Recently, the number of patients requiring vascular access points involving a permanent vascular catheter (PVC) (particularly dialysis patients in whom creating an arteriovenous fistula would be difficult, e.g., because of cardiovascular dysfunction and/or long‒term bed rest) or a temporary vascular catheter (TVC) (e.g., patients who require incident dialysis or have occluded vascular access points) has increased. Central venous catheterization can cause various complications, such as artery puncture, hematoma formation, and pneumothorax. In the present study, we investigated the validity and safety of a surgical technique for the orthotopic exchange of a TVC for a PVC using a guidewire, with the aim of reducing the risk of complications of PVC insertion. We reviewed the cases of 87 patients who underwent PVC insertion at our center between April 2017 and April 2020. We compared the results of 27 patients who underwent orthotopic TVC exchange for a PVC using a guidewire with those of 60 patients who underwent catheter insertion at a new site. There were no significant differences in patient background factors between the groups. In addition, we observed no significant difference with regards to the complications rate, operating time, catheter‒related infections, or the short‒term patency rate. The patients who underwent guidewire‒based exchange reported no complications. Thus, these results suggest that the orthotopic exchange of a TVC for a PVC using a guidewire may be clinically useful.

［Background］In Japan, most patients who require renal replacement therapy (RRT) choose hemodialysis (HD) rather than peritoneal dialysis (PD). We investigated the factors associated with the selection of PD in patients who received pre‒dialysis education. ［Methods］This study included 356 patients who received pre‒dialysis education between April 2011 and August 2018 and were subsequently started on dialysis. We retrospectively investigated the factors associated with the selection of PD using logistic regression analysis. The candidate factors included age, sex, the estimated glomerular filtration rate (eGFR), the glycated hemoglobin level, diabetes mellitus (DM), the cardiothoracic ratio, the subjects’ ability to perform activities of daily living, and family support. A subgroup analysis was also performed by age (cut‒off：65 years). ［Results］The percentage of patients that select PD‒based RRT has recently decreased. Of the study subjects, 262 (74％) chose HD, and 94 (26％) chose PD. The factors associated with the selection of PD were age (adjusted odds ratio［OR］per 10 years, 0.74；95％ confidence interval［CI］, 0.60‒0.82), the eGFR (adjusted OR per 1 mL/min/1.73m², 0.89；95％ CI, 0.82‒0.96), and DM (adjusted OR, 0.41；95％ CI, 0.22‒0.76). In the subgroup analysis, family support was associated with the selection of PD in patients aged ≥65 years (adjusted OR, 8.19；95％ CI, 1.07‒62.9). ［Conclusion］The percentage of elderly patients that selected PD‒based RRT was very low, but family support was associated with the selection of PD in patients aged ≥65 years. Family support may help elderly patients choose PD‒based RRT.

［Objective］Polymyxin B‒immobilized fiber column direct hemoperfusion (PMX) is used to treat urosepsis/septic shock after flexible transurethral lithotripsy (f‒TUL). We retrospectively examined the usefulness of PMX for urosepsis/septic shock after f‒TUL. ［Methods］Of 728 patients who underwent f‒TUL for renal/ureteral lithiasis in a 3‒year period (from Jan. 1, 2016), 16 were treated with PMX. Of these, 5 required nephrectomy due to pyonephrosis. We compared the following between the patients that did (nephrectomy group) and did not (non‒nephrectomy group) undergo nephrectomy： 1) patient background factors, clinical variables, PMX‒related items, and the clinical course； 2) the Sequential Organ Failure Assessment (SOFA) score, mean arterial pressure (MAP), hourly urinary output, and body temperature. ［Results］In the nephrectomy group, large (≥20 mm) calculi or staghorn calculi were found in 60％ of patients. Gram‒negative bacilli were detected in preoperative urine cultures in most patients, and all patients received preoperative antibiotic therapy. On average, PMX was started 3‒4 h after the completion of f‒TUL in both groups. The 28‒day mortality rate was 0％ in both groups. MAP was significantly elevated after PMX in both groups. Significant improvements in the SOFA score were seen after PMX in the non‒nephrectomy group, whereas the SOFA score worsened after PMX in the nephrectomy group. Only a small increase in urinary output was observed after PMX in the latter group. PMX treatment for urosepsis/septic shock led to improved hemodynamics in patients that experienced sustained shock after f‒TUL. Nephrectomy should be considered if the patient’s SOFA score worsens after PMX.

