Short-term vascular catheter is used as a vascular access for continuous blood purification (CBP) or shunt failure. Catheter problems, such as infection and poor bloodstream, are often encountered. Therefore, we examined the incidence of catheter infection and poor bloodstream associated with various catheters. Of 199 catheters (32.7%), 65 had to be removed. The causes of removal were infection in 30 catheters, poor bloodstream in 18, and blood coagulation in 11. In triple lumen catheter, the incidence of catheter removal due to infection was more frequent than it was for other types of catheters. The incidence of infection by insertion site did not show any difference between placement via the internal jugular vein and viathe femoral vein. Regarding treatment method, there were significantly more frequent problems arising in continuous blood purification than in intermittent therapy. Poor bloodstream occurred more frequently when using a triple lumen catheter. The incidence of poor bloodstream did not show any difference by insertion site, however, the incidence was significantly less in the end-hole type of catheter than in the side-hole type. Additionally, we compared the incidence of poor bloodstream between end-hole types of catheter, Niagara Slim (Bard Access System) and Gentle Cath (Japan Sherwood), which have different types of tip. The incidence of poor bloodstream was significantly less in the Niagara Slim (p<0.05), being 68.2% less in Niagara Slim compared with that in Gentle Cath. Reviewing the incidence of poor bloodstream by insertion site, Gentle Cath showed poor bloodstream significantly more frequently with placement via femoral vein (p<0.01). We conclude that the incidence of poor bloodstream was significantly less with the end-hole type of catheter than with the side-hole type. Even with the end-hole type of catheter, the incidence of poor bloodstream differs depending on the shape of the tip and the insertion site. Therefore, choosing an appropriate catheter and insertion site should be considered during treatment planning.

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Generally, hemodialysis patients with a subcutaneously fixed artery proceed to arteriovenous graft implantation when their superficial veins are exhausted. Inserting a double lumen hemodialysis catheter, however, could be disadvantage in terms of infection control once the graft has failed due to infection. Under real-time ultrasound guidance, we repeatedly cannulated the brachial vein in two patients whose graft failed due to infection and succeeded in avoiding the insertion of a double lumen catheter until the infection was controlled. Tips for ultrasound-guided cannulation are as follows : 1) Locations of the brachial vein, artery and nerve were fully observed in advance. 2) After the brachial vein was visualized on short axis view, the ultrasound probe was slanted and set perpendicular to the hemodialysis needle, which improved visualization of the needle echo, resulting in precise identification of the needle tip location. 3) After successfully inserting the needle tip into the venous lumen, the probe and the needle were reciprocally advanced little by little in order to avoid injuring the vessel wall. As a result, we performed 51 brachial vein cannulations in these two patients with a 100% cannulation success rate and 0% arterial puncture and nerve injury rates. In conclusion, in patients with a subcutaneously fixed artery and exhausted veins, the brachial vein can be repeatedly cannulated under ultrasound guidance until another vascular access is established, making this route especially useful in cases of infection.

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Since its introduction to Japan, the manufacturers' recommended procedure for exchanging the connecting tube in peritoneal dialysis (PD) has been accepted as a standard without any re-examination. Exchanging the PD connecting tube is conducted every 4-6 months using a specialized set of equipment, povidone iodine as disinfectant, and two sets of sterile gloves. The exchange involves complicated procedures and poses a significant burden on both patients and medical personnel. In this study, the method of exchanging PD connecting tube on PD patients was re-examined and the safety and usability of the disinfectant were also reviewed. The appearance and results of tensile strength tests conducted on segments of catheter previously soaked in disinfectant (povidone iodine or isopropanol) showed that there was no effect of changing the disinfectant from povidone iodine to isopropanol as long as the contact time is adequate. The safety of the exchange procedure was also confirmed by determining the incidence of bacterial infection and peritonitis. A simple and comprehensive method for exchanging PD connecting tube using 70% isopropanol to achieve more rapid disinfection has been successfully developed. As of August 2010, this method has been implemented 163 times on a total of 153 PD patients without any signs of problems. It is thought that adopting this method as the standard procedure will be largely beneficial.

