A study was conducted on salt intake in hemodialysis patients. We studied 547 patients who had been undergoing maintenance hemodialysis treatment for over two years as of April 2005 to measure the distribution and fluctuation of their salt intake and examine the connection between age, weight and blood pressure. Using the calculation of salt intake at the start of the observation, which was stratified into five groups (less than 6 grams, 6 to 8 grams, 8 to 10 grams, 10 to 12 grams, over 12 grams), and the survival rates measured during the period of the observation, we performed a comparison of salt intake and survival rate in patients below the age of 66 as well as those over the age of 66. The salt intake declined with increase in age and was higher in patients with higher body mass index, but no correlation was found with blood pressure (average BP). The hazard ratio was lower at all levels of salt intake from 6 to 12 g than at less than 6 g by regression analysis. Therefore, it cannot be said that a better prognosis can be maintained by a salt intake of less than 6g. In the group aged over 66, patients with a lot of salt intake were not significantly different, but the survival rate was higher. The recommended salt intake for HD patients is less than 6 grams per day to prevent overflow; however, we believe it is necessary to set a target value for each individual considering age, weight, or level of physical activity, especially since salt intake is largely associated with diet. For elderly patients whose appetites are declining, nutritional guidance should focus on “maintaining the physical condition,” not on the “limitation” of salt and water intake.

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 We report a patient undergoing maintenance dialysis who developed life-threatening intestinal perforation during bixalomer therapy, which was successfully treated by prompt surgical intervention. A 75-year-old man had been treated with bixalomer at 3,000 mg/day for 3 months prior to hospitalization for the control of decreased serum phosphate level. He suddenly suffered lower abdominal pain and was admitted to our hospital. Imaging diagnosis (computed tomography of the abdomen and pelvis) identified intestinal perforation and emergency surgery was performed on the same day. Following the surgery, multidisciplinary therapy, including polymyxin B-immobilized fiber column-direct hemoperfusion (PMX-DHP) and continuous hemodiafiltration (CHDF), was administered, and the patient successfully recovered. Bixalomer is a phosphate binder with a reportedly lower rate of gastrointestinal events such as constipation and abdominal distention than other phosphate binders. Although no case of intestinal perforation occurring during bixalomer therapy has yet been reported, this drug is likely to carry the risk of intestinal perforation.

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 We experienced 5 cases of HIT among hemodialysis patients (HIT during dialysis) from 1 July, 2008, to 31 Aug, 2012. We show the clinical characteristics of these cases compared with those of 74 patients starting dialysis (emergency dialysis in 32 patients) during the same period in our hospital. All of these 5 cases experienced HIT during the period of introduction of emergency dialysis using intravascular catheters. Given that the incidence of HIT during the hemodialysis introduction period was 6.8% (5/74 cases), the incidence in patients starting emergency dialysis using intravascular catheters was considered to be high at 15.6% (5/32 cases). Six out of 74 cases experienced intravascular catheter blockage at least twice, and 4 cases among them developed HIT. The HIT antibody did not become negative in 1 patient, who died of another disease. All 4 cases negative for HIT antibody received heparin administration again, and their clinical courses have been uneventful without recurrence to date.

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 This medical case involves a 75-year-old male who had been on hemodialysis since April, 2007 due to chronic renal failure stemming from chronic nephritis. He began experiencing abdominal distension early in July, 2012 and came to the hospital the next day for hemodialysis. Prominent distention of the intestinal tract was detected by plain X-ray of the abdomen and a diagnosis of left obturator hernia was made by plain CT of the abdomen. Hernioplasty was carried out the same day through emergency surgery, and the patient made good post-operative progress. An obturator hernia is a rare disorder that makes up only 0.073% of all hernias and 0.4% of all ileus. In addition, the disorder appears most commonly in older, thin women, with men affected in only 5% of cases. In some instances, the clinical manifestation is mild, and although it is difficult to suspect obturator hernia, early diagnosis and early treatment are important since the disorder has a high fatality rate.

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 An 81-year-old hemodialysis patient was admitted to our hospital complaining of a serious bleeding tendency. The prolongation of activated partial thromboplastic time (APTT), a decrease in factor VIII and a high titer of factor VIII inhibitor (1,261 Bethesda Units/mL) were found. Under the diagnosis of acquired hemophilia A, he was treated with prednisolone at 50 mg/day (1 mg/kg/day) and double-filtration plasmapheresis (DFPP). On the 30th day, findings indicated hemorrhagic gastric ulcer. We undertook endoscopic hemostasis for the bleeding gastric ulcer several times, but the bleeding did not stop. Because of the gastric ulcer, prednisolone had to be reduced and cyclophosphamide was added. Despite decreasing titer of factor VIII inhibitor, the gastrointestinal hemorrhage was refractory. However, the duration of hemostasis of arteriovenous fistula after hemodialysis was gradually shortened. The patient died of ventricular fibrillation with hyperkalemia. We reported a rare case of acquired hemophilia A treated with steroids and DFPP.

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 To minimize the environmental contamination of dust and microorganisms in dialysis fluid, we assembled an isolator using HEPA filter for powder-dissolving systems. After adoption of the isolator, the endotoxin level and bacterial count of dialysis fluid at the outlet of the central delivery system were decreased to as low as those of dialysis (reverse osmosis) water. Our simple, inexpensive system is expected to ensure ultrapure dialysis fluid and to reduce the burden of endotoxin-retentive filters.

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