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Background: The factors contributing to the development of severe coronavirus disease 2019 (COVID-19) following infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remain unclear. Although the presence of immune complexes (ICs), formed between antibodies and their antigens, has been linked to COVID-19 severity, their role requires further investigation, and the antigens within these ICs are yet to be characterized., Method: Here, a C1q enzyme-liked immunosorbent assay and immune complexome analysis were used to determine IC concentrations and characterize IC antigens, respectively, in the sera of 64 unvaccinated COVID-19 patients with PCR-confirmed SARS-CoV-2 infection, enrolled at seven participating centers in 2020. For the analysis, the patients were split into the severe (n = 35) and non-severe (n = 28) groups on the basis of their COVID-19 symptoms., Results: We found that neither serum IC concentration nor IC antigen number was associated with COVID-19 severity. However, we identified six IC antigens, which were significantly enriched in the severe versus non-severe group. These IC antigens were all derived from human proteins, namely haptoglobin, the serum amyloid A-2 protein, the serum amyloid A-1 protein, clusterin, and lipopolysaccharide-binding protein, and complement-factor-H-related protein 3. Meanwhile, we found no association between COVID-19 severity and IC antigens derived from SARS-CoV-2 proteins. Collectively, the six IC antigens predicted COVID-19 severity with a moderate degree of accuracy (area under the receiver operating characteristic curve = 0.90, sensitivity = 94 %, specificity = 79 %)., Conclusions: The IC antigen signature identified in this study may have important implications for the diagnosis and treatment of severe COVID-19., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.)

Iatrogenic arteriovenous fistula (AVF) is a complication accompanying venous and arterial puncture. Herein we report a case of ligation closure of an iatrogenic AVF in the brachial artery after percutaneous coronary intervention (PCI) for the patient with end-stage kidney disease (ESKD). A 68-year-old woman presented with a history of several coronary angiographies (CAG) and PCI through the right brachial artery. After PCI, the patient experienced a thrill in the right elbow. Two years later, the patient initiated hemodialysis (HD) using a temporary HD catheter for ESKD and congestive cardiac failure. Ultrasonography and computed tomographic angiography revealed an iatrogenic AVF between the right brachial artery and the medial brachial vein. Blood flow in the brachial artery was 760 mL/min. However, the iatrogenic AVF was unusable as vascular access for HD, and prior ligation closure of the iatrogenic AVF was performed, considering the risk of cardiac failure due to double AVFs after the creation of a new AVF for HD. Subsequently, a new radial-cephalic AVF was created in the left forearm. Therefore, clinicians should consider the possibility of iatrogenic AVF in patients with ESKD having a history of CAG or PCI., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: In this study, we aimed at clarifying the usefulness of drug-coated balloon catheters (DCBs) for arteriovenous fistulas (AVFs) that repeatedly undergo restenosis over a short period and to examine the factors that influence the patency period after DCB use., Methods: This retrospective observational study was conducted using IN.PACT AV in 29 cases of AVFs with repeated restenosis within approximately 3 months, and temporary patency before and after DCB use in the same patients was compared. For target participants, the flow volume, resistive index (RI), and vascular diameter of the brachial artery were measured using an ultrasound diagnostic device. Stenosis diameter, reference vessel diameter, and stenosis length of the lesion were measured before and after DCB dilatation using digital subtraction angiography., Results: Before DCB angioplasty, the postintervention primary patency at 3 months was 66%, and the average interval was 92 ± 21 days (mean ± standard deviation). After DCB angioplasty, the postintervention primary patency rates at 3 and 6 months were 92% and 36%, respectively. The postintervention primary patency was significantly higher after than before DCB angioplasty ( p  < 0.0001). A sub-analysis was performed on 25 patients who were followed up for 4 months or more after DCB. The RI values before and after dilatation with DCB significantly differed between the patency group 4 or more months after DCB and the patency group less than 4 months after DCB., Conclusion: For AVFs that require frequent PTA over a short period of time, DCB improved the patency rate 3 months after PTA, but the improvement effect at 6 months was limited. The effect of DCB on prolonging the patency rate of AVFs that require frequent PTA over a short period of time may be correlated with the RI value before and after PTA., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: The impact of coronavirus disease 2019 (COVID-19) infection control on other infections in patients with dialysis has not received sufficient consideration., Methods: We compared hospitalization and mortality rates among patients who underwent hemodialysis (HD) at three dialysis centers before (March 2018-February 2020) and during (March 2020-February 2022) the COVID-19 pandemic., Results: This study included 1696 patients undergoing HD (mean age, 70 years; 1099 men). Compared to before the COVID-19 pandemic, the emergency hospitalization rate (per 100 dialysis patient-years) for non-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) respiratory infectious diseases (IDs) (7.0 vs. 4.1, p < 0.001) significantly decreased during the COVID-19 pandemic, whereas the hospitalization rates for other IDs were comparable. The mortality rates for non-SARS-CoV-2 respiratory IDs were comparable before and during the COVID-19 pandemic., Conclusions: Hospitalizations for non-SARS-CoV-2 respiratory IDs among patients undergoing HD may have decreased owing to the implementation of infection control measures for COVID-19., (© 2023 International Society for Apheresis and Japanese Society for Apheresis.)

