Aim: Preemptive kidney transplantation (PKT) is an ideal renal replacement therapy for end-stage renal disease (ESRD); however, the rate of PKT is still low in Japan. This is because there is a disparity between the attitudes toward PKT, including the timing of referral to a transplant facility, between clinicians treating patients with chronic kidney disease (CKD) and transplant centers. Therefore, we conducted a survey of clinicians and transplant centers, inquiring about the timing of PKT induction. Materials and Methods: Forty-two attendees (all clinicians) of a seminar about renal disease who had treated CKD and the 31 leading Japanese kidney transplant facilities in 2009 were surveyed about PKT induction. The inquiries consisted of questions concerning the acknowledgment of the necessity for PKT, timing until referral, etc. Results: The response rate was 59% for attendees and 76% of them had referred patients to transplant facilities for PKT. Thirty-seven percent did so when the glomerular filtration rate (eGFR) fell to less than 30mL/min/1.73mm². However, the same percent did not do so until it became less than 15mL/min/1.73mm². More than half of the attendees referred patients for PKT when the serum creatinine was elevated to above 5mg/dL, and less than half of them did so when it rose to above 3mg/dL. On the other hand, more than half of the patients were referred to transplant facilities when their eGFR fell to under 15mL/min/1.73mm²; thus, only 20% could actually undergo PKT in most facilities. Surprisingly, 62% of the facilities experienced referral after dialysis access creation. Most facilities required earlier referral, in CKD stage3 or 4, which was a clear difference between CKD clinicians and transplant facilities. Conclusion: Even CKD clinicians who understand and favor PKT tend to delay referral to transplant facilities. Thus, suitable timing for referral is the key to increasing PKT.

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The N-terminal fragment of the brain natriuretic peptide precursor (NT-proBNP) concentration, which is a marker of heart failure, has been reported to exhibit a negative correlation with the BMI in both the general population and in chronic heart failure patients. However, in dialysis patients, the impact of the BMI on the relevance of the NT-proBNP concentration is unclear. We examined the influence of visceral obesity on the NT-proBNP and cTnT levels in HD patients. This study observed 80 HD patients. We evaluated the visceral fat areas (VFA) using computed tomography (CT) at the level of the umbilicus, and patients with a VFA≥75cm² were considered to show visceral obesity. In the non-visceral obese group, the median NT-proBNP concentration was 7,155pg/mL, and the median cTnT concentration was 0.028ng/mL. In the visceral obesity group, the median NT-proBNP concentration was 3,604pg/mL, and the median cTnT concentration was 0.038ng/mL. The NT-proBNP concentration in the visceral obesity group was significantly lower than that in the non-visceral obesity group (p=0.016). However, the cTnT concentration was not significantly different between the two groups. Although there was a significant positive correlation between the NT-proBNP and cTnT in the non-visceral obesity group, there was no correlation between the NT-proBNP and cTnT in the visceral obesity group. Therefore, the NT-proBNP concentration in visceral obesity subjects was significantly lower than in non-visceral obesity subjects, and this appears to reflect a low level of myocardial injury.

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The diameter of a hemodialysis double lumen catheter (DLC) and its dilator is markedly larger than its introducer needle. It is, therefore, crucial to rule out inadvertent arterial guidewire misplacement before inserting the dilator. For that reason, after inserting a guidewire in the internal jugular vein, we obtain a short axis ultrasound view of the guidewire proximal to the heart by tilting an ultrasound probe at the medial supraclavicular fossa. In this study, we analyzed an optimized guidewire for this procedure. First, ultrasound visibility of three different hemodialysis DLC guidewires was compared in a simulator. Visibility of the guidewire of 0.97mm in diameter was superior at an ultrasound incident angle of 40 degrees compared to that at 90 degrees. On the contrary, visibility of the guidewires of 0.64 and 0.46mm in diameter was inferior at 40 degrees compared to that at 90 degrees. Second, ultrasound visibility of the two different guidewires was compared in patients. The visibility of the guidewire of 0.64mm in diameter was inferior to that of 0.97mm in diameter; therefore, it took more time to confirm the successful insertion of the former in the brachiocephalic vein. Conclusion : Using larger guidewires showing superior ultrasound visibility and visualization of the guidewire, appropriate venous placement can be confirmed before inserting a dilator.

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The patient was an octogenarian man who started hemodialysis with heparin for the treatment of chronic renal failure due to diabetic nephropathy in another hospital. Then, the platelet count decreased and right femoral vein thrombosis occurred. He was diagnosed with HIT with positive HIT antibody. After treatment with argatroban and warfarin, his condition became stable and he was referred to our clinic to receive maintenance hemodialysis. About one and a half years later, we tried to re-start heparin after confirming negative HIT antibody for more than three months. However, a decrease of the platelet count, coagulation in the dialyzer and shunt occlusion occurred. Because HIT antibody converted to positive, we considered that HIT had relapsed.

