Shared decision-making for kidney replacement therapy (KRT) selection is a two-way process that should constitute an equal partnership between the healthcare team and patient. However, some patients are at a disadvantage due to a difference in power relations because the discussion is led by the healthcare team. In the United States and United Kingdom, Deciding Not to Decide (DND) has been added to the KRT options. DND provides a period before the selection decision is made after explaining to the patient the physical risks of delaying the decision. Then, patients feel less anxious and are more likely to make a decision. The option of DND, based on open communication between the healthcare team and patient/their family, provides the patient with flexibility in treatment planning, and this option should be welcomed by all concerned. When providing information on KRT, the option of DND (postponing the selection decision) should be provided at an appropriate time prior to kidney transplantation, peritoneal dialysis, or hemodialysis, thereby increasing patientsʼ autonomy and making it easier for them to come to their own decisions.

We switched from etelcalcetide to upacicalcet without a washout period, and investigated the effects on clinical laboratory values and concomitant medications. Twenty-three chronic hemodialysis patients who switched from etelcalcetide to upacicalcet were included in this study and followed for fifty-two weeks. A decreasing trend of whole PTH was observed in the second week after switching, followed by an increasing trend until the eighth week, and then a decreasing trend from the tenth to fifty-first weeks. After the switch, corrected calcium transiently decreased in the first week, but soon returned to the original levels. Thereafter, corrected calcium remained largely unchanged. There were no cases of severe hypocalcemia or other events necessitating the discontinuation of treatment during the observation period. Also, there was no significant variation in concomitant vitamin D or phosphate binder medication. The results suggest that upacicalcet is a useful calcimimetic that is unlikely to cause excessive calcium-lowering.

[Background] Microbial contamination of most of the dialysis monitoring devices newly installed in 2015-2016 was noted, and the same residual strain was isolated year after year even following clinical use that met the water quality standards for standard dialysate. There was also information that the cleaning and disinfection method was voluntarily changed at the time of manufacturing. [Purpose and Method] We evaluated the level of contamination at the time of installation (end of 2022) of 25 new devices when relocating to a new facility. The total number of bacteria before passing through the endotoxin (ET) retentive filter and ET activity were measured, and the bacteria were cultured for 10 days and identified by mass spectrometry. Devices with high levels of contamination were retested for clinical use 25 days after the initial cleaning and disinfection. [Results] Six units had a total bacterial count of 1,000 cells/mL or higher, and three units had ET of 50 mEU/mL or higher (high level of contamination). There were 7 genera and 14 species of bacteria, the α-β-proteobacterial network was 76%, and 25 days after initial cleaning and disinfection, even those showing high-level contamination were improved by 1 to 2 digits. [Conclusion] Although the level of contamination of the new dialysis equipment had improved in comparison with 2015-2016, it was still not sterile, and initial cleaning was considered important.

The diagnosis and treatment of dialysis-associated allergic reactions are important for patients on hemodialysis. Here, we report two cases in which the drug-induced lymphocyte stimulation test (DLST) was positive for dialysate. We treated the patients without changing the dialysate, and the symptoms improved. Case 1 involved a 68-year-old man complaining of itching. DLST for Carbostar^Ⓡ P solution A was positive. After changing the priming with saline, the symptoms improved. Case 2 involved an 85-year-old man complaining of itching and hives. DLST for Carbostar^Ⓡ P solution B and Lympack TA3^Ⓡ was positive. The symptoms disappeared after changing the priming with saline and a smaller dialysis membrane. We investigated the characteristics of five other cases with positive DLST for dialysate. Three had fever. The fever in Case 3 did not improve because of the presence of a tumor. Case 4 showed a false-positive result for DLST. In Case 5, the fever improved on changing the dialysate. Four cases showed CRP elevation, and only one had an increased eosinophil count. We should test dialysate with DLST if allergy is suspected.

A 71-year-old male presented in 2012 with symptoms of alveolar hemorrhage, abnormal urine analysis, and renal dysfunction (serum creatinine level：4 mg/dL). The patient was positive for MPO-ANCA. Renal biopsy revealed crescentic glomerulonephritis, and he was diagnosed with ANCA-associated vasculitis. Treatment with prednisolone and various immunosuppressive drugs resolved the alveolar hemorrhage and improved the creatinine level to around 2 mg/dL. In March 2017, the patient was treated for alveolar hemorrhage with methylprednisolone pulse therapy. His renal function gradually worsened, and in October 2017, hemodialysis was initiated. At the time of initiation, alveolar hemorrhage was present, and the patient received methylprednisolone pulse therapy. Within a few days, the bloody sputum disappeared, and there were no respiratory symptoms. He had been taking trimethoprim-sulfamethoxazole to prevent pneumocystis pneumonia for a prolonged period and continued to take the drug after admission (80 mg of trimethoprim twice a week). However, on the 19^th day, a nodule shadow appeared in the right middle lung field on plain chest X-ray and it was enlarging. No respiratory symptoms were present, but Nocardia was identified via sputum culture, ultimately leading to a diagnosis of pulmonary nocardiosis. The background of steroid therapy and induction of dialysis were considered to be the trigger for pulmonary nocardiosis in this case. Treatment with trimethoprim-sulfamethoxazole was initiated, and the nodule shadow reduced. In the early stages of dialysis initiation, there is a well-known higher incidence of tuberculosis due to cellular immunosuppression. In dialysis-initiated patients undergoing immunosuppressive therapy, Nocardia infection should also be considered.

In order to safely place a peritoneal dialysis (PD) catheter in the pelvic cavity, we performed PD catheter insertion using a flexible cystoscope. Here, we report the method, complications, and short-term results. This method involves a flexible cystoscope being inserted through the conventional peritoneal incision for a PD catheter without the need for any additional incision. Between December 2015 and December 2017, it was performed in 6 cases at the operatorʼs discretion. All procedures were completed without any notable adverse events. Compared with 10 conventional procedures performed in the same period, there was no significant difference in patient background, perioperative time, amount of bleeding, or complications. However, the PD continuation rate was significantly prolonged in the flexible cystoscope group (p＝0.019). Based on this case study, PD catheter insertion using a flexible cystoscope does not require an insufflation device, and the catheter can be placed relatively safely and reliably.