It is important to conduct daily shunt examination, especially diagnosing shunt stenoses for hemodialysis patients. Auscultation of shunt murmur is the most common method of diagnosing shunt stenosis in the hemodialysis therapy because it is easy and non-invasive. Based on clinical experience, high frequency components of the shunt murmur are observed when a shunt has one or more stenoses. However, this method has not been established as an objective diagnosis standard. Therefore, we tried to analyze the relation-ship between stenosis levels and frequency components of the shunt murmur as a basic study to establish an objective diagnostic standard of the shunt stenosis by the shunt murmur. For this purpose, frequency characteristics of some shunt murmur samples of an arterio-venous fistura (AVF) recorded at 3～6 locations were analyzed using short-term Fourier transformation at the beginning. Secondly, we analyzed the significance of differences in average values of frequency spectra of shunt murmurs between stenosis levels. The findings demonstrated that significant differences in frequency levels of shunt murmurs between stenosis levels especially at the anastomosis (upper stream of the stenosis), the stenotic segment and just behind the stenotic segment of the shunt, while there were no significant differences at the mid-point of the shunt (far down stream from the stenosis). It is considered that from the flow field theory, blood flow becomes turbulent with the progression of shunt stenosis, which causes a high frequency of shunt murmur at the anastomosis, stenotic segment and just behind the stenotic segment. It is expected that these findings may be applicable to establishing a clinical guideline for shunt stenosis based on shunt murmur.

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Background : Vascular access interventional therapy (VAIVT) is now widely chosen for thrombotic complications. However, there are limited data demonstrating that VAIVT provides better results for access patency than surgical intervention. Therefore, we evaluated the durations of freedom from treatment after VAIVT and surgical interventions for thrombotic complications. Methods : Between January 2004 and December 2008 879 surgical procedures were performed. We divided these patients into 2 groups ; Group 1. Surgical repair (stenotic lesion was bypassed or another access was newly constructed), Group 2. Surgical balloon angioplasty (thrombosis was surgically removed and stenotic lesion was dilated by balloon angioplasty). Group 1 included 690 procedures, and Group 2 included 189 procedures. VAIVT was performed 156 times between April 2006 and March 2009 (Group 3). We analyzed the duration of freedom from treatment until access failure after each intervention. Results : Using the Kaplan-Mayer method, 2 years freedom from treatment was found in 34.0% (Group 1), 11.5% (Group 2), and 11.1% (Group 3) (p<0.0001). For graft access, 2 years freedom from treatment was found in 22.8% (Group 1), 9.2% (Group 2), and 5.9% (Group 3) (p<0.0001), and for native vessel fistula, the data were 59.8% (Group 1), 35.7% (Group 2), 33.7% (Group 3) (p=0.0005). Hypertention, diabetes, and hyperlipidemia hade no siginicant effect on the duration of freedom from treatment. Considerations : Considering patency, stenotic lesion should be diverted by surgical procedures. However, surgery will cause difficulties in vascular access construction, because the number of useful vessels for access is limited. Surgical thrombectomy plus balloon angioplasty seems to provide better patency than VAIVT because it removes thrombosis completely. However, we demonstrate the same patency between the two groups. The benefits of VAIVT are that it is low-invasive and repeatable, which is beneficial to the patient. Conclusions : We concluded that VAIVT should be the first choice of treatment for thrombotic complications.

