[Purpose] Recently, home hemodialysis (HHD) has become common in Japan. However, vascular access (VA) is difficult in some patients. To perform stable HHD, it is important to achieve favorable VA. With respect to VA for HHD patients in our hospital, we analyzed VA maintenance/control before and after the introduction of HHD. [Subjects/Methods] The subjects were 4 patients undergoing chronic maintenance dialysis in whom HHD management had been conducted in our hospital (42.8±7.1 years, male-to-female ratio: 2: 2, duration of HHD: 20.8±20.5 months) (mean±SD). We retrospectively examined VA orientation as guidance before HHD introduction and the management of puncture/problems after HHD introduction based on interviews on consultation at the outpatient clinic and reports/records regarding the treatment course on each session. [Results] The mean frequency of guidance before HHD introduction was 27.3±10.9 times (mean±SD). Of these, the frequency of guidance for puncture was 21.5±9.0 times. VA problems after HHD introduction consisted of mis-puncture-related internal hemorrhage (11 episodes), pain/swelling at the puncture site (6 episodes), puncture-position switching related to an increase in the venous pressure or pain at the puncture site (7 episodes), PTA selection (1 episode), and additional guidance for puncture (2 episodes). Sharp needle-related problems caused swelling/pain, markedly influencing the patients' stress. On the other hand, buttonhole (BH) puncture reduced stress. [Conclusion] As a specific interval is required to learn self-puncture, it may be necessary to start guidance for puncture in the early phase. BH puncture may lead to a decrease in the number of puncture-related problems, and should be utilized as a puncture method to put patients' mind at ease. However, guidance for puncture with a sharp needle must be performed in patients in whom BH puncture is difficult or as a strategy when it is impossible. For VA management in HHD patients, it is important to accurately acquire puncture methods matched to individual patients and continue regular observation with dialysis staff.

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MBD-5D (Mineral and Bone Disorders Outcomes Study for Japanese Chronic Kidney Disease stage 5D patients) is a prospective, multicenter, observational study on hemodialysis patients with secondary hyperparathyroidism (SHPT). Here, we report the results of a “survey on practice patterns” that 79 facilities responded to at the end of a study and compared them with their baseline results in terms of the achievement of “Guidelines for the management of SHPT in dialysis patients” published in 2006, discussing possible impacts on practice patterns and treatment. The percentage of facilities whose target range at the baseline fell within that of the guidelines was 60% with corrected serum calcium, 71.8% with serum phosphorus, and 54.1% with serum iPTH, and 59.5, 73.4, and 57.0%, respectively, at the end of the study. The percentage of facilities that set their upper-limit of the serum phosphorus target range lower than 6.0 mg/mL in the guideline increased from 26.6 to 35.4%. In contrast, the percentage of facilities that set their upper-limit of iPTH higher than the guideline value of 180 pg/mL decreased from 34.2 to 29.1% at the end of the study. Moreover, averaged serum iPTH levels decreased from 328 to 225 pg/mL, and the percentage of patients with iPTH over 180 pg/mL markedly decreased from 82.5 to 47.1% and the achievement of the guidelines significantly increased from 14.7 to 42.2% (p<0.001). The survey results show the change in practice patterns and treatment for CKD-MBD management and wide acceptance of the guidelines. With some suggested impacts of new CKD-MBD-related drugs on therapeutic management, the results of the present study are expected to contribute to guidelines for the management of CKD-MBD in the future.

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We encountered a hemodialysis patient with sarcomatoid renal cell carcinoma. The patient was a 58-year-old male, who had been on hemodialysis for 23 years. He was admitted to the hospital because of a high level of C-reactive protein. In June 20xx, we found masses in his livers in computed tomography (CT) images, but could not idenfy the primary site of the tumor. His condition rapidly deteriorated, and he finally died on the 96th hospital day. Autopsy demonstrated right renal cancer as well as metastatic tumors in the liver, spine, and peritoneal membrane. Pathologically, we diagnosed sarcomatoid renal cell carcinoma (RCC) arising from the right kidney mass. It is well-known that RCC occurs in hemodialysis patients. To diagnose this disease in the early stage, regular examinations are essential, but, in sarcomatoid renal cell carcinoma, renal tumors remain difficult to diagnosis correctly, even with CT images. Further examinations are necessary to develop a plan for screening or therapy for sarcomatoid renal cell carcinoma.

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A woman in her fifties was admitted to our hospital with generalized weakness in July, 2008. Her blood urea nitrogen was 102.1 mg/dL and creatinine was 9.9 mg/dL. We performed hemodialysis with catheterization into her right femoral vein on the admission day. The catheter was an Argyle^® double lumen hemofiltration catheter, slide type. Four days later, the catheter was exchanged using a guide wire because of blood flow failure. In 2010, the migration of the catheter into her heart was discovered in another institute. Retrospectively chest X-ray imaging in our hospital after the replacement procedure showed that the inner catheter had migrated into the right ventricle via the superior vena cava and the right atrium. It was retrospectively clarified that the catheter had separated into the inner and outer parts because of cutting at the bifurcation, and so the inner catheter had migrated into the patient's heart. In the catheter manual, there is a caution which states that; “cutting is prohibited because of the risk of migration into the patient's body”. This accident was due to a very careless mistake in the catheter replacement procedure. We very deeply regretted that one of our staff had replaced catheter without reading the manual. Reading a manual for a catheter, or indeed any piece of equipment, is a fundamental attitude that all physicians should continuously bear in mind, especially when they have had no prior experience with the same type of catheter. This patient has been carefully followed up with warfarin, and a pulmonary embolism was found with a regular pulmonary blood flow scintigram in August, 2012. We increased the dosage of warfarin immediately. There has been no symptom so far. We report herein on a case with migration of a hemodialysis catheter into a patient's heart because of a very careless mistake on the part of our staff.

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