After the initial administration of etelcalcetide hydrochloride (Etel), its dosage might be adjusted depending on the attending physician’s view. Therefore, at dialysis facilities, where patients are managed by multiple doctors, the management of secondary hyperparathyroidism (SHPT) with Etel can take many different courses. In this study, an Etel administration protocol was devised to prevent variations in Etel-based SHPT management within the same dialysis facility, and its effects were examined. The protocol was devised in accordance with the findings of domestic phase III trials of Etel. Twenty-two subjects were enrolled. The study period lasted for 28 weeks, starting from the administration of the first dose of Etel. During the study, 5 subjects dropped out, including 2 patients who died because of other factors, and so 17 subjects completed the study. The mean dose of Etel decreased significantly from 5 mg at the start of the study to 4.4±1.7 mg at the end of the study (p=0.0084). In addition, by the end of the study the proportion of patients whose intact-parathyroid hormone levels were controlled at ≤240 pg/mL had significantly increased from 12 (54.5%) out of 22 subjects to 15 (88.2%) out of 17 subjects (p=0.0238). No new side effects developed during the study period. This Etel administration protocol might enable physicians to manage and control SHPT more effectively.

Percutaneous peritoneal dialysis catheter placement can be performed under local anesthesia. In our hospital, we conducted such procedures using the Seldinger technique under ultrasonography and fluoroscopy in 20 patients. The procedure was successful in all cases except one, including in 6 patients who had previously undergone abdominal surgery. Intestinal puncture did not occur in any case. Peritoneal dialysis was initiated via the SMAP technique in 8 patients and via one-step surgery in 9 patients (waiting period until dialysate injection: 6-16 days), but no fluid leakage was observed. As early complications, catheter tip migration occurred in 2 patients; peritonitis arose in one patient; and blood was seen in the peritoneal dialysate in 2 patients, one of whom exhibited catheter obstruction. However, all of these complications were dealt with non-invasively, and peritoneal dialysis was continued in each case. One catheter was withdrawn after 15 months, but it was easily removed under local anesthesia. This peritoneal dialysis catheter placement method is minimally invasive, and it is particularly useful in Japan, as the dialysis patient population is aging.

Advances in dialysis have increased the number of cases of secondary arteriovenous fistulas (AVF), advanced arteriosclerosis, and intractable vascular access trouble (VAT). Among patients with existing forearm access points, we compared arteriovenous anastomosis sites, vascular access patency rates, and the frequency of VAT between a transposed basilic vein (TBV)-brachial artery AVF group (Group I) and a TBV-radial artery/ulnar artery AVF group (Group II), in order to re-evaluate the optimal surgical method for secondary AVF. The study population comprised 151 patients with confirmed access loss who had been followed-up for at least 3 months (Group I: 96 patients, Group II: 55 patients). The mean duration of the follow-up period was 37 months. In Group I, the primary patency rate was 40% and 24.7% at 1 and 2 years after the procedure, respectively, while the secondary patency rate was 91.7% and 85.2% at 1 and 2 years, respectively. In Group II, the primary patency rate was 39.5% and 28.5% at 1 and 2 years, respectively, while the secondary patency rate was 92.4% and 87.1% at 1 and 2 years, respectively. Although the frequency of VAT, which was defined as an event that required percutaneous transluminal angioplasty (PTA), was high (86.5% in Group I and 83.6% in Group II), there was no difference between the two groups in either patency rates or the frequency of VAT. Due to the efficacy of PTA, we were able to maintain 5-year secondary patency rates of approximately 80% in both groups.

The incidence of hypozincemia, which can cause of erythropoiesis-stimulating agent (ESA) hypoactive anemia, is high among hemodialysis patients. In March 2017, zinc acetate, which was first approved in Japan for use against hypocupremia, became available. We administered 100 mg/day zinc acetate to 3 patients on maintenance hemodialysis who had ESA hypoactive anemia. Their serum copper concentrations reached markedly low values of 0 to 3 μg/dL after 4 to 7 months’ treatment, and they exhibited hypocupremia and blood disorders, such as pancytopenia. In all 3 patients, the zinc acetate was discontinued, and the doses of ESA were increased. Blood transfusions were carried out in 2 patients, and the oral administration of 10 g/day of pure cocoa was started, which improved the blood disorders of all 3 patients. We administered zinc acetate to 22 additional maintenance hemodialysis patients with hypozincemia, and after 6 months’ treatment their mean serum copper concentration had decreased from 78.2±15.4 μg/dL to 60.6±18.6 μg/dL. As the amount of zinc acetate was reduced as needed during the administration period, no blood disorders were observed. The serum copper concentrations of maintenance hemodialysis patients who receive zinc acetate must be periodically examined. The dose of zinc acetate should also be adjusted as necessary.

A male in his 90s presented with hematemesis after hemodialysis. He had been receiving maintenance hemodialysis for about 3 years. His medical history included right nephrectomy for renal carcinoma 9 years ago, and he had suffered hypertension and renal insufficiency after the operation. He was treated with an antiplatelet drug due to frequent vascular access failure and coagulation of the dialysis circuit. Blood tests performed on admission revealed elevated hepatobiliary enzyme levels. Computed tomography (CT) demonstrated swelling of the gallbladder and a gallstone. The patient was diagnosed with cholecystocholangitis and upper gastrointestinal bleeding, and endoscopic retrograde cholangiopancreatography was performed, which revealed bleeding from the duodenal papilla. Thus, he was diagnosed with hemobilia. Contrast-enhanced CT demonstrated that a pseudoaneurysm of the cystic artery had caused the hemobilia. The patient was treated with transcatheter arterial embolization of a branch of the cystic artery, based on his age and wishes. His postoperative course was uneventful, and he was discharged after 19 days. Hemobilia should be kept in mind as a cause of upper gastrointestinal bleeding in hemodialysis patients.

Case 1: Gemcitabine was administered to a male of over 70 years of age due to the postoperative recurrence of pancreatic cancer. After two years of treatment, he was admitted to our hospital with an acute kidney injury, hemolytic anemia with schizocytes, and thrombocytopenia. He was diagnosed with gemcitabine-induced thrombotic microangiopathy (TMA). The gemcitabine was stopped, and treatment with steroid pulse therapy, plasma exchange, and hemodialysis was started. Hemodialysis was continued as necessary up to the patient’s death from pneumonia on the 37th hospital day. An autopsy showed findings that were indicative of TMA in both kidneys, such as glomerular basement membrane duplication, mesangiolysis, and a lobular pattern in the glomeruli.

Case 2: A woman in her eighties received gemcitabine chemotherapy due to the postoperative recurrence of cholangiocarcinoma. After nine months of treatment, laboratory tests showed severe renal impairment, hemolytic anemia with schizocytes, and thrombocytopenia. Under a diagnosis of gemcitabine-induced TMA, the gemcitabine treatment was stopped, and hemodialysis was initiated. As the patient’s renal function did not recover, regular hemodialysis was continued for 11 months, but she died of her malignancy. Gemcitabine-induced TMA is a life-threatening complication with no established treatment. The early recognition of hemolytic findings and subsequent discontinuation of gemcitabine are crucial in such cases.