The status of hospital infection control for viral hepatitis in dialysis facilities was investigated in 2006 and findings were compared to those obtained in 2000. We mailed questionnaires to hemodialysis facilities and recovered them from 1817 facilities (recovery rate of 50.63%). An infection control system such as an infection control commission and infection control manual was organized in a higher portion of facilities in 2006 than in 2000. The rate of bed fixation for anti-HCV antibody-positive patients was 67.3% and was higher than that in 2000. Administration of erythyropoietin in a divided dose to different patients, reuse of the used syringe, and use of leftover saline for another patient had decreased, but these practices had not been eradicated. A pre-filled syringe with erythyropoietin was used in 94.9% of facilities, but the use of pre-filled syringes for heparin was still limited to 27.1%. The HBs antigen- and anti-HCV antibody-positive rates were lower in facilities using gloves when returning blood. Information on anti-HCV antibody-positive result and the daily life consultations for anti-HCV antibody-positive patients were related to the lower anti-HCV antibody-positive rate. Image inspection of viral hepatitis patient was done periodically in 80% of facility, but medical examination by hepatologists was limited to 25.3%. Therapy for viral hepatitis was given in 39.6% of facilities, but anti-viral medical therapy with interferon was administered to fewer patients. In conclusion, infection control measures showed an improvement since 2000, but there is still considerable room for improvement. The diagnosis and treatment of viral hepatitis in dialysis patients remains insufficient. Guidelines for diagnosis and treatment of viral hepatitis in dialysis patient appear to be necessary.

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Darbepoetin alpha was administered intravenously for one year to 157 hemodialysis (HD) patients, and the efficacy, safety and medical economics were investigated. Weekly intravenous doses of 10μg, 15μg or 20μg of darbepoetin alpha were administered to maintain the hemoglobin (Hb) values of the HD patients at the target Hb concentration(10g/dL to 11g/dL); however, washout was performed if the Hb value exceeded 11g/dL. When iron deficiency was diagnosed from iron-related test values (TSAT of 20% or lower or serum ferritin concentration of 100ng/mL or less), saccharated ferric oxide was slowly administered intravenously 10 times at each dialysis. To investigate the medical economics, the total costs of darbepoetin alpha and recombinant human erythropoietin (rHuEPO) administered for one year were calculated and compared. The Hb concentration profile by month was 9.68±1.11g/dL to 10.58±1.56g/dL, which was basically within the target Hb concentration range. A single dose of 10μg was the most common, accounting for 57% of all doses. This was followed by 15μg at 23% and 20μg at 20%. The washout period was 1.5±0.4 weeks. No definite adverse drug reactions due to darbepoetin alpha were observed. The cost (reimbursement price) of rHuEPO for one year was about ¥51.58 million and that of darbepoetin alpha was about ¥30.04 million. These results suggested that the administration of darbepoetin alpha maintained the Hb value within the target Hb concentration range in HD patients administered 10μg to 20μg of darbepoetin alpha intravenously once a week for a long period, there were no adverse drug reactions and darbepoetin alpha should have significant medical economic effects.

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We developed new software with which doctors can access the hemodialysis management system (Miracle DIMCS21) during doctor's rounds. Miracle DIMCS21 obtained laboratory data and content of prescription from the electronic chart system (HOPE/EGMAIN-FX) of the hospital. Using this new software, the information necessary for doctor's rounds was collected on a screen from Miracle DIMCS21 and the electronic chart system of the hospital. The information on dialysis notes, main lab data, CTR, summary of problems and other data were collected and displayed on a single screen. This new software facilitated access to previous lab data, as well as detailed information on dialysis, prescription, and lab data at the touch of a button. This software is used at present for 188 dialysis patients in a 90-bed facility. Since the software is able to load multiple data sets before beginning rounds, the physician is able to move instantly to the next patient's screen by one click of the computer terminal using a wireless LAN connection. When the patient is changed, accessing information on the electronic chart system takes time, but this limitation could be compensated for using this software. Doctor's rounds are assisted by this new software because the information required can be obtained in a shorter time than that with the conventional clinical recording system using paper.

