Pain during intravenous cannulation is a common problem associated with the hemodialysis procedure. In 11 hemodialysis patients, we compared the pain of arteriovenous fistula cannulation with a cooling the local skin temperature to 20°C (CD), that with dermal lidocaine patch (LP) and that without either a patch or cooling down the local skin (C). In every patient, three hemodialysis sessions were performed with CD, LP and C respectively. Degree of pain was expressed by pain scale (0 : lack of pain, 10 : unbearable pain). In each patient the scores of three cannulations utilizing each method were added and compared. Local skin temperatures at the cannulation site were 21.0±2.3℃ in CD, 34.7±0.7℃ in LP and 34.9±1.4℃ in C, respectively. Sum of pain scores was 9.8±4.7 in CD, 9.3±6.8 in LP and 15.3±6.4 in C (CD vs. LP : p=n. s., CD vs. C : p=0.0012, LP vs. C : p=0.0002). In contrast to an occasional rash associated with the use of dermal LP, CD was performed without any complication. CD is an effective option to reduce the pain associated with intravenous cannulation in hemodialysis procedure.

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Several studies have shown the usefulness of measuring glycated albumin (GA) to assess glycemic control in diabetic patients with end-stage renal disease (ESRD). To identify the characteristics of GA as a glycemic marker, we compared GA with hemoglobinA_1c (HbA_1c) to investigate its association with the daily blood glucose profile in these patients. Fifteen diabetic patients on chronic hemodialysis (51～82 years, HbA_1c 4.5～6.8%, GA 18.6~28%) performed self-monitoring of blood glucose (SMBG) for two consecutive days. Stepwise multivariate regression analysis found that GA was independently associated with the standard deviation of SMBG values and body mass index, and that HbA_1c was independently associated with the maximum SMBG values. In addition, a dataset of 31 SMBG values obtained from six patients also showed that GA was independently associated with the maximum values for SMBG and HbA_1c was independently associated with fasting morning blood glucose. In conclusion, GA reflects fluctuation and postprandial elevation of blood glucose, and HbA_1c reflects fasting and postprandial elevation of blood glucose in diabetic ESRD patients.

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Vascular calcification which induces advanced atherosclerosis is a serious problem in hemodialysis patients. Fetuin-A (alpha 2-Heremans-Schmid glycoprotein) is synthesized by liver cells and has anti-calcification effects. Especially, in hemodialysis patients, fetuin-A is associated with malnutrition, inflammation, and atherosclerosis. In this study, to clarify the association between the extent of atherosclerosis and fetuin-A concentrations, we investigated carotid ultrasonography longitudinally. The study included 78 hemodialysis patients aged 59.5 years, with a duration of hemodialysis of 90.9 months. In 2005 and 2008, we measured intima media thickness including plaques of the bilateral common carotid arteries using B-mode ultrasonography to evaluate atherosclerosis quantitatively, and observed the status of calcification. We defined the sum of both intima media thicknesses as IMT. Serum fetuin-A concentrations were determined by ELISA in 2008. The IMT of the calcification(+) group showed a significantly greater increase than the calcification(-) group. However, fetuin-A concentrations were not significantly different between the two groups. Then, we divided all subjects into two groups according to the level of fetuin-A (=0.235±0.043 g/L). ΔIMT in the lower fetuin-A group (<0.24 g/L) was significantly greater than that in the higher fetuin-A (≥0.24 g/L) group (p=0.022). During a 3-year follow-up period, the calcification progressed in 18 patients. Fifteen of these patients were in the lower fetuin-A group and 3 were in the higher fetuin-A group. In the lower fetuin-A group, the progression of carotid arterial calcification occurred with high frequency (p=0.001). Although there was no correlation between fetuin-A and IMT in data collected during 2005 or 2008. However, there was an inverse correlation between fetuin-A and ΔIMT (r=-0.276, p=0.014). Therefore, we considered that the current serum level of fetuin-A reflectes the earlier progression of atherosclerosis. These findings demonstrate that a lower level of fetuin-A concentrations is related to calcification and thickening of the intima media of the carotid artery in hemodialysis patients.

