We retrospectively investigated the clinical usefulness of continuous hemodiafiltration (CHDF) with AN69ST membrane in the treatment of patients with severe sepsis or septic shock. The subjects of this study were 28 consecutive patients with severe sepsis or septic shock who underwent CHDF for at least 24 hours during the period between January 2013 and October 2014. We divided the subjects into two groups : 11 subjects undergoing CHDF with AN69ST membrane (AN69ST membrane group) and 17 subjects undergoing CHDF with polymethylmethacrylate (PMMA) membrane (PMMA membrane group). Clinical parameters including blood pressure levels and the catecholamine index for 72 hours after the start of treatment were compared between these two groups. At the time of starting treatment with CHDF, the sequential organ failure assessment (SOFA) scores and levels of AST, ALT, LDH, total bilirubin, and CRP were significantly higher in the AN69ST membrane group than in the PMMA membrane group. A significant decrease in the catecholamine index was observed after treatment in both groups. Although there were no significant differences in blood pressure levels, changes in blood pressure, and the catecholamine index between the two groups, urine volume per unit time at the end of treatment was significantly greater in the AN69ST membrane group than in the PMMA membrane group. In addition, the duration of treatment with CHDF was significantly lower in the AN69ST group than in the PMMA membrane group. Although this study was retrospective, the results suggest that the effect of CHDF with AN69ST membrane was equivalent to or better than that of CHDF with PMMA membrane in patients with severe sepsis or septic shock.

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We surveyed the current situation of supported patients on hemodialysis (HD). We sent questionnaires to Japanese HD facilities nationwide, and obtained 1,524 responses. It was found that 832 facilities provided pickup transportation for patients on maintenance HD. The number of HD patients using the pickup transportation was 28,715 in 811 HD facilities. For 77.1% of these facilities, this was a great burden, but not for 19.8% of them. Approximately one-third of the HD facilities (506 of 1,524) accepted HD patients using permanent HD catheters, and 36.1% (550 of 1,524) of HD facilities accepted long-term hospitalized HD patients without acute serious diseases, totaling 5,275 patients. There were 1,323 HD facilities that performed HD for some insured patients receiving long-term care. Only 123 HD facilities did not perform HD for such patients. On the basis of this survey, we could assess the current supportive situation of the disabled and/or aged patients on HD. It is suggested that a more refined supportive system for the disabled and/or aged patients on HD should be developed in various ways in the near future.

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Intermittent infusion hemodiafiltration (I-HDF) has been introduced to improve the peripheral circulation of dialysis patients and to reduce the occurrence of hypotension during hemodialysis treatment. The clinical effectiveness of I-HDF, however, has not been clarified in comparison with that of other on-line HDF therapies. A prospective, multicenter, parallel group comparative trial was carried out to reveal the clinical effectiveness of I-HDF compared with predilution on-line HDF (Pre-HDF), which is currently the most popular on-line HDF therapy in Japan. Patients were allocated to two groups after matching for age (±5 y.o.), dry weight (±5 kg), and with/without diabetes. After obtaining informed consent, 36 patients, namely, 18 pairs, participated in this clinical trial. During the trial, we evaluated the clinical condition and quality of life (QOL) of the patients and solute removal characteristics. The results showed no difference in clinical condition and QOL score between the two groups. The reduction ratio of the systolic blood pressure originally showed no difference between the two groups, but it decreased slightly as the trial proceeded after changing from hemodialysis therapy. There was also no difference in the number of treatments by medical staff, but this also significantly decreased as the trial proceeded in both groups. On the other hand, the Pre-HDF group demonstrated significantly higher removal rates of β₂-microglobulin and α₁-microglobulin than the I-HDF group. At the same time, the amount of albumin leakage in treatment was also significantly larger in Pre-HDF than in I-HDF. In conclusion, the clinical condition and QOL of patients undergoing I-HDF were not inferior to those having Pre-HDF. Furthermore, Pre-HDF demonstrated a significantly higher removal rate for medium-sized and larger solutes and larger albumin leakage in comparison with I-HDF.

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【Objective】To examine the mortality of hemodialysis patients with advanced dementia newly admitted to a psychiatric unit. 【Methods】 The subjects consisted of 20 hemodialysis patients admitted to our psychiatric unit during a period of 7 years. We divided them into two groups : advanced dementia group and non-advanced dementia group. We investigated the background of these two groups and examined the mortality by Kaplan-Meier survival analysis. 【Results】 Twenty patients were divided into the advanced dementia group (n=7) and the non-advanced dementia group (n=13). The advanced group tended to include more men, with an average age of 70 and decreased activity. We found a significant difference in mortality between the two groups, and the advanced dementia group was associated with a poor prognosis. 【Conclusion】 The findings suggest that hemodialysis patients with advanced dementia admitted to a psychiatric unit have poor clinical outcomes.

