［Objective］ In order to improve drug adherence, we interviewed dialysis patients about how many pills they could reliably take per dose (hereafter referred to as the acceptable pill count). ［Method］ A total of 455 chronic hemodialysis outpatients were interviewed about the acceptable pill count, and the relationships between patient background factors and the total number of pills prescribed per day (hereafter referred to as the actual pill count) were analyzed. ［Results］ The median acceptable pill count was 5.5 (4.5‒7.0) pills/dose, and the modal acceptable pill count was 5 pills (19.8％). The acceptable pill count was not related to sex or dialysis vintage, but decreased as age increased and was higher in patients with diabetic mellitus and those on semi‒night dialysis. The median actual pill count was 16.8 (11.4‒23.3) pills/day and was positively correlated with the acceptable pill count. Multiple regression analysis showed that the presence of diabetes, semi‒night dialysis, and the actual pill count were significant independent positive predictors of the acceptable pill count. ［Considerations］ The positive correlation between the acceptable pill count and the actual pill count may be due to patients’ habituation and acceptance of high pill burdens.

To clarify the sleep characteristics of hemodialysis patients, we investigated the sleep of 41 hemodialysis patients using subjective and objective methods, the Pittsburgh Sleep Quality Index (PSQI) and actographic recordings. The global PSQI score showed disturbed sleep in all hemodialysis patients who were taking sleeping medications (SM＋) and 40％ of those who were not taking sleeping medications (SM－). The objective evaluation showed poor values for both sleep induction and sleep interruption, which resulted in short total sleep times. The number of awakenings of longer than 5 minutes (NA＞5) score of the SM－ patients was greater than that of the SM＋ patients. Among the former patients, complaints of daytime dysfunction and the NA＞5 score were correlated. We compared these findings with those obtained in previous studies of healthy people and found that the sleep of hemodialysis patients was poor in terms of both sleep induction and interruption. The subjective and objective evaluations revealed that the sleep of hemodialysis patients is severely disturbed. Sleeping medications are partially effective against sleep interruption, but are not sufficiently effective at promoting sleep induction. Some patients who are unaware of their sleep interruption, but experience daytime dysfunction, tend to be missed and go untreated.

Twenty hemodialysis patients underwent 6 months’ exercise therapy. Physical motor function and nutritional assessments were performed before and 3 to 6 months after the start of the intervention. The Holm’s multiple comparison procedure was used for the statistical analyses. The patients’ quality of life (QOL) was evaluated before and after the intervention and compared using the Wilcoxon signed‒rank test, with p‒values of ＜0.05 considered significant. Physical motor function was assessed based on grip strength (non‒shunt limb), knee extension muscle strength, toe grip strength, and abduction muscle strength at 3 months after the intervention. The subjects exhibited improvements in muscle strength and the results of the 30‒second chair stand test and 6‒minute walking test after 3 months, which were maintained after 6 months. No significant changes in nutritional parameters, including the blood hemoglobin concentration, were observed. The QOL evaluation revealed that physical function, mental health, the subjects’ overall view of their health, and vitality increased. It is presumed that the improvement in physical function alleviated daily fatigue and increased the subjects’ motivation to continue being active, resulting in increased levels of daily activity. The abovementioned results suggest that exercise therapy during dialysis improves psychological QOL as well as physical function.

A 73‒year‒old male had started undergoing hemodialysis due to diabetic nephropathy seven years ago. He was receiving dual antiplatelet therapy, as he had undergone coronary stenting. He was diagnosed with novel coronavirus disease 2019 (COVID‒19) by contact screening and admitted to our hospital. Chest CT only showed a single ground glass opacity； however, prophylactic heparin treatment was started because his D‒dimer level was slightly elevated. Dexamethasone was started on the 4th day of hospitalization, as the patient had had a fever since the second day. Lower back pain appeared on the 6th day and changed to abdominal pain the next day. On the same day, he presented with hypovolemic shock during hemodialysis and progressive anemia； therefore, dialysis was discontinued. Contrast‒enhanced CT showed a huge left retroperitoneal hematoma and contrast medium extravasation. A blood transfusion was started, and angiography was performed, while care was taken to avoid a secondary infection. Angiography revealed bleeding from the 4th lumbar artery, which was successfully treated with coil embolization. The anemia did not progress further, and the patient was transferred to another hospital on the 60th day. COVID‒19 has many thrombotic complications, and prophylactic heparin is often administered that are at high risk of bleeding complications, such as those taking and dialysis patients, careful judgments should be made regarding therapy.

A 78‒year‒old female was transferred to our facility with a disturbance of consciousness. She had been undergoing hemodialysis for chronic renal failure caused by pregnancy‒induced hypertension for 11 years. One year earlier, she had started to experience disturbances of consciousness during or after dialysis sessions. She was subsequently diagnosed with hyperammonemia at another hospital and was administered lactulose and branched‒chain amino acid therapy. Her condition improved; however, her symptoms had recurred two months ago, and she was admitted to our hospital. Laboratory tests showed that her serum ammonia level was 190 ug/dL. Contrast‒enhanced computed tomography revealed a portosystemic shunt, and she was diagnosed with cirrhosis and hepatic encephalopathy secondary to non‒alcoholic steatohepatitis. The hepatic encephalopathy was attributed to reduced intrahepatic blood flow secondary to the hemodialysis‒induced diversion of blood into extrahepatic shunts. The patient and her family refused invasive treatment; therefore, rifaximin was administered to eliminate ammonia‒producing gastrointestinal bacteria. Her serum ammonia level rapidly decreased to approximately 100 ug/dL, and her level of consciousness improved and has remained stable for a year.

A 38‒year‒old female with HELLP syndrome was admitted to our hospital after developing an acute kidney injury (AKI) after delivery. Laboratory analysis revealed kidney dysfunction (creatinine： 6.69 mg/dL), liver dysfunction, and thrombocytopenia, and computed tomography showed pleural effusion and ascites. After admission, these conditions did not improve； therefore, we decided to perform plasma exchange (PE) and hemodialysis. Consequently, the patient’s kidney function improved markedly, and she was able to stop undergoing hemodialysis. There are few reports about the successful treatment of HELLP syndrome‒induced AKI with PE. Furthermore, the detailed pathophysiology of the condition has not been fully elucidated. Therefore, we measured the level of asymmetric dimethylarginine, which is known to be responsible for endothelial dysfunction, to investigate its potential role in HELLP syndrome.

［Objectives］ Electrolyzed water dialysis has been reported to reduce oxidative and inflammatory stress and fatigue. However, there are few reports about its nutritional effects. We examined the changes in nutritional status seen after the transition from standard dialysis to electrolyzed water dialysis. ［Method］ Fifty‒one hemodialysis patients (40 males, 11 females； mean age： 63.8±13.3) were enrolled from 1 month before the transition from standard dialysis to 12 months after the transition. Dry weight (DW), body mass index (BMI), serum albumin (s‒Alb), the Geriatric Nutritional Risk Index (GNRI), and the standardized protein catalysis rate (nPCR) were assessed before and after the transition and compared. ［Results］ There were no marked changes in DW, BMI, or the GNRI in either sex. S‒Alb was significantly increased at 3 months in males. The nPCR was significantly increased in all patients and females at 6‒9 months. ［Conclusion］ Electrolyzed water dialysis may improve the nutritional status of patients on maintenance hemodialysis, but longer‒term studies are needed to confirm this.