Background : Recently, interest in advance directives (ADs) has risen with respect to the patient's right of self-determination and various problems with end-of-life decision-making. However, there are many administrative problems that should be resolved, such as confirmation or restatement and assessment of decision-making capacity. Those problems could be resolved in dialysis patients who must be continuously involved with dialysis facilities throughout their life. We, therefore, conducted an attitude survey regarding terminal care among hemodialysis patients (HDs) and predialysis chronic kidney disease patients (non-HDs) in our hospital to investigate whether dialysis patients were better suited for advance directives. Material and Methods : We conducted an anonymous questionnaire survey among one hundred thirty HDs (collection rate 70.8%) and one hundred non-HDs in January and March 2009. Results : The rate of patients familiar with ADs among HDs (22.6%) was greater than that among non-HDs (11.1%) (p=0.022), and the rates of patients who wanted to make an AD were 48.8% and 41.8% among HDs and non-HDs, respectively. The rates of patients who had talked with someone about end-of-life decision were 21.7% and 19.8%, among HDs and non-HDs, respectively. The rate of patients who clearly express their wishes about receiving artificial feeding when the ability to communicate was judged to have been irreversibly lost was greater among HDs (54.6%) than among non-HDs (22.5%) (p=0.001). In the superscription situation, the rate of patients who clearly expressed their wishes about the continuation or withdrawal of dialysis in HDs was 60.7%. Conclusions : Among HDs, the rate of applicants making ADs reached 48.8%, and there were more patients who could clearly express their wishes about end-of-life decisions compared to that among non-HDs. Therefore, it was thought that dialysis patients were better suited for advance directives.

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During a typical hemodialysis (HD) treatment, excessive water removal often induces hypotension and muscle spasm, thereby leading to peripheral circulatory failure. Intermittent infusion hemodialysis (I-HD) using backfiltration of ultrapure dialysis fluid produced by an automated dialysis machine, GC-110N (JMS Co. Ltd., (Town), Japan) was newly developed to improve the physical condition of patients. I-HD may therefore transiently improve the peripheral circulation by repeated intermittent infusion. The aims of this modality are : (1) improving the blood flow condition ; (2) enhancing extravascular to intravascular water transfer ; and (3) improving the efficacy of solute removal from the intracellular compartment. A multi-center clinical trial was carried out to evaluate the clinical effectiveness of the I-HD therapy in comparison with normal HD (N-HD). We enrolled 20 chronic renal disease patients in this cross-over study of I-HD and N-HD. I-HD includes the intermittent infusion (rapid infusion at a rate of 200-300 mL per occasion of infusion ; 7-10 times per treatment) and changes in the amplitude of the patient's circulatory blood flow volume must be maintained within approximately 5%. The values for removal rate (RR), solute clearance (CL) and clear space (CS) for urea, creatinine, uric acid, inorganic phosphate, β₂-microglobulin (β₂-MG) and α₁-microglobulin (α₁-MG) were compared between I-HD and N-HD therapies. Time course of blood volume (BV) and peripheral blood flow rate of the patient were measured continuously by a hematocrit monitor and laser flowmeter, respectively. As a result, increases of BV and peripheral blood flow rate were observed for each infusion in all patients. Time-averaged BV reduction during treatment was significantly lower in the I-HD than in the N-HD, despite removal of almost an identical amount of water. Although there was no significant difference in the RR for all solutes between I-HD and N-HD, the average of CS values in I-HD was higher than those in N-HD for all solutes. In particular, I-HD showed significantly higher CS values for inorganic phosphate and α₁-MG than N-HD. Improvement of peripheral circulation due to intermittent infusion might be increased in extravascular to intravascular water transfer and solute transport from the intracellular compartment. From 1 to 4 hours after the start of treatment, α₁-MG CL deterioration with time in the N-HD and the I-HD were 73% and 30%, respectively. Moderate reduction of CL in I-HD was due to the prevention of membrane fouling by intermittent backfiltration of the dialysis fluid. The validity of I-HD therapy using GC-110N was clarified on the basis of these observations and results during the clinical trial. Therefore, improvement of peripheral circulation and solute removal from the extravascular compartment for relatively larger molecular weight substances were observed in I-HD by enhanced plasma refilling.

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[Objective] To examine the influence of ischemic heart disease (IHD) against poor mental health (MH) in dialysis patients. [Methods] Subjects consisted of 50 patients with end-stage renal failure who underwent regular hemodialysis in a hospital affiliated with Showa University Hospital. MH was estmated by the MH score on SF-36v2.0. Moreover, depressive symptoms were assessed by the Center for Epidemiologic Studies-Depression (CES-D) Scale. All subjects underwent SF-36v2.0, CES-D Scale, clinical and laboratory tests, and were divided into two groups (IHD group or non-IHD group). [Results] Morbidity due to diabetes mellitus and serum levels of high sensitive C-reactive protein were significantly higher, and MH scores were significantly lower in patients in the IHD group. Stepwise regression analysis demonstrated that the history of IHD had a significant impact on MH score in hemodialysis patients. [Conclusion] These findings suggest that IHD may be involved in poor MH among hemodialysis patients.

