【Background and Purpose】Steal syndrome is diagnosed by integrating the objective findings and subjective symptoms. Since a serious ischemic symptom is accompanied by an ulcer, necrosis or irreversible neuropathy nerve paralysis, an objective rating method with high diagnostic capability is required. In severe ischemia of the lower limbs, it is reported that the measurement of skin perfusion pressure (SPP) is useful and is used for the decision on treatment policy and the judgment of the prognostic healing ability clinically. In this study, we examined the usefulness of SPP for dialysis-associated steal syndrome. 【Subjects and Methods】This study involved 106 patients with vascular access obtained by measuring the SPP at our clinic. By an interview on the presence of steal symptoms during an examination, subjects were classified into four groups of Stage I~IV by Fontaine's severity classification, with an additional fifth group without symptoms. The average values of SPP in the five groups were computed. Moreover, the subjects were classified according to the existence of steal condition, and the cut-off value was computed using cumulative relative frequency. 【Results】Among the subjects, 43 patients did not have steal condition and 63 patients did. In terms of the mean SPP level of each group, that of the symptomless group was 85.8±25.0 mmHg (44 cases), Stage I group 48.4±11.7 mmHg (28 cases), Stage II group 35.8±13.5 mmHg (17 cases), Stage III group 24.7±10.0 mmHg (16 cases), and Stage IV group 17.3±2.4 mmHg (3 cases). The cut-off value of steal syndrome generated using the cumulative relative frequency was 57.5 mmHg (sensitivity : 87.1%, specificity : 95.3%, positive likelihood : 18.2). 【Conclusions】SPP has high ability to diagnose steal syndrome and is useful as an objective laboratory procedure for investigating the condition of a patient.

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 A 63-year-old female with type 1 diabetes mellitus complicated by neurogenic bladder started hemodialysis due to end-stage kidney disease associated with diabetic nephropathy in 2005, and underwent living-donor renal transplantation from her husband in 2007. However, the function of the transplanted kidney decreased due to repeated pyelonephritis, and hemodialysis was resumed in 2011. Nine months after the introduction of hemodialysis, she presented with fever and swelling of the right lower abdomen. CT revealed enlargement of the transplanted kidney, loss of its internal structure, and partial liquefaction and gas formation. She was diagnosed with emphysematous pyelonephritis and admitted to our hospital. After percutaneous drainage and antibiotic administration, the clinical symptoms and inflammatory reactions improved. However, the amount of drained fluid did not decrease. Further conservative treatment was considered to be difficult, and allograft nephrectomy was performed. The postoperative course was favorable, showing improvement in the inflammatory findings and no recurrence of infection. Emphysematous pyelonephritis is a serious necrotizing bacterial infection involving the renal parenchyma, and sometimes requires surgical treatment. Emphysematous pyelonephritis in a transplanted kidney has rarely been reported. The determination of treatment principles including immediate diagnosis and surgery is important. We report a case and review the literature.

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 A 58-year-old man had been treated with hemodialysis using heparin as an anticoagulant since December 1991. Eosinophilia appeared in November 2005 without changes in other clinical and laboratory findings. In August 2006 (15 years after the start of dialysis), blood coagulation in the dialyzer and extracorporeal circuit began to occur during hemodialysis. Blood coagulation gradually worsened, despite an increase in the dose of heparin and change of the dialysis membrane, which was then accompanied by chest discomfort and severe hypotension just after the commencement of dialysis. Both blood coagulation and shock during hemodialysis were improved by the administration of aspirin. However, aspirin administration ceased because of skin itching, after which the above symptoms recurred. Laboratory data disclosed an extreme decrease in platelet count after hemodialysis and specific immunoglobulin G antibodies to platelet factor 4-heparin complex. Accordingly, the patient was diagnosed with heparin-induced thrombocytopenia (HIT) and heparin was changed to nafamostat mesilate as an anticoagulant. Clotting in dialysis equipment, thrombocytopenia, shock during hemodialysis, and eosinophilia were all improved following the use of nafamostat mesilate. The present case was a rare case of HIT characterized by late occurrence following long-term hemodialysis for 15 years, complication of shock during dialysis, and eosinophilia preceding the onset of HIT.

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 Lanthanum carbonate chewable tablets can be administered without water. However, it has been reported that phosphate (P) absorption varies according to the degree of chewing of the lanthanum carbonate tablet. To resolve this problem, a granule formulation of lanthanum carbonate has been released. We investigated P absorption when the new granule formulation of lanthanum carbonate was administered. We administered the granule formulation of lanthanum carbonate to 18 hemodialysis patients previously treated with a chewable tablet formulation of lanthanum carbonate. The mean serum P concentration significantly declined from the initial level of 5.69±0.86 mg/dL to 5.38±0.86 mg/dL at two weeks and to 5.20±1.20 mg/dL at four weeks. When the daily dose of lanthanum carbonate was higher, the decrease in the serum P concentration might be larger. No significant changes were seen in the serum calcium (Ca) or intact parathyroid hormone (iPTH) levels.

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