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This study investigated differences in blood test results between surviving and non-surviving patients, the relationship between albumin (Alb) and other blood parameters, and improvements in the prognosis of hemodialysis (HD) patients, focusing on Alb as a nutritional parameter in HD patients. First, we calculated the average Alb value in 160 HD patients in 2005. Then we established a positive cohort using the preliminary result as mean (m-) Alb, and followed this cohort for 2 and a half years. During the follow-up period, we divided these patients to deceased and surviving patients, and analyzed the differences in m-blood urea nitrogen (BUN), m-phosphorus (P), m-normalized protein catabolic rate (nPCR), average age, and other factors. We also analyzed the relationship between m-Alb and other m-blood parameters. M-Alb of deceased patients was significantly lower than that of surviving patients (3.5 g/dL vs. 3.8 g/dL, p<0.0001). M-BUN (57.5 mg/dL vs. 67.8 mg/dL, p=0.0002), m-P (4.4 mg/dL vs. 4.9 mg/dL, p=0.0123), m-potassium (K) (4.4 mEq/L vs. 4.8 mEq/L, p=0.0018), and m-nPCR (0.9 g/kg/day vs. 1.1 g/kg/day, p=0.0011) of deceased patients were also significantly lower than those of surviving patients. The average age of deceased patients was significantly higher than that of surviving patients (71.5 years vs. 60.8 years, p=0.0008), and the HD history of deceased patients was longer than that of surviving patients, and the percentage of diabetic patients among deceased patients was greater than that among surviving patients, but the difference was not significant, and there was not a significant difference in the gender distribution between deceased and surviving patients. There were not significant differences in m-total protein (TP) or m-Kt/V between deceased and surviving patients. M-total cholesterol (TC) of deceased patients was lower than that of surviving patients, and m-C-reactive protein (CRP) of deceased patients was higher than that of surviving patients, but these differences were not significant. Moreover, there were positive significant correlation between m-Alb and m-BUN, m-P, m-K, m-TP, m-TC, and m-nPCR. And there was an inverse correlation between m-Alb and average age, and m-CRP. However, there was no correlation between m-Alb and HD history, and m-Kt/V. M-Alb of HD patients is a useful prognostic factor to predict survival. M-Alb m-BUN, m-P, and m-nPCR of deceased patients were all lower than those of surviving patients, suggesting that it is necessary to ensure sufficient intake of energy and protein to improve survival prognosis. Especially for elderly patients, it is necessary to ensure adequate intake and manage the rise in BUN and P prior to hemodialysis. When caring for elderly HD patients, it is necessary to change the concept of dietary restriction to the practice to appropriate intake of foods.

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Oseltamivir is an influenza virus neuraminidase inhibitor that is considered to be effective for treatment or prevention of influenza virus A and B infection. However, there have been few studies about the use of oseltamivir to treat or prevent influenza virus infection in ESRD patients on maintenance dialysis and dosing recommendations are not available for either the treatment or prevention of influenza infection in ESRD patients. We experienced an influenza outbreak at our hemodialysis center during the 2006/2007 season. Patients with ESRD are susceptible to influenza and have an increased risk of complications. Therefore, effective treatment and prevention of influenza virus infection is considered essential. Among 385 hemodialysis patients at our dialysis center, patients who consented were administered an oral dose of oseltamivir (75 mg) one time after a dialysis session. We enrolled 339 hemodialysis patients, but 31 patients did not take the drug. Oseltamivir was given to nine patients for treatment and to 299 patients for prevention. All nine patients treated for influenza improved rapidly and none of them showed deterioration. None of the patient developed influenza after administration for prevention. Among those who did not receive preventive administration, however, two patients were infected by influenza A virus. These two patients improved soon after oseltamivir administration. In this study, the incidence of adverse gastrointestinal events were less frequent than that reported for patients without renal dysfunction in a previous study, but insomnia was more frequent. Laboratory parameters did not show any significant differences between oseltamivir treated patients and untreated patients. Our data suggest that a single oral dose of oseltamivir (75 mg) is effective and well tolerated for the treatment and prevention of influenza in hemodialysis patients.

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[Purpose] This study examined the optimal approach providing to support to maintenance hemodialysis patients with terminal mandibular cancer and to their families, using the Watanabe Family Assessment Model. [Methods] Based on the Watanabe Family Assessment Model, we clearly defined “Specific problems”, “Implemented policies during the care course”, “Implemented policies for the care target”, and “Needs of families and the role of caregivers”, and developed and implemented policies to support patients and their families. [Results] As a result of assessment, nursing care for patients could be continued at home until the day before their death. [Conclusion] The assessment model helped identify problems in providing care for terminal cancer patients and their families, as well as future directions for patient support. In implementing nursing care for terminal patients, considerations should also be given to individual family situations to help encourage coping behavior and promote mutual interaction within families.

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Since September 2006, our institution has performed 64-slice multidetector computed tomographic coronary angiography (MDCTA), which allows coronary assessments. At this institution, approximately 200 dialysis patients are followed as outpatients or inpatients. Of these patients, those at high risk for ischemic heart disease are actively followed by to computed tomographic coronary angiography. A woman of highly advanced age (in her 90s) come to our institution on foot in order to undergo same-day coronary angiography via the right radial artery. Although she had experienced almost no chest symptoms indicating unstable angina, coronary MDCT suggested mild stenosis of the right coronary artery. The same-day coronary angiography demonstrated 99% stenosis in segment 1 of the proximal coronary artery. The lesion was much more severe than expected on prior angiograms. Following the same-day angiography, percutaneous coronary angioplasty was successfully performed via the right radial artery. Percutaneous coronary intervention (PCI) via the radial artery is called transradial intervention (TRI) by PCI specialists. Although TRI requires more advanced techniques than PCI via the femoral artery, it is less invasive (causing less bleeding) and safer than femoral PCI. The patient was at substantially higher risk for PCI because of her very advanced age and history of dialysis. Her chest pain was mild and stable and did not suggest the presence of such a severe stenosis, which could not be expected based on prior computed tomographic coronary angiography. Under these circumstances including risk factors, the highly stenotic lesion in the right proximal coronary artery was successfully treated by TRI, which is considered tolerable by patients of highly advanced age. We herein report this case of successful TRI with a discussion of the literature.

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