Pruritus in hemodialysis patients is intractable. This condition has attracted increasing attention as a factor that decreases the QOL and adversely affects the prognosis. Nalfurafine hydrochloride (nalfurafine) became clinically available in March 2009 for the treatment of intractable pruritus in hemodialysis patients. Herein, we investigated the efficacy and safety of a 2-year (104-week) administration of nalfurafine in hemodialysis patients with intractable pruritus that is resistant for alternative treatment. The study involved 13 patients whose visual analogue scale (VAS) scores were≥70 mm or itch severity scale (Shiratori's classification) scores were≥3 (moderate), and who were able to take nalfurafine for 104 consecutive weeks. The initial dose of nalfurafine was set at 2.5 μg/day, and a questionnaire survey including assessment by VAS and Shiratori's classification was periodically conducted. The mean scores of both VAS and Shiratori's classification for daytime and nighttime at week 104 were significantly decreased after nalfurafine administration. The frequency of insomnia also decreased, and the number of patients experiencing insomnia became zero by week 74 and remained so until week 104. There were only 3 patients whose nalfurafine dosage was increased to 5 μg/day because pruritus symptoms did not improve. No attenuation of efficacy resulting from drug resistance was observed. All adverse reactions due to nalfurafine appeared within 2 weeks after nalfurafine administration. These results indicate that nalfurafine is effective and safe for long-term administration.

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Objective: Injury of the finger extensor tendon in the opisthenar is commonly seen in dialysis patients, but the pathology of this condition remains to be elucidated. This study was designed to determine the cause, incidence, and symptoms of finger extensor tendon injury on the opisthenar and investigate what patients would be candidates for surgery. Subjects: This study included fifty patients (seventy-one hands) with swelling on the dorsal side of the wrist joint and, as confirmed by ultrasound examination, hyperplasia of the extensor tenosynovium. Results: 1) Injury of the finger extensor tendon on the opisthenar developed in patients who had undergone dialysis over 15 years or longer. The prevalence was increased as dialysis persisted for a longer duration; 2.7% for a dialysis duration of 10 to 19 years, 34.9% for 20 to 29 years, and 82.8% for 30 years or longer. 2) For subjective symptoms, swelling was noted in twenty-six patients, pain in five patients, and restricted finger extension in three patients. Approximately half of patients had no subjective symptoms. 3) Ultrasonography was useful as an adjunctive diagnostic method for injury of the finger extensor tendon. 4) In five patients treated surgically, the synovium, extensor retinaculum, and tendon were collected during surgery for histopathologic examination, suggesting the presence of amyloid deposition. 5) Dialysis amyloidoses, including carpal tunnel syndrome, amyloid bone cyst, and amyloid shoulder arthropathy, were complications in 94% of the patients with injury of the finger extensor tendon on the opisthenar. Discussion: Injury of the finger extensor tendon on the opisthenar represents stenosing tendosynovitis that develops as a result of amyloid deposition in the tenosynovium and extensor retinaculum. Clinical observation and ultrasonography are useful in the diagnosis of this disease. As the disease progresses, swelling and pain on the opisthenar as well as hypertrophy of the tendon occur. The characteristics in the end-stage of this disease include degeneration of the tendon and restricted range of motion in the fingers. In the advanced stage, which is associated with tendon hypertrophy and tenosynovial hyperplasia, aggressive surgical treatment is indicated.

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Fractures are a prevailing complication in dialysis patients. Although the association of age, female gender, diabetes, and malnutrition with fractures has been described, the significance of bone quality is unknown. Pentosidine and homocysteine appear to be useful biochemical markers of bone quality. Therefore, we studied the association of pentosidine, homocysteine, and other factors with the prevalence of fractures in hemodialysis patients. Serum pentosidine, homocysteine, albumin, creatinine, and whole PTH were determined before hemodialysis. The bone mineral density (BMD) of the lumbar spine (L1-L4, vertebrae with compression fractures were excluded), proximal femur, and distal 33% site of the radius was determined by dual-energy X-ray absorptiometry using DPX BRAVO (General Electric, Fairfield, CT, USA) and expressed in percentages of young adult means of both genders. The presence of vertebral and hip fractures was determined by history-taking and X-ray films. These data were collected from 81 patients on hemodialysis in our hospital. Vertebral and hip fractures were identified in 19 patients. Comparison between patients with and without fractures was performed using the Mann-Whitney U-test. Patients with fractures showed an older age (p=0.005), lower creatinine (p=0.011), lower whole PTH (p=0.020), lower lumbar BMD (p=0.025), lower hip BMD (p=0.001), and higher pentosidine (p=0.017). However, no significant differences were found in homocysteine, the body mass index, radius BMD, gender, DM, age, or albumin. Then, multivariable logistic regression analysis was performed with the prevalence of fractures as a dependent variable. In a stepwise model, pentosidine, creatinine, and hip BMD were chosen as independent variables. These results suggest that deterioration of the bone quality could be an independent risk of fractures in hemodialysis patients. Further studies are necessary to elucidate the association of high pentosidine with the incidence of fractures in uremic patients.

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In order to expand the availability of sources for vascular access. The feasibility and safety of the superficialization of the radial artery was studied. Prior to the surgery, the bore and severity of arteriosclerosis of the radial artery were examined with ultrasound tomography. An incision was made medial to the radial artery of the forearm in order to avoid damaging the lateral cutaneous nerve. Then, subcutaneous tissue was exfoliated carefully to reach the fascia. Finally, the radial artery was dissected in the space between the flexor carpi radialis and brachioradial muscles. Throughout the procedure, care was taken not to injure the superficial branch of a radial nerve which is running closely with the radial artery on its lateral side. After arterial dissection, the fascia was sutured to form the posterior wall. The procedure was completed by attaching the artery to the skin. Superficialization of the radial artery was performed safely in 5 cases (age: 58～90, male: 4, female: 1) including 2 primary cases with heart failure. In 2 cases, radial artery superficialization was performed as a backup access for ordinary arteriovenous fistula reconstruction. One case did not have a suitable vein in the forearm, and blood was drawn from a superficalized radial artery and returned to the vein of the fossa cubitalis. In 3 cases, the constructed vascular access provided sufficient blood flow (>250 mL/min) for stable hemodialysis. Superficialization of a radial artery can be a useful alternative for the construction of vascular access for hemodialysis.

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Telemedicine using Skype video calls for vascular access problems was attempted among a regional key hospital and satellite hospitals for patients on hemodialysis. Useful information for the initial judgment of the need for intervention or surgery (triage) was efficiently collected in real time. Appropriate instructions of specialized physicians to local medical staff through the system allowed the follow-up of patients without any problems at satellite hospitals. In addition, at the time of acceptance of patients in the key hospital, a more appropriate response could be quickly prepared due to an increased amount of information available about the access problems. The dissemination of this technology is expected to correct the regional disparities in areas without specialized physicians for vascular access.

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