We herein report a case of encapsulating peritoneal sclerosis (EPS) in a patient without chronic kidney disease after gastrectomy. A 69-year-old man underwent distal gastrectomy for early gastric cancer at 25 years old. After 43 years, he developed bowel obstruction and underwent enterolysis of the encapsulated small intestine. A pathological examination of the capsular membranes revealed inflammation, foam, and giant cells that destroyed foreign substances. The patient was discharged 1.5 months later. Foreign body reactions to surgical instruments used in gastrectomy are considered a cause of EPS. EPS due to foreign body reactions to surgical instruments should also be considered in such cases.

Online hemodiafiltration (OL-HDF) is a treatment modality using diffusion and ultrafiltration. There are two types of dilution methods in OL-HDF: pre-dilution, which is commonly provided in Japan, and post-dilution, which is commonly provided in Europe. The optimal OL-HDF method for individual patients is not well studied. In this study, we compared the clinical symptoms, laboratory data, spent dialysate, and adverse events of pre- and post-dilution OL-HDF. We conducted a prospective study of 20 patients who underwent OL-HDF between January 1, 2019 and October 30, 2019. Their clinical symptoms and dialysis efficacy were evaluated. All patients underwent OL-HDF every 3 months in the following sequence: first pre-dilution, post-dilution, and second pre-dilution. We evaluated 18 patients for the clinical study and 6 for the spent dialysate study. No significant differences in spent dialysates regarding small and large solutes, blood pressure, recovery time, and clinical symptoms were observed between the pre- and post-dilution methods. However, the serum α1-microglobulin level in post-dilution OL-HDF was lower than that in pre-dilution OL-HDF (first pre-dilution: 124.8 ± 14.3 mg/L; post-dilution: 116.6 ± 13.9 mg/L; second pre-dilution: 125.8 ± 13.0 mg/L; first pre-dilution vs. post-dilution, post-dilution vs. second pre-dilution, and first pre-dilution vs. second pre-dilution: p = 0.001, p < 0.001, and p = 1.000, respectively). The most common adverse event was an increase in transmembrane pressure in the post-dilution period. Compared to pre-dilution, the post-dilution method decreased the α1-microglobulin level; however, there were no significant differences in clinical symptoms or laboratory data., (© 2023. The Japanese Society for Artificial Organs.)

Introduction: Predictive markers and prognosis remain unclear in hospitalized hemodialysis (HD) patients with coronavirus disease 2019 (COVID-19) during the Omicron epidemic., Methods: We evaluated characteristics, laboratory parameters, and outcomes in hospitalized HD patients with COVID-19 (n = 102) at two centers between January and April 2022., Results: The 30-day mortality rate was higher in moderate-critical group (n = 43) than mild group (n = 59) (16.3% vs. 1.7%; p = 0.007), and higher in patients with lower CC chemokine ligand 17 (CCL17) levels (<95.0 pg/mL) compared with normal CCL17 levels (19.0% versus 4.9%; p = 0.03). In multivariate analyses, a low CCL17 level (p = 0.003) was associated with moderate-critical conditions, and moderate-critical conditions (p = 0.04) were associated with 30-day mortality, whereas CCL17 was not associated with 30-day mortality., Conclusions: COVID-19 remains a fatal complication, and CCL17 was a predictive marker of severity in hospitalized HD patients during the Omicron epidemic., (© 2023 International Society for Apheresis and Japanese Society for Apheresis.)

Introduction: The association between tunneled central venous hemodialysis catheters (TCVCs) and mortality in hospitalized elderly hemodialysis (HD) patients remains unclear., Methods: This retrospective observational study was conducted in a long-term care hospital. We evaluated the association between TCVC and mortality in HD patients hospitalized between 2015 and 2020., Results: A total of 463 patients were compared: TCVC group (n = 53) and non-TCVC group (n = 410) including arteriovenous fistula (AVF, n = 369), arteriovenous graft (AVG, n = 30), and superficialized brachial artery (SBA, n = 11). The mean ages were 80 and 78 years in the TCVC and non-TCVC groups, respectively. Overall mortality rates for all-cause and cardiovascular diseases (CVDs) were higher in the TCVC group than in the non-TCVC group (log-rank, p = 0.01, and p = 0.009). Overall mortality was higher in the TCVC group than in the AVF group (p = 0.04), but there were no significant differences between the TCVC, AVG, and SBA groups. In Cox proportional hazards regression models, age, dialysis vintage, male sex, Charlson Comorbidity Index (CCI), and serum albumin level were associated with all-cause, CVD, and infectious disease (ID) mortalities, but TCVC was not associated with all-cause (hazard ratio, 1.31; 95% confidence interval, 0.95-1.80; p = 0.1), CVD (1.54; 0.99-2.39; p = 0.051), and ID (0.91; 0.48-1.70; p = 0.8) mortalities. Among patients aged ≥80 years, with dialysis vintage ≥7 years and CCI ≥10, the overall mortality rates were comparable between the two groups., Conclusions: Among elderly HD patients in the long-term care hospital, TCVC was not associated with mortality., (© 2023 S. Karger AG, Basel.)

