Peripheral arterial disease (PAD) is one of the serious complications that can arise in patients on hemodialysis. The prognosis of critical limb ischemia due to PAD is extremely poor. Therefore, it is important to evaluate and treat such patients at an early stage. In this regard, we designed a risk stratification and foot care program (the Kamakura classification), which divided hemodialysis patients into six stages based on the presence of foot lesions and PAD. The Kamakura classification also indicates the type and frequency of foot care required. We started this foot care program for the hemodialysis patients in our hospital in August 2011. As a result, the incidence of foot ulceration fell significantly from 4.9 cases/100 person-years prior to the introduction of the care program to 3.1 cases/100 person-years in the first year and 1.5 cases/100 person-years in the second year (p=0.03). Furthermore, the incidence of amputation decreased from 1.6 cases/100 person-years prior to the introduction of the care program to 1.0 cases/100 person-years in the first year and 0.5 cases/100 person-years in the second year. Thus, the incidence of amputation fell, but not significantly (p=0.14). Furthermore, we compared the ankle-brachial pressure index and toe-brachial pressure index values of patients with or without foot lesions. Both parameters were significantly lower in the patients with foot lesions. Therefore, both PAD and foot lesions seem to be important markers for classifying the risk for PAD. In conclusion, a foot care program based on the Kamakura classification was found to be useful for reducing the incidence of foot ulceration in hemodialysis patients with PAD. The provision of continuous foot care at an early stage played an important role in this improvement.

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【Objectives】 To investigate the efficacy of pharmaceutically manufactured oral essential amino acids (EAA) for improving the serum amino acid profiles and nutritional indexes of hemodialysis patients. 【Subjects】 Thirty-four patients who fulfilled the following entry criteria : undergoing hemodialysis or hemodiafiltration three times a week for >1 year, 3.0 g/dL≤serum albumin<3.8 g/dL, and an estimated daily calorie intake of ≥25 kcal/kg. Patients that met the following criteria were excluded from the study : advanced hepatic failure, C-reactive protein level of ≥2.0 mg/dL, a pre-dialysis HCO₃ level of <16 mEq/L, a glycated hemoglobin level of >6.5%, or a body mass index of <18 kg/m². 【Methods】 A series of blood tests were performed prior to the commencement of the oral EAA therapy, and at 1, 2, and 3 months after the start of therapy. The patients’ serum amino acid profiles were assessed before and 3 months after treatment. 【Results】 The mean EAA level increased from 844.1±159.4 nmol/mL to 868.0±222.9 nmol/mL. The mean non-essential amino acid (NEAA) level decreased from 2278.2±464.5 nmol/mL to 2053.6±356.7 nmol/mL (p<0.01). The mean EAA : NEAA ratio increased from 0.38±0.07 to 0.44±0.08 (p<0.01). The mean branched chain amino acid (BCAA) level increased from 337.8±94.0 nmol/mL to 378.3±96.3 nmol/mL. The mean BCAA : total amino acids ratio increased from 0.11±0.02 to 0.13±0.02 (p<0.01). The mean 3-methylhistidine level decreased from 24.3±5.6 nmol/mL to 22.5±5.1 nmol/mL (p<0.05). The mean serum albumin level increased to 3.51 g/dL after 3 months and remained stable thereafter in patients whose serum albumin levels were <3.5 g/dL before the start of therapy (p=0.156). 【Conclusion】 The oral administration of EAA improved the serum amino acid profiles of hemodialysis patients and might be an effective therapy for treating malnutrition in such patients.

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We present the cases of three patients who were undergoing maintenance hemodialysis and were diagnosed with uremic pleuritis after thoracoscopic pleural biopsy examinations. The patients had been receiving hemodialysis treatment for 3 to 37 years and were suffering from dyspnea with pleural effusion. In each case, the pleural fluid appeared hemorrhagic and exudative ; cultures of the fluid were negative for bacteria, including Mycobacterium tuberculosis ; and cytological examinations did not detect malignancy. Each pleural biopsy specimen showed fibrous thickening and inflammatory cell infiltration, without any findings that were indicative of infectious disease or malignancy. Based on these findings, we diagnosed the patients with uremic pleuritis. The pleural effusion did not respond to intensive hemodialysis treatment or a change in the anticoagulant drug used for hemodialysis in any case. Furthermore, the two patients who received anti-tuberculosis treatment did not exhibit any improvement in their pleural effusion and died of respiratory failure combined with pneumonia. The remaining patient was given oral prednisolone, which resulted in an improvement in their pleural effusion and enabled them to breathe normally. In conclusion, thoracoscopic pleural biopsy is helpful for diagnosing uremic pleuritis. Although refractory uremic pleuritis exhibits a poor prognosis, corticosteroid treatment might improve the outcomes of this condition.

