[Purpose] We investigated the significance of measuring the osmotic pressure of dialysate. [Methods] The Na and Cl levels of powder‒type dialysate (Kindaly 4E： K.4E) for multi‒person dialysis and liquid‒type dialysate (Kindaly AF‒4： KAF4) for personal dialysis were measured by a biochemical automatic analyzer (BAA), and then they were compared with the osmotic pressure. A 10% saline solution and 7% sodium bicarbonate solution were each diluted step‒wisely with purified water, and Na and osmotic pressure of the diluted solutions were compared. [Results] Compared with KAF4, K.4E had significantly higher osmolality, Na, and Cl, but significantly lower Na‒Cl‒0.25, which represents HCO₃. Compared with the sodium bicarbonate solution, the saline solution had a higher osmotic pressure ratio due to the Na concentration. [Discussion] Osmotic pressure depends on the ion concentration in solution. Since NaCl has a higher degree of ionic dissociation than NaHCO₃, it is considered that the ratio of solutions A to B in the dialysate can be estimated by measuring the osmolality. [Conclusions] Measuring osmotic pressure is useful to understand the dialysate composition, and it is superior to electrolyte measurement because the value does not vary depending on the measuring device.

A man in his 70s, living alone on welfare, had been undergoing hemodialysis for seven years due to end‒stage kidney disease caused by nephrosclerosis. He had been diagnosed with uremic pruritus. One day, bed bugs were suspected, and inspection confirmed their presence on the dialysis bed he used. Therefore, the bed was isolated and measures to prevent contact infection were implemented. Ten days later, a dermatologist diagnosed the patient with bed bug bites, and he underwent dialysis in temporal isolation. On another day, bed bugs were found in the patient’s locker, so dialysis was switched to a private room to prevent further spread, an infection‒prevention manual was created, and strict infection control measures were implemented for medical staff in the dialysis room. The community support center and exterminator reported that it was difficult to exterminate bed bugs at the patient’s home, and that it would be more practical for him to move to a facility. For this reason, the patient was admitted to our hospital in isolation and as much of his personal belongings as possible were disposed of before admission. After confirming that the patient was bed bug‒free, he was admitted to the facility. Although it was difficult to deal with the highly reproductive nature of bed bugs, we were able to prevent the spread of infection by isolating the patient in a private room, creating the infection‒prevention manual, and co‒operating with the government.

An 86‒year‒old male patient was hospitalized with generalized edema that had persisted for one week. The patient presented with nephrotic syndrome, characterized by low albumin (1.4 g/dL) and high urine protein (5.81 g/day) levels. Kidney biopsy confirmed the diagnosis of minimal change nephrotic syndrome (MCNS). Despite the initiation of prednisolone sodium succinate (70 mg), the patient’s renal function deteriorated. Due to pleural and pulmonary edema, hemodialysis was started on the seventh day of hospitalization. Heparin sodium was administered to treat the thrombosis in the left lower limb and right internal jugular veins. However, the patient developed duodenal ulcer bleeding, leading to discontinuation of dialysis and repeat endoscopic hemostasis procedures. In contrast, discontinuation of heparin sodium led to multiple cerebral infarctions and thromboses in the left upper arm and internal jugular vein. His serum creatinine level improved to 0.74 mg/dL, and heparin was replaced with apixaban, which prevented bleeding recurrence. On the 62nd day of hospitalization, the patient achieved complete remission. Although MCNS presents with a high risk of thrombosis, it is also associated with the risk of gastrointestinal hemorrhage due to high‒dose steroid use. For thrombosis related to nephrotic syndrome, apixaban may be effective to treat clots while minimizing the bleeding risk.

Dupilumab is a biologic that inhibits IL‒4/IL‒13 and is used to treat refractory prurigo nodularis. Here, we report the successful use of dupilumab in three dialysis patients. Case 1： A 58‒year‒old man who had been on dialysis for 8 years. He was diagnosed with atopic dermatitis in childhood. Dupilumab was administered because he had some itchy nodules on his trunk that were difficult to treat. His Worst Itch‒Numerical Rating Scale (WI‒NRS) score of 8 decreased to 1 after 12 weeks. Case 2： A 66‒year‒old female who had been on dialysis for 2 years. Dupilumab was administered because she had some itchy nodules on her back due to chronic kidney disease‒associated pruritus (CKD‒aP). Her WI‒NRS score of 6 decreased to 2 after 12 weeks. Case 3： A 57‒year‒old male who had been on dialysis for 5 years. Dupilumab was administered because he had some itchy nodules on his trunk and extremities due to CKD‒aP. His WI‒NRS score of 6 decreased to 1 after 12 weeks. No treatment‒related adverse events were observed in any of the cases. If prurigo nodularis is diagnosed in dialysis patients and they show resistance to existing treatments, administration of dupilumab may be a treatment option.

A man in his 40s underwent surgery for valvular disease. Postoperatively, he could not be weaned off cardiopulmonary bypass, and was admitted to the intensive care unit with a percutaneous cardiopulmonary support device. As his cardiac function did not improve, an extracorporeal left ventricular assist device (LVAD) was attached on the 8th day after valvular surgery. After LVAD attachment, his urine output decreased, and hemodialysis was initiated due to acute kidney injury (AKI). He experienced fluid retention of 14 kg above his preoperative weight, with the central venous pressure elevated to 20 mmHg. This led to a diagnosis of AKI due to right heart failure. Fluid management strategies successfully reduced the patient’s weight by 2 kg from his preoperative baseline, subsequently improving urine output and enabling the discontinuation of dialysis. Right heart failure after LVAD implantation is estimated to occur in approximately 20‒40％ of cases, often resulting in AKI due to a reduced effective glomerular filtration rate caused by renal vein congestion. The key to treatment is appropriate fluid volume management, with this case culminating in reversible AKI.

A 76‒year‒old woman with end‒stage renal failure on hemodialysis was admitted to our institution due to repeated vomiting. She had edema of the left face and neck, and intracranial venous stasis was suggested based on head MRI. Contrast‒enhanced CT showed severe stenosis of the left brachiocephalic vein, suggesting that intracranial hypertension was caused by central venous reflux of blood flow from the left graft shunt. The symptoms resolved within a few days after graft shunt ligation. Neurologic symptoms due to intracranial venous reflux of shunt blood flow are varied and because of the hemodynamics unique to hemodialysis patients, it can be difficult to diagnose, particularly when edema of the shunt limb is inconspicuous. Since symptoms resolve rapidly with appropriate treatment, unexplained neurologic symptoms in hemodialysis patients should be considered in the context of central venous reflux.