A prevalent cross-sectional sample of Japanese hemodialysis (HD) patients from the Dialysis Outcomes and Practice Patterns Study was analyzed to determine the percentage of patients whose values failed to meet targets in six different areas of hemodialysis practice. Cox survival models, with adjustments for patient characteristics, were used for these analyses to estimate mortality hazard ratios. Patient-years attributable to each of the six practice patterns were estimated. To calculate the expected gain in patient-years, the five-year survival curve for the Japanese HD population (based on actual current death rates) was compared with the projected five-year survival curve for the Japanese HD population if all patients were within the six practice guidelines. These calculations were performed separately for the Japanese guidelines and the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines. The proportion of patients failing to meet the six practice targets in Japan and the relative risk of mortality associated with being outside the targets were the basis for all life-years estimation. A considerably high number of Japanese HD patients were found to be outside the target ranges. Very few Japanese patients were within the targets for five or six indicators. The vast majority of patients (78.1%) were within two to four of the six indicators, and 20.5% of patients were within zero to one of the practice targets. The two individual practices resulting in the greatest life-year gains were increasing the proportion of patients with albumin levels above 4.0g/dL (43,525 life-years, 3.1% gained) and increasing the proportion of patients with hemoglobin levels above 11g/dL (24,878 life-years, 1.8% gained). The total potential life-years gained (72,958) was 27% lower than that suggested by the simple sum of patient-years obtained from the six individual practice patterns when modeled independently from each other (99,815). Results for hemoglobin in Japan vary depending on which target cut-off is used. If, instead of 11g/dL, a target value of hemoglobin ≥10g/dL were used, 16,580 patient-years could be saved if all patients achieved the target. Japanese guidelines should be revised based on the outcome of prospective, randomized controlled studies.

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Tumoral calcinosis is a rare disorder that most often occurs in periarticular regions of the extremities. Here, we report a case of cervical tumoral calcinosis in a hemodialysis patient. The patient was a 67-year-old Japanese man on maintenance dialysis for 5 years. He presented with a 2-week history of progressive cervical myelopathy in March 2006. Findings on cervical plain radiography showed spondylotic change and narrowing of the disc space between C-5 and C-6, but there was no definitive calcification. A spinal mass lesion posterior to the spinal cord at C3-4 level, resulting in marked spinal cord compression was demonstrated on magnetic resonance imaging of the cervical spine. Thus, the tentative preoperative diagnosis was cervical spine tumor. The patient underwent surgery to remove the mass for spinal cord decompression and stabilization of the cervical spine via a C3-C4 laminectomy and laminoplasty. Histologically, the lesion consisted of numerous nodules with calcified materials and a foreign body granulation reaction of multinucleated giant cells ; the histological characteristics were identical to those of tumoral calcinosis. Eventually, we diagnosed cervical tumoral calcinosis. Tumoral calcinosis should be considered in a maintenance hemodialysis patient with a mass lesion involving the cervical spine even if patients do not have metabolic abnormalities involving calcium/phosphate or metastatic calcification.

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Advances in medical treatment and hemodialysis (HD) therapy have increased the life expectancy of patients with chronic renal failure on HD, and now, improvements in the motor functions and quality of life (QOL) of these patients are being sought, to allow these patients to lead more fulfilling social lives. We sought to confirm the safety and effectiveness, especially for elderly patients, of exercise training during HD sessions as one of the methods of improving motor functions and QOL for patients on maintenance HD. A 3-month exercise training program was undertaken during the HD sessions in a 75-year-old male patient (Case1) and 65-year-old male patient (Case2) with chronic renal failure on maintenance HD. The patients exercised in their beds using a stationary cycle ergometer three times a week, during their routine HD sessions. There were no exercise-induced adverse events in any patient throughout the 3-month exercise training period. Laboratory and echocardiographic examination did not demonstrate significant changes in any patient after the exercise training period. On the other hand, significant improvements were observed in the motor functions, as assessed by the peak oxygen consumption, leg strength and sit-to-stand test time, and also on certain subscales of health-related QOL, after the exercise training period. In conclusion, exercise training during HD sessions appears to be a safe and effective intervention for improving motor functions and QOL in elderly HD patients.

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We report a 78-year-old man on chronic hemodialysis who presented with encephalitic symptoms caused by central nervous system (CNS) malignant lymphoma. The patient presented with a two-week history of headache after every hemodialysis session. Computer tomography (CT) of the brain did not detect abnormal findings. Cerebrospinal fluid examination demonstrated 83/3mm³ of mononuclear cells and 295mg/dL of protein, suggesting viral meningoencephalitis. Despite treatment with acyclovir, the patient gradually became unconscious and was intubated because of respiratory failure. Steroid pulse therapy was transiently effective to improve conciousness. Repeated brain CT demonstrated enhanced tumor-like mass lesion involving right posterior limb of the internal capsule and left posterior cingulated sulcus. Serum and cerebrospinal fluid IL2-receptor levels were elevated to 919IU/mL and 259IU/mL, respectively. Cytological examination of the serial cerebrospinal fluid samples showed atypical lymphocytes with coarse patterns, strongly suggesting malignant lymphoma of the CNS. The patient died after a 6-month clinical course of disease. Autopsy was not performed. In the earlier stage of the clinical course, viral meningoencephalitis was suspected because of typical symptoms and increased mononuclear cells and protein in the spinal fluid. Brain CT and cerebrospinal fluid findings along with subacute unconsciousness and poor response to corticosteroid over time strongly suggested the presence of CNS malignant lymphoma. Therefore, CNS malignant lymphoma should be considered in the differential diagnosis of subacute unconsciousness in patients undergoing dialysis.

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