【Background】Angiographic examination is often performed in patients on hemodialysis as they have a high risk for cardiovascular diseases. However, it is still unclear when the first hemodialysis session should be performed after angiography. 【Methods】We conducted a retrospective review of 323 consecutive hospitalized patients on hemodialysis (age 68±8 years, male 73%) who had undergone angiography at our hospital from April 2010 to November 2012. Hemodialysis complications were defined as symptomatic hypotension, bleeding, and dialysis interruption due to pain. All complications were extracted from the medical records. Factors associated with complications were examined. 【Results】Dialysis complications after angiography were observed in 79/323 patients (24.4%). Among them, symptomatic hypotension was the most common complication. In terms of the timing of hemodialysis, patients dialyzed on the day of angiography had a higher risk for complications than those dialyzed the day after (odds ratio 3.24, 95%CI 1.11-9.42, p=0.02). Multivariate analysis showed that hemodialysis on the same day as angiography and use of a large amount of contrast medium were significantly related to the complications. No clinical complications related to residual contrast agent were observed. 【Conclusions】Dialysis complications after angiography were often observed during the first hemodialysis session, especially performed on the same day as angiography. Therefore, first hemodialysis could be safely performed on the day after angiography.

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To reveal the long-term (ten or more years) postoperative course of hemodialysis-related carpal tunnel syndrome patients treated with the Universal Subcutaneous Endoscope (USE) system, we retrospectively compiled and analyzed pre- and postoperative clinical results (tingling, sensory disturbance, motor deficiency, electrophysiological testing) and when there were one or more surgeries for recurrence. This study included 264 hands of 194 patients who were followed up for ten or more years following initial endoscopic carpal tunnel release surgery. Preoperative clinical symptoms improved to normal following initial surgery using the USE system in 96% with tingling, 97% with abnormal pain sensation, 94% with abnormal touch sensation, 87% with preoperative manual muscle testing of the abductor pollicis brevis muscle from [0, 1, 2, 3] to [5], 80% with abnormal distal sensory latency, and 83% with abnormal distal motor latency. Surgery for recurrence at a mean of 12 postoperative years was needed in 97 out of 264 hands. In these cases, we performed endoscopic neurolysis using the USE system on 77 hands and flexor index to little digitorum superficialis (FDS) resection surgery on 20 hands. Three out of these 97 hands needed a third surgery because of re-recurrence and we performed FDS resection surgery and two endoscopic neurolysis surgeries at means of 12 and 13 postoperative years after the initial surgery, respectively. One hand needed a fourth surgery at 20 years postoperatively. Hemodialysis leads to continuous beta-2-microglobulin amyloid deposition inside the carpal canal structures and this leads to carpal tunnel syndrome. In recent years, the lifetimes of patients undergoing hemodialysis have lengthened and, as a result, these patients are more likely to suffer from multiple recurrences of carpal tunnel syndrome. At each recurrence, consideration of less invasive procedures for treatment over the course of the patients’ lifetime should be made.

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We investigated the relationship between the various values and free carnitine concentration in 258 hemodialysis patients. To investigate the association of laboratory values and free carnitine concentration of 125 healthy subjects, we compared the values of hemodialysis patients and healthy subjects. We divided 190 hemodialysis patients into four groups and conducted a prospective study to compare in various values to investigate the effects of carnitine IV with that of nutritional guidance. Free carnitine concentration and age of dialysis patients showed a negative correlation. Prealbumin and free carnitine concentration, muscle mass/height² showed a significant positive correlation. Unlike dialysis patients, free carnitine concentration showed a positive correlation with age in healthy subjects. Carnitine by intravenous injection showed a marked increase of free carnitine concentration in hemodialysis patients. Free carnitine concentrations also increased in nutritional guidance group. Erythropoietin resistance index and lower limb entanglement was also investigated, those suggest that there is a limit to the effect of carnitine replacement therapy, it was considered that it is necessary to select patients in their use.

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Renin-angiotensin system inhibitors (RASI), having superior therapeutic effects on cardiovascular outcome beyond blood-pressure lowering, have been widely used for dialysis patients. In this study, we investigated the effect of angiotensinII receptor blockers (ARB) and angiotensin-converting enzyme inhibitors (ACEI) on mortality for patients with maintenance dialysis in Yoshikawa Clinic. Dialysis outpatients in our clinic had been registered in our dialysis-patient database from April 2006 onwards, and followed up prospectively with collection of their clinical and laboratory data. Each propensity score of our whole cohort was calculated by multiple logistic regression analysis using the absence/presence of RASI as the objective variable. The three groups, non-RASI group and ACEI and ARB groups from the RASI group, were extracted by a propensity score-matching method. Comparisons among the three groups were made by log-rank test between their survival curves of death due to disease as the endpoint. A total of 347 dialysis patients had been registered in our database by July 2013 and 93 of these, consisting of 31 matched trios, were extracted. Eligible patients were 54 males and 39 females, with an average age of 67.1 years, and their duration of dialysis was 4.3 years at the start of observation. Blood pressure and laboratory data were not significantly different among the three groups under good control. A total of 30 patients died in the observation period (mean follow-up period was 4.2 years) and 19 patients died due to cardiovascular disease. The ACEI group showed better prognosis in terms of all-cause mortality than the ARB group ; however, cardiovascular death was not significantly different among the three groups. In the ACEI group, all-cause mortality of maintenance dialysis patients was suppressed ; however, the use of ARB did not affect their prognosis. A randomized prospective multi-center study is needed in the future.