Introduction: Penile calciphylaxis is rarely reported in dialysis patients., Methods: We experienced cases of dialysis patients who had penile calciphylaxis between 2003 and 2020., Results: Seven patients undergoing dialysis were treated for penile necrosis (hemodialysis [HD], 5; peritoneal dialysis [PD], 1; hybrid therapy comprising PD and HD, 1). Their mean age was 62.8 years and their mean dialysis vintage 116.1 months. All had severe penile pain and were clinically diagnosed with calciphylaxis. Four received partial penectomy and three received percutaneous transluminal angioplasty (PTA) due to rapid aggravation. The number of analgesia types and the critical-care pain observation tool score significantly decreased after invasive treatment (both, p = 0.008). The 90-day and 1-year survival rates after onset were 85.7% and 57.1%, respectively., Conclusion: In dialysis patients, penile calciphylaxis has poor prognosis; however, invasive treatments for pain management are effective. PTA may be beneficial in dialysis patients in poor condition., (© 2022 International Society for Apheresis and Japanese Society for Apheresis.)

Background: Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) is a fatal complication in the general population. However, there are few reports on CAPA in patients undergoing hemodialysis (HD)., Methods: This retrospective observational cohort study was conducted at a single center between December 2020 and June 2021. We enrolled 21 HD patients with COVID-19 undergoing treatment and divided them into two groups, CAPA and non-CAPA (COVID-19 with and without pulmonary aspergillosis), and evaluated their characteristics, clinical outcomes and comorbidities., Results: The log-rank test revealed that the 90-day survival rate after the initiation of treatment for COVID-19 was significantly lower in the CAPA ( n  = 6) than in the non-CAPA group ( n  = 15) (P = 0.0002), and the 90-day mortality rates were 66.6% and 0% in the CAPA and non-CAPA groups, respectively. In the CAPA group, four patients died due to respiratory failure (on Days 6 and 20), gastrointestinal bleeding (Day 8) and sepsis (Day 33); the reverse transcription-polymerase chain reaction (RT-PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remained positive when they died. The remaining two patients survived and the negative conversion of RT-PCR for SARS-CoV-2 was confirmed on Days 10 and 15. The negative conversion of serum (1, 3)-β-d-glucan (BDG) was confirmed on Day 15 in one patient; the BDG remained positive on Day 64 in the other., Conclusions: CAPA is a fatal complication in HD patients and the general population. Therefore, clinicians should consider the possibility of testing for CAPA in patients undergoing HD. Mycological workups may be helpful for the early detection of CAPA., (© The Author(s) 2022. Published by Oxford University Press on behalf of the ERA.)

Introduction: For dialysis patients with end-stage kidney disease, infectious diseases (IDs) are the most common causes of hospitalization and death. However, the association between dialysis modality and IDs remains unclear. We aimed to determine the association between the dialysis modality and IDs., Methods: This retrospective observational cohort study compared the emergency hospitalization and mortality for IDs between peritoneal dialysis (PD) and hemodialysis (HD) patients. After propensity score matching, the risk factors were evaluated by the Cox proportional hazard regression models., Results: A total of 260 patients were compared - 130 of 135 PD and 130 of 706 HD patients. When the modality-specific ID (PD-catheter ID/peritonitis- and vascular access-related ID) was excluded, no significant differences in emergency hospitalization and mortality rates for overall IDs were observed between the PD and HD groups. Serum ferritin (HR, 2.17; CI, 1.06-4.43; p = 0.03) and Charlson Comorbidity Index (CCI) (HR, 1.24; CI, 1.01-1.52; p = 0.04) were significant predictors of emergency hospitalization for IDs, whereas age (HR, 1.12; CI, 1.05-1.19; p < 0.001), male (HR, 3.38; CI, 1.01-11.3; p = 0.048), serum alkaline phosphatase (ALP) (HR, 6.87; CI, 2.18-21.7; p = 0.001), C-reactive protein (CRP) (HR, 10.7; CI, 3.55-32.1; p < 0.001), and CCI (HR, 1.79; CI, 1.27-2.52; p < 0.001) were significant predictors of ID mortality. When modality-specific ID was included, the emergency hospitalization rate for overall IDs was higher in the PD groups, and PD was a significant predictor of emergency hospitalization for IDs, whereas no significant difference in mortality rate for overall IDs was found between the PD and HD groups., Conclusions: ID events were not associated with dialysis modality when modality-specific ID was excluded, whereas the risk of modality-specific IDs was higher in PD than HD. Serum ferritin and ALP as well as age, male sex, CRP, and CCI were the risk factors for ID events., (© 2020 S. Karger AG, Basel.)