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A 70-year-old woman consulted a doctor complaining of persistent fatigue (day 1). Her laboratory data were indicative of hyperkalemia and anemia accompanied with acute renal failure. Chest X-ray and computed tomograpy (CT) examinations detected pneumonia and alveolar hemorrhaging. She was then transferred to another hospital for hemodialysis treatment and a blood transfusion. The detection of abnormal red blood cells in the patient’s urinary sediment and a high myeloperoxidase-antineutrophil cytoplasmic antibody titer (>350 IU/mL) suggested that she was suffering from rapidly progressive glomerulonephritis caused by microscopic polyangiitis. Metylprednisolone was administered intravenously for three days. On day 4, the patient was transferred to our hospital for more intensive management. From day 6, prednisolone (40 mg) was administered orally. However, the patient’s renal function did not improve. Hemodialysis was continued, and heparinization was started to control her activated partial thromboplastin time APTT and high D-dimer level (36.2μg/mL). On day 21, she developed a sudden pain in her right lower abdomen. On day 22, an egg-sized mass was detected in the same region, which was later shown to be a rectus sheath hematoma during a plain CT examination. The patient’s hemoglobin level was within the safe range for conservative treatment. On day 23, however, it was found that her hemoglobin level had fallen from 7.4 g/dL to 5.4 g/dL. Contrast-enhanced CT did not detect any significant hemorrhaging. The blood transfusions and conservative treatment were continued. Non-traumatic rectus sheath hematomas are very rare, and therefore, are difficult to definitively diagnose. There have been several reports about cases in which rectus sheath hematomas were misdiagnosed as appendicitis or ovarian cystoma. Here, we report a rare case of non-traumatic rectus sheath hematoma.

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Kommerell’s diverticulum of an aberrant subclavian artery, which is a rare condition, is a congenital abnormality of the aortic arch. We report a case of Kommerell’s diverticulum of an aberrant left subclavian artery in patient with a right-sided aortic arch. The patient was a 78-year-old man who was diagnosed with a right-sided aortic arch and Kommerell’s diverticulum of an aberrant left subclavian artery. A right renal tumor was detected on follow-up computed tomography, and he was referred to our department. A further examination revealed that he had bilateral renal cell carcinoma (cT1aN0M0). In November 2013, we performed laparoscopic nephrectomy for right renal cell carcinoma and a simultaneous arteriovenous shunt plasty. After the operation, the patient had a bronchial asthmatic attack and developed an acute respiratory disorder and so was admitted to the intensive care unit (ICU). In the ICU, we attempted extubation, and the patient relapsed into dyspnea again. His bronchial asthma started to improve, but he developed respiratory obstruction. Bronchoscopy showed that the Kommerell’s diverticulum had enlarged and compressed both the trachea and esophagus. We confirmed that the patient’s symptoms were caused by his vascular anomaly. We performed capillary hydrodynamic fractionation to reduce the volume load and the mucosal edema in the patient’s respiratory tract. However, he died of severe respiratory failure on postoperative day 18.

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A 67-year-old woman with a history of paroxysmal atrial fibrillation and combined valvular disease was suddenly admitted to our hospital due to acute left hemiplegia. She had been on maintenance hemodialysis for 18 years. Magnetic resonance imaging and magnetic resonance angiography revealed a newly formed embolism in her right middle cerebral artery. At this time, four hours and thirty minutes had passed since the onset of her acute ischemic stroke. We initially treated her with intravenous recombinant tissue plasminogen activator (rt-PA), but it did not improve her symptoms. So, endovascular therapy was administered, which resulted in successful endovascular recanalization and an improvement in the patient’s symptoms within 7 hours of the onset of her condition. The patient did not exhibit any neurological disorders, and therefore, was discharged on day 17 after admission. This report indicates that the administration of endovascular therapy soon after the failure of rt-PA might be effective against acute ischemic stroke in maintenance hemodialysis patients.

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An 80-year-old female was admitted to our hospital for left back pain, epigastralgia, vomiting, and diarrhea. As she exhibited severe renal dysfunction, anuria, and congestive heart failure, hemodialysis was started on day three. The patient had an elevated serum lactate dehydrogenase level (2,270 U/mL), and contrast-enhanced computed tomography revealed multiple defects in the left renal parenchyma associated with marked right renal atrophy. She was diagnosed with a renal infarction. Echocardiography showed large thrombi in the left and right atria (42×26 mm and 21×17 mm, respectively) together with a dilated left atrium and a normal left ventricular ejection fraction. Heparin was administered intravenously for seven days followed by the oral administration of warfarin for renal thrombosis and bilateral atrial thrombosis. However, the patient’s renal function did not improve, and the hemodialysis was continued. Here, we report a rare case of renal infarction associated with atrial fibrillation and unusually large atrial thrombi.

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