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【Purpose】In recent years, the number of patients with chronic kidney disease (CKD) has increased with the increase in the number of elderly people. Patients with CKD frequently fall ill with congestive heart failure (CHF), which affects their life expectancy. Currently, evaluating vascular calcification (VC) is generally recommended as a predictive factor for CHF. However, a simpler method to evaluate VC quantitatively is needed. We examined whether abdominal aortic calcification score (AACS) is associated with the incidence of CHF and mortality among CKD patients in a prospective cohort study. 【Method】The study subjects were 72 chronic hemodialysis outpatients at a single dialysis center in January 2009. Clinical indicators, blood test samples, and AACS evaluated by abdominal plain X-ray were obtained at the baseline of this study. The subjects were divided into a high-AACS group (≧7) and a low-AACS group (＜7), and were followed up with the incidence of CHF as a primary endpoint and mortality as a secondary endpoint for two years. 【Results】Using other clinical indicators and blood test samplings at baseline, the high-AACS group showed a longer duration of dialysis and higher serum calcium concentration than the low-AACS group. In each group, AACS was positively correlated with age (high-AACS group : r=0.21, p=0.002 ; low-AACS group : r=0.09, p=0.001) ; however, no correlation was observed with the duration of dialysis. In survival analysis, the high-AACS group had an increased chance of CHF (log-rank test : χ²=5.69, p=0.02) and mortality (χ²=4.21, p=0.04). By Cox hazard analysis, no significant difference was observed, possibly due to the small sample size. 【Conclusion】Although further evaluations are needed, AACS is a potential predictive factor for CHF and mortality among chronic hemodialysis patients.

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A 50-year-old woman undergoing hemodialysis presented sudden onset of dyspnea and was diagnosed as having pulmonary edema related to acute heart failure. After admission, she lost weight and began antihypertensive drug treatment. Four days after discharge, she experienced respiratory distress and returned to our hospital. On arrival, she presented respiratory failure and severe hypertension. Plain chest radiographs showed marked pulmonary edema, but echocardiographic findings did not show fluid retention. Our diagnosis was acute heart failure driven by shifting of body fluids to the heart and lungs due to blood vessel contraction (vascular failure). She received supplemental oxygen and nitroglycerin as primary treatment, and her respiratory status rapidly improved. After admission, acute heart failure recurred. After beginning to take alpha-1 blockers in addition to beta blockers, acute heart failure did not recur. In cases of acute cardiac failure due to vascular failure, even in HD patients, primary treatment with vasodilators is useful. Vascular failure was caused by hyperactivity of the sympathetic nervous system. Hyperactivity of the sympathetic nervous system was widely reported in HD patients. Noting acute heart failure due to hyperactivity of the sympathetic nervous system could improve the prognosis of dialysis patients.

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We experienced two rare cases of nyctalopia in maintenance hemodialysis patients. These cases had been on maintenance hemodialysis for over 10 years for non-diabetic nephropathy, and were prescribed non-calcium-containing phosphate binders. Their serum low-density-lipoprotein cholesterol levels and serum vitamin A levels were low, and the b-waves on electroretinogram (ERG) were reduced. The fundi of the eyes in these two cases were normal. Magnetic resonance imaging (MRI) of the brain showed no abnormal findings. According to these results, we diagnosed nyctalopia caused by vitamin A deficiency. They recovered from the nyctalopia within a few days after the administration of retinol palmitate. Although they had no significant change in BMI, serum albumin level, KT/V, malnutrition-inflammation score (MIS), and food intake, while their normalized protein catabolic rate (nPCR) levels were less than or equal to 1.0 g/kg/day over two months in a row. Another nutritional reason for the nyctalopia besides low vitamin A level might be considered.

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Case 1 : A man in his 60s who had started peritoneal dialysis (PD) for diabetic nephropathy came to hospital due to abdominal pain 58 months after beginning PD. He was diagnosed with an incarcerated right inguinal hernia by marked bulging and tenderness of the right groin. The abdominal pain was immediately improved after manual repositioning by a surgeon. However, he underwent hernia repair surgery because of the risk of recurrence. He then resumed PD on postoperative day 2. Case 2 : A woman in her 50s came to the hospital due to abdominal pain 44 months after starting PD for chronic glomerulonephritis. At the visit, she was suspected of having peritonitis. However, her umbilicus was bulging slightly and abdominal CT showed an incarcerated umbilical hernia. Emergency surgery was performed that day, and PD was resumed on postoperative day 9. Incarcerated inguinal hernias can be easily diagnosed by the presence of prolapsed organs. However, an incarcerated umbilical hernia might be misdiagnosed as peritonitis because a prolapsed organ cannot always be confirmed.

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