Introduction: Perforative peritonitis in patients on peritoneal dialysis (PD) is a serious adverse event associated with significant mortality. The signs and symptoms of perforative peritonitis in patients on PD are often confused with those of PD-related peritonitis; therefore, early diagnosis is often difficult., Presentation of Cases: In all three cases, antibiotic therapy was started for peritonitis. Although contrast-enhanced computed tomography (CT) was not performed, perforative peritonitis was suspected due to severe cloudiness of PD effluents, and emergency surgeries were performed 8, 5, and 6 days after therapy onset in cases 1, 2, and 3, respectively. In case 1, the ileum was perforated owing to ischemia, and partial ileal resection and divided ileostomy were performed. The patient died 18 days postoperatively. In case 2, partial ileal resection and divided ileostomy were performed for an incarcerated obturator hernia and perforated ileum. The patient was transferred for hemodialysis (HD) and discharged 117 days postoperatively. In case 3, lavage drainage was performed for peritonitis because of mesenteric penetration of a sigmoid colon diverticulum. The patient was then transferred for HD, and colostomy was subsequently performed. He was discharged 159 days postoperatively., Discussion: Early diagnosis between PD-related peritonitis and perforative peritonitis is often difficult since the washing effect of the peritoneal dialysate might relieve peritoneal irritation., Conclusion: In PD patients with refractory peritonitis, it is necessary to keep in mind the possibility of perforative peritonitis, and the differential diagnosis should be performed using contrast-enhanced CT within at least 5 days after antibiotic therapy., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: In patients with end-stage kidney disease (ESKD), cardiovascular diseases (CVDs) are the most common causes of hospitalization and death., Objective: We aimed to determine the association between dialysis modality and CVDs., Methods: This retrospective observational cohort study compared the emergency hospitalization and mortality of patients with CVDs who underwent peritoneal dialysis (PD) versus hemodialysis (HD). After propensity score matching, the risk factors were evaluated using Cox proportional hazards regression models., Results: A total of 260 patients were matched: 130 of 135 PD (75 men; age, 65.4 years; dialysis vintage, 3.3 years) and 130 of 706 HD (70 men [p = 0.5]; 66.6 years [p = 0.4]; dialysis vintage, 3.1 years [p = 0.5]) patients. Emergency hospitalization rates (hospitalizations/person-years) for overall CVDs (0.138 vs. 0.066, p = 0.002) and pulmonary edema (0.048 vs. 0.019, p = 0.03) were significantly higher in patients who underwent PD than those who underwent HD. The log-rank test revealed that all-cause and CVD mortalities were significantly higher in PD (both p < 0.001). Mortality rates (deaths/person-years) for overall CVDs (0.058 vs. 0.015, p < 0.002), cerebrovascular disease (0.019 vs. 0.004, p = 0.03), and ischemic heart disease (0.010 vs. 0, p = 0.02) were significantly higher in PD. The Cox proportional hazards regression model showed that PD and age were significant predictors of emergency hospitalization (hazard ratio [HR] 2.70; 95% CI 1.53-4.77; p = 0.001) and mortality (HR 4.41; 95% CI 1.66-11.72; p = 0.003) for CVDs., Conclusions: PD is a risk factor for emergency hospitalization and mortality associated with CVDs in dialysis patients with ESKD. Strict control of body fluid balance may prevent cardiovascular events in patients undergoing PD., (© 2019 S. Karger AG, Basel.)

Iliopsoas abscess in HD patients is rare. We examined nine HD patients with iliopsoas abscess (six men and five diabetes mellitus cases) treated between 2005 and 2015. Mean age and dialysis vintage at onset were 72 years and 109 months, respectively. Of the nine patients, four had lumbar orthopedic diseases, and two had all components of the classic triad of iliopsoas abscess at onset. All nine patients underwent percutaneous drainage, while seven underwent antimicrobial therapy. The most common pathogenic bacterium was methicillin-resistantStaphylococcus aureus(MRSA) (n = 5). Four patients had multilocular recurrence on the same side as the initial abscess and did not undergo CT before drainage catheter removal. Five patients died in the hospital, in which three died due to infectious diseases by MRSA. We suggest percutaneous drainage as the first-line therapy for HD patients with iliopsoas abscess and recommend combining antimicrobial therapy for MRSA, because of poor prognosis., (© 2019 International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy.)

Background: Management of vascular access (VA) is essential in hemodialysis (HD) patients. However, VA often fails and percutaneous transluminal angioplasty (PTA) is required. Conventional hemostasis at the puncture site is associated with complications. This study aimed to analyze the efficacy and safety of a hemostatic wound dressing made of calcium alginate at the puncture site of VA after PTA and evaluate other factors affecting hemostasis., Methods: After PTA for VA, 200 HD patients were randomized to a calcium alginate sheet (CA) group (n = 100) or a no drug-eluting sheet (control) group (n = 100). We recorded time to hemostasis at the puncture site every 5 min, noting any complications., Results: In the CA group, rates of hemostatic achievement at 5, 10, 15 and >15 min were 57, 25, 8 and 10%, respectively. In the control group, the rates were 39, 28, 14 and 19%, respectively. Rates of hemostatic achievement at 5 min were significantly higher in the CA group (P = 0.01). In logistic regression analysis, factors affecting hemostasis within 5 min were use of the CA sheet [odds ratio (OR) 2.33; 95% confidence interval (CI) 1.26-4.37], platelet count ≤100 000/μL (OR 0.19; 95% CI 0.04-0.69), number of antithrombotic tablets used per day ≥1 tablet (OR 0.50; 95% CI 0.26-0.94) and upper arm VA (OR 0.16; 95% CI 0.03-0.55)., Conclusions: A CA sheet can safely reduce time to hemostasis at the puncture site after PTA, and should be considered for treating patients with a bleeding tendency., (© The Author(s) 2018. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.)

