【Objective】In order to examine the efficacy of ferric citrate hydrate against renal anemia, we discontinued the administration of iron when ferric citrate hydrate was administered. 【Subjects】 Among 95 hemodialysis patients at our hospital between June 2014 and February 2015, 45 patients (31 males and 14 females) who met the entry criteria were enrolled in this study. 【Methods】We discontinued iron administration to patients who were receiving intravenous or oral iron administration while ferric citrate hydrate 1,500 mg/day was administered, and investigated iron metabolism markers, darbepoetin α (DA) doses and erythropoietic resistance index. 【Results】 Examination of all the subject patients showed that there were no significant changes in serum ferritin levels and TSAT levels. However, Hb concentration significantly increased. DA doses significantly decreased and 40.1% DA reduction effect was observed. Examination of each iron dose group showed that the DA reduction effect was 50.2% in the intravenous iron discontinuation group and 33.5% in the oral iron discontinuation group, and the erythropoietic resistance index decreased. 【Conclusion】We were able to prevent excessive iron intake by discontinuing iron administration when ferric citrate hydrate 1,500 mg/day was administered. Furthermore, Hb concentration increased. Ferric citrate hydrate was more effective in improving anemia than intravenous or oral iron administration. Thus, the efficacy of ferric citrate hydrate against renal anemia was demonstrated.

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The purpose of this study is to examine the effectiveness and safety of antegrade percutaneous transluminal aortic valvuloplasty (ante-PTAV) in maintenance dialysis patients. From among all cases of ante-PTAV at our facility between November 2009 and March 2014, we focused on 20 cases of patients on dialysis. Between pre- and post-surgical pressure gradient measurements, the level of severity of AS improved on average from 55.6±15.4 mmHg to 19.0±9.9 mmHg, the average aortic valve area increased from 0.69±0.17 cm² to 1.24±0.34 cm², and the average NYHA classification improved from 3.4±0.68 to 1.75±0.85, while the lowest intradialysis systolic blood pressure improved from 96.6±22 mmHg prior to treatment to 112.2±24.9 mmHg after treatment. On the other hand, death resulted in one case, and other complications were observed in 3 cases. Restenosis was noted in two cases following surgery, as a result of which, ante-PTAV was implemented again. For patients on maintenance dialysis complicated by severe AS, ante-PTAV is a minimally invasive and safe procedure. Observations indicated that the treatment is effective in bringing about improvements in clinical conditions and eliminating some difficulties of dialysis.

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A 79-year-old man was admitted to another hospital in January 201X due to fever and eruptions. He was diagnosed with toxicodermatitis and was discharged from the hospital after steroid therapy. In April 201X, he was admitted to the hospital for thrombocytopenia, but was transferred to our hospital on suspicion of hematologic disease because of the appearance of anemia and disturbance of consciousness. Because he had thrombocytopenia, hemolytic anemia and mental confusion, he was suspected to have thrombotic thrombocytopenic purpura and immediately received plasma exchange and high-dose steroid therapy. A deficiency in ADAMTS13 activity confirmed the diagnosis of TTP later. Although improving temporarily, his laboratory tests showed recurrence of thrombocytopenia and he was administered cyclophosphamide and rituximab. Because his platelet count became stable after starting the combination therapy, PE was stopped and he was discharged from the hospital with oral steroid therapy. It was shown that rituximab and cyclophosphamide should be considered with refractory TTP.

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Case 1 : A 58-year-old man who had been receiving maintenance hemodialysis therapy for 28 years underwent computed tomography (CT) for elevated C-reactive protein level of unknown cause. CT showed multiple liver tumors, and a chemotherapy regime was started. Autopsy showed right spindle cell renal cell carcinoma (RCC) with multiple metastases. Case 2 : A 61-year-old man began hemodialysis therapy at the age of 47 years because of the loss of a kidney graft. At the age of 61 years, he underwent laparoscopic right radical nephrectomy. Pathological examination indicated spindle RCC. Three months after the operation, CT showed metastases to the liver and rectum. Despite administration of everolimus, the patient died of disease progression. Case 3 : A 60-year-old man who had been receiving maintenance hemodialysis therapy for 25 years presented with high fever of unknown origin and anorexia. CT showed multiple liver masses and renal cysts. Because he had right dorsal pain and continuous fever, we suspected right renal cyst infection or RCC, and laparoscopic right nephrectomy was performed. A pathological examination indicated spindle RCC. Two weeks after the operation, the patient died of a cardiogenic embolism. It is well known that regular screening by abdominal echo and CT are useful for long-term dialysis patients. However, we need to recognize that some cases of spindle RCC in hemolysis patients are difficult to diagnose with imaging tests.

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A 48-year-old man with diabetic nephropathy underwent hemodialysis (HD) from April 201X. Fever was observed just after the induction of HD, but it was caused by unknown origin. We suspected bacterial infection because the antibiotics were effective. In August 201X, he was referred to our hospital because of an abdominal mass and vomiting. The cystic mass, measuring 12×5×8 cm around the small intestine, was observed on abdominal CT scanning. During surgery, peritoneal adhesion, a large number of solid tumors in the parietal and visceral peritoneum, and the main tumor, which we were unable to remove due to the adhesion, were found to be severe. The mass was regarded as a progressive sarcoma, but metastasis to other organs was not observed. Histological examination showed extensive proliferation of inflammatory cells, including neutrophils and foamy histiocytes, and scattered atypical giant cells with one or more irregular, hyperchromatic nuclei. In immunohistochemistry, there were no responses to specific markers. Based on the pathology, the patient was diagnosed as having inflammatory malignant fibrous histiocytoma (MFH) with peritoneal dissemination. Since there have not been previous reports of this disease in a dialysis case, this may be a valuable case.

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Caroli’s disease and Caroli’s syndrome are rare congenital disorders characterized by non-obstructive cystic dilatation of the intrahepatic bile ducts. These disorders are often associated with autosomal recessive polycystic kidney disease. A 78-year-old male had been under hemodialysis since January 2008 because of chronic renal failure due to polycystic kidney disease. He had experienced fever of unknown origin since April 2011 and had frequent hospitalizations. Computed tomography and sonograms of the liver showed multiple peribiliary cysts. Magnetic resonance cholangiopancreatography in August 2012 showed multiple cystic dilatation of the intrahepatic bile duct. Endoscopic retrograde cholangiography showed cystic dilatation of the segmental intrahepatic bile duct, and a diagnosis of Caroli’s disease was made. The diagnosis was based on the findings of MRCP and other imaging examinations. Caroli’s disease is classified into two types depending on the type of congenital hepatic fibrosis : a pure type and a periportal fibrosis type. We diagnosed our case as Caroli’s disease with acquired hepatic fibrosis because the hyaluronic acid value (14,164 ng/mL) exceeded the standard value. The result of the cultivation test of the bile sampled in the ERCP examination was negative. Hemodialysis treatment complicated by polycystic kidney disease in combination with Caroli’s disease is rarely reported. We present this case report with some references.

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