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Since April 2010, combination therapy consisting of peritoneal dialysis and hemodialysis (PD+HD) can be calculated as a medical service covered by the Japanese National Health Insurance. Prior to April 2010, billing for medical service fees was confusing and hindered the widespread adoption of PD+HD combination therapy. Therefore, the EARTH (Evaluation on the Adequacy of Renal Replacement Therapy) Study Group conducted a questionnaire survey to investigate the actual state of affairs with regard to billing for medical service fees related to PD+HD combination therapy. A questionnaire survey was conducted between August 2009 and September 2009 at 30 facilities by the EARTH Study Group. PD+HD combination therapy had been performed at 29 of these facilities. During this 1-month period, 1,267 patients underwent PD, and 281 of these patients underwent PD+HD combination therapy. The following items included in the insurance billings for these patients were reviewed : management fees for continuous ambulatory peritoneal dialysis (PD management fees), PD material costs, outpatient medical management fees for chronic maintenance dialysis patients (medical management fees), HD material costs, and HD procedure fees. The actual situation regarding billing for these items was determined at only 16 facilities that responded that they were performing PD and HD as combination therapy within their own facility. The results showed that PD material costs were billed at all 16 facilities and PD management fees were billed at all 16 facilities except one. Medical management fees were billed at 6 facilities (37.5%). HD material costs were billed at 14 facilities (87.5%), but were not billed at the other 2 facilities. HD procedure fees were billed at only 2 facilities (12.5%). The results for the insurance billing at 13 facilities that responded that they had asked another facility to perform HD showed that there were 15 different patterns of billing for PD performed at the facility itself and HD performed at the other facility. Prescription drug fees or specific health insurance fees for medical materials can be calculated for PD+HD combination therapy according to the insurance calculation rules. Furthermore, this can be done in cases in which HD and PD are performed at different sites. However, only 3 (23.1%) of the 13 facilities interpreted the rule as such to claim the medical fees. This survey showed that there is a great deal of confusion at clinical sites with regard to the billing rules for PD+HD combination therapy.

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A 73-year-old female with nephrosclerosis underwent hemodialysis treatment 3 times a week over a seven-year period. In 2000, the patient underwent artifical blood vessel replacement of the ascending aorta and stent grafting of the descending aorta because of the asymptomatic dissecting aneurysm. On March 26, 2006, the patient underwent a medical examination due to fever and was admitted to our department due to vascular access infection accompanied by smelly purulent discharge from the vascular access. Therefore, we started antibiotic treatment. Staphylococcus aureus growth was detected on culture of blood and pus from the vascular access. We diagnosed the patient as having aortic graft infection and infected aneurysm based on finding an expansion of the aortic arch on chest X-ray photograph and an aortic aneurysm of the descending aorta was found on chest computed tomography scans on the 3rd day. Thereafter, we continued antibiotic therapy. However, the patient suddenly began to spit blood and developed hemorrhagic shock on the 10th day. Since we detected rupture of the infected aneurysm and aortoesophageal fistula, artifical blood vessel replacement of the ascending aorta, aortic arch and descending aorta, filling in the greater omentum, esophagectomy, esophagostomy and gastrostomy were performed on the 12th day. However, the general state of the patient worsered and the patient died due to septic shock on the 30th day. Dialysis patients have a high risk of infection and may easily become seriously and even fatally ill. When signs of infection are observed in dialysis patients, infected aneurysm should be considered in the differential diagnosis.

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It is difficult to remove protein-bound uremic toxins (PBTx) by hemodialysis. In order to improve PBTx removal, we carried out an in vitro study to evaluate the effects of dilution and pH change on PBTx dissociation from albumin. Human plasma harvested by aphaeresis therapy was diluted by saline or isotonic aqueous NaHCO₃. Free fractions of indoxyl sulfate and homocysteine were determined. As results, indoxylsulfate was easily dissociated from albumin by dilution and pH change. Higher dilution was more effective in increasing the free fraction of indoxylsulfate. However, homocysteine was not dissociated from albumin by these procedures. Development of an effective method is required for dissociation of each type of PBTx.

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