[Purpose] We assessed the effects of a group intervention program used in home-dwelling elderly individuals to promote home exercise and prevent locomotive syndrome. [Participants and Methods] Pre- and post-intervention evaluations were performed in all participants. Group intervention was performed thrice between the pre- and post-intervention evaluations in all participants. A total of 19 elderly individuals participated in the pre- and post-intervention evaluations. Tests used for evaluation were the two-step test, standing-up test, and 25-question geriatric locomotive function scale. [Results] Among all participants in this study, 12 who performed all 3 aforementioned tests were classified as the non-absence group, whereas 7 who were absent more than once were classified as the absence group. We examined intergroup differences with respect to changes between the pre- and post-intervention evaluations, and we observed significant changes only in the results of the two-step test. [Conclusion] We conclude that low-frequency intervention in the form of workshops led to positive results with respect to improved physical function in home-dwelling elderly individuals.

Introduction: Recurrent central venous restenosis is problematic in patients with ipsilateral arteriovenous fistula. We report our experience using a drug-eluting stent for the treatment of recurrent central vein restenosis., Case Report: A 60-year-old man consulted our hospital because of recurrent swelling of his left upper limb with radial-cephalic arteriovenous fistula that originated in the distal forearm. More than 3 years prior, two bare-metal stents were placed for the obstructed lesions in the left subclavian and brachiocephalic venous lesions, and repeated balloon angioplasty for recurrent in-stent stenosis was performed approximately every 3 months. Angiography with iodinated contrast agents revealed an approximately 3-cm-long restenosis at the distal part of the bare-metal stents. One drug-eluting stent (Zilver PTX Drug-Eluting Peripheral Stent; Cook Medical, Bloomington, IN, USA) was deployed at the narrowing lesion, followed by balloon angioplasty. The stenotic lesion was successfully and safely dilated. The patient consulted our hospital 5.5 months after drug-eluting stent placement because of restenosis at the distal part of the drug-eluting stent, but only in a shorter segment than before. Freedom from clinically driven target-lesion revascularization (TLR) extended from 3.1 to 5.5 months after drug-eluting stent placement. Although additional implantation of the second drug-eluting stent was required 14.6 months after the first drug-eluting stent placement, freedom from TLR before/after the second drug-eluting stent placement extended from 4.4 months to more than 8.6 months., Conclusion: Drug-eluting stent placement is an effective strategy for recurrent central venous stenosis in patients with ipsilateral arteriovenous fistula. To our knowledge, this is the first report of drug-eluting stent placement for recurrent venous stenosis in a patient undergoing hemodialysis.

Background: In transplant recipients, due to the use of immunosuppressive therapy, it is occasionally difficult to distinguish between an infection and malignancy, especially in the case of a lung lesion. Here, we report a case of isolated pulmonary cryptococcosis after kidney transplantation that was difficult to distinguish from a lung tumor., Case Report: A 52-year-old man underwent a kidney transplant from his mother when he was 44 years old. Immunosuppression was maintained with tacrolimus, methylprednisolone, and mycophenolate mofetil. His post-transplant course was uneventful and serum creatinine levels were maintained. Five years post-transplantation, a non-contrast computed tomography (CT) examination revealed a nodule measuring 3 mm in diameter in the middle lobe of the right lung. The nodule gradually increased to 12 mm in 2 years. Positron emission tomography/CT examination showed a maximum standardized uptake value of 0.5 for the nodule. Biochemical examination revealed no elevation in total leucocyte count and C-reactive protein levels. However, tumor markers were elevated: serum carcinoembryonic antigen, 5.9 ng/mL; pro-gastrin-releasing peptide, 84.6 pg/mL. Furthermore, the serum cryptococcus antigen was negative. Therefore, thoracoscopic partial lung resection was performed. Pathologically, a number of spherical fungi from the necrotic substance of the tumor were confirmed positive by periodic acid-Schiff and Grocott-Gomori staining. The patient was therefore diagnosed with pulmonary cryptococcosis. Two years later, the patient is alive and has shown no evidence of recurrence., Conclusions: In lung nodules after kidney transplantation, even if serum cryptococcus antigen is not identified, it is necessary to keep in mind the possibility of pulmonary cryptococcosis., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The intermittency of conventional hemodialysis (HD) leads to an increase in cardiovascular events., Objective: We aimed to evaluate the effect of in-center frequent HD (FHD, 4-6 times a week) as a rescue option for cardiovascular events., Method: Patients who failed to achieve fluid volume control with conventional HD (thrice a week) were administered FHD. A total of 52 patients were divided into 2 groups by left ventricular ejection fraction (LVEF): low ejection fraction (LEF [n = 26], LVEF < 55%) and normal ejection fraction (NEF [n = 26], LVEF ≥55%). Mortality and hospitalization rates were evaluated., Results: All-cause mortality tended to be higher in the LEF than in the NEF group (p = 0.09). The 1-year hospitalization rate for acute cardiovascular events decreased in both LEF (1.24-0.89; p = 0.049) and NEF (0.36-0.16; p = 0.01) groups. In Cox regression models, LVEF < 55% (hazard ratio 3.81; 95% CI 1.15-12.66; p = 0.03) was identified as the risk factor for hospitalization for acute cardiovascular events., Conclusion: In-center FHD may decrease acute cardiovascular events., (© 2018 S. Karger AG, Basel.)

