It is important to understand whether a clinician’s decision to withdraw dialysis treatment is permitted under criminal law. This study examines the permissions required for a clinician to take such action. The withdrawal of dialysis treatment is considered to be an act of forbearance. Clinicians are bound by a legal duty to their patients through their practice contracts. When a clinician withdraws dialysis treatment, this could be viewed as a crime by omission. Thus, it is important that clinicians obtain the permissions required under their legal duty before withdrawing dialysis treatment. The patient’s right of self-determination could be used as grounds for justifying the removal of dialysis treatment. Therefore, to remove the legal duty on the clinician the patient must request that dialysis be stopped. Once the clinician’s legal duty has been removed, the withdrawal of dialysis treatment by a clinician would no longer carry a risk of the clinician being found guilty of a crime by omission. If the patient is of full mental capacity, their permission can be sought. If, however, the patient is not of full mental capacity problems can arise when decisions regarding whether dialysis treatment should be withdrawn fall to another person. In such cases, the putative intention of the patient should be respected to the greatest extent possible and must be determined strictly, although substituted judgment is permitted. In cases in which the patient does not request that dialysis be withdrawn, the ending of dialysis treatment does not constitute a crime by omission in cases in which substituted judgment is allowed. In such cases, the actions of the clinician do not fulfill the criteria for the crime, and hence, the clinician should not be penalized under criminal law. It is not up to clinicians to apply substituted judgment when determining the putative intention of the patient. Instead, substituted judgment falls to the relatives of the patient after consultation with specialists.

【Objectives】To calculate the phosphate binder pill burden relative to all oral drugs prescribed to dialysis patients and to examine whether the magnesium (Mg) contained in phosphate binders as a pharmaceutical excipient affects the serum Mg levels of such patients. 【Methods】The oral drugs prescribed to 520 chronic hemodialysis patients were categorized according to their pharmacological classes, and then the percentage of phosphate binders among all drugs was calculated based on the daily number of prescribed pills. The serum Mg levels of the phosphate binder-prescribed patients and non-phosphate binder-prescribed patients were compared. The relationship between the number of prescribed pills and the serum Mg level was also analyzed. In addition, we measured the Mg content of the phosphate binders using inductively coupled plasma mass spectrometry. 【Results】The mean daily pill burden was 17.8 pills/patient, and phosphate binders accounted for 35% (6.2 pills) of all pills. The serum Mg levels of the phosphate binder-prescribed patients were significantly higher than those of the non-phosphate binder-prescribed patients. In addition, the patients’ serum Mg levels were positively correlated with the number of prescribed pills. Multivariate regression analysis showed that pill number quintile was a significant independent predictor of the serum Mg level in 169 patients who were receiving monotherapy with precipitated calcium carbonate 500 mg (SANWA), the most commonly prescribed drug at our hospital. Furthermore, this drug contained 1.8 mg/g of Mg, which was much higher than the Mg concentrations of the other phosphate binders. 【Conclusion】There is a possibility that the Mg included in phosphate binders as a pharmaceutical excipient might affect the serum Mg levels of dialysis patients because of the frequent use of such pills.

【Objective】The aim of this study was to examine the dietary intake and nutritional status of chronic hemodialysis patients with sarcopenia. 【Subjects】Ninety hemodialysis patients (mean age : 62.8±1.2 yrs) were enrolled in this study. 【Methods】We screened the subjects for sarcopenia using the diagnostic criteria developed by the European Working Group on Sarcopenia in Older People. Three nutritional assessments were conducted : the malnutrition-inflammation score (MIS), the geriatric nutritional risk index (GNRI), and a diagnostic assessment for protein energy wasting (PEW), and we completed the food frequency questionnaire for all patients. 【Results】The prevalence of sarcopenia was 22%. The MIS, GNRI, and PEW exhibited sensitivity values of 35%, 50%, and 10%, respectively, for detecting sarcopenia. Multivariate analysis showed that age (odds ratio (OR) : 1.12, 95% confidence interval (CI) : 1.05-1.21, p<0.001) and low protein intake (OR : 0.37, 95%CI : 0.19-0.88, p=0.022) were associated with sarcopenia. The sarcopenic patients consumed significantly less beans (31±11 g vs. 61±6 g, p=0.014) ; fish and meat (110±15 g vs. 153±8 g, p=0.006) ; and confectionery, beverages, and sugar (126±77 g vs. 306±41 g, p=0.006) than the non-sarcopenic patients. 【Conclusion】Sufficient protein intake and calorie intake are essential for preventing sarcopenia. In patients without an appetite, the intake of confectionery, beverages, or sugar might be necessary to prevent muscle loss. However, malnutrition-related sarcopenia was only seen in 10-50% of sarcopenic hemodialysis patients. It is important to assess the muscle strength and muscle function of hemodialysis patients because the use of nutritional measurements alone is not sufficient for screening for sarcopenia.