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The patient was a 57-year-old man who had begun hemodialysis in May 2000 duo to sclerotic kidney. In January 2008, periodic computed tomography showed an enhanced cystic mass in the left kidney. We diagnosed this patient as having renal cell neoplasm arising in acquired cystic disease of the kidney (ACDK). In February 2008, laparoscopic retroperitoneal nephrectomy was performed. Histopathological evaluation demonstrated that the tumor do not fit into the categories recognized in the current classification system. This tumor was composed mainly of large eosinophilic cells arranged in a solid pattern and contained deposits of calcium oxalate crystals.

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Less common indications for dialysis therapy include life-threatening electrolyte and acid-base disorders. We encountered a case of severe metabolic alkalosis, hypernatremia and hypokalemia after treatment of fluminant hepatitis. A 31-year-old man with arterial fibrillation was admitted to our hospital because of severe liver dysfunction. He was diagnosed as having fluminant hepatitis and treated with three sessions of plasma exchange. Then he received steroid therapy and infusion of fresh frozen plasma. Although he recovered from hepatic failure, severe metabolic alkalosis, hypernatremia and hypokalemia emerged. These disorders were considered mainly due to iatrogenic factors such as plasma exchange and steroid therapy as well as administration of glycyrrhizin. Since cardiac and renal functions were also diminished, it seemed difficult to treat these disorders by conservative therapy. Two sessions of hemodialysis successfully corrected the electrolyte and acid-base disorders.

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The patient was a 58-year-old man who had been diagnosed as having diabetes mellitus at age 51 and received therapy thereafter. Hemodialysis was started at age 54, because of end stage renal failure due to diabetic nephropathy. The patient was transferred and admitted to our hospital on July 9, 2008, complaining of a painful ulcer on the tip of the penis. At the time of admission, ulcers and necrosis were observed on the prepuce and penis, which had turned black. Because of marked pain associated with penile necrosis, he underwent partial penectomy on July 17. After surgery that ultimately resolved severe pain, the wound re-opened. Therefore, debridement was carried out. After debridement, the wound was healing well. Pathologic evaluation demonstrated inflammatory and necrotic changes without any signs of malignancy. Although diabetic arterial obliteration sometimes causes necrosis of toes and feet, penile necrosis is rare. We found only 18 reported cases of penile necrosis due to diabetes in Japan.

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A 56-year-old female with chronic renal failure caused by chronic glomerulonephritis underwent continuous ambulatory peritoneal dialysis (CAPD) in December 2005. Approximately 3 months later, a large right hydrothorax suddenly developed. The concentration of glucose in the intrapleural fluid was markedly higher than that in serum, suggesting pleuroperitoneal communication. Technetium-99m-labeled macroaggregated albumin scan clearly demonstrated communication between the peritoneal and pleural cavities. Despite the condition, the patient wanted to continue with CAPD and thus video-assisted thoracoscopic surgery was performed. Using dialysis solution containing indigo carmine infused through a CAPD catheter, we found two blebs on the diaphragm that gradually became enlarged and stained blue. Dialysis solution flowed through one of these blebs. Following cyst removal, the diaphragm defect was directly closed with a surgical stapler. The postoperative course was very favorable and the patient could restart CAPD the day following surgery, and was discharged from our hospital on day 7 postoperatively. Two years and 10 months since the surgery, there has not been any recurrence of hydrothorax.

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The patient was a 61-year-old woman undergoing peritoneal dialysis (PD) due to chronic glomerulonephritis since 1996. She developed bacterial peritonitis in December 1998 and January 1999. PD therapy was discontinued because of peritoneal calcification in August 2006, and 1 month later the PD catheter was withdrawn. After withdrawal of the catheter, she complained of abdominal fullness due to a gradual increase in ascites, and an elevated level of C-reactive protein (CRP) was detected. Since progressive calcification of the peritoneum was observed, development of encapsulating peritoneal sclerosis (EPS) was suspected. After the symptoms of ileus were observed in April 2007, she was admitted to our hospital under a diagnosis of EPS. On admission, she showed significant emaciation with low fever and abdominal computed tomography demonstrated massive ascites and calcification of the peritoneum. Since the high-levels of CRP persisted despite prednisolone therapy, PD catheter reinsertion was performed for removal of the ascites and peritoneal lavage. Subsequently, the levels of CRP and IL-6 in the ascites improved. In conclusion, we report a case in which prednisolone therapy, removal of ascites and abdominal lavage by reinsertion of a catheter were effective for intractable EPS.

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