The edema index (ECW/TBW), which is the ratio of extracellular water (ECW) to total body water (TBW) measured by bioelectrical impedance analysis (BIA), has been reported as one indicator for determining dry weight (DW) in dialysis therapy. Standard ECW/TBW values range from 0.360 to 0.400, and those exceeding 0.400 are considered high. However, ECW/TBW is influenced not only by fluid volume but also factors such as age, nutritional status, and skeletal muscle mass index. Referring to reports by Ueno, Seino, and Sasaki using InBody, we considered sex, age, muscle mass, presence of diabetes mellitus (DM), and hypoalbuminemia (Alb) as factors affecting ECW/TBW. We calculated a standard ECW/TBW for each patient and used this value in the InBody calculation formula to estimate ideal DW and evaluate its utility. The calculated ideal DW showed a strong correlation with clinical DW (r＝0.997, p ＜0.001). While ECW/TBW showed a weak correlation with the difference between post‒dialysis body weight and clinical DW (Δclinical DW) (r＝－0.167, p ＝0.001), there was a good positive correlation with the difference between post‒dialysis body weight and ideal DW (Δideal DW) (r＝0.892, p ＜0.001). Therefore, ideal DW calculated using a patient‒specific standard ECW/TBW may better reflect the degree of fluid overload, and so is considered a useful indicator for DW determination.

Objective： This retrospective study aimed to evaluate the safety and clinical utility of reduced‒ or no‒heparin strategies during percutaneous transluminal angioplasty (PTA) for vascular access by comparing them with a conventional full‒dose heparin protocol. Methods： We analyzed cases of PTA performed between 2014 and 2023, comparing rates of major vascular rupture (defined as cases requiring surgical intervention, including surgical closure due to irreparable rupture) between the conventional heparin protocol period (2014‒2018) and reduced‒ or no‒heparin strategy period (2019‒2023). We also assessed intraoperative thrombosis and 6‒month primary patency between the heparin and non‒heparin groups. Multivariable logistic regression was used to identify independent factors associated with heparin administration. Results： Compared with the heparin group, adoption of the reduced‒ or no‒heparin strategy was correlated with a significant decrease in the incidence of major vascular rupture (11 vs. 2 cases, respectively, p ＝0.010). There were no significant differences in short‒term occlusion rates or 6‒month primary patency between the heparin and non‒heparin groups, and no clinically problematic thrombosis occurred. Key factors associated with heparin use included： arteriovenous graft (AVG), chronic total occlusion (CTO), and vascular spasm. When heparin was administered, the median dose was low, at 500 units (IQR： 300‒800). Conclusion： Systemic heparin administration may not be mandatory for PTA. The reduced‒ or no‒heparin strategy significantly lowers the risk of major vascular rupture while maintaining short‒ and mid‒term patency. Key elements facilitating this safe approach include the： short procedural duration, real‒time ultrasound guidance, and rapid team‒based management of thrombosis.

To provide medical care that complements patients’ preferred lifestyles, flexible approaches are required even for those with end‒stage kidney disease (ESKD) complicated by multiple comorbidities. Here, we present the case of a bedridden hemodialysis (HD) patient who wanted to transition from hospital to home. The patient, who had neuromuscular disease requiring mechanical ventilation, successfully received 10‒month home care by switching to peritoneal dialysis (PD). Specifically, the patient was a 35‒year‒old man with ESKD due to IgA nephropathy, who had been diagnosed with myasthenia gravis six years ago. His condition gradually worsened, resulting in a ventilator‒dependent bedridden state and enteral tube feeding requirements. One year ago, he was transferred to a long‒term care hospital. Subsequently, suicidal ideations developed, and both he and his family expressed a strong desire for home care. PD was therefore introduced as an alternative renal replacement therapy. The patient’s family received comprehensive training in PD, as well as ventilator and enteral feeding procedures. Home visits by physicians, visiting nurses, and home helpers were arranged, and the patient was discharged home. Although the burden on the family was marked, no complications related to PD or ventilator use occurred. However, owing to the development of general fatigue, the patient resumed HD 10 months after discharge. In Japan, support systems for patients with PD who require care are insufficient. Thus, medical and social support for such patients requiring home care must be improved on an individual basis to reduce the burden.

In recent years, the use of parathyroidectomy (PTx) for secondary hyperparathyroidism (SHPT) has declined due to the availability of drugs such as calcimimetics. However, it remains useful for patients resistant to medical treatment or prior to kidney transplantation. Here, we report a case of rapid recurrence following PTx and autotransplantation. Case： A 37‒year‒old man began hemodialysis at age 30 for kidney failure. He was treated with calcimimetics for SHPT. Six years after initiating dialysis, he underwent PTx with a 150‒mg gland autotransplanted into his left forearm for refractory SHPT. Blood samples on postoperative day 1 showed a marked decrease in intact PTH to 4 pg/mL, indicating successful removal of all parathyroid glands. Thirteen months after the initial PTx, the patient was referred to our hospital for recurrence of SHPT due to the autotransplanted parathyroid gland. His PTH level was 1380 pg/mL, and a recurrent autologous glandectomy was performed 15 months after the initial PTx, removing 12.8 g of parathyroid tissue. This case illustrates rapid recurrence after PTx and highlights the characteristics of SHPT following treatment with calcimimetics, as well as considerations for surgical management.

Patient： A male in his 30s. Background： Six years ago, the patient was diagnosed with chronic kidney disease due to tubulointerstitial nephritis； however, he discontinued medical follow‒up under his own volition. In year X, he presented to our hospital with end‒stage kidney disease (serum creatinine： 28 mg/dL) and required emergency hemodialysis. Clinical Course： A left forearm arteriovenous fistula was created but immediately became obstructed. Therefore, an arteriovenous graft (AVG) was implanted in the left forearm. Due to persistent chronic diarrhea and hematochezia, a diagnosis of ulcerative colitis was made, and mesalazine was initiated. After discharge, left forearm edema developed, and percutaneous transluminal angioplasty (PTA) with stent‒graft interpolation was performed for outflow stenosis of AVG. However, AVG became thrombosed two weeks later. Screening tests for thrombotic factors revealed weak positivity for lupus anticoagulant. Despite the initiation of anticoagulation therapy, AVG rapidly developed recurrent thrombotic obstruction. As the next step, a new AVG was implanted in the left upper arm. Conclusion： End‒stage kidney disease patients with comorbid ulcerative colitis are at high risk of developing a hypercoagulable state due to factors such as dehydration and systemic inflammation. Regarding vascular access placement for patients with ulcerative colitis, clinicians should be aware of the risk of dehydration and thrombotic tendencies due to their thrombotic predisposition.