Background: The impact of hybrid therapy comprising peritoneal dialysis (PD) and hemodialysis on cardiovascular events in PD patients remains unclear., Objective: We aimed to evaluate the effect of hybrid therapy on cardiovascular events., Methods: A total of 93 PD patients undergoing hybrid therapy for ≥3 years were divided into 2 groups according to left ventricular ejection fraction (LVEF): lower ejection fraction (LEF [n = 29], LVEF < 60%) and normal ejection fraction (NEF [n = 64], LVEF ≥60%). Hospitalization rates and echocardiographic parameters were evaluated., Results: The 1-year hospitalization rate for acute cardiovascular events decreased after the therapy initiation in both groups (LEF: 0.36-0.11, p = 0.02 and NEF: 0.43-0.06, p < 0.001). In generalized linear mixed models, LVEF (44 ± 15%) improved at 1, 2, and 3 years after initiation (53 ± 18, 55 ± 17, and 58 ± 7%; p < 0.05) in the LEF group, whereas, in the NEF group, LVEF (68 ± 5%) was maintained at 1, 2, and 3 years after initiation (67 ± 8, 67 ± 9, and 68 ± 9%; p > 0.05). Mitral inflow E velocity to tissue Doppler e' ratio was maintained at the same level at 1-3 years after initiation in both groups. Left ventricular mass index (LVMI; 189 ± 41 g/m2) was decreased at 1 (178 ± 35 g/m2; p = 0.8), 2 (160 ± 45 g/m2; p = 0.008), and 3 (166 ± 47 g/m2; p = 0.05) years after initiation in the LEF group, whereas in the NEF group, LVMI (157 ± 45 g/m2) was maintained at 1, 2, and 3 years after initiation (153 ± 40, 155 ± 54, and 158 ± 52 g/m2; p > 0.05)., Conclusion: Hybrid therapy decreased acute cardiovascular events and improved systolic cardiac function in PD patients in the LEF group., (© 2018 S. Karger AG, Basel.)

Encapsulating peritoneal sclerosis (EPS), treated with surgical enterolysis as a final option, may become refractory to surgical intervention due to intraperitoneal complications. We report the case of a 59-year-old man presenting with EPS who underwent enterolysis at the age of 50, following 15 years of peritoneal dialysis (PD) and peritonitis. During the patient's first surgery, complete surgical enterolysis could not be performed due to severe intestinal adhesions with a deteriorated/calcified small bowel. Six months after the surgery, the obstructive bowel symptoms occurred several times a year. Nine years later, the patient suffered cystitis-like symptoms and fecal discharge from the urinary meatus. The patient was subsequently diagnosed with EPS recurrence with ureteroileal fistula between the right ureter and ileum. During the second surgical intervention, we conducted a divided jejunostomy, as surgical enterolysis and fistulectomy were unachievable due to severe ileal adhesion with calcified capsule and inflammation. Thereafter, symptoms reduced dramatically and oral intake became possible. Three years following surgery, the patient's condition is improved, with no evidence of EPS recurrence or cystitis-like symptoms. Although EPS with ureteroileal fistula is extremely rare, we propose that jejunostomy may be an effective treatment option for patients with EPS refractory to surgical enterolysis or intestinal bypass due to intraperitoneal complications., (Copyright © 2017 International Society for Peritoneal Dialysis.)

Introduction: Early access failure is an important complication of autogenous arteriovenous fistulas (AVFs). We prospectively monitored patients who underwent AVF creation using ultrasonography., Methods: Color flow imaging was used to assess access blood flow in patients undergoing creation of a new AVF in the distal forearm preoperatively and at 1 day and 1 week postoperatively. We measured the flow volume (FV) and resistive index (RI) of the brachial artery, and the internal diameter of the brachial artery and outflow vein. The primary outcome was the primary patency of the AVF without percutaneous angioplasty (PTA) or surgical revision 40 days after access creation., Results: We recruited 35 patients with newly created AVFs (men, 21; mean age, 73 years). Within one day of operation, the overall FV increased from 62 to 352 mL/min (p<0.0001) while the overall RI decreased from 1.0 to 0.63 (p<0.001). Five patients required PTA or surgical revision (intervention group [IG]), whereas 30 patients did not (non-intervention group [NIG]). The FV increased while the RI decreased from day 1 to week 1 in the NIG, but not in the IG (p<0.0001). The diameter of the brachial artery and outflow vein significantly increased in the NIG at 1 week. The FV of 235 mL/min and RI of 0.63 at 1 day were the thresholds for predicting early fistula failure., Conclusions: Access FV and RI at 1 day after AVF creation can predict primary patency and help plan intervention.

