As the Japanese population has been aging, the number of chronic hemodialysis (HD) patients per physician/nurse and the severity of HD patients’ disease have been increasing. To further confound the situation, as erythropoiesis-stimulating agents (ESA) are now included in the Diagnosis Procedure Combination/Per-Diem Payment System (DPC/PDPS), there has been an increasing focus on reducing ESA-associated costs. Thus, we healthcare practitioners are called on to ensure patient safety and provide quality care, while at the same time managing stress among health practitioners and keeping hospital operations financially viable. Against this background, we conducted a cohort study involving a total of 27 HD patients who were converted from darbepoetin (DA) to epoetin kappa (EPOκ), a less expensive option, and investigated the impact of the increase in the dosing frequency (from 2 twice monthly to up to 3 times weekly) associated with this conversion on the mental stress experienced by medical staff, the incidence of medical accidents/incidents, and economic costs. The differences in the biological activity of the two ESA were also examined. No significant change in the mental stress experienced by the staff was seen after the conversion from DA to EPOκ (as evaluated by the New Brief Job Stress Questionnaire), despite the associated increase in dosing frequency. Likewise, there was no significant increase in the incidence of injection-related medical accidents/incidents after the conversion. The conversion also led to an impressive 46.3% reduction in monthly ESA-related costs. Furthermore, a longitudinal study did not detect a significant difference in the biological activity of the two ESA. Given the paucity of information regarding the efficacy of long-acting versus short-acting ESA, caution needs to be exercised when choosing among the currently available ESA.

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The administration of ferric citrate hydrate (FCH), an iron-based phosphate binder, increases patients’ hemoglobin (Hb) levels via iron absorption. However, some patients’ Hb levels can overshoot the target level despite reductions in the use of erythropoiesis stimulating agents (ESA). We retrospectively reviewed the cases of patients that were undergoing hemodialysis and were treated with FCH and determined which patients exhibited Hb overshoot. We defined Hb overshoot as a maximum Hb level of ≥14.0 g/dL or an increase in the Hb level of ≥3.0 g/dL from the baseline. Among the 20 examined patients, 11 displayed Hb overshoot (overshoot group, OS), and 9 patients did not (non-OS group). There were no significant differences between the clinical characteristics of the two groups prior to the administration of FCH. In the OS group, the Hb levels recorded after 2 and 3 months were significantly higher than those seen in the non-OS group. In the OS group, the red cell distribution width-coefficient of variation (RDW-CV) and the mean corpuscular volume (MCV) were higher in the OS group than in the non-OS group after 1 (p=0.0240 and 0.0411, respectively) and 2 months (p=0.0190 and 0.0411, respectively). The reduction in the use of ESA did not differ significantly between the two groups. As RDW-CV and MCV rose significantly before the Hb level increased in the OS group, higher RDW-CV and MCV values might be useful predictors of Hb overshoot in patients undergoing hemodialysis who receive FCH.

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Percutaneous vertebroplasty (PVP) is increasingly used to treat pain in patients with osteoporotic thoracolumbar vertebral compression fractures. However, few studies have determined which patient subgroups would benefit from the use of PVP for pain control. In this study, we examined the efficacy and safety of PVP in four maintenance hemodialysis (HD) patients. Compression fracture-associated pain was markedly improved soon after the PVP in all patients, and there were no major complications that were directly related to the PVP. One patient experienced recurrent compression fractures twice. Therefore, PVP was repeated three times, and all of these procedures were highly effective at providing pain relief and preventing a decline in the patient’s ability to perform activities of daily living. This study suggests that PVP is an effective and safe procedure even for maintenance HD patients.

