Cinacalcet, a representative calcimimetic compound, can reduce parathyroid hormone levels, but it causes a high incidence of gastrointestinal (GI) tract-related adverse events. Evocalcet is a new calcimimetic that is expected to reduce GI symptoms. Using the Izumo scale questionnaire, we analyzed the changes in GI symptoms seen after switching from cinacalcet to evocalcet. Nineteen hemodialysis patients with secondary hyperparathyroidism were included. We prospectively analyzed their GI symptoms at three points：before they switched to evocalcet and at three and six months after they switched to evocalcet. Switching to evocalcet decreased the number of patients suffering from GI symptoms from 14 to 9 after three months and to 12 after six months. In particular, the score for the feeling of fullness significantly decreased from 0.8±1.3 points (mean ±standard deviation) before the switch to 0.7±1.5 points after three months and 0.1±1.9 points after six months (p＜0.05, respectively), and that for diarrhea also significantly decreased from 1.1±2.3 points to 0.6±1.6 points after six months (p＜0.05). Conversely, five patients without GI symptoms prior to switching to evocalcet subsequently developed GI symptoms. Evocalcet effectively ameliorated the GI symptoms of the patients who switched from cinacalcet. However, switching from cinacalcet to evocalcet may cause new GI symptoms, and it is important to be aware of this.

The patient was a 57-year-old male, who had been undergoing hemodialysis for 10 years. When he was admitted to our hospital to undergo parathyroidectomy, he had a slight fever (37℃), and his serum C-reactive protein level had been elevated for several months. The findings of chest X-rays and chest and abdominal computed tomography were not remarkable, and no vegetation was detected on the cardiac valves by transthoracic echocardiography (TTE). Several sets of blood cultures were negative. He underwent TTE again during his hospitalization, and it showed vegetation on the aortic valve. We suspected infective endocarditis and started antibiotic therapy. However, because the vegetation had increased in size and become unstable, aortic valve replacement was performed. A pathological examination showed valve destruction and that inflammatory cells had infiltrated into the valve tissue. Furthermore, long-term cultures of aortic valve tissue were found to be positive for Propionibacterium acnes (P. acnes). P. acnes is part of the normal flora of the skin and oral cavity, but rarely causes infective endocarditis. In addition, it is difficult to detect P. acnes using standard blood cultures alone. Clinicians should be aware that that infective endocarditis in hemodialysis patients may be caused by unusual bacteria that are hard to isolate from standard blood cultures.

The patient was a 69-year-old male. He had been on hemodialysis since 2011 due to nephrosclerosis. He underwent open left nephrectomy for left renal cell carcinoma in June 2020. In July 2021, computed tomography showed multiple lung metastases. His IMDC risk classification was intermediate, and immune checkpoint inhibitor therapy (nivolumab-ipilimumab combination therapy) was started in August 2021. His blood pressure decreased rapidly from day 30, and his adrenocorticotropic hormone (ACTH) and cortisol levels tended to decrease；therefore, 20 mg/day hydrocortisone was started from day 35. An ACTH stress test was performed, which showed a normal cortisol response；i.e., he retained adrenal function. A corticotropin-releasing hormone stress test showed a low response for ACTH and no response for cortisol. A thyrotropin-releasing hormone stress test showed no response for thyroid-stimulating hormone and a low response for prolactin. These results were suggestive of panhypopituitarism. After 3 courses of treatment, he achieved a partial response (PR), and after 5 courses, the PR was maintained, and the major lesions had disappeared.

A 79-year-old male with end-stage renal disease due to IgA nephropathy was admitted to hospital so that peritoneal dialysis (PD) could be initiated. He had undergone PD catheter insertion four months earlier. An exit site was created, and he started undergoing PD using glucose-based PD solutions. Ten days after the initiation of PD, he developed a cough and fever. He was diagnosed with pneumonia, but antibiotics were ineffective. Bronchoscopy revealed marked eosinophilia (67％) in his bronchoalveolar lavage fluid, and a diagnosis of eosinophilic pneumonia (EP) was confirmed. It was considered unlikely that the EP had been caused by drugs or environmental factors. Instead, we suspected that the dialysate or PD catheter had triggered the onset of EP. Non-invasive positive pressure ventilation and transient hemodialysis (HD) were needed. However, after high-dose steroid therapy, his symptoms immediately improved, although he still needed home oxygen therapy. After his condition improved, he hoped to resume PD until he was discharged. He resumed PD without any recurrence of the EP until discharge. He was subsequently readmitted for vertebral compression fractures. His pneumonia relapsed during steroid tapering. He died of respiratory failure despite intensive treatment. Only four cases of PD-associated EP have been reported. In all of these cases, the patients were successfully treated with steroids or the removal of the suspected cause, and PD was resumed without the EP going into remission. However, when such patients are in incomplete remission, we should consider transitioning from PD to HD because relapsed pneumonia can be fatal.

An 85-year-old male patient with type 2 diabetes mellitus had been undergoing hemodialysis for end-stage renal disease for 2.7 years. He was complicated with hypertension and bronchial asthma. He presented with a fever without a cough or dyspnea. A SARS-CoV-2 antigen rapid test was performed because COVID-19 was prevalent. The antigen test was positive, and he was admitted to our hospital. Laboratory tests showed a white blood cell count of 4,830/μL, a neutrophil count of 2,801/μL, a platelet count of 8.4x10⁴/μL, and a C-reactive protein level of 1.04 mg/dL. Chest computed tomography (CT) showed ground glass opacities (GGOs) in the bilateral lungs. On day 2, he presented with worsening dyspnea and required oxygen. CT showed worsening of the GGOs. The patient was transferred to the designated medical institution for infectious diseases and treated with remdesivir, dexamethasone, and favipiravir. His symptoms and the GGOs improved rapidly. He returned to our hospital on day 14. CT performed on day 14 showed a new nodular shadow with a small cavity in the left upper lobe. On day 27, the nodular shadow and cavity had enlarged, and the cavity contained an area of hyperdense soft-tissue attenuation. On day 28, serum galactomannan（ GM) antigen and β-D-glucan tests were positive. Treatment with voriconazole for pulmonary aspergillosis was initiated from day 36. His serum GM antigen level decreased, and CT showed improvement of the pulmonary lesion. When hemodialysis patients with COVID-19 show new nodular shadows with cavities in the lung, it is necessary to consider pulmonary aspergillosis.