In recent years, the age and dialysis period of dialysis patients have become longer. In order to maintain and improve the health condition of dialysis patients, therapeutic exercise has become important. Generally, their activity level decreases on dialysis days due to time limitations and fatigue after dialysis. Thus, therapeutic exercise during hemodialysis is important. It has been reported that motor function and quality of life of dialysis patients are improved by therapeutic exercise with sports equipment during hemodialysis. Twenty-three hemodialysis patients underwent a 12-week strength training program without sports equipment ; ability of transfer and quality of life were compared before and 12 weeks after the program. Ability of transfer, muscle strength of knee extension, and role functioning and quality of life improved. This kind of training program as therapeutic exercise is effective for physical function and quality of life in hemodialysis patients.

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The aim of this study was to reveal useful tools for fall tendencies. We prospectively enrolled 123 ambulatory hemodialysis patients, and the primary outcome measure was the incidence of falls during a 1-year follow-up period. Cox proportional hazard regression was used to assess the contribution of variables, which were physical performance (short physical performance battery, SPPB), muscle strength, muscle mass, nutritional status, and intra-dialytic hypotension (IDH), in the incidence of falls. Thirty-eight patients (31%) fell during the follow-up period. In multivariable analysis, IDH was an independent risk factor (hazard ratio (HR) =2.66, log-rank p=0.002). In addition, the HR for falls in patients with less than 7 points on SPPB was 2.41 (95% confidence interval of 1.13−5.35, log-rank p=0.02) compared with more than 11 points as reference. Determining the presence of IDH and low-level physical function extremely useful to predict falls in hemodialysis patients.

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To assess the accuracy of estimated blood flow volume at the location of the arteriovenous fistula (eAVF-FV), we compared estimated brachial arterial blood flow volume (eBA-FV) measured by the flow profile ultrasound method (FP) and pulsed Doppler ultrasound method (PD) with estimated AVF blood flow volume (eAVF-FV) measured by an ultrasound velocity dilution technique. We evaluated 17 hemodialysis patients with native forearm AVF. eBA-FV was measured at the mid-forearm (MF) with a duplex scan probe using ProSoundα7 (A7) (Hitachi Aloka Medical Co., Ltd.) and LOGIQ Book XP (LB) (GE Healthcare), and eAVF-FV was measured using an HD-02 monitor (Transonic Systems) during a continuous hemodialysis session. eAVF-FV values were 155～1,045 mL/min (566±322 mL/min) and relative errors (RRs=[|eBA-FV-eAVF-FV|]/AVF-FV×100) of eBA-FV were 39±42% (A7-FP), 47±45% (A7-PD), and 83±59% (LB-PD). eBA-FV using LB-PD at the MF was significantly overestimated (p=0.025). FP and PD were clinically useful in eAVF-FV evaluation when the errors of eBA-FV were considered.

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Hemodialysis patients are at a greater risk of developing renal cell carcinoma (RCC) than the general population. RCC is an important factor in determining life prognosis. However, it is difficult to detect RCC in patients with acquired cystic kidney disease. Therefore, dialysis patients should periodically undergo diagnostic imaging. Here, we report the case of a long-term hemodialysis patient in whom PET-CT was useful in diagnosing metastatic RCC in the lumbar spine as well as the primary RCC.

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An 80-year-old female patient, who had been receiving maintenance hemodialysis for eight years for end-stage kidney disease due to diabetic nephropathy, presented to the ER with difficulty in walking after a fall. Severe trauma was not observed, but she presented with signs of inflammation and persistent mildly disturbed consciousness. Therefore, she was referred to our department for further evaluation. Collagen disease and malignancy were ruled out. On reviewing her detailed history, she was found to have had persistent eosinophilia, at least since the commencement of dialysis, and allergic reactions to drugs or dialysis equipment had been suspected. However, despite changing to erythropoiesis-stimulating agents and dialysis membranes, the eosinophilia did not improve, and she was administered steroids (maximum 5 mg of prednisone) to address a tentative diagnosis of idiopathic eosinophilia. Since eosinophilia persisted until the present admission, thorough evaluation was carried out to explain the eosinophilia, including tests for parasitic diseases as a differential diagnosis. Strongyloides was detected in a stool sample and a final diagnosis of strongyloidiasis was made, although findings of organ damage, including lung or gastrointestinal tract damage, were not detected, and the patient had no history of travel to strongyloidiasis endemic areas. When unexplained eosinophilia is detected in dialysis patients, parasitic diseases should be excluded, including those not endemic to the area in which the patient resides.

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In patients with autosomal dominant polycystic kidney disease (ADPKD), most cases of hepatic cyst infection develop from transbiliary infection, which is usually caused by intestinal bacterial flora or anaerobic bacteria. However, we experienced a rare case of hepatic cyst infection in ADPKD caused by Streptococcus gordonii, a type of oral streptococcus, which was detected by the 16S ribosomal RNA method. The patient was treated by subcutaneous drainage of the infected cysts along with 8-week intravenous administration of antibiotics. In this case, poor periodontal condition, including the presence of caries, and lack of careful precautions during hemodialysis needle puncture were considered to be the causes of streptococcus bacteremia, which finally led to cyst infection. We report this highly educational case that suggests the importance of good oral hygiene and careful infection control during hemodialysis in patients with ADPKD.

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Non-occlusive mesenteric ischemia (NOMI) is defined as diffuse intestinal ischemia without any organic blood vessel occlusion. Although rare, NOMI has a very high mortality rate (70-90%) among patients undergoing dialysis. We herein report two patients with NOMI triggered by hypotension during hemodialysis. Case 1 : A 52-year-old man with a low left ventricular ejection fraction after myocardial infarction presented with intradialytic prolonged hypotension and acute abdomen. Case 2 : An 88-year-old woman who had been on maintenance hemodialysis for 5 years developed intradialytic hypotension with acute abdomen. We performed multidetector computed tomography (MDCT) and found patent mesenteric vessels in both cases. A subsequent surgical procedure revealed necrosis of the terminal ileum in Case 1, and an autopsy revealed necrosis of the cecum in Case 2. Finally, we diagnosed both patients with NOMI. The patient in Case 1 underwent a surgical procedure and was discharged alive, but the patient in Case 2 died. An early diagnosis of NOMI is crucial considering that this condition has a very high mortality rate. However, diagnosing NOMI is very difficult because the clinical manifestations are nonspecific. We speculate that the hemodialysis profile is similar to that of the risk factors ; therefore, patients with intradialytic hypotension and an acute abdomen on MDCT should be evaluated.

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We report a case of tuberculous lymphadenitis in a hemodialysis patient. A 71-year-old male, who had undergone maintenance hemodialysis for diabetic nephropathy, suffered from an A-V fistula occlusion. He received reconstruction of the A-V fistula at the opposite forearm, and he had a fever on the 4th postoperative day. Although we treated him with various antibacterial agents, fever remained for several weeks. A computed tomography (CT) scan revealed several swollen lymph nodes in the left cervical and para-aortic regions, and a blood examination showed a high IL-2R level. According to these results, we suspected malignant lymphoma and performed a left cervical lymph node biopsy. Histopathologic findings indicated caseating granuloma, and it was shown by PCR assay the detection of tubercle bacillus in the specimen; therefore, we made a diagnosis of tuberculous lymphadenitis. Remission was achieved after simultaneous administration of four anti-tuberculous drugs, and left cervical and para-aortic lymph node swelling was not seen in a CT scan one year after treatment. A fever of unknown origin (FUO) is occasionally seen in patients receiving hemodialysis. Tuberculosis may be the cause of the FUO, so it should be considered in differential diagnosis in these patients.

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