Despite hemodialysis staff often being exposed to blood splatter, little information is available about the risk of infection due to microscopic blood splashes. We quantitatively evaluated the degree of blood splatter using a Lumitester PD-30 (Kikkoman, Japan), which measures the extent of blood splashing on gloves and goggles during puncture procedures. Visible blood splatters were excluded from the analyses. The following measurements of ATP+AMP (relative light units [RLU] ) were obtained before and after skin puncture procedures : Right glove : 64.3±48.2 (RLU) →493.8±304.4 (RLU) ; left glove : 83.3±55.8 (RLU) →407.1±251.5 (RLU) (p<0.01 and p<0.05, respectively) ; goggles : 59.5±37.8 (RLU) →134.2±94.0 (RLU) (p<0.01). It is suggested that staff are exposed to blood splashing during dialysis puncture procedures, particularly on their hands and eyes.

A 67-year-old female who had started receiving maintenance hemodialysis seven years ago presented with bilateral multiple arthralgia (of the fingers, wrist, glenohumeral joint, and knee joints) together with tenderness and joint swelling, which had lasted for four years. She was diagnosed with rheumatoid arthritis at another hospital based on her serological findings (her C-reactive protein and matrix metalloproteinase 3 levels) and imaging studies. Despite initial treatment with disease-modifying anti-rheumatic drugs, including salazosulfapyridine, leflunomide, and 12.5 mg/day of prednisolone, her disease activity remained constant. Etanercept, a biological agent that is often used to treat rheumatoid arthritis, was also ineffective. Thus, she was referred to our hospital three years ago, and abatacept treatment was started. Thereafter, her arthralgia and laboratory findings improved. There are few case reports about the use of biological agents to treat rheumatoid arthritis patients on hemodialysis, but the effective use of abatacept treatment in the present study suggests that abatacept is an alternative treatment for patients on hemodialysis with intractable rheumatoid arthritis.

A 7X-year-old female who was undergoing hemodialysis presented to our hospital with sudden general malaise and a fever. A blood culture was positive for group G Streptococcus. She developed a high-grade fever exceeding 39°C, and sepsis was revealed by laboratory tests. She was treated with antibiotics, and her symptoms and fever gradually disappeared. However, she suffered visual disturbance and was diagnosed with endogenous endophthalmitis due to group G Streptococcus. Endogenous endophthalmitis is known to have a poor visual prognosis ; however, her visual disturbance fortunately resolved after systemic antibiotic therapy and the frequent ocular instillation of antibiotics. Early diagnosis and systemic antibiotic treatment are important for treating endogenous endophthalmitis in hemodialysis patients.

A 56-year-old male was started on peritoneal dialysis for end-stage renal failure due to chronic glomerulonephritis 4 years ago. He had been on antiplatelet medication for retinal artery branch occlusion for the previous 6 months. While riding a bus, he developed sudden nausea, vomiting, and left hypochondriac pain. As bloody peritoneal dialysate was noted when his bag was changed, he was examined at our hospital. Plain abdominal computed tomography (CT) revealed a hematoma around the spleen, and the bloody peritoneal dialysate was attributed to splenic rupture. As the patient had no history of trauma, and no apparent infectious disease, malignant tumor, or other underlying condition was detected, he was diagnosed with spontaneous rupture of the spleen. He was admitted immediately. The antiplatelet medication was discontinued, and his condition was monitored conservatively. The bloody peritoneal dialysate gradually improved, and as plain CT revealed that the hematoma had regressed, he was discharged from hospital. Non-traumatic splenic rupture can lead to hemorrhagic shock, and splenectomy might be required in some cases. If unexplained bloody peritoneal dialysate is observed in patients on peritoneal dialysis, non-traumatic splenic rupture must be excluded as soon as possible. If unexplained bloody peritoneal dialysate persists in peritoneal dialysis patients, it is important to perform imaging as quickly as possible to exclude hemorrhaging due to splenic rupture.

It is difficult to manage hepatic cyst infections in chronic kidney disease patients with autosomal dominant polycystic kidney disease (ADPKD), and active infections are contraindications for organ transplantation. We report a case in which a living-related renal transplantation was performed in a patient with ADPKD complicated with a refractory hepatic cyst infection. The case involved a 58-year-old female with ADPKD, who developed abdominal pain and fever, and was diagnosed with a hepatic cyst infection. After puncture drainage and antibiotic therapy, her symptoms disappeared, while her C-reactive protein level remained between 2.0～4.0 mg/dL. We decided to carry out a hepatic cyst fenestration operation, after which a living-related renal transplantation was performed (the patient’s husband acted as the donor). The patient has not suffered any rejection or infections for 2 years. These findings suggest that renal transplantation can be performed successfully in patients with ADPKD who develop refractory hepatic cyst infections, providing suitable surgery is performed.