We developed a new simple buttonhole (BH) method combining Twardowski's method and Toma's method. In this study, we evaluated the usefulness and safety of our method. We enrolled hemodialysis patients who were clinically stable, and receiving outpatient dialysis 3 times per week. Nine patients (male/female : 6/3, age : 62.3±17.1 years, primary disease : DM 5, CGN 4) were enrolled. Written informed consent was obtained from each patient. A simple BH was made by repeated cannulation at the same site and in the same direction as the initial cannulation. To ensure precise repitition of the procedure in each patient, cannulation was performed by the same staff using the same type of needle. We repeated cannulation until the resistance to needling decreased, at which point, we considered the establishment of the matured BH route complete. Thereafter, we used a dull needle for the BH and started HD. One patient needed to be re-routed due to difficulty in cannulation. Therefore, we evaluated a total of 10 procedures. Cannulation was repeated 3.3±0.3, 80% and the total BH was generally completed by 3 repeated cannulations. All patients continue using the BH successfully and there has not been any report of infection or drop out during the period of observation (one to ten months). This simple BH method can improve the limitations of both Twardowski's method (expansion of BH) and Touma's (cost of BH creation), and can also be performed safely. The BH method can lead to the prevention of needle-stick injury and should be promoted for the sake of medical safety.

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An 81-year-old male on maintenance hemodialysis since December 2008 had been taking various medications including Lansoprazole. The patient developed symptoms of chronic watery diarrhea in March 2009. On colonoscopy, a longitudinal ulcer was noted on the left side of the colon. Biopsy speciments demonstrated thickened subepithelial collagen bands. After discontinuing Lansoprazole, the patient's symptom improved. The patient's clinical and histological findings were compatible with a diagnosis of Lansoprazole-associated collagenous colitis. Many hemodialysis patients have been administered proton pump inhibitors such as Lansoprazole. If a hemodialysis patients with chronic diarrhea has been taking Lansoprazole, the possibility of collagenous colitis should be considered.

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A teen-ager developed cardiogenic shock and acute heart failure due to dilated cardiomyopathy. Although he had been administered vasopressor and placed on intra-aortic ballon pumping (IABP) at an another hospital, it was difficult to maintain his systemic circulatory dynamics. He was transferred to our hospital to consider the indications for heart transplantation and extra corpored left ventricular assist system (LVAS). Because he could not recover from shock despite the above therapy, we tried to save his life by applying percutaneous cardiopulmonary support (PCPS). Furthermore, he required renal replacement therapy and plasma exchange because of multiple organ failure derived from cardiogenic shock before considering the indications for LVAS. After initiation of hemodialysis, hemofiltration and plasma exchange, renal and hepatic functions were fully recovered. LVAS was implanted on the 25^th day after the onset of cardiogenic shock. He is currently continuing to receive therapy in our hospital without major complications.

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To treat hyperphosphatemia, calcium carbonate and sevelamer hydrochloride are conventionally prescribed, and lanthanum carbonate is a newly developed phosphate binder that does not contain calcium and shows strong phosphate adsorption. Although only a slight amount of lanthanum is absorbed, the safety of lanthanum long-term administration is not clear because of its deposition in several tissues. Here we report a chronic hemodialysis patient treated with lanthanum carbonate, who died of ischemic colitis and hypertrophic cardiomyopathy. A 52-year-old male undergoing regular hemodialysis at another dialysis center was admitted to our hospital for evaluation of lower abdominal pain. He had begun to take lanthanum carbonate (chewable tablet) 1 month before admission. Abdominal X-ray image showed 4 round lesions that appeared to be foreign objects such as metal or mineral in the bowel. The patient developed cardiopulmonary arrest with a bloody bowel discharge and died despite efforts of resuscitate. Autopsy findings demonstrated extensive intestinal ischemia but no ulceration of the mucosa and no perforations. Lanthanum carbonate tablets remaining in the intestine retained their original forms with the carved seals on the surface because there was no elution in the intestine. These remaining tablets could not be associated with intestinal disorder. The efficacy of phosphate adsorption, however, could not be exerted. It is necessary to educate patients undergoing hemodialysis about the appropriate administration of this tablet.