There have been no studies as yet that have evaluated how hemodialysis (HD) schedules affect the day of the week of hospitalization for cardiovascular diseases (CVDs) and infectious diseases (IDs), over a period of time. Herein, we performed a retrospective observational cohort study (1995-2014) evaluating 11,111 hospitalizations in 1,953 patients with end-stage renal disease, receiving HD 3 times a week (following either a Monday-Wednesday-Friday [MWF] schedule or a Tuesday-Thursday-Saturday [TTS] schedule) or receiving frequent HD (FHD) at least 4 times a week. Overall, hospitalization rates for CVDs and IDs were the highest on Monday in the MWF schedule and Tuesday in the TTS schedule compared to the average rates for all the days of the week. When generalized estimating equations (GEEs) were used in conjunction with robust variance estimators of each type of CVD, the risk for pulmonary edema was found to be significantly higher on Sunday and Monday in the MWF schedule and Monday and Tuesday in the TTS schedule. For both cerebrovascular and ischemic heart disease, the risks were significantly higher on Tuesday in the MWF schedule and Wednesday in the TTS schedule. Moreover, there were significant differences in the day of the week risks among the various CVD types. On trend analysis, the overall hospitalization rate for CVDs on the first HD day did not decrease (P = 0.2); however, the hospitalization rate for IDs on the first HD day significantly decreased (P = 0.02) over a span of 20 years. When GEEs were used in the case of FHD patients with severe heart failure, the hospitalization rate on the first HD day (Monday) significantly decreased after FHD initiation (P = 0.04). It was found that HD schedules affected the day of the week of hospitalization for CVDs. FHD may lower the day of the week risk.

Background: In 2008, the Japanese Society for Dialysis Therapy (JSDT) proposed a standard for the quality of fluids for hemodialysis. The standard was geared toward Japan, where the central dialysis fluid delivery system is routinely used. After establishment of the standard, dialysis fluid quality was markedly improved in facilities across the country. Moreover, the number of on-line hemodiafiltration patients dramatically increased., Summary: However, the 2008 standard specifies only microbiological qualities and does not cover toxic chemicals. The basis of toxic chemical management depends on the source water and water treatment equipment for hemodialysis, but no standard applies to water treatment equipment as a medical device. Specifications for the equipment were, for the most part, entrusted to individual manufacturers. Key Messages: The JSDT is investigating revision of its standard for dialysis fluid quality for hemodialysis to add control standards for toxic chemicals and water treatment equipment, with the aim of achieving quality of dialysis water superior to that of terminal dialysis fluid., (© 2017 S. Karger AG, Basel.)

The aim of this study was to evaluate the pharmacokinetic profile of daclatasvir (DCV) and asunaprevir (ASV) dual therapy in haemodialysis patients infected with hepatitis C virus (HCV). Eighteen haemodialysis patients and 54 patients with normal renal function were treated with DCV and ASV dual therapy for 24 weeks. We evaluated the pharmacokinetic profiles of DCV and ASV and examined the rate of sustained virological response 12 weeks after the end of treatment (SVR 12 ) and incidence of adverse events during treatment of haemodialysis patients infected with chronic HCV genotype 1 infection. To adjust for potential differences in baseline characteristics between haemodialysis patients and patients with normal renal function, we used propensity scores case-control matching methods. Area under the plasma concentration time curve from 0 to 6 h (AUC 0-6 h ) of DCV was slightly lower in haemodialysis patients than in patients with normal renal function (P > 0.6). AUC 0-6 h of ASV was significantly lower in haemodialysis patients (P = 0.012). SVR 12 rates were 100% (18/18) for haemodialysis and 96.2% (52/54) for patients with normal renal function. Changes in mean log 10 HCV RNA levels and viral response were higher in haemodialysis patients compared to patients with normal renal function. No discontinuations due to adverse events occurred. In conclusion, DCV and ASV dual therapy for HCV infection is effective and safe with similar results in haemodialysis patients compared to patients with normal renal function., (© 2016 John Wiley & Sons Ltd.)

Introduction This study aimed to evaluate the association between proton pump inhibitor (PPI) use and serum magnesium levels, and the role of hypomagnesemia and PPI use as a risk factor for mortality in hemodialysis patients. Methods An observational study, including a cross-sectional and 1-year retrospective cohort study. The study comprised 399 hemodialysis patients at a single center, and was conducted from January to September 2014. Multiple linear regression analysis was used to investigate the independent relationship between serum magnesium levels and baseline demographic and clinical variables, including PPI and histamine-2 receptor antagonist use. Cox regression model was used to identify lower serum magnesium level and PPI as a predictor of 1-year mortality. Findings Serum magnesium levels were lower with PPI use than non-PPI use (2.39 ± 0.36 vs. 2.56 ± 0.39 mg/dL, P < 0.001). Multiple linear regression analysis showed that PPI use, low serum albumin levels, and low serum potassium and high-sensitivity C-reactive protein (hs-CRP) levels were significantly associated with low serum magnesium levels. A total of 29 deaths occurred during the follow-up period. According to Cox regression analysis stratified by hs-CRP, only high serum hs-CRP levels (>4.04 mg/L) in association with low serum magnesium levels was an independent risk factor for 1-year mortality (hazard ratio: 2.92; 95% CI: 1.53-6.40, P < 0.001). Discussion Serum magnesium levels are lower in PPI use. In the inflammatory state, a low serum magnesium level is a significant predictor of mortality in hemodialysis patients., (© 2016 International Society for Hemodialysis.)

