【Purpose】 This study investigated the frequency of education being provided to patients with stage 1-4 chronic kidney diseases(CKD)by nurses on an outpatient basis, and the “structures” of outpatient care that affected their performance. 【Methods】 This study was based on a questionnaire survey conducted by mail. The targets were 2,024 medical institutions extracted from the membership lists of the Japanese Society for Dialysis Therapy and the Japanese Society of Nephrology. The analysis methods involved the classification of medical institutions into three (educated, quasi-educated, and non-educated) groups according to the definition of patient education, summation in each group, and the testing of “structural” differences among the groups. 【Results】 The analysis of 354 valid responses demonstrated the following : 1) the rate of nurses providing education was 13.0% ; 2)such education was significantly associated with the introduction of more than one type of renal replacement therapy, and, regarding the trend of pathology in those patients, the predominance of medical diseases of the kidney (the same was true for the quasi-educated group) ; 3) providing education was significantly associated with a great workload ; and 4) it was also significantly correlated with the assignment of certified nurses as specialist and the preparation of blood collection rooms. 【Discussion】 The rate of nurses providing education, which is considered intended for mainly peritoneal dialysis, was only 13%. However, since the assignment of certified nurses as specialists is expected to facilitate patient education, it is important to train highly specialized nurses such as Certified Nurse Specialist in Chronic Care Nursing. It is also beneficial to prepare blood collection rooms as a means to functionally differentiate outpatient nursing. Under the conditions of complicated outpatient work, to overcome the current situation, it is necessary to streamline outpatient work, avoid complications, and “concentrate” on their patients.

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Two cases of secondary hyperparathyroidism under maintenance dialysis by either hemodialysis or peritoneal dialysis were treated with an extended dosing interval of one tablet containing 25mg of cinacalcet. Those patients were initially prescribed a daily dose of one 25mg tablet. However, one week later symptomatic hypocalcemia appeared ; therefore, the mode of dosing with one 25 mg tablet was changed from daily dosing to an extended dosing interval every other day (PD patient) or immediately after the HD session 3 times a week. Three months after the change of dosing mode, iPTH levels were maintained below 100pg/mL. This mode of dosing is a useful modification of cinacalcet administration, especially in patients showing symptomatic hypocalcemia induced by daily dosing.

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Many studies have reported that carotid parameters measured by ultrasonography are predictors for cerebral infarction in nondialysis patients. Using a cross-sectional design, this study investigated whether those carotid parameters are also associated with cerebral infarction and left ventricular diastolic function in chronic hemodialysis (HD) patients. We studied 63 HD patients aged 61.4±11.5 years who underwent regular hemodialysis in Hidaka Hospital. All subjects underwent carotid ultrasound measurements when they performed brain magnetic resonance imaging (MRI) or computed tomography (CT). Cerebral infarction was detected significantly more frequently in patients with max intima-media thickness of common carotid artery (IMT)>2.2mm (Odds ratio=3.14, 95%CI=1.11-8.92). There was a positive correlation between PS and E/E' (r=0.322, p=0.009). These findings suggest that max IMT is significantly associated with the presence of cerebral infarction, while PS is related to left ventricular diastolic function in chronic HD patients.

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The patient was a 74-year-old woman with chronic renal failure being treated conservatively. The cause of renal failure might be renal sclerosis. She had complained of nausea and anorexia since October 2007. She was admitted to Handa City Hospital due to the progression of renal failure on October 23, 2007. On admission, serum levels of blood urea nitorogen (BUN), creatinine (Cr), and bicarbonate (HCO₃^-) were 64.1mg/dL, 5.14mg/dL, and 13.2mmol/L, respectively. There was no abdominal pain and no signs of severe lesion on abdominal ultrasonograph. Only chronic gastritis was detected in the endoscopy. Her serum levels of BUN and Cr were elevated to 80.4mg/dL and 6.38mg/dL on the third day after admission. Hemodialysis was started for uremia on the fourth day. However, her complaint did not improve and poor sight and unclearness appeared. Consciousness gradually became somnolent, so magnetic resonance imaging (MRI) of the brain was performed on the 8th day. T2, FLAIR, and diffusion-weighted MRI showed high-signal-intensity areas in the periaqueduct, over the mamillary bodies, and inside the thalamus, which was a characteristic finding of Wernicke's encephalopathy. Thiamine treatment was immediately initiated, and consciousness promptly improved. Later, a low plasma thiamine level of 14ng/mL (normal range 20-50 ng/mL) was demonstrated. She was treated with regular hemodialysis and rehabilitation, then transferred to another hospital for rehabilitation on the 57th day. The cause of Wernicke's encephalopathy was considered to be in adequate nutrition due to diet therapy and uremia, coupled with the loss of water-soluble vitamins during the dialysis procedure.

