommodated. These results indicate that in Ishikawa Prefecture, accommodating hemodialysis patients at the available facilities or hospitals is difficult and that hemodialysis patients requiring daily life assistance or having disabilities often need assistance from home care service providers or their family members so that they can continue receiving hemodialysis. I therefore propose that, when providing nursing care for hemodialysis patients requiring daily life assistance, it is essential to make better use of home care services for hemodialysis patients and to pay close attention to the important role played by family members.

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A report on the current status of maintenance dialysis therapy in Japan has been presented annually by the Japanese Society of Dialysis Therapy. The most fundamental and important issue is a shift in the cumulative number of dialysis patients, which has been expressed as a linear increment for last some 30 years. This report indicates that a shift in dialysis patient number is not adequately expressed as a linear increment, but is approaching a ceiling. The relation between a cumulative dialysis patient number (Y) and year of investigation (X) is expressed as a multiitem approximation formula (MIAF). When the first degree is applied in a MIAF (1st MIAF), the approximation value (R) is 0.9779 while, when the fifth degree (5th MIAF) is applied, the value is as high as 0.9996. An analysis of the first, and second degree differential of the 5th MIAF, which is postulated as the speed and acceleration of the shift in dialysis patient numbers, demonstrated that a decrement in the acceleration first appeared in 1991, while a decrement in the speed appeared and negative acceleration started in 1999. Such a ceiling tendency is assumed to be derived from consecutive shrinkage in the application of social medical insurance starting as an “inclusion” in 1992.

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With an increasing number of hemodialysis patients, surgery on hemodialysis patients is also increasing. From an anesthetic perspective, chronic renal failure patients on hemodialysis belong to a high risk group. However, there are no statistical data on anesthesia-related critical incidents among this group. We investigated the morbidity, mortality and etiology of critical incidents (cardiac arrest/other critical events such as serious hypotension, serious hypoxemia and serious bradycardia) during anesthesia among 998 chronic renal failure patients on hemodialysis. Based on ASA physical status (ASA-PS), the numbers of the patients in ASA-PS 3, 3E, 4, 4E were 895 (89.7%), 72 (7.2%), 13 (1.3%), 18 (1.8%), respectively.
Critical incidents occurred to 30 patients, and 11 of them died during anesthesia or within 7 postoperative days. The morbidity and mortality rates of critical incidents (per 1,000 cases of anesthesia) were 30 and 11, respectively. Cardiac arrest occurred to 3 patients. The incidence of cardiac arrest was 3 per 1,000 cases of anesthesia.
Etiologies of critical incidents were preoperative complications in 23 cases (76.7%), and anesthetic management in 7 cases (23.3%). The major preoperative complication related to critical incidents was cardiac failure, followed by sepsis. The most frequent problem of anesthetic management was regional anesthesia such as spinal anesthesia or epidural anesthesia. The incidence of critical events was higher in the patients with ASA-PS 4 and 4E than in those with ASA-PS 3 and 3E. ASA-PS correlated with incidences of critical events in hemodialysis patients.
We conclude that hemodialysis patients should be considered high risk group for anesthesia. Furthermore, preanesthetic assessment and preparation are essential for the safety of anesthetic management.

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A woman in her 50s who had lupus nephritis (LN ; type Vb) was treated with prednisolone (10 mg/day). Her serum levels of creatinine (Cr) and uric acid (UA) were around 1.2 mg/dL and 8.0 mg/dL, respectively. In the middle of October 2005, mizoribine (MZ ; 50 mg/day) was started due to LN relapse. She, however, discontinued MZ on day 4 of administration because of nausea and loss of appetite. Despite the withdrawal, she noted worsening of general medical conditions. Then two weeks later, she developed an oliguric state, acute renal failure (ARF ; Cr 14.2 mg/dL) and hyperuricemia (UA 25.1 mg/dL). Serum MZ concentration was detected at 0.43 μg/mL even 2 weeks after the withdrawal of MZ. ARF was thought to have been caused by hyperuricemia concomitant with uric acid nephropathy as an adverse effect of MZ. Hemodialysis (HD) was performed and her renal function recovered to the previous level. In this case, a vicious cycle consisting of prolonged MZ metabolism, hyperuricemia and progressive renal dysfunction is thought to have influenced the development of uric acid nephropathy and oliguric ARF.

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An 82-year-old female with autosomal dominant polycystic kidney disease (ADPKD) who had received hemodialysis therapy for 14 years is reported. She experienced pain in the right leg on walking and eventually became bed-ridden. She consulted our emergency room for severe nausea and epigastralgia and vomitted blood. Since she was diagnosed as having severe gastroesophageal reflux disease by endoscopic examination and concomitant pneumonia of the inferior lobe of left lung by chest X-ray finding, she was admitted to our hospital. When both diseases were considered recovered, she was allowed to start ingestion again on the 7 th day after the admission. On the next day, she complained of recurrent abdominal pain, and she was diagnosed as having a small intestinal ileus. Oral intake was stopped and an ileus tube was inserted immediately. She developed pyrexia and hypotension on the 10th day and died due to sepsis on the 11th day. We obtained consent for an autopsy from her family on the day of death. Autopsy demonstrated that part of the ileum 30 cm oral from the ileocecal portion was completely impacted in the right obturator foramen. Therefore, we diagnosed that ileus was induced by obturator hernia. In general, an obturator hernia is thought to be rare as a cause of ileus and is not familiar to physicians. There was no erosion, ulcer or necrosis in the incarcerated intestine on autopsy performed on the day of death. Even in the early stage before necrosis has occurred in the incarcerated intestine, the obturator hernia could induce serious complications such as sepsis particularly in immunocompromised hosts. We conclude that we should not overlook obturator hernia and should consider surgery when we encounter a dialysis patient with ileus.

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