Cancer is the third most common cause of death among dialysis patients in Japan. Nevertheless, there are no guidelines for the treatment of cancer in dialysis patients. This study aimed to examine the treatment of cancer in dialysis patients and non‒dialysis patients according to cancer stage in real‒world settings. In this multicenter retrospective cohort study, cancer registry data and administrative data were used to identify dialysis patients (n＝687) and non‒dialysis patients (n＝47900) aged 18‒79 years who were newly diagnosed with colorectal, stomach, or lung cancer between 2010 and 2015 at 36 hospitals in Osaka Prefecture, Japan. The records of these datasets were linked to obtain patient‒level information about dialysis treatment, cancer diagnoses, and cancer‒specific treatments. Dialysis patients were significantly more likely to undergo endoscopic resection and less likely to undergo surgical resection for early‒stage colorectal and stomach cancer than non‒dialysis patients. Dialysis patients were significantly more likely to receive radiotherapy for early‒stage lung cancer. Dialysis patients were significantly less likely to undergo combination treatment involving surgical resection and chemotherapy for colorectal, stomach, or lung cancer of any stage. Dialysis patients were significantly less likely to receive chemotherapy alone for distant recurrent stomach or lung cancer. Dialysis patients were significantly less likely to receive any treatment for lung cancer, regardless of its stage. In conclusion, dialysis patients were less likely to receive aggressive treatment for cancer than non‒dialysis patients. This study supports the development of evidence‒based practice guidelines for the treatment, particularly using chemotherapy, of cancer in dialysis patients.

［Purpose］We examined the treatment results of patients who developed bladder cancer during maintenance hemodialysis at our hospital. ［Materials and Methods］This study included 5 males and 1 female who were treated for bladder cancer between January 2010 and December 2019. The primary reason for dialysis, dialysis period, clinical pathological results, surgical procedure, and prognosis were retrospectively examined. ［Results］The primary reason for dialysis was diabetic nephropathy in 4 cases and unknown in 2 cases. The median age at transurethral resection of the bladder tumor (TURBT) was 68 years, and the median dialysis period was 53 months. The initial symptom was hematuria in 5 cases and irregular genital bleeding in 1 case. Preoperative urinary cytology resulted in 5 cases and 1 case being classified as class 4 and class 5, respectively. TURBT was performed in all cases, and the pathological diagnosis was urothelial carcinoma in 5 cases and small cell neuroendocrine cancer in 1 case. All patients had high‒grade pT1 or more advanced disease, and 3 patients underwent total cystectomy. Intravesical recurrence was observed after TURBT in 2 cases, and metastasis developed after total cystectomy in 1 case, which resulted in death. ［Conclusion］It is important that dialysis patients undergo urinary tests/cytology regularly because bladder cancer that is detected during maintenance hemodialysis has high malignant potential, and many cases involve advanced disease.

Dialysis patients are at increased risk of cerebrovascular disease and cognitive dysfunction. Many studies have suggested that cerebral blood flow declines during hemodialysis (HD), and HD procedures themselves may have deleterious effects on the brain. Here, we report 3 cases of intradialytic hypotension, in which frontal lobe regional oxygen saturation (FL‒rSO₂), which is used as a proxy for cerebral blood flow, was measured. Case 1 involved a 76‒year‒old male with diabetic nephropathy, who underwent online hemodiafiltration. Two hours after the start of dialysis, two rapid reductions in blood pressure and a reduction in FL‒rSO₂ were observed. Case 2 involved a 65‒year‒old female with chronic glomerulonephritis, who underwent intermittent infusion hemodiafiltration (slow‒IHDF) with 50 mL of fluid replacement every 15 minutes. Her blood pressure and blood volume (BV) remained low from the start of the dialysis, while her FL‒rSO₂ remained stable between 40％ and 50％. Although her BV decreased slightly, her blood pressure decreased from 3 hours after the start of the dialysis, and her FL‒rSO₂ changed in response to the substitution of the IHDF fluid. The mechanism responsible for regulating cerebral blood flow during dialysis is complex. Therefore, it is difficult to use blood pressure or BV as indicators of cerebral blood flow. Monitoring FL‒rSO₂ during dialysis may be useful for cerebral circulation management.

A 79‒year‒old female, who had been on hemodialysis for 19 years and taking 5 mg/day prednisolone for rheumatoid arthritis for two years, presented with a complaint of lower abdominal pain. She had a fever and pyuria, and residual urine was revealed by plain abdominal computed tomography (CT). She was initially diagnosed with a urinary tract infection and received meropenem. Escherichia coli was detected in a urinary culture performed on admission, and Bacteroides thetaiotaomicron was detected in a blood culture. A second CT scan performed with contrast medium on the third hospital day revealed a peri‒vesical abscess. Percutaneous drainage was placed around the bladder on the fourth hospital day, and a urethral catheter was inserted. Clindamycin was added after Peptostreptococcus sp. were detected in the abscess culture. The patient’s symptoms improved； however, the abscess remained, and drainage was continued. She was transferred to another hospital to continue undergoing drainage. In this case, long‒term steroid use and chronic cystitis may have made the patient susceptible to bladder perforation. In addition, although the bacteria detected in the blood and urinary cultures differed, no anaerobic urinary culture was performed； therefore, it is important to perform appropriate cultures after considering the pathophysiology of each case.