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A fifty-year-old male was diagnosed as having systemic lupus erythematosus (SLE), complicated by Lupus nephritis, which was confirmed on kidney biopsy to be classV of the WHO classification in January 1986. The patient began to develop epilepsy seizures since September 2004. Brain MRI scan findings suggested that the epilepsy was likely associated with multiple intracranial ischemic lesions. Afterwards, the patient had the repetition of epilepsy seizures on an irregular basis, regardless of his regular taking of an oral anticonvulsant such as phenobarbital. In addition, his renal dysfunction advanced slowly, and reached end-stage renal disease in July 2006. On November 16, 2007, he was emergently admitted to our hospital due to a generalzed epileptic seizure after hemodialysis treatment at a dialysis clinic. Blood examination showed that blood concentrations of phenobarbital rather varied among the measurements after taking the drug. After switching the route of drug administration to intramuscular injection, the blood concentration of phenobarbital increased and stablized, and then the seizures disappeared. We thought that this could be associated with poor control of epilepsy despite taking regular oral medication. To study concurrent gastroduodenal illness, endoscopic examination was performed and the existence of a large Zenker's diverticulum was detected in the upper part of esophagus. It was likely that an orally administered anticonvulsant tablet could become trapped in the esophageal diverticulm, resulting in a decrease in drug concentration levels in blood. This might have been a cause of poor epilepsy control in this case. Therefore, an endscopic stapler was used to perform esophagodiverticulostomy, since this stapling technique is considered safe and effective in such compromised individuals as dialysis patients, compared with other surgical techniques. The prevalence of Zenker's diverticulum is quite low in the Japanese population, and it is often overlooked because it hardly ever causes clinical symptoms. To our knowledge, there are no previous reports that the existence of Zenker's diverticulum significantly affected treatment of a comorbidity. We herein report a hemodialysis patient with a large Zenker's diverticlum that was considered responsible for poor control of epilepsy being treated by an oral anticonvulsant.

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A 53-year-old male with end-stage renal failure due to IgA nephritis commenced peritoneal dialysis. Two months after initiation of CAPD, right hydrothorax developed. After the second recurrence under conservative therapy, dialysis therapy was switched from CAPD to hemodialysis. He was admitted to our hospital to undergo video-assisted thoracoscopic surgery (VATS) for pleuroperitoneal communication (PPC) complicating CAPD. VATS was performed but resulted in failure because we could not detect any communication intraoperatively. He resumed CAPD, with recurrence of hydrothorax. Then we investigated the success rate of VATS for PPC in Japan. The success rate was lower than that had been reported previously, and the success rate was much lower in cases in which communication was not detected intraoperatively. The surgical indications for VATS for PPC in CAPD patients should be given sufficient consideration.

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A 57-year-old female had demonstrated swelling of the fingers and complained of pain in both knee joints for about a year. Her ADL gradually decreased over the same period, along with the development of marked generalized weakness. The family finally transported her by ambulance to our hospital on December 13, 2008. Clinical examination demonstrated evidence of kidney failure (s-Cre 6.38mg/dL, BUN 104.9mg/dL), hyperkalemia (s-K 7.0mEq/L), and an abnormal electrocardiogram, necessitating hospitalization. After admission, hyperkalemia was corrected by hemodialysis, however, persistent oliguria necessitated maintenance hemodialysis. Systemic scleroderma was suspected from her facies and skin findings, and a definitive diagnosis was made based on a positive serological test for anti-Scl-70 antibody. Further testing demonstrated pericardial effusion, pulmonary hypertension, and interstitial pneumonia. We initiated treatment with captopril 6.25mg/day with cardioprotective intent, and prednisolone 20mg/day for the control of pericardial disease. The fluctuations in blood pressure gradually improved and the patient became able to take food. However, on the early morning of the 16th day in the hospital, the patient developed sudden cardiac arrest. While emergency cardiopulmonary resuscitation was initially successful, the patient died without regaining consciousness on the 18th day of hospitalization. At autopsy, hardening of the skin, mild interstitial pneumonia, changes in pulmonary hypertension, evidence of pericarditis and myocarditis, and also renal findings suggestive of scleroderma crisis were identified. In particular, diffuse fibrosis and inflammatory cell infiltration observed in the heart suggested that a recurrent episode of myocarditis may have caused cardiac arrest.

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