Globalization has led to a world in which national borders have become increasingly irrelevant; therefore, international standards in medicine must also be adopted by hospitals around the world. In November 2012, we were certified to have met the Joint Commission International (JCI) accreditation standards. This JCI certification guarantees the international standard medical care and safety management in the hospital. The number of JCI-accredited hospitals has been increasing in recent years, particularly in Asian countries. Many hospitals in Japan will likely consider and begin preparations for the JCI survey in the near future. Surveyors from the JCI visited our hospital and subsequently evaluated patients' rights, safety of medical interventions, treatment processes, infection control, and facility management. In preparation for the survey, we spent more than one year reevaluating dialysis manuals, patient identification methods, infection control, and maintenance of both high-alert medicine and devices in our dialysis unit. Here, we report our past experiences and future expectations in relation to ongoing improvements in quality in the dialysis unit.

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【Objectives】We evaluated the effects of levocarnitine on the cardiac function of dialysis patients. 【Subjects】Among our 192 patients on maintenance dialysis, 153 eligible patients met the entry criteria based on the results of a questionnaire. We investigated the oral group (113 patients) who requested internal use. 【Methods】The study was an interventional, non-randomized control study. Patients in the oral group received levocarnitine at a dose of 20 mg/kg/day (up to 1,200 mg/day) for 6 months. Echocardiographic parameters and NT-proBNP level as predictors of heart failure were measured at baseline and after 3 and 6 months. 【Results】In the oral group, there was no significant change in LVDd, LAD, and the ratio of diastolic function parameters E/A and E/e' at 3 and 6 months compared with those at baseline. However, significant improvements of EF and left ventricular structure (LVMI) were noted at 3 and 6 months compared with those at baseline. We performed a subgroup analysis in which the patients were divided into 2 groups with and without left ventricular hypertrophy (LVH). In the group with LVH, EF increased significantly from 58.0±6.5% at baseline to 61.0±6.9% at 3 months and 60.5±6.8% at 6 months, and LVMI decreased significantly from 132.2±20.9 g/m² to 108.5±23.9 and 110.8±22.3 g/m², respectively. In contrast, there was no significant improvement in EF and LVMI in the group without LVH. There was no significant change in NT-proBNP level in the oral group compared with that at baseline. 【Conclusion】 Levocarnitine showed favorable effects on the cardiac function of dialysis patients, as shown by improved EF and decreased LVMI. Subgroup analysis revealed that responders to levocarnitine were patients with LVH.

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【Objective】We investigated the minimum and optimal serum ferritin (Frn) levels required to maintain stable hemoglobin (Hb) levels in patients receiving hemodialysis. 【Methods】We conducted a prospective intervention study (duration, 12 months) in accordance with a new treatment protocol. The subjects were divided into 3 groups on the basis of their serum Frn levels at the start of the study (high-rank group, Frn≥100 ng/mL; moderate-rank group, Frn 50～100 ng/mL; and low-rank group, Frn<50 ng/mL), and the Frn control range and criteria for iron supplementation were established for each group. Stratification analysis was conducted for all subjects and for all 3 groups according to the time of initiation of Frn administration. In addition, the subjects were classified according to whether or not they were able to continue treatment on the basis of certain criteria (successfully or unsuccessfully). Evaluation: The Frn level measured immediately before a significant increase in the erythropoietic resistance index (ERI), which was associated with decreased Frn levels, was considered to be the minimum optimal Frn level. 【Results】A total of 333 subjects were enrolled and 282 were included in the analysis. In all subjects, hepcidin-25, which is associated with decreased Frn levels, decreased significantly, and the minimum optimal Frn level was 62.2±64.3 ng/mL. During stratification analysis, hepcidin was significantly decreased in the high-rank group, and the minimum optimal Frn level was 103.4±80.4 ng/mL. In the moderate-rank group, the minimum optimal Frn level was 55.2±42.0 ng/mL. In the high-rank, successfully treated subjects, hepcidin-25 was significantly decreased, and the minimum optimal ferritin level was 61.6±29.6 ng/mL. Serum albumin levels were significantly elevated in association with the decrease in Frn levels. 【Conclusion】An Frn level of 60 ng/mL is a suitable criterion for initiating iron supplementation.

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A 74-year-old female with a history of 6 years on dialysis for autosomal dominant polycystic kidney disease (ADPKD) developed left lower extremity pitting edema. Dry weight was properly controlled and no abnormalities were found in the following laboratory findings: liver function tests, lower limb venous ultrasonography, echocardiogram, and contrast-enhanced computed tomography (CT). The cause of edema was not determined, but it improved relatively quickly with bed rest. She was discharged and followed up as an outpatient. However, the recurrence of edema was found a week after discharge and she was hospitalized again for re-examination. The edema was exacerbated upon prolonged standing or when in a left lateral position at home; as she had been in a right lateral position during hospitalization, this suggested that the change in body position might have made the edema worse. Left lateral position CT revealed that the inferior vena cava (IVC) was completely obstructed by the right cystic kidney, which was thought to be the direct cause of the edema. We confirmed by renogram that the residual renal function had been almost completely abolished and performed right renal transarterial embolization. The lower extremity edema completely disappeared without recurrence for three years. We promptly diagnosed the compression of IVC by left lateral position CT. This suggests that left lateral position CT may be helpful for early detection of cystic compression of IVC and enable us to provide early intervention.

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A 68-year-old female with pyonephrosis had been on maintenance hemodialysis due to end-stage renal disease (ESRD) for 25 years. Arteriovenous fistula (AVF) developed in the left forearm and swelling of the left limb appeared in 2010. Therefore, we performed percutaneous transluminal angioplasty (PTA) employing a balloon for the left stenotic brachiocephalic vein, based on a diagnosis of venous hypertension. At this time, venous hypertension was recurrent, and we again performed PTA with angiography using a 9-mm semi-compliant PTA balloon at the same site. However, the patient suffered massive hemoptysis just after the procedure and progressed to respiratory failure. CT scan showed reticular shadows in both lung fields, yielding a diagnosis of diffuse alveolar hemorrhage (DAH). As the hemoptysis was not continuous, we treated her with hemostatic agents and oxygenation. In addition, we created an AVF in the right forearm after closing the one in the left arm. The causes of DAH are well known and include not only non-immunological factors, such as heart failure, tumor, and pulmonary hypertension, but also immunological factors such as vasculitis syndrome and collagen diseases. On the other hand, there are no reports of DAH in an ESRD patient undergoing PTA. In conclusion, DAH might be caused by elevation of intra-alveolar capillary pressure due to the release of overflow capacity into the right-sided flows by PTA. We need to consider the optimal choice of therapy for long-term hemodialysis patients with multiple complications.

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