Recently in Japan, several guidelines regarding terminal care issues have been published and all of them refer to respect for individual autonomy. Similarly, the preference of patients requiring maintenance hemodialysis (MHD) should be respected so that they may spend the rest of their lives peacefully. This study utilized a virtual scenario in which a patient decides to withdraw from MHD in a broadly- defined terminal state, and discusses the implications of both MHD cessation based on self-determination and medical care in and after the decision-making process, based on the “Proposal for the Shared Decision-Making Process Regarding Initiation and Continuation of Maintenance Hemodialysis” (The Japanese Society for Dialysis Therapy, 2014). The results of the study suggest that it is ethically permissible and proper to allow MHD cessation if patients properly discuss and adequately understand their medical conditions and treatments and are permitted to make decisions without external pressures when in a broadly- defined terminal state. However, the decision-making process must be reviewed carefully while considering contextual features. In Japan, health professionals also require continual awareness of the inconvenient fact that there is no law providing immunity. This study suggests agendas that will supplement the proposal. In conclusion, it is necessary to comprehensively develop education about palliative care, consultation systems and subsequent grief care.

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For hemodialysis patients, an older average age reflects a more frequent occurrence of malignancy. However, reports on chemotherapy for hemodialysis patients are lacking. For chronic myeloid leukemia (CML) in hemodialysis patients, there have been few reports about long-term survival with imatinib, and no reports about therapy with dasatinib. Our case involves an 87-year-old man who was introduced to hemodialysis at 81 years old. He was diagnosed with CML at 82 years old by detection of Philadelphia chromosome in bone marrow, and was treated with imatinib. The basic dose of imatinib was 300 mg on alternate days. Complete hematologic response was achieved for three years. However, refractoriness to imatinib gradually appeared. Due to imatinib refractoriness, imatinib was switched to dasatinib. Although there was complete hematologic response, there was also cardiotoxicity, including cardiac wall motion hypokinesis, and heart failure worsened in spite of a decrease in dry weight. After stopping dasatinib, the cardiotoxicity disappeared immediately. This case shows that imatinib can control CML even in hemodialysis patients, and dasatinib can easily induce cardiotoxicity in hemodialysis patients.

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We report a case of hydrocele in a patient receiving peritoneal dialysis. A 61-year-old man with end-stage renal disease received peritoneal dialysis for about four months. He was seen at our hospital because of genital swelling. We stopped peritoneal dialysis and genital swelling resolved after 12 days. However, he had a recurrence of scrotal and penile swelling 5 days after restarting peritoneal dialysis. Computed tomography peritoneoscrotography showed contrast media in the right spermatic cord via the vaginal process of the peritoneum. Surgical exploration disclosed patency of the vaginal process of the peritoneum, and so high ligation was performed. The swelling resolved and peritoneal dialysis was reinstituted 7 days after the operation.

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We report a case of sarcomatoid renal cell carcinoma (sarc-RCC) with hemodialysis for a long period of time. In May 2011, a 56-year-old woman who had been on hemodialysis for 20 years was admitted to our hospital for fever of unknown origin. Computed tomography showed a 3 cm tumor in the right kidney and an 8 cm one in the pubic bone. Because a needle biopsy of the pubic bone tumor showed sarcomatoid cancer, we made a diagnosis of metastatic bone tumor from right renal cancer. The patient’s condition worsened rapidly, despite shortterm molecular targeted therapy with sunitinib, and she died of cachexia at 40 days of hospitalization. An autopsy confirmed papillary renal cell carcinoma with sarcomatoid component in the right kidney and sarcomatoid cancer in the liver, right adrenal gland, vertebra and pubic bone. A literature review revealed that 23 cases of sarc-RCC have been reported in patients receiving hemodialysis in Japan, with 87% (20/23) of the cases occurring in patients receiving hemodialysis longer than 10 years and 74% (16/23) of the cases having a tumor less than 7 cm in diameter. There was no relationship between tumor size and duration of hemodialysis. It is noteworthy that sarc-RCC might exist in a small renal tumor in patients receiving hemodialysis for a long period of time. Physicians should consider the duration of hemodialysis as important when indicating surgery for a renal tumor in patients receiving hemodialysis.

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A 61-year-old female chronic hemodialysis patient excreted tarry stool during postoperative course for acute hemorrhagic cholecystitis. She was diagnosed with acute small bowel bleeding by dynamic computed tomography. Selective visceral angiography was performed to identify the bleeding region. A 4-Fr cobra catheter could not be fully inserted into the superior mesenteric artery because of arterial sclerosis and stenosis. A 2.8-Fr microcatheter was advanced through the inside of the cobra catheter for selective angiography and transcatheter arterial embolization. Active contrast extravasation was observed in the small bowel. Super selective embolization was attempted, but the microcatheter could not reach the vasa recta because of the slipping out of the cobra catheter and deviation of the microcatheter. Embolization was performed with porous gelatin grains at a selective position as close as possible. The patient was discharged without postoperative re-bleeding or ischemic complications. Although the procedure of angiography and transcatheter arterial embolization was limited by arterial sclerosis and stenosis, we accurately diagnosed and appropriately controlled acute small bowel bleeding in a hemodialysis patient.

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We report a case of right basilic vein to left external jugular vein venovenous crossover graft against right brachiocephalic vein occlusion. The patient was a 69-year-old woman with end-stage renal disease (ESRD). Hemodialysis (HD) was induced due to chronic glomerular nephritis in 1981. At first, left radio-cephalic arteriovenous fistula (RCAVF) was created on her left forearm, but frequent PTAs and several reconstructive operations were needed against repeated stenosis. Therefore, there was no site for blood access on her left arm, and TBBAVF was created on her right upper arm in 2006. However, it also became completely occluded at the right brachiocephalic vein in November 2014 after repeated stenosis and dilatation with PTA. A right basilic vein to left external jugular vein venovenous crossover bypass graft with vascular prostheses was then created. Blood access was kept patent for over 2 years as of April 2015, though frequent PTAs were needed every 2-7 months. Thus, this operative method can be effective for central vein occlusion in a hemodialysis patient.

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