[in Japanese]

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Generally, patients without an established vascular access, such as an arterio-venous fistula, undergo the insertion of a double-lumen catheter when they need blood purification therapy; however, severe complications, such as blood stream infection and thrombosis, are essentially inevitable using a double-lumen catheter. Therefore, we performed blood purification without inserting a double-lumen catheter by repeated ultrasound-guided femoral vein puncture before either a vascular access was established or blood purification was withdrawn. Sixteen patients were treated with repeated ultrasound-guided femoral vein puncture between June 2008 and August 2011. Underlying diseases were end-stage renal failure in 9, autoimmune disease in 3, nephrotic syndrome in 2, acute renal failure in 1, and poly-neuropathy associated with dysproteinemia in 1. Six patients were taking either steroids or immunosuppressants. The mode of blood purification was hemodialysis in 11, double-filtration plasmapheresis in 2, a combination of double-filtration plasmapheresis and plasma exchange in 1, the extracorporeal ultrafiltration method in 1, and LDL-apheresis in 1. A 16-gauge hemodialysis needle was used. The location of the needle tip was identified utilizing the acoustic shadow of the needle by active scanning with an ultrasound probe. The femoral vein and superficial vein of the extremities were used as the blood-drawing and blood-returning sites, respectively. Overall, 156 blood purifications (1-48/person, 9.8 times on average) were performed using this method without any new onset of blood stream infection or hematoma formation. As the femoral artery has many branches, arterial bleeding cannot be prevented completely by the “blind” puncture technique based on anatomical knowledge and palpation. Repeated ultrasound-guided femoral vein puncture appeared to be a safe and useful temporary vascular access when the use of a double-lumen catheter should be avoided.

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Although the maximum approved dosage of recombinant human erythropoietin (rHuEPO) is 24,000IU/month in patients on peritoneal dialysis (PD) therapy in Japan, the improvement of renal anemia is not always satisfactorily maintained at a blood hemoglobin (Hb) level>10.0g/dL. Among 46 patients on PD therapy in our hospital, we investigated the effects of darbepoetin alfa (DA) in 8 patients (DA group) with Hb<10.0g/dL after the administration of rHuEPO at 12,000IU/2 weeks, compared with the 38 other patients (non-DA group) with Hb>10.0g/dL after the administration of rHuEPO at a dose<12,000IU/2 weeks. In terms of background data, the residual renal function was lower and serumβ₂ microglobulin level was higher in the DA group, compared with the non-DA group. As an inflammatory marker, the serum C-reactive protein level was also higher in the DA group than in the non-DA group. After 18 weeks of DA administration instead of rHuEPO, the mean (±standard deviation) Hb level increased to 11.0±0.8g/dL. The Hb level eventually reached>10.0g/dL in all patients using DA instead of rHuEPO. Of note, serum ferritin levels in all 46 patients were within the normal range, suggesting that low iron storage was not a direct reason for anemia in this study. The present results suggest that renal anemia in patients on PD therapy who remained inadequately managed using the maximum approved dosage of rHuEPO was caused by an inadequate dosage of rHuEPO, and might be controlled to target levels using an adequate dosage of DA.

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Numbers of dialysis patients are increasing annually in Japan, and improvements of the quality of dialysis and life are required. We investigated the association between the temperature of a dialysate used in hemodialysis and pain of the upper limb on needle prick as a complication in hemodialysis. First of all, how the blood temperature in the external circulation changed by varying the temperature of the dialysate was examined. The study involved a crossover test every three weeks, and the influence of the temperature of the dialysate on pain was examined. When the temperature of dialysis liquid was set as 36.0°C or less, the blood temperature which passed the dialyzer fell. Moreover, when the temperature of dialysis liquid was set as 36.5°C, the blood temperature which passed the dialyzer was changeless. When the temperature of dialysis liquid was set as 37.0°C, the blood temperature which passed the dialyzer rose. Next, when the temperature of dialysis liquid was set as not less than 36.5°C, pain of the upper limb on needle prick decreased intentionally. When the temperature of dialysis liquid was set as not less than 36.5°C, the measures against the pain of the upper limbs on needle prick decreased intentionally. It was thought that a setup of dialysis liquid temperature was an effective means which can ease the pain of the upper limbs on needle prick which arise during dialysis.

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A 52-year-old man with diabetic nephropathy started peritoneal dialysis (PD) in June 2008. On September 14, 2009, he underwent a medical examination because of abdominal fullness, a low drain volume, and cloudy dialysate. Blood examination did not indicate infection or inflammation. The mesenteric fat tissue appeared as a large, high-density mass on an abdominal computed tomography scan. We assumed that this mass obstructed the flow of the dialysate. Because no specific treatment has been established, we administered antibiotics and steroids. Subsequently, the area of the large mass decreased, and dialysate drainage improved. However, the patient developed repeated bacterial peritonitis, and underdialysis occurred. His dialysis therapy was switched to hemodialysis in May 2010. Thus, although mesenteric panniculitis is a rare disease, it should be considered in the differential diagnosis of PD patients with a low drain volume.

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We present the case of a 68-year-old male hemodialysis patient who developed portal-systemic shunt encephalopathy. Hemodialysis was started owing to diabetic nephropathy in April 2000. He previously underwent partial gastrectomy for gastric ulcer and blood transfusion. Since September 2004, fecal incontinence, some cognitive symptoms, and depression have sometimes occurred. Although he had been a heavy drinker and was a hepatitis C virus carrier, abdominal echography and computed tomography (CT) did not indicate any evidence of liver cirrhosis, and laboratory examination findings were normal except for the serum ammonia level, which was elevated at 232μg/dL. Moreover, abdominal enhanced CT and angiography revealed a portal-systemic shunt from the splenic vein via the left testicular vein to the left renal vein. Despite treatment with a solution containing branched-chain amino acids (Aminoleban^®), hyperammonemia did not improve. Balloon-occluded retrograde transvenous obliteration (B-RTO) was performed. The serum ammonia level was normalized and cognitive symptoms improved after the obliteration. During a 9-month follow-up period, there was no recurrence of encephalopathy.

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A 53-year old man was diagnosed with myelodysplastic syndrome-refractory anemia with excess blasts (MDS-RAEB) in March 1990. In October 1998, as he developed pancytopenia with increasing myeloblasts, he was enrolled as a recipient for hematopoietic stem cell transplantation in the Japanese bone marrow bank. In February 2008, as an HLA-matched yet ABO-blood type mismatched unrelated donor was found, he was admitted to our hospital to receive bone marrow transplantation (BMT). Red blood cells and plasma were fully eliminated from the donor stem cells harvested, following administration of both busulfan and cyclophosphamide as preparative regimens. Cyclosporin A and methotrexate for the prevention of acute graft versus host disease (GVHD) were started from day1 after BMT. On day9, as he developed dark-brown colored urine with prominent elevation of serum bilirubin and lactase dehydrogenase, and manifested positive tests for direct Coombs' antiglobulin and anti-B antibody, we suspected “passenger lymphocyte syndrome (PLS)”, which is derived from the phenomenon that an immunocompetent donor's memory B lymphocytes produce secondary antibodies against a recipient's red blood cell antigens. From day10, consecutive treatments combining plasma exchange with hemodialysis were required, as he developed oliguric acute kidney injury (AKI) due to hemoglobinuria. On day38, he completely recovered from AKI. This is a rare case of severe AKI associated with PLS after ABO blood type mismatched BMT, which required renal replacement therapy.

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