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A 50-year-old patient underwent hemodialysis for chronic renal failure due to autosomal dominant polycystic kidney disease for 5 years. Six years previously, thoracico-abdominal graft surgery was performed for acute aortic dissection. He was hospitalized for examination of fever of unknown origin (FUO) persisting for one month. Methicillin-susceptible Staphylococcus aureus (MSSA)was detected by blood culture, but conventional imaging techniques such as body CT and ultrasonography could not detect the focus of infection. However, ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) definitively identified the foci of increased FDG uptake in the aortic graft, leading to a diagnosis of aortic graft infection by MSSA. Pan-prosthetic aortic graft infection is a life-threatening complication, and the traditional surgical therapy requiring total graft excision and extra-anatomic reconstruction is thought to be associated with high morbidity and mortality. Therefore, the patient was treated with long-term antibiotics without graft removal and pyrexia was finally improved a few months later. Generally, ¹⁸F-FDG accumulates not only in malignant tissues but also at sites of infection and inflammation due to the increased metabolic rate both in cancer cells and inflammatory cells. Therefore, it was demonstrated that FDG-PET is useful for detecting infections as well as malignant tumors. Hemodialysis patients are susceptible to various kinds of infectious diseases causing FUO due to their immunodeficiency. Moreover, it is difficult to diagnose such patients due to their atypical symptoms and lower positivity rates on various examinations. As demonstrated in the present case, FDG-PET could become a promising tool for evaluating FUO in hemodialysis patients.

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We report a case of heparin-induced thrombocytopenia (HIT) that developed during hemodialysis (HD) in a patient with ANCA-associated glomerulonephritis. A 91-year-old female with no previous disease history was admitted to our hospital because of rapidly progressive glomerulonephritis manifesting acute renal dysfunction (BUN 105 mg/dL ; Cr 8.2 mg/dL). Concomitant alveolar hemorrhage and an elevated serum level of MPO-ANCA were present. Given her clinical features, she was diagnosed as having either ANCA-associated glomerulonephritis or microscopic polyangitis (MPA). Shortly after admission, continuous HD was started with unfractionated heparin used as an anticoagulant. Thirteen days later, severe thrombocytopenia (1.7×10⁴/μL) developed without thromboembolic or hemorrhagic complications. Even after heparin was switched to nafamostat mesilate for further HD, the platelet count remained below 5.0×10⁴/μL. Subsequently, anti-heparin/platelet factor 4 (PF4) complex antibody (HIT antibody) was detected in her serum and she was diagnosed with HIT, an immune-mediated disorder caused by heparin exposure leading to thrombocytopenia. We used Argatroban, a synthetic direct thrombin inhibitor, as an alternative anticoagulation therapy. Under this treatment, the platelet count gradually recovered and was maintained above 10×10⁴/μL after day 38. Meanwhile, systemic steroid therapy for ANCA-associated nephritis decreased the serum MPO-ANCA level to within the normal range. Renal function also improved, with the serum creatinine level stabilizing at around 4.0 mg/dL. HD was consequently discontinued and the patient was discharged on day 58. HIT is a well-recognized complication of HD, with an overall incidence of 3.9% in patients newly treated with HD. However, it is important to distinguish HIT from thrombocytopenia that can occur in ANCA-associated nephritis for a variety of reasons, such as DIC, drug-induced disorder, and thrombotic microangiopathy. The most feared complication of HIT is venous or arterial thrombosis, with an estimated mortality rate of 20%. In order to avoid this life-threatening complication, early recognition of the disease by full blood count on a regular basis while receiving heparin, and initiation of appropriate treatment are essential.

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Leukocytapheresis (LCAP) is an effective therapeutic strategy for ulcerative colitis (UC). A synthetic serine protease inhibitor, nafamostat mesilate (NM), is clinically used as an anticoagulant during LCAP. NM reduces the bleeding risk and inhibits bradykinin (BK) generation during LCAP. For NM-intolerant patients, NM is usually substituted with heparin sodium (HS) to perform LCAP. Since HS has no inhibitory property against BK generation, NM-intolerant UC patients are often compelled to discontinue LCAP due to BK-associated symptoms. Because gabexate mesilate (GM), a synthetic serine protease inhibitor, also suppresses BK generation, we used GM instead of NM during LCAP, and successfully prevented BK-related symptoms. Therefore, we conclude that LCAP is applicable for NM-intolerant UC patients by substituting GM for NM as an inhibitor of BK generation.

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A 66-year-old man who had been undergoing hemodialysis treatment for 27 years showed a refractory fever in November 2006, and was admitted to Kitasato University Hospital in December 2006. Multiple metastatic lesions of the bone, bilateral adrenal glands and peritoneum were revealed, although the original carcinoma lesion could be not found in the kidney, urinary tract, gastrointestinal tract, lung, heart, liver or gall bladder before he died in February 2007. Autopsy revealed a renal clear cell carcinoma with a diameter of 3.0×2.0 cm in the upper part of the right kidney. Renal clear cell carcinoma growing on aquired cystic disease of the kidney (ACDK) is difficult to see by conventional imaging techniques. Renal cell carcinoma should be considered in cases of ACDK.

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