Due to advances in medical technology and aging populations, end of life medical care has become an urgent issue. As this is also true for patients with end-stage renal failure, we retrospectively investigated the perimortem circumstances of dialysis patients that were being treated at our hospital. During the 14-year study period, 180 dialysis patients died. In total, 81.7% and 18.3% of the subjects died inside and outside (e.g., at home or an emergency center) hospital, respectively. Only two patients died while receiving home medical care. Compared with the patients who died inside the hospital, those who died outside the hospital were younger, and fewer of them were predicted to die. Dialysis treatment was withdrawn from 36 patients; however, only 6 patients presented advance directives that included instructions to withdraw dialysis. The mean duration of the period from the withdrawal of dialysis to death was 7.9 days, and half of the subjects died within 2 days of dialysis being withdrawn. On the other hand, many patients did not wish to undergo cardiopulmonary resuscitation (CPR), and CPR was performed in 22 subjects who were not predicted to die. In conclusion, even patients in terminal states tend to undergo dialysis until just before death. It is desirable to disseminate advanced care plans/advance directives that include information regarding dialysis, in order to allow dialysis patients to die with dignity.

To understand the condition of aged hemodialysis patients and identify relevant medical and nursing care issues, we evaluated the background factors and prognoses of 231 patients in whom hemodialysis was initiated from the viewpoint of their residences and the means of transportation they used to get to dialysis facilities. Regarding the subjects’ residences, 203 patients lived at home (87.8%, in-home group: IHG) and 28 patients lived outside of their homes (12.2%, out-home group: OHG). Among the IHG patients, only 89 (43.8%) visited dialysis facilities on their own. The remaining 114 (56.2%) patients, including 12 super elderly people (age: over 85 years old) needed some kind of assistance with such outpatient visits. Both the degree of independent living and the subjects’ cognitive functions decreased more in the OHG than in the IHG. Furthermore, the proportion of patients that lived with support personnel and the proportion of patients that were cared for by their spouse were higher in the IHG than in the OHG. On the other hand, the proportions of patients that had newly registered for long-term care insurance or received late referrals to nephrologists were higher in the OHG than in the IHG. During the median observation period of 38 months, 22 (10.8%) IHG patients and 9 (32.1%) OHG patients died. These findings indicate that not only a patient’s physical situation, but also their social background, influence patients’ residential circumstances after the initiation of hemodialysis.

Dyspnea is a common and distressing symptom, which is sometimes observed in terminally ill hemodialysis patients. Oxycodone is widely used to alleviate dyspnea in patients without renal dysfunction. However, in patients with renal failure, oxycodone use is avoided owing to concerns regarding the adverse effects associated with the accumulation of oxycodone. In this case series, we examined the usefulness and safety of oxycodone for ameliorating dyspnea in 7 terminally ill hemodialysis patients. Oxycodone was administered either orally or via a continuous subcutaneous infusion at a mean dose of 3.8 mg/day, and the dose was gradually increased as needed. We used the Japanese version of the Support Team Assessment Schedule (STAS-J) to quantitatively evaluate dyspnea. The STAS-J-based evaluations indicated that oxycodone significantly ameliorated dyspnea. No adverse events, such as respiratory depression, were reported in any patient. In conclusion, oxycodone can be safely used (following dose adjustments) to ameliorate dyspnea in patients undergoing hemodialysis.

Tsubasa Music Exercise (TMX), a combination of aerobic exercise and resistance training, which is performed to music during hemodialysis, has been used by the hemodialysis patients at our clinic, and it has enhanced their exercise tolerability. It aims to promote blood flow in the lower extremities (the exercises involve lower extremity elevation) because a large number of hemodialysis patients suffer peripheral arterial disease as a complication. We categorized our patients into 4 groups, Normal, Risk I, Risk II, and Risk III, based on a our foot risk classification system, and conducted skin perfusion pressure (SPP) tests of the lower extremities in 10 patients from each group. No significant change in the mean SPP was observed in any of the 4 groups; however, some patients’ SPP values fell below 50 mmHg after the TMX. We conclude that careful observation of the state of the lower extremities after TMX might be necessary in cases in which exercise therapy is performed during hemodialysis.

Hypokalemia causes muscle weakness and is associated with an increased incidence of sudden cardiac death. As the standard dialysate potassium concentration in Japan is 2 mmol/L, the incidence of hypokalemia might be high after dialysis. We adjust the dialysate potassium concentration to 3 mmol/L as necessary. Therefore, we evaluated the serum potassium level and the amount of dialysate potassium removed after hemodialysis had been performed three times in perioperative patients using a dialysate potassium concentration of 2 mmol/L (dialysate 2) or 3 mmol/L (dialysate 3). Hypokalemia; i.e., a potassium level of <3 mmol/L, was seen after dialysis in 14.8% of patients in the dialysate 2 group, but no patients in the dialysate 3 group. The total amount of potassium removed was 36 [24-48] mmol in the dialysate 2 group, whereas it was significantly decreased to 24 [12-24] mmol in the dialysate 3 group. Performing hemodialysis with a dialysate potassium concentration of 3 mmol/L might be useful for preventing hypokalemia after dialysis in perioperative patients.

We report a case of renal failure caused by scleroderma renal crisis (SRC), which required the initiation of hemodialysis. The patient was a 44-year-old female, who developed SRC approximately 2 years after being diagnosed with systemic sclerosis (SSc). She was prescribed angiotensin-converting enzyme inhibitors, but her renal function did not improve. As a renal transplant was not an option, it was recognized that she would eventually require hemodialysis or peritoneal dialysis. It was difficult to decide on the ideal type of dialysis. For example, the patient’s comorbidities (SSc and vascular lesions) presented challenges with regard to maintaining vascular access for hemodialysis, and the skin tightening caused by her SSc hindered fine movement, which is a requisite for maintaining a peritoneal dialysis catheter. Ultimately, the patient opted for hemodialysis, but there were difficulties establishing a functional arteriovenous fistula. SSc is a connective tissue disease, involving multiple organs, and it is characterized by skin dysfunction and vascular injuries; therefore, little is known about the stability of peritoneal clearance in patients with SSc. For these reasons, the management of SSc patients with renal failure requires further study, and there is a need to develop an appropriate maintenance dialysis method for such patients.