Although the incidence of peripheral arterial disease (PAD) is high among dialysis patients, it is not uncommon for patients to develop ulcers and necrosis suddenly because of their low activity levels and the lack of symptoms caused by PAD. The prognosis of life after lower limb amputation is poor, and the early diagnosis of PAD and determination of the need for treatment are necessary to improve the prognosis of patients with the condition. In this study, lower limb ultrasonography (LUS) was found to be useful as an early diagnostic tool for PAD, and it was also demonstrated to be useful for estimating the sites of lesions, evaluating stenosis, and assessing the risk of critical limb ischemia progressing. It is considered that LUS should be actively performed in dialysis patients that are at risk of PAD.

We investigated whether the presence/absence of vasodilation in cases of shunt stenosis affected flow volume (FV) and resistance index (RI) values, as well as outcomes and vascular access (VA) prognosis. The subjects were 96 patients who underwent ultrasound‒guided vascular access intervention therapy (VAIVT). They had stenotic cross‒sectional areas of ≤3.14 mm² in a non‒vasodilated state. They were divided into a poor vasodilation and good vasodilation groups, and the cross‒sectional area, FV, RI, and maximal diastolic pressure without avascularization before VAIVT were compared. The results suggested that the effects of treatment were weaker in the good vasodilation group than in the poor vasodilation group, in which some subjects showed significant stenosis in the non‒vasodilated state. If blood vessel cross‒sectional area in a non‒vasodilated state is used as the only criterion for VAIVT interventions, excessive therapeutic interventions may be employed. Therefore, in patients with shunt stenosis the vasodilatory capacity of the stenotic regions should be checked when considering the indications for treatment.

A post‒marketing surveillance study of levocarnitine injections was conducted in hemodialysis patients with carnitine deficiency to examine the safety and efficacy of the long‒term usage (1 year) of such injections. Ninety‒nine medical facilities across Japan enrolled 675 patients in this study. Of these patients, 670 and 669 were included in the safety analysis and efficacy analysis, respectively. The administration period for approximately 80％ of the patients was ≥48 weeks. The incidence of adverse drug reactions (ADRs) was 9.25％ of the 670 patients in the safety analysis (62 patients, 96 events). The following ADRs were reported in ≥3 cases： 5 cases of hypertension (0.75％)；4 cases each of shunt stenosis and pneumonia (0.60％)；and 3 cases each of limb abscesses, decreased appetite, and cardiac failure (0.45％). The serum concentrations of free carnitine (FC), total carnitine, and acylcarnitine (AC) were significantly increased after 3, 6, and 12 months’ treatment. The ratio of AC to FC (AC/FC) decreased slightly during the study period. The efficacy evaluation showed pharmacological effects in ＞70％ of the 669 patients (470 patients).

A 60‒year‒old female was started on dialysis at 58 years of age due to diabetic nephropathy. On day X, she sought a hospital evaluation for a fever. Her arteriovenous graft was infected； thus, it was removed. The culture results were positive for MRSA. On day 7, she complained of neck pain. MRI was performed and revealed an epidural abscess in the cervical spine； therefore, a laminectomy was carried out. A lumbar epidural abscess, bilateral iliopsoas abscesses, and lumbar discitis were subsequently noted. A laminectomy and percutaneous drainage treatment were conducted. During the course of treatment, vancomycin, daptomycin, and linezolid were used as anti‒MRSA drugs. The epidural and bilateral iliopsoas abscesses improved with anti‒MRSA drug treatment and drainage. As the discitis persisted, the anti‒MRSA drugs were administered for a prolonged period. Linezolid caused thrombocytopenia and was replaced with tedizolid (TZD), which was administered for 63 days. Grade 0 thrombocytopenia was noted on day 30 of the TZD treatment and persisted, but it was mild, so the TZD was continued. After the TZD therapy, the patient’s platelet count improved rapidly, and she was discharged without any re‒exacerbation of the infection.