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Objective : The correction of renal anemia with recombinant human erythropoietin (rHuEPO) has not been fully achieved in the majority of peritoneal dialysis (PD) patients. One of the main reasons might be the inadequate approved dosage of rHuEPO (≤6,000 IU/week in PD patients) compared to that in patients on hemodialysis (≤9,000 IU/week) in Japan. In order to improve this outcome, choosing darbepoetin (DA), a long-acting erythropoiesis stimulating agent (ESA) with a relatively high dosage can be a solution. The present study explored an whether increased dosage of DA could be effective for PD patients who had previously been treated with rHuEPO without attaining the target hemoglobin (Hb) levels. Material and methods : In 44 patients on PD whose clinical condition had been stable, 31 (31/44=70%) did not achieve the goal of Hb≥11 g/dL, and 14 patients (14/44=32%) did not achieve Hb≥10 g/dL despite conventional therapy with rHuEPO of 12,000 IU/2 weeks s.c. Patients in the latter group (14 cases) were enrolled in the study on a therapeutic protocol of DA. On switching from rHuEPO to DA, DA was given intravenously with a starting dose of 60 μg/2 weeks (equivalent to rHuEPO 12,000 IU/2 weeks using a conversion factor of 200 : 1). The dose of DA was increased in a step-wise fashion by 20 μg biweekly if the Hb values did not achieve a goal of 11 g/dL. Iron was administered orally to properly maintain TSAT≥20% and serum ferritin concentration≥100 ng/mL. Results : The results were as follows ; 1) The levels of Hb during the DA-treated period were substantially elevated in 13 (effective rate=93%) of 14 patients showing a significant difference from that in the rHuEPO-treated period (p=0.016 by Fisher's direct method). The Hb value at the beginning of rHuEPO-treated period was 9.4±1.4 g/dL and 9.2±0.9 g/dL at the end (n.s.). However, it rose from 9.2±0.9 g/dL to 10.7±1.4 g/dL in response to treatment with DA (p<0.001 by Student's t test). 2) Seven of 14 patients (50%) attained a Hb goal≥11 g/dL with a DA dose ranging from 60 μg to 140 μg/2 weeks. 3) Thirteen of 14 patients (93%) attained an increase in the Hb levels by 0.5 g/dL with a DA dose ranging from 60 to 140 g/2 weeks. 4) There were no serious adverse side effects such as hypertension during the observation period with DA. Conclusion : The present study suggests that therapy with conventional rHuEPO has not been effective in achieving the recommended Hb level of 11 g/dL in the majority of PD patients. DA with a relatively high dosage might be useful to improve anemia in these patients.

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After taking cinacalcet hydrochloride, hemodialysis patients with secondary hyperparathyroidism often complain of upper gastrointestinal symptoms. In order to evaluate gastrointestinal function, the activity of gastric acid secretion was examined by measuring intragastric pH, serum gastrin and serum pepsinogen concentration and gastric emptying test was examined by measuring serum acetoaminophen concentration. Cinacalcet elevated serum gastrin concentration, but was independent of gastric acid secretion. Meanwhile cinacalcet delayed gastrointestinal motility. In cases showing delayed gastrointestinal motility and gastric atrophic mucosa, gastrointestinal complication often occurred. Because cinacalcet operates on gastrointestinal tract as calcimetics, it is supposed that gastrointestinal complication is due to suppression of the parasympathetic nervous system. In order to reduce this complication, it is useful to take cinacalcet during gastric emptying time or post hemodialysis and to take digestive medicine together such as medication releasing acetylcholine or prostaglandin to advance gastrointestinal motility. Before using cinacalcet, it is preferable to check for gastric disease, intragastric acid, intragastric mucosal condition, and gastric motility by endoscopic examination. If the mechanism of upper-gastrointestinal complication after taking cinacalcet can be resolved, compliance with cinacalcet will improve. It is suggested that cinacalcet therapy is more effective and acceptable for hemodialysis patients with secondary hyperparathyroidism.

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ST-T changes on electrocardiograms (ECGs) and abnormal ultrasonic cardiographic findings have each independently been reported to be predictors of death from cardiac failure in chronic dialysis patients. In the present study, we identified factors associated with ST-T changes on resting ECGs of 149 maintenance dialysis patients with a mean age of 66.7 years. Multivariate analysis was performed with the presence or absence of ST-T changes as the target variable and left atrial dimension at end-systole (LADs), left ventricular dimension at end-diastole (LVDd), left ventricular posterior wall thickness (PWT), left ventricular fractional shortening (%FS), left ventricular mass (LVM), and the following parameters as explanatory variables, age, sex, underlying disease (diabetes mellitus [DM] or non DM), coronary artery disease (CAD), dialysis history, blood pressure, increase in body weight, blood chemistry values, and drugs used. UCG was performed after dialysis or in the morning of the following day, and the mean of values obtained over 6 months of dialysis were used. The mean duration of dialysis was 14.4 years. The patients were divided into two groups according to whether ST-T changes were present, and factors that affected UCG abnormalities in each group were extracted by multiple regression analysis. The underlying diseases were DM in 41 patients and 26 patients were complicated by CAD. The mean values of UCG findings were 42.4 mm in LADs, 52.4 mm in LVDd, 10.8 mm in PWT, 36.3% in %FS and 224.4 g in LVM. Angiotensin-converting enzyme inhibitors were administered to 8 patients, angiotensin receptor blockers to 103, β or α β blockers to 52, and calcium channel blockers (CCBs) to 116. ST-T changes were detected in 79 patients, and were associated with the presence, of ST-T changes LADs and use of CCBs on multiple logistic analyses, and the odds ratios were 5.141, 1.087, 0.339, respectively. LADs values were positively associated with LVM in patients with ST-T changes in ECG, suggesting that LA dilatation might reflect left ventricular hypertrophy.