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A 52-year-old male started a hemodialysis session. To estimate his dry weight, the percentage changes in his blood volume (%BV) were monitored using a CRIT-LINE^® monitor. As he was scheduled to undergo surgery, nafamostat mesilate (NM) was used as an anticoagulant. Approximately 5 minutes after the start of the hemodialysis, he suddenly experienced a burning sensation in his shunt-side upper limb together with generalized itching. Systemic skin redness and bloodshot eyes were also observed. After 15 minutes, his %BV abruptly decreased by 16.8% but he did not develop circulatory collapse. The hemodialysis was suspended, and 100 mL of saline were infused. Then, the hemodialysis was resumed after replacing the NM with heparin. The patient’s symptoms improved. Fluid removal was continued, and his %BV had recovered to the baseline level after 1.5 hours and sharply peaked at +20% after 2 hours. A blood sample obtained during the hemodialysis session was subjected to a test for NM-specific IgE antibody, which produced a positive result. We concluded that the patient had suffered NM-induced anaphylaxis. Despite the abrupt reduction in his circulating blood volume, the patient was overhydrated at the beginning of the hemodialysis session and was not complicated by shock. In addition, he recovered rapidly from the reduction in his circulating blood volume. This might be explained by the changes in the volume and distribution of bodily fluids seen in hemodialysis patients.

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Dialysis partients with arteriovenous shunts occasionally develop organ disorders. Although cardiac overload has often been reported in such cases, only a limited number of studies have described cases in which central nervous system lesions arose in dialysis patients with arteriovenous shunts. Herein, we report a case in which a 70-year-old female presented with absence and convulsion seizures during hemodialysis shortly after the implantation of a synthetic graft. Maintenance dialysis therapy was initiated due to diabetic renal failure, initially via a shunt created from the patient’s native vessels. However, a second surgical graft procedure was eventually required a couple of months later in order to increase the shunt flow rate because severe calcification was detected in the radial artery. Although the patient did not have a history of stroke despite exhibiting various vascular risk factors, including diabetes mellitus, hypertension, and dyslipidemia, radiological images clearly showed occlusion of the bilateral internal jugular and vertebral arteries, whereas there were few significant abnormalities in the cerebral parenchyma. On the presumption that hemodialysis via the arteriovenous graft had resulted in blood being diverted away from the brain, surgical occlusion of the shunt was performed. Afterward, a central venous catheter was used as a substitute for a vascular access port. As expected, no neurological symptoms were experienced, reflecting the marked improvement in cerebral blood flow demonstrated on ¹²³I-iodoamphetamine perfusion scintigraphy. Interestingly, the patient’s shunt flow was not very high (346 mL/min), which disagrees with the findings of previously-reported cases of shunt-related cerebral involvement. Our findings indicate that when clinicians are selecting a vascular access method for dialysis, both generalized vascular pathologies and the state of the anastomotic vessels should be taken into consideration. The present case might provide a deep insight into surgery for dialysis shunts.

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An 85-year-old female underwent Tenckhoff catheter removal. The catheter had been inserted 6 years ago via a transrectal (paramedian) approach. Three hours after the catheter removal, a large subcutaneous hematoma (diameter : >10 cm) developed. The patient was taken to theater, where the injured inferior epigastric artery was ligated, and the hematoma was evacuated. The patient’s recovery was uneventful. During the removal of a Tenckhoff catheter that was inserted via a transrectal approach, the risk of inferior epigastric artery injury should be considered.

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A 73-year-old male with diabetic nephropathy underwent surgical resection for cancer of the sigmoid and rectum colon. Seven months after the surgery, an elevated serum carcinoembryonic antigen level and two liver metastases were detected after the patient underwent hemodialysis. Chemotherapy involving the modified FOLFOX6 (mFOLFOX6) regimen plus bevacizumab (BV) was initiated for the liver metastases. The dose of oxaliplatin was 65 mg/m², and that of bevacizumab was 3.5 mg/kg. Hemodialysis was started after the administration of oxaliplatin on day 1. Vomiting (grade 3) and hypertension (grade 3) were observed after five treatment cycles. However, no BV-specific adverse events, such as neutropenia, were observed during these five treatment cycles. We started the oral administration of UFT (tegafur/uracil) chemotherapy, as the patient rejected further mFOLFOX6 + BV therapy. A computed tomography scan obtained at 12 months after the initiation of chemotherapy showed that the liver metastases had disappeared. It is considered possible that mFOLFOX6 + BV therapy is safe and useful and does not cause severe side effects in hemodialysis patients, although there have been few reports about the use of chemotherapy in hemodialysis patients.

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