Surgical enterolysis is the final option for patients with encapsulating peritoneal sclerosis (EPS). However, EPS is sometimes refractory to surgical enterolysis. This is the first report of successful use of percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) in a patient with EPS that was refractory to surgical enterolysis. We propose that sustained drainage of digestive juices by PEG-J, along with central venous nourishment at home, can be a treatment option for patients with EPS that cannot be treated with radical measures., (Copyright © 2016 International Society for Peritoneal Dialysis.)

Since 2009, the peritoneal dialysis (PD) registry survey has been carried out as part of the annual nationwide survey conducted by the Statistical Survey Committee of the Japanese Society for Dialysis Therapy with the cooperation of the Japanese Society for Peritoneal Dialysis. In this report, the current status of PD patients is presented on the basis of the results of the survey conducted at the end of 2012. The subjects were PD patients who lived in Japan and participated in the 2012 survey. Descriptive analysis of various items was performed, which included the current status of the combined use of PD and another dialysis method such as hemodialysis (HD) or hemodiafiltration (HDF), the method of exchanging dialysate, the use of an automated peritoneal dialysis (APD) machine, and the rates of peritonitis and catheter exit-site infection. From the results of the facility survey in 2012, the number of PD patients was 9514, a decrease of 128 from 2011. Among the entire dialysis patient population, 3.1% were PD patients, a decrease of 0.1%. Among the studied patients, 347 had a peritoneal catheter and underwent peritoneal lavage, 175 were started on PD in 2012 but introduced to other blood purification methods in the same year, and 1932 underwent both PD and another dialysis method such as HD or HDF. The percentage of patients who underwent PD and another dialysis method increased with PD vintage: <1 year, 4.8%; 1 to <2 years, 9.2%; 2 to <4 years, 16.3%; 4 to <8 years, 32.0%; and ≥8 years, 47.5%. The percentage of PD patients who completely manually exchanged the dialysate was 29.8%. The percentages of PD patients who used a double-bag exchange system with ultraviolet-light irradiation and those who used the same system but with a sterile connecting device were 54.7 and 13.9%, respectively. The percentage of patients on PD for <1 year using an APD machine was 43.4%, and it decreased with a PD vintage of ≥2 years. The mean rate of peritonitis was 0.22 per patient per year. The mean rate of catheter exit-site infections was 0.36 per patient per year., (© 2015 Japanese Society for Dialysis Therapy Reproduced with permission.)

An amphiphilic polyglycerol dendron (PGD) conjugated porphyrin (PGP) bearing a polymerizable group was successfully synthesized. The PGP was used as an effective surfactant in emulsion and microsuspension polymerization systems to prepare styrene and methacrylate polymer particles, and the use of PGP provided the simple polymer particles with fluorescence derived from the metalloporphyrin and high colloidal stability due to the PGD. Furthermore, based on confocal laser scanning microscopy, we observed that the particles spontaneously formed a core-shell morphology with the PGP localized in the shell region during the polymerization and demonstrated drug loading in the shell region using rhodamine B as a model drug. The results indicate that the use of the functional surfactant PGP led to the preparation of multifunctional polymer particles from simple monomer species, and the resulting particles possessed high colloidal stability, fluorescence, and drug loading capability.

No previous reports have focused on surgical treatments and risk factors of umbilical hernia alone in peritoneal dialysis (PD) patients. Herein, we evaluated the treatments and risk factors. A total of 411 PD patients were enrolled. Of the 15 patients with umbilical hernia (3.6%), six underwent hernioplasty. There was no recurrence in five patients treated with tension-free hernioplasty. The mean PD vintage after onset of hernia in the hernioplasty group tended to be longer than that in the non-hernioplasty group. An incarcerated hernia occurred in one non-hernioplasty patient. Although the incidence was significantly higher among women (P = 0.02), female sex was not a risk factor for umbilical hernia (P = 0.08). Our findings suggest that umbilical hernias should be repaired for continuing PD. Furthermore, there were no significant risk factors for umbilical hernia in PD patients. Future studies with larger sample groups are required to elucidate these risk factors., (© 2015 International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy.)

Purpose: In developed countries, dialysis patients are aging along with the general population. The choice of vascular access (VA) is a more complex decision among elderly patients and is not specifically addressed by clinical practice guidelines. We investigated the relationship between the VA type at dialysis initiation in elderly patients and their prognosis, as well as the selection of the optimal VA type., Methods: We conducted a retrospective observational cohort study of consecutive adult patients (age ≥18 years) as their first form of renal replacement therapy (RRT) between January 1, 2003, and December 31, 2010. For this study, VA included both arteriovenous fistula (AVF) and temporary central venous catheter (CVC)., Results: A total of 402 patients were included in this study. The percentage of patients who started dialysis with CVC increased with age, and 63% of those were over 80 years. The survival rate in the group of elderly patients (≥70 years) using CVC at dialysis initiation was significantly lower. In contrast, the survival rates were comparable between nonelderly patients (<70 years) using CVC or AVF. One hundred and thirty patients