A 75‒year‒old male with a 20‒year history of type I diabetes mellitus was treated for diabetic nephropathy with anti‒glutamic acid decarboxylase antibody positivity, hypertension, diabetic retinopathy, massive proteinuria, and peripheral neuropathy. Later, his renal dysfunction deteriorated； therefore, hemodialysis was started. While he was admitted to hospital for hemodialysis, a rash on his trunk and serum IgA‒λ positivity were observed, and the possibility of systemic amyloidosis was considered, but a gastric endoscopic biopsy showed no amyloid deposition, and echocardiography showed normal function. He started to receive outpatient dialysis at his local clinic, but his blood pressure frequently dropped during the dialysis sessions, and he was often admitted to our hospital due to heart failure. During his third hospitalization, low cardiac function without coronary artery lesions was observed, and the patient suddenly died of ventricular fibrillation. A pathological autopsy was performed to elucidate the cause of death, and findings suggestive of amyloidosis were observed, but immunostaining failed to identify any amyloid precursors. Mass spectrometry led to a diagnosis of amyloid light‒chain amyloidosis with IgA‒λ as the precursor. We experienced a case of systemic amyloidosis with rapid progression of cardiac dysfunction after the initiation of dialysis.

The patient was an 88‒year‒old male who had been undergoing hemodialysis (HD) for 8 years at our hospital. His family members, who were living with him, were infected with the SARS‒CoV‒2 alpha variant. Subsequently, he was also found to have been infected. No symptoms of respiratory system were observed on admission. Thereafter, hypoxemia due to pneumonia (severity classification： moderate Ⅱ) developed. Supportive therapy with nasal oxygen administration to maintain an SpO2 of ≥93％, dexamethasone (6.6 mg/day for 10 days) and remdesivir (100 mg/HD session, 3 times) were started, resulting in his recovery from COVID‒19. It was uncertain whether remdesivir can be used safely in patients with COVID‒19 undergoing hemodialysis. However, in this case, which involved an elderly patient, administering remdesivir at a dose of 100 mg 4 hours before each HD session was useful.

As the number of patients who have difficulty with arteriovenous fistulas is increasing, the use of arteriovenous grafts is rising. Although some reports have suggested that buttonhole puncture is effective for maintaining arteriovenous grafts, it is not recommended due to the risk of infection. We have prepared a buttonhole puncture manual, which recommends the use of dull needles to maintain arteriovenous grafts and limited punctures, and we have not experienced any vascular access infections in the 6 patients with arteriovenous grafts treated at our hospital over the past 7 years. As for puncturing, we measured the number of attempts and the success rate of buttonhole puncture for one month and found that the success rate was 97.9％ and 50％ when ≤10 and ＞10 punctures were performed, respectively. By strictly following the manual, the long‒term maintenance and preservation of arteriovenous grafts was possible.

We reported that the quality of shunt sounds can be quantified and evaluated by artificial intelligence. However, information on the auscultatory sites was missing, and few predictors of obstruction were identified. In addition, it is difficult to predict occlusion based on the mean brachial artery blood flow and vascular resistance index according to Doppler ultrasound because the blood flow through a shunt with many branches is unlikely to decrease if one branch becomes occluded. We consider that shunt sounds from the anastomotic site alone, which are easy to record, may be related to the above ultrasonic findings. Comparisons were made of the sound quality at the shunt anastomosis, the mean brachial artery blood flow according to ultrasound, and the vascular resistance index. As a result, the mean brachial artery blood flow, which indicates shunt blood flow, was found to be correlated with the intensity of shunt auscultatory sounds. The vascular resistance index as indicated by ultrasonic waves was weakly correlated with intermittent sounds assessed by artificial intelligence. It is considered possible to indirectly evaluate shunt blood flow through daily auscultation. However, performing auscultation over the entire length of the shunt, not just at the anastomotic site, is important for assessing stenotic sounds.