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A self-cannulation support device for home hemodialysis was developed in order to increase the ease of self-treatment by patients. The prototype model made of acrylonitrile-butadiene-styrene (ABS) resin was manufactured using three-dimensional modeling technology. The device was mainly composed of a basement, expansion/contraction, arm, projection, and torsion spring parts. Especially, the arm of the device was energized by the spring to press and fix a venous vessel of the patient's forearm. When cannulation is conducted, the patient's forearm is inserted into the aperture between the basement and the arm of the device. The patient's vessel was pressed by the projecting part and subsequently fixed by a slight movement of the patient's forearm in the direction of cannulation.

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Pregnancy is extremely rare in continuous ambulatory peritoneal dialysis (CAPD) patients, possibly because of the presence of hypertonic dialysate in the peritoneal cavity or physical factors whereby the intra-peritoneal fluid interferes with transport of the ovary to the fallopian tube. In-vitro fertilization with embryo transfer (IVF-ET) may improve this situation, and planned and anticipated conception is expected. A 37-year-old female on CAPD underwent hemodialysis once a week for seven years. She wished to conceive, and IVF-ET had been performed at another clinic. After three attempts, pregnancy was confirmed by intra-vaginal echography at six weeks of gestation. She remained on CAPD and hemodialysis twice a week, but because of in adequate dialysis she was switched to regular hemodialysis three times a week in the 14th gestational week. Premature labor occurred in the 17th gestational week, and she was admitted to the University of Occupational and Environmental Health. Caesarean section was performed in the 32nd weeks of gestation. The infant was a healthy female weighing 2,284 g. After delivery, the patient's Tenchkoff catheter malfunctioned and migrated, and the catheter was repositioned laparoscopically. She resumed CAPD three months after delivery.

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A 53-year-old male on hemodialysis for 5 years, was hospitalized due to bloody stools. Colonoscopy was performed, but the source of bleeding could not be identified. Clinical observation was carried out under transfusion therapy, but as the patient continued to pass bloody stools several times. Thereafter, the patient was referred to our department for treatment. After admission, a colonoscopy, abdominal CT scan, and angiography were performed, but the site of the hemorrhage could not be identified. Transcatheter arterial embolization was not practical. Since a small intestine hemorrhage was suspected, laparotomy was performed and small intestine endoscopy was carried out during laparotomy ; a diagnosis of ulcer hemorrhage from Meckel's diverticulum was made and partial resection of the ileum was performed. The postoperative course was uneventful and the patient was discharged on the 10 th post-operative day. In general, hemorrhage from Meckel's diverticulum is not rare as a cause of digestive tract hemorrhage, but there are few reports of such hemorrhage occurring in a ward dialysis patient. In dialysis patients, there is a latent tendency to hemorrhage due to various factors including the fragility of the blood vessels, the deterioration of platelet function, and the use of anticoagulants during dialysis ; moreover, transfusion therapy increases the risk of hyperhydration and electrolyte abnormalities, and maintenance dialysis remains essential during the course of diagnosis and therapy. There is thus a need to bear in mind that these factors inevitably impose a time restriction. In the present case, as a definitive preoperative diagnosis was not possible, exploratory laparotomy was performed, which resulted in successful diagnosis and treatment.

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A 57-year-old male on maintenance hemodialysis since 2003, who was complicated with rheumatoid arthritis (RA), diabetes mellitus and ischemic heart disease, had been administered etanercept twice a week since May 2005 because of high disease activity of RA and his condition had been well controlled. However, in the beginning of July 2007, cough with hemosputum appeared and chest X-ray findings showed cavitary lesion measuring 3 cm×2 cm in the S₃ region of the right lung. Subsequently, Nocardia was detected in his sputum. Therefore, etanercept was discontinued and the administration of Trimethoprim-Sulfamethoxazole was started. As a result, the cavitary lesion thereafter became scarred. However, RA worsened soon after the discontinuation of etanercept and even though the dosage of prednisolone was increased and leukocytapheresis was performed, his condition still did not successfully improve. Since many kinds of antirheumatic drugs can not be administered to RA patients on hemodialysis, TNF inhibitors provide an alternative choice. Because of immune dysfunctions that sometimes exist in these patients, scrupulous care is thus required when prescribing TNF inhibitors.

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