[Purpose] The digital brachial pressure index (DBI) has become an established tool for diagnosing dialysis access steel syndrome (DASS), but it has not been adopted in Japan. There have also been many reports about the use of skin perfusion pressure (SPP) to diagnose DASS. In this study, we compared the utility of the DBI and SPP as tools for diagnosing DASS. [Methods] The subjects were 119 patients with AV shunts. They were classified based on the presence/absence of DASS, and the diagnostic ability of each parameter was compared via ROC analysis. Moreover, DASS was classified into mild and severe cases, and the ability of each parameter to discriminate between such cases was compared via ROC analysis. [Results] This study involved 51 patients (108 fingers) without DASS and 68 patients (130 fingers) with DASS. The DBI and SPP cut-off values used to diagnose DASS were 0.67 and 61 mmHg, respectively, and those used for distinguishing between mild and severe cases were 0.51 and 30 mmHg, respectively. SPP was significantly superior to DBI for diagnosing DASS and determining its severity. [Conclusions] It was suggested that SPP is superior to DBI as a tool for diagnosing DASS.

A perioperative protocol that followed the JSDT guidelines for cardiac surgery in dialysis patients was developed to improve interprofessional collaboration and patient care. We evaluated the perioperative protocol and surgical complications at our hospital. The subjects were 128 patients who underwent cardiac surgery between January 2016 and December 2018, excluding those who underwent concomitant aortic surgery. The subjects were divided into two groups; i.e., into those who were (dialysis group) and were not (control group; i.e., non-dialysis group) on maintenance dialysis therapy. The dialysis and control group consisted of 29 and 99 patients, respectively. Aortic valve replacement and coronary artery bypass grafting were the most common forms of cardiac surgery, and they exhibited similar frequencies in both groups. There were 2 (7%) and 3 (3%) in-hospital deaths in the dialysis and control groups, respectively. The postoperative hospital stay was significantly longer in the dialysis group (30.7 days vs. 23.3 days), and the proportion of patients requiring unplanned extracorporeal circulation was significantly higher in the dialysis group (17% vs. 1%). However, among cases involving isolated coronary artery bypass grafting, the duration of the postoperative hospital stay and frequency of unscheduled extracorporeal circulation were comparable between the two groups. In valve operations involving dialysis patients, further examinations should be carried out in order to reduce the risk of unscheduled extracorporeal circulation and shorten the hospitalization period.

[Introduction] The efficacy of zinc (Zn) replacement therapy for anemia associated with hypozincemia in hemodialysis (HD) patients has not been clearly defined. [Subjects] Thirty-three HD patients who received >9,000 U per week of erythropoietin and exhibited serum Zn levels of <80 μg/dL were enrolled in this study. [Methods] The patients were prescribed 45-50 mg of Zn per day from the start of the study. [Results] After 3 months’ treatment, the patients’ serum Zn levels were significantly increased, but their serum copper (Cu) levels were decreased. The patient’s erythropoietin resistance indexes (ERI) were significantly lower after 3 months’ treatment than at the start of the therapy. [Conclusion] It appears that Zn replacement therapy is useful for treating erythropoietin-resistant anemia in HD patients. However, even if Zn replacement therapy is only used for a short period, such as for 3 months, the risk of hypocupremia is quite high. Thus, it is necessary to routinely measure HD patients’ Zn and Cu levels during Zn replacement therapy.

A 61-year-old male with chronic kidney disease due to diabetic nephropathy received hemodialysis (HD) therapy 3 times per week. Recently, he had frequently experienced intradialytic hypotension, but we judged that his body fluid status was well controlled based on a physical assessment, his cardiothoracic ratio, and monitoring of his circulating blood volume. After obtaining informed consent for an observational study, we monitored cerebral regional oxygen saturation (rSO₂). The patient’s mean blood pressure gradually decreased, and about 120 minutes after starting HD his right cerebral rSO₂ had markedly decreased. We suspected brain ischemia, and therefore, we performed magnetic resonance imaging and found severe stenosis of the right internal carotid artery. On single photon emission computed tomography, his cerebral blood flow appeared to be stable, and no interventions were conducted. Monitoring of cerebral rSO₂ could help to diagnose cerebral ischemia-related diseases in HD patients in the future.

The patient was a 66-year-old male, who had been undergoing hemodialysis for 9 years for chronic renal failure due to diabetic nephropathy. He was diagnosed with hypercalcemia and hyperparathyroidism based on a blood test (Ca: 10.4 mg/dL and intact PTH: 568 pg/mL). Hypoechoic masses (size: 8-14 mm) were found in the right thyroid lobe, the dorsal side of the left thyroid lobe, and the lower pole of the thyroid gland on ultrasonography. MIBI scintigraphy showed no abnormal accumulation by the masses. The patient was diagnosed with secondary hyperparathyroidism (SHPT). Moreover, a nodule with calcification, which had a viable blood supply, was detected in the thyroid gland. It was suspected to be a thyroid malignancy. Total parathyroidectomy was performed in October X. A rapid pathological examination revealed thyroid cancer, and total thyroidectomy was conducted. The subsequent pathological examination revealed parathyroid hyperplasia, and an oxyphil cell adenoma was found in one gland. We report a case of thyroid cancer associated with SHPT that was complicated with oxyphil cell adenoma.

We report a case of light-chain-type multiple myeloma without serum M-protein in a hemodialysis patient. The patient was a 47-year-old male, who was found to have a serum creatinine level of 1.2 mg/dL, but exhibited no evidence of proteinuria or hematuria. A marked increase in his serum creatinine level (to 6.9 mg/dL) was noted 2 years later, and hemodialysis treatment was started. Left ventricular hypertrophy was diagnosed, and liver dysfunction together with hepatomegaly and splenomegaly were detected 2 months later. The patient gradually developed back pain, and a serum immunoglobulin free light chain (FLC) assay was performed. His κ/λ ratio was extremely high (68.23), and based on the results of a bone marrow biopsy, we made a definitive diagnosis of multiple myeloma. The serum M-protein, which is usually present in multiple myeloma, was not detected at any time. The immunoglobulin FLC κ/λ ratio assay was the key to diagnosing multiple myeloma in this case.