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A 62-year-old male patient began to receive hemodialysis due to end-stage renal disease in the presence of chronic glomerulonephritis and arteriovenous fistula (AVF) and an arteriovenous graft (AVG) was frequently established by the obstruction of these. The last AVG was established in the left upperarm in 2008 and swelling of the left upper limb appeared around February 2010. Therefore, we performed percutaneous transluminal angioplasty (PTA) with balloon angioplasty and stent placement for the stenotic brachiocephalic vein. Left upper extremity swelling did not improve; however, we believe that there is a potential for another lesion in addition to lesions in the left brachiocephalic vein stenosis as a cause of venous hypertension. We again performed PTA with angiography using the pressure wire^TM. Angiography demonstrated 90% stenosis of the length of the distal approximately 20mm prior to stenting in the left brachiocephalic vein. The pressure wire^TM also demonstrated 8mmHg at the superior vena cava (SVC), an increase in pressure and 53mmHg on the distal side of the brachiocephalic vein stenosis. Therefore, PTA with balloon angioplasty and stent placement was performed and angiography was obtained with a good extension. In addition, regarding the observations with pressure wire^TM, the pressure of SVC did not change and the pressure of the distal side of the brachiocephalic vein stenosis was reduced from 53 to 11mmHg before the PTA. In addition, angiography demonstrated that the stenotic lesion is unclear near the anastomosis at the graft and basilic vein, and the blood is flowing into the basilic vein retrogradely from the graft, with the proliferation of vessel collaterals. Concerning observations with the pressure wire^TM, the pressure near the anastomosis of the graft and basilic veins was high, at 86mmHg. The pressure wire^TM also suggesis lesions in the vicinity of the anastomosis graft and basilic vein responsible for venous hypertension, and it has been assumed that there are two lesions; therefore, we performed PTA with balloon angioplasty stenting at the same site. Angiography demonstrated the disappearance of reflux into the basilic and collateral veins. Using pressure wire^TM, the pressure of stenosis of the anastomosis graft and basilic vein was reduced from 86 to 12mmHg after the PTA. Thereafter, swelling of the upper arm during the next few days had almost disappeared after PTA. The pressure wire^TM was thought to be a diagnostic device that could aid in the enforcement of a difficult PTA.

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Hemodialysis was introduced in a 72-year-old female patient with diabetic end-stage kidney disease. Due to internal shunt occlusion, synthetic grafts were implanted in the bilateral brachia; however, she showed repeated steal phenomenon, so insertion of the indwelling central venous catheter for dialysis was attempted via the right internal jugular vein. At this time, a persistent left superior vena cava (PLSV) was suspected because of the unusual passage of the catheter through the blood vessels. The end of the inserted angiographic catheter was found to reach the right atrium via the PLSV. Polysplenia in the category of visceral heterotaxia syndrome was diagnosed with a CT scan showing an absent right superior and inferior vena cava with hemiazygos continuation and the existence of 3 spleens. Subsequently, hemodialysis has been successfully conducted on an outpatient basis for 3 years with a one-time exchange of the catheter due to a catheter embolus. Visceral heterotaxia syndrome should be considered when the unusual passage of a guidewire is observed. A finding of multiple spleens or spleen absence is helpful for this diagnosis.

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The case was a 73-year-old female receiving outpatient treatment for hypertension, diabetes mellitus, articular rheumatism and chronic kidney disease (CKD) due to diabetic nephropathy. She was admitted to a hospital with systemic edema and anemia in June 2007 and hemodialysis (HD) was initiated because of end-stage renal disease. After the introduction of HD, a bleeding tendency such as left femoral hematoma around the left femoral vein and hemorrhage in the knee joint and digestive organs, became more pronounced. Laboratory data revealed that the activating partial thromboplastin time (APTT) was prolonged, the factor VIII was decreased, and the factor VIII inhibitor level was high, at 39 Bethesda Units/mL. She was referred to our hospital because of abnormality of her coagulation system, and was diagnosed with acquired hemophilia A. After admission, HD was performed three times per week with indwelling of a right femoral vein catheter. Activated prothrombin complex concentrates were administered to control severe bleeding symptoms, and immunosuppressive therapy (oral prednisolone) was started to eliminate the factor VIII inhibitor. Arteriovenous fistula formation was performed in the period of treatment for acquired hemophilia. This is a rare case involving a patient on HD diagnosed with acquired hemophilia in the induction period. It is important to control bleeding to perform HD and arteriovenous fistula formation for HD.

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