One-eighth of adults are Chronic Kidney Disease (CKD) in Japan. Intensive multifactorical interventions are required to prevent the onset of End Stage Kidney Disease (ESKD) and Cardio Vascular Disease (CVD). In this report, we will describe hypertension, diabetes and hyperuricemia that are the maximal cause of CKD, as well as our findings. The hypertension treatment target value of the CKD patient is still controversial. However, the prepotency of the Renin-Angiotensin-Aldosterone System (RAS) inhibitor is denied for the patient without proteinuria. The characteristic of hypertension to be found in the CKD patient is Na-sensitive hypertension and disorder of the circadian rhythm, whereas the improvement of the medication adherence is important, too. We showed that adherence improvement of long-action type Angiotensin II Receptor Blocker (ARB) olmesartan had good influences on renal function. Also, the decrease in albuminuria was found, too. However, we were not able to prove the renal protective effect for patients with CKD Stage 4 or more about the direct renin inhibitor aliskiren. 40% of patients with type II diabetes mellitus are CKD, and incretin related drug and Sodium Glucose Transporter-2 (SGLT-2) inhibitor were released, and the option of treatment expanded. Recently, it has been known that various mediators and nervous systems were involved between gastrointestinal tract and kidney. This is called Gut-Renal Axis. As for the incretin related drug, it is suggested by gastrointestinal tract for body fluid homeostasis maintenance in that through Glucagon-like peptide-1 (GLP-1) which is a main mediator to work to kidney. It is hoped that the incretin related drug prevents progress of diabetic nephropathy. We examined the effect to inflict for renal function of alogliptin and showed the possibility that alogliptin improved progression of diabetic nephropathy. Hyperuricemia was associated with a cause and progress of CKD seriously, but available therapies were limited to the patient whom renal function decreased. We performed the change to febuxostat in the CKD patient whom the uric acid level did not decrease in allopurinol enough. As a result, the uric acid level achieved the goal, and the renal function was significantly improved, too. The kidney links with various kinds of organs to maintain quantitative and qualitative homeostasis of the body fluid and finally manages the regulation. With the decrease of renal function, metabolic derangements such as water, electrolyte, sugar, uric acid, lipids, acid base, bone mineral, iron and erythropoiesis develops. The noumenon of CKD is organ linkage, and the viewpoint for it is important.

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Behçet's disease (BD) is a chronic inflammatory disorder with recurrent oral aphthosis, skin lesions, uveitis, and genital ulcers as its main manifestations. More serious involvement of the central nervous system (CNS), gastrointestinal tract, and large vessels is observed in some patients. Because of the diverse clinical manifestations, diagnosis is made on the basis of symptoms. Therapeutic approach is determined according to the disease phenotype, and anti-TNFα mAb therapy is available for serious subtypes of BD in patients with ocular, CNS, gastrointestinal tract, and large vascular involvement. This therapy is ineffective in some patients, but it generally improves prognosis greatly and has proved effective in cases of organ involvement. Both genetic and environmental factors have been shown to contribute to the immunopathology of BD, and whether BD is an autoimmune disease or an autoinflammatory disorder is a subject of debate. In the 1990s, we and others showed that 60/65 kD heat shock protein (HSP) T cells play a pathological role in mediating cross-immune reactions between microbial pathogens and hosts, although no disease specific antibodies have been ever identified. On the other hand, its clinical features, responsiveness to colchicine, and increased levels of proinflammatory cytokines rather suggest that BD is an autoinflammatory disorder. A recent genome-wide association study (GWAS) and subsequent studies have shown that BD is associated with IL10, IL23R/IL12RB2, ERAP1, CCR1, STAT4, KLRC4, TLR4, NOD2, MEFV in addition to HLA-B^*51, suggesting that both innate and acquired immune systems are involved in the development of BD. IL10, CCR1 and KLRC4 suggest the involvement of macrophages and NK cells, while IL23R/IL12RB2 and STAT4 indicate that Th1/Th17 cells play pathological roles. TLR4 and NOD2 indirectly suggest that microbial organisms are environmental factors. Moreover, epistasis between HLA-B^*51 and risk allele of ERAP1 suggest the contribution of an antigen-specific CD8+T cell response to the disease. Elucidation of the immunopathology of BP would lead to new therapeutic targets.

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Carbon ion radiotherapy is more effective than ordinary radiotherapy for locally advanced cancer control. However, its use against tumors adjacent to the gastrointestinal tract or urinary tract is restricted, because the intestines have low tolerance to radiation. This article describes a new technical procedure of laparoscopic spacer insertion (LSI) that prevents radiation-induced intestinal damage during treatment of sacral chordomas. On the basis of computed tomography and magnetic resonance imaging, a patient with sacral pain was diagnosed with an unresectable chordoma (5×3.5 cm in size) located at S3 and S4. We selected carbon ion radiotherapy, but because the tumor was adjacent to the rectum, we first performed LSI. We mobilized the colon and the rectum from the distal sigmoid colon to the lower rectum at the levator ani muscle via two 12-mm and three 5-mm ports. Then we covered the tumor completely with a spacer, a GORE-TEX^® Soft tissue patch (2 mm thick, 20×12 cm in size), and sutured it in place with 4-0 Vicryl^®. The postoperative course was uneventful, and the patient was discharged on the 6th postoperative day. Simple, relatively noninvasive, and effective in reducing intestinal damage, this LSI procedure opens up new possibilities for the application of carbon ion radiotherapy.

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