The Great East Japan Earthquake (March 11, 2011), which caused unprecedented damage, also greatly affected dialysis facilities in Miyagi Prefecture. In particular, the coastal areas were devastated, affecting numerous chronic dialysis patients. The Supply of electricity and water was unstable, and communication links were paralyzed. The living conditions of the people were miserable. We requested dialysis facilities outside the disaster areas to provide treatment for chronic dialysis patients, because the quality of dialysis could not be maintained under the conditions. In regard to dialysis treatment, requesting the afflicted dialysis facilities to provide usual medical information about chronic dialysis patients does not fit into the basic philosophy of disaster relief. On the other hand, we had to treat many chronic dialysis patients who were admitted to our hospital for the first time. Issues related to the medical treatment of patients who were evacuated from the disaster-afflicted areas were quite different from those in ordinary situations. Therefore, we formulated a “clinical pathway for the hospitalization of chronic dialysis patients” as a tool to visualize information and allow it to be shared among different professionals and institutions. The clinical pathway allowed the standardization and understanding of patients conditions during hospitalization and was also helpful for the handover of patients to dialysis facilities in Hokkaido. The findings suggested that the clinical pathway would be a useful tool for chronic dialysis patients. We report the details in this article.

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A 33-year-old woman was referred to our hospital following 2 habitual abortions. Her blood type was ccDee, and her husband was CCdeE. At the third pregnancy, her serum anti-E antibody was 1:512 after 9 weeks of pregnancy, and its titer increased gradually. Therefore, we started double filtration plasmapheresis from 12 weeks of pregnancy, and it was performed a total of 34 times. Five-unit transfusion was performed via the funiculus umbllicalis, because severe anemia was recognized in the embryo. She gave birth to a girl by cesarean section in the 34th week. The newborn infant underwent exchange transfusion, and was treated by the administration of γ-globulin and actinotherapy in the NICA. The infant left the hospital showing a favorable course on the 62nd day. The spread of immune globulin therapy and progress of the iatrotechnique of intrauterine fetal transfusion have increased the role of plasma exchange for pregnant mothers with Rh(E)-incompatible pregnancy. However, PE is necessary for cases such as this with a high titer of antibody in Rh(E)-incompatible pregnancy. In addition, DFPP is a superior therapy, and there are few side effects.

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A 56-year-old man with end-stage kidney disease caused by IgA nephropathy started peritoneal dialysis (PD) in March 1992. He had four episodes of bacterial peritonitis during 11 years of PD treatment. At the 4th episode of persistent peritonitis in 2003, he was switched to hemodialysis (HD). After the cessation of PD, he was hospitalized six times due to abdominal pain and bowel obstruction from 2003 to 2009. Calcification of the peritoneum in the pelvis developed after the cessation of PD. Since encapsulating peritoneal sclerosis (EPS) findings such as ascites, peritoneal thickening, or abdominal cocoon were not observed on abdominal CT, he was diagnosed with adhesive intestinal obstruction. In 2010, he showed symptoms of ileus five times, but they were promptly resolved by fasting and decompression with an ileus tube. Because these episodes occurred frequently, surgery was performed in February 2011. During the operation, serious diffuse adhesion in the peritoneal cavity and local encapsulated small intestine and bowel calcified adhesion in the pelvic cavity were observed. He underwent synechiotomy and partial intestinal resection. He has been free from the symptoms for 10 months after surgery. In this patient, EPS might have developed due to pelvic calcification without an obvious inflammatory phase. It is important to observe patients carefully to avoid the development of peritoneal injury even after the cessation of PD.

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The most common cause of death in Japanese dialysis patients is heart failure. It is becoming more important to treat terminal dialysis patients with end-stage heart failure as the number of elderly patients with severe diabetic or non-diabetic complications increases. However, there are no guidelines, especially regarding withdrawal from dialysis, for terminal dialysis patients. We report a 69-year-old man with “end-of-life” heart failure caused by hypertrophic cardiomyopathy. He needed comprehensive palliative care in cooperation with a palliative care physician, a cardiologist, dentists, pharmaceutists, nursing staff and dietitians. The medical and ethical application of anxiolytic medication, withdrawal from dialysis, turning the defibrillator off and sedation had been discussed. We could not use some drugs, including hydromorphone, because of renal failure. Also, the explanation of dialysis withdrawal for the patient and his family was difficult. These problems are unique to dialysis patients. The number of such severely complicated patients has been predicted to increase as medical technology progresses. We report this case to show the necessity of formulating some guidelines for terminal dialysis patients in the future.

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