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We report a diabetic kidney disease patient with myelodysplastic syndrome (MDS) who was treated with high-dose darbepoetin-alfa and whose anemia improved, making it possible to decrease the use of red blood cell transfusion. He was diagnosed with diabetic kidney disease and MDS at the age of 74 years. He continued to have severe anemia despite continuous treatment with an erythropoiesis-stimulating agent (ESA) and transfusions as an outpatient. He was admitted to our hospital for severe anemia and over-hydration at 76 years of age. On admission, his hemoglobin was 6.8 g/dL and he experienced frequent angina attacks. After initiating dialysis, the dosage of darbepoetin-alfa was increased gradually to 180 μg administered intravenously weekly. As a result, his hemoglobin concentration was sustained at 8.0～9.0 g/dL, the frequency of transfusion could be reduced, and the angina attacks disappeared. However, his serum ferritin level increased and we attempted treatment with an oral iron-chelating agent, but severe nausea developed. High-dose ESA might be effective for MDS patients with CKD.

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Although laparoscopic surgery is a well-established minimally invasive option, it still requires several incisions. With the aim of improving cosmesis and preventing port-site complications, surgical procedures, devices, and instruments have been developed. A new alternative to conventional laparoscopic surgery is single-port or single-incision laparoscopic surgery. Furthermore, embryonic natural orifice transluminal endoscopic surgery via the umbilicus is a recent technical innovation. We report here a case of adrenal myelolipoma successfully managed by transumbilical laparoendoscopic single-site (LESS) adrenalectomy in a patient under hemodialysis. A 75-year-old man receiving hemodialysis for 8 years was incidentally discovered to have a tumor, 7.2×6.7×8.9 cm in diameter, at the left adrenal gland. A 3.5 cm periumbilical longitudinal incision for Gelpoint was made and three trocars were inserted into the abdominal cavity. We performed transumbilical LESS adrenalectomy for left adrenal tumor using a flexible laparoscope and articulating instrument. The resected specimen was pathologically diagnosed as adrenal myelolipoma. There were no intraoperative and postoperative complications. The patient started oral intake and ambulation on the first postoperative day, and left the hospital five days after surgery. Transumbilical LESS adrenalectomy is safe and feasible for patients with hemodialysis.

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Onychomycosis of the feet and other parts of the body frequently progresses subclinically and remains untreated in patients who consider it a sign of aging. However, onychomycosis can be exacerbated in the presence of peripheral arterial disease and critical limb ischemia, diseases that have shown a trend toward increasing incidence in recent years. Therefore, it is important to treat onychomycosis in order to prevent lower limb amputation and improve the prognosis of such patients. We report a case of successful treatment of toenail onychomycosis with the application of efinaconazole in a patient undergoing maintenance hemodialysis. The patient was a 66-year-old woman undergoing hemodialysis for chronic renal failure resulting from diabetic nephropathy at our hospital since June 2011. Onychomycosis was present in both halluces ; we treated the patient by applying efinaconazole 3 days a week when she visited the hospital for hemodialysis starting late October 2014. Approximately 3 months after initiating the treatment, favorable nail growth was observed macroscopically. These results indicate that efinaconazole is a potentially effective treatment option for onychomycosis in patients undergoing hemodialysis.

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A 47-year-old woman with chronic renal failure caused by IgA nephropathy had a peritoneal dialysis catheter placed in February 2014. Peritoneal dialysis was prescribed in March. On the 19th day, she began to have frequent episodes of inflow and outflow problems. Peritoneal dialysis was therefore stopped on the 126th day. On the 143rd day, diagnostic laparoscopic surgery was performed to determine the cause of the problem. The side holes of the peritoneal dialysis catheter had been blocked by the right fimbria of the fallopian tube. We removed this aberrant tissue. After the operation, peritoneal dialysis was restarted without difficulty. On the 221st day, right-sided pleural effusion developed. We applied thoracentesis on the 227th day, which caused the pleural effusion to decrease. The concentration of glucose was markedly higher in the intrapleural fluid than in serum, suggesting pleuroperitoneal communication. Thus, peritoneal dialysis was stopped again on the 234th day and restarted two weeks later with a small amount of peritoneal dialysis fluid only in the daytime. Her pleural effusion did not reappear, and the patient has continued to undergo peritoneal dialysis without problems.

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