Case 1：A 58-year-old woman who has been undergoing hemodialysis for eight years was admitted to our hospital for fever and right shoulder pain. Computed tomography (CT) showed right sternoclavicular joint arthritis, and clavicular abscess and blood culture tests revealed methicillin-sensitive Staphylococcus aureus. Despite the initiation of antibiotics, the shoulder pain worsened. On day 37, right clavicular osteomyelitis was identified by magnetic resonance imaging. On day 66, the patient was transferred to another hospital for surgical treatment. Case 2：An 83-year-old man who has been undergoing hemodialysis for six years. The infection of an arteriovenous fistula (AVF) with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia was initially treated by antibiotics, and then AVF removal surgery was performed three months previously. The symptoms improved and blood cultures became negative. After two weeks, a blood laboratory test showed elevated C-reactive protein and a blood culture test was again positive for MRSA. Contrast-enhanced CT showed a mediastinal abscess. Regardless of the administration of mediastinal drainage and antibiotics, the patient died on day 17. Concerning Staphylococcus aureus bacteremia in patients undergoing hemodialysis, we should maintain vigilance for atypical disseminated infections.

We herein report a 60-year-old man receiving maintenance dialysis for 9 years due to diabetic nephropathy. He was diagnosed with hemodialysis vascular access-related infection with endogenous bacterial endophthalmitis. Intravenous vancomycin was started on day 1, seven days before he was admitted to our hospital. Vitrectomy and intraocular lens surgery were performed nine days after onset. He was also diagnosed with septic pulmonary embolism and bruise infection of the lower leg. Blood culture was negative, but methicillin-sensitive Staphylococcus aureus was detected in the aqueous humor, exudate from the vascular access, and exudate from the leg. We de-escalated from intravenous vancomycin to intravenous cefazolin. The vascular access-related infection, septic pulmonary embolism, and bruise infection of the lower leg were treated successfully. Enucleation was avoided, but he subsequently showed no light perception. We should keep in mind the possibility of endogenous bacterial endophthalmitis complicated with vascular access-related infection. Endogenous bacterial endophthalmitis should be diagnosed and treated as soon as possible for a better outcome and the avoidance of enucleation.

Sarcoidosis is a granulomatous disease that affects multiple organs throughout the body, and is known to occur in patients with chronic hepatitis C virus (HCV) infection in two different situations：caused by HCV itself, or related to antiviral therapy. We report a case of sarcoidosis involving a patient with chronic hepatitis C treated with Direct Acting Antivirals (DAA). The patient, a male in his 40s, was transfused at the age of 20 during surgery for a road traffic injury, and started maintenance hemodialysis for chronic kidney disease due to IgA nephropathy in X-5 years. Subsequently, the patient started DAA treatment for chronic HCV infection in June X-1 years, and developed blurred vision during dialysis in February X. In the same month, the patient was treated by the Department of Ophthalmology. Ophthalmic examinations revealed bilateral granulomatous uveitis. Blood tests showed high sIL-2R levels, and biopsy of a hilar lymph node revealed non-desmoplastic epithelial granuloma, leading to a diagnosis of sarcoidosis. The patient did not show overt hypercalcemia, but had endogenously elevated 1α,25-dihydroxyvitamin D₃ and decreased PTH-intact before the onset of blurred vision. In cases of renal failure, sarcoidosis should be considered as a differential diagnosis when PTH-intact is suppressed, regardless of the presence or absence of hypercalcemia.

A 48-year-old man was started on hemodialysis with an arteriovenous fistula (AVF) in the left forearm seven years ago. An AVF aneurysm appeared three years previously, and because its long diameter increased to 55 mm, he was referred to our hospital. Aneurysmectomy and aneurysmoplasty require a large incision, and graft replacement is likely to cause anastomotic stenosis. For these reasons, we chose graft insertion into the aneurysm by applying the ʻgraft inclusion techniqueʼ. About 2-cm skin incisions were made up- and downstream of the aneurysm and the in- and outflow vessels were secured. We confirmed that the aneurysm collapsed by clamping these vessels. A semi-circumferential incision was made on the anterior wall of the inflow vessel. After coating with sterilized jelly, a tunneler with an external cylinder was inserted into the inflow vessel and was passed through the aneurysm under ultrasound guidance and reached the outflow vessel. A semicircumferential incision was made in the anterior wall of the outflow vessel, and the tunneler was guided out of the vessel through the incision. After leaving the outer cylinder of the tunneler, a 5-mm ePTFE graft was inserted therein. By subsequently removing the outer cylinder, the graft was left in the vessel across the aneurysm. Both ends of the graft were trimmed and sutured to fix the stumps to the vessel wall to close the incisions. After releasing the clamps, it was confirmed that the aneurysm was not re-bulging and the thrill was good, and the operation was completed. There was no anastomotic stenosis or recurrence of the aneurysm for 2.5 years after the operation. This is a simple procedure that involves only two small incisions and does not require aneurysm resection or end-to-end anastomosis. Therefore, it can be an option in radical surgery for an AVF aneurysm.

The case involved a 75-year-old man on maintenance hemodialysis who frequently underwent repeated shunt stenosis. He was suspected of having low-flow low-gradient aortic stenosis based on echocardiography performed before surgery for an arteriovenous fistula newly replaced in the contralateral upper limb, but, since he was asymptomatic, detailed examinations for low-flow low-gradient aortic stenosis were scheduled after the surgery. On the third day after the surgery, he was urgently admitted to our hospital because of the development of acute heart failure. Even after admission, he remained refractory to heart failure treatment. Thus, it was difficult to perform dobutamine stress echocardiography examination to evaluate the severity of the disease, but he was finally diagnosed with severe aortic stenosis with a high aortic valve calcification score. He subsequently underwent surgical aortic valve replacement therapy, which improved his symptoms of heart failure. Low-flow low-gradient aortic stenosis is a condition in which the aortic valve flow rate and mean pressure gradient do not increase, and the severity of the condition is often underestimated. Since patients on hemodialysis show a high incidence of aortic stenosis, it is important to assess the severity of low-flow low-gradient aortic stenosis and treat it appropriately.