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A 65-year-old female underwent maintenance hemodialysis in 1983 due to idiopathic renal failure. Thereafter she underwent a renal transplant from a living donor. Maintenance hemodialysis was re-instituted in 2001. In July 2007, synthetic vascular prosthesis was implanted on her left forearm, due to occlusion of the right native arterioveous fisutula. There was limited bleeding during the operation (less than 50mL). Ten days after, the hemoglobin level decreased from 10.7g/dL to 7.7g/dL. Increase of erythropoietin and iron injection improved anemia. Fifty days later, the hemoglobin level began to decrease again gradually. Ninety days later, the hemoglobin level decreased to 6.6g/dL. The diagnosis of hemolysis was based on elevated serum aspartate aminotransferase (AST 43 IU/L) and lactate dehydrogenase (LDH 974 IU/L), and decreased serum haptoglobin (3mg/dL). The Coombs test and cold agglutinin were negative. Ultrasonography and angiography showed a dissociation of the arterial wall in the upper arm and a pseudo cavity at the anasotomosis. Blood was flowing backward in the pseudo cavity. Blood transfusion was performed by 4 units. About 3 months later, hemolytic anemia has improved by administration of erythropoietin only. Despite persistent dissociation of the artery, there has not been any recurrence of hemolytic anemia during 1-year follow-up.

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The safety and effective method of interferon (IFN) therapy has still not been established in HD patients. Therefore, this study assessed the clinical significance of IFN-β therapy. The first patient was a 38-year-old male with a high baseline viral load and serotype 1. IFN-β (6 million units per day) was administered intravenously daily for 2 weeks, and subsequently administered on the day of HD therapy for the next 22 weeks. IFN-β was infused for 30 minutes before HD on the day of HD therapy. The patient achieved early virological response (EVR) but not sustained virological response (SVR). He received IFN-β re-treatment because HCV titer was increased after treatment. The same dose was administered intravenously daily for 1 week, and subsequently administered on the day of HD therapy for the next 2 years. IFN-β was infused for 30 minutes at the same time as starting HD. He had no side effects and was negative for HCV-RNA, but did not achieve SVR after further treatment for 2 years. The Cmax of IFN-β infused during the initial time of HD therapy was slightly high compared with that infused before HD (262±41pg/mL vs. 214.7±38.25pg/mL). The second patient was a 58-year-old male with a low baseline viral load and serotype 2. IFN-β was administered intravenously by the same protocol as re-treatment protocol in the first patient. He achieved SVR after 24 weeks. The dose of IFN-β (3 million unit per day) was changed after 8 weeks because of hypotension, and then the symptom improved. Cmax of IFN-β decreased from 259±43.9pg/mL to 143.5±5.09pg/mL. There were no other side effects. This study suggests that IFN-β is useful for HD patients from the perspective of safety and efficacy.

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Guillain-Barré syndrome (GBS) is a clinical entity characterized by acute onset and paralyzing inflammatory peripheral nerve involvement. Plasma exchange (PE) and intravenous immunoglobulin (IVIg) have been recommended to date as treatment modalities for GBS, and the efficacy of these two treatments was reported to be equivocal in patients without renal failure. Since the incidence of GBS in hemodialysis patients is rare, the therapeutic recommendation for GBS in patients with renal failure has not yet been established. We encountered 4 hemodialysis patients complicated by GBS. In 2 of these patients, we initially administered IVIg, but there was no beneficial effect was observed. Therefore, we performed PE on these patients. A remarkable improvement on their muscular strength was observed immediately after PE. We selected PE as the first line of treatment for GBS based on these experiences. Therefore, the subsequent 2 patients were initially treated with PE and the results were successful. We conclude that PE is better than IVIg for the patients with renal failure.

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