Arteriovenous loop grafts (AVLGs) on the forearm make excellent vascular access points because they have a wide puncture range and make it easy to perform daily puncture procedures and achieve hemostasis. However, their long-term use causes hardening of the loop graft itself, intimal thickening, and pseudoaneurysm formation caused by frequent puncturing, which often leads to thrombosis. It becomes increasingly difficult to treat these problems during vascular access intervention therapy (VAIVT). In 13 patients with AVLGs on their forearms that were used for VAIVT, we performed surgery to remove the aging loop graft, create a skin flap, and transfer a new graft to the original loop graft site. Only half of each loop graft was replaced, and daily dialysis was continued using the remaining part of the loop that had not been replaced. Postoperatively, the patients only experienced mild wound pain and slight swelling of the forearm. After that, VAIVT was performed in all cases, as appropriate, and second operations on the remaining parts of the loop grafts were performed in 6 cases. Dialysis via the forearm loop graft was able to continue as before in all cases. No temporary hemodialysis catheters were required during the surgical procedure. Creating a skin flap has the advantage that the puncture range of the graft is not limited in the future.

[Objectives] In Japan, most patients who require renal replacement therapy (RRT) choose to undergo hemodialysis (HD), and only 2.7% of patients choose to undergo peritoneal dialysis (PD). In 2011, dialysis nurses at our hospital started to provide patients with explanations about RRT in an outpatient setting based on a shared decision-making (SDM) approach in order to facilitate the selection of appropriate RRT modalities. We investigated whether more patients, especially elderly patients, selected PD after receiving a detailed explanation about RRT. [Methods] The subjects of this study were 637 consecutive patients (mean age: 67.0±12.7 years) who required RRT at our hospital during the period from January 1, 2013, to December 31, 2018. We retrospectively investigated the first RRT modality selected by the patients and whether the patients received an explanation about RRT. [Results] The 637 patients were divided into two groups: patients who received an explanation about RRT (SDM group, n=387) and patients who did not receive an explanation about RRT (non-SDM group, n=250). The percentage of patients who selected PD was significantly higher in the SDM group than in the non-SDM group (30.7% vs. 16.8%, p<0.001). When the analysis was restricted to patients aged ≥75 years, the percentage of patients who selected PD was still significantly higher in the SDM group (25.0%, n=112) than in the non-SDM group (7.8%, n=90) (p=0.001). [Conclusion] This study suggested that more patients, including elderly patients, would select PD if detailed explanations about RRT were provided via a SDM approach. These results are important considering the current aging of the population in Japan.

Dialysis therapy is administered in an environment in which patients and healthcare workers are at high risk of being exposed to blood, droplet-based horizontal direct contact transmission, and contact transmission (because many patients enter and leave the room). Recently, wiping and disinfection have been emphasized as ways to prevent contact transmission. At our hospital, quaternary ammonium compounds (QUAT) have been used for wiping and disinfection in our dialysis room, but given the existence of blood-borne viruses, chlorine compounds are considered to be more suitable. In this study, we introduced a multipurpose disinfectant cleaning agent (RST), containing a potassium peroxymonosulfate compound, which is recommended in the guidelines, and compared its cost and the number of cloths required per dialysis treatment with those of QUAT-based cleaning. After healthcare workers were educated about the proper usage of RST, the number of cloths used per dialysis treatment decreased, and the cleaning cost remained stable. In a re-verification study performed one year after the introduction of RST, the number of cloths used and the cleaning cost remained at their initial levels. When comparing products for disinfecting dialysis rooms, analyzing the product‘s unit price and its cost-effectiveness after educating healthcare workers regarding its use are important.

We experienced three cases in which schizophrenia patients with water intoxication underwent hemodialysis. The patients were admitted to our hospital and underwent hemodialysis. However, they could not undergo water restriction and exhibited weight gain of 10-30% and hyponatremia. Within one year of admission, they died because of volume expansion. In these cases, we had to consider the administration of diuretics, such as tolvaptan, to maintain appropriate urinary output, and the severe hyponatremia seen in case 3 required careful dialysate preparation. Water intoxication is difficult to treat in schizophrenia patients, and performing hemodialysis sustainably is challenging in such cases.

The patient was a 78-year-old male. He visited our department because of nephrosclerosis, but had repeatedly suffered gastrointestinal bleeding due to angiodysplasia of the stomach and duodenum before the introduction of hemodialysis. Even after hemodialysis was introduced, gastrointestinal bleeding from the stomach and duodenum was observed. Capsule endoscopy of the small intestine revealed angiodysplasia with active bleeding in the upper jejunum. Conservative treatment with oral rebamipide was started, and the patient did not require hemostasis or a blood transfusion.

The patient was an 87-year-old female. She was weak and suffered from limb numbness and vomiting. She was suspected of having cholangitis and was referred to our hospital. Emergency ERCP was performed, and antibiotic treatment was started. Her abdominal symptoms were ameliorated, but a fever and high CRP levels persisted. A blood test showed an increased MPO-ANCA level (1,545 U/mL), and microscopic polyangiitis was diagnosed. The patient’s renal function subsequently worsened, and intermittent hemodialysis was performed temporarily. Methylprednisolone and oral prednisolone were administered, followed by 7 rounds of plasma exchange and rituximab treatment, which resulted in dialysis no longer being required. The patient’s MPO-ANCA level decreased to 39.6 U/mL, and the associated organ damage, including renal problems, stabilized. This case involved an aged patient, who was diagnosed with ANCA-associated vasculitis caused by cholangitis. Remission was achieved with immunosuppressive therapy and plasma exchange.

A premenopausal non-diabetic female in her early 40 s was diagnosed with a low bone mineral content while she was undergoing hemodialysis treatment (for 4.5 years). Her total hip T and Z scores (dual-energy X-ray absorptiometry) were 68% (−2.4 standard deviation [SD]) and 70% (−2.2 SD), respectively. The low bone mineral content was caused by renal osteodystrophy, being female, a low body mass index (16.0 kg/m²), smoking, low levels of physical exercise, short-term steroid therapy, and an unbalanced and unhealthy diet. A nutritional survey, involving a questionnaire examining the consumption frequency of various food groups and a 3-day meal record, was performed. It revealed a high energy intake of 61 kcal/kg body weight, caused by high lipid intake due to the consumption of cakes and fried foods. A low protein intake (10.8% of total energy intake) and the absence of fish from the patient’s diet were also noted. The patient’s serum 25-dihydroxyvitamin D level was 7.5 μg due to extremely low vitamin D intake (0.9〜2.7 μg/day). Carbohydrates accounted for 51.5% of her energy intake, partly due to the consumption of up to 1 L/day of soft drinks. She had maintained similar eating and exercise habits since childhood. She had a low calcium intake of 143〜415 mg/day. Her phosphate intake was elevated (873 mg/day), partly due to the inorganic phosphate content of her favorite beverages. She was exposed to normal levels of sunlight. Her low bone mineral content was considered to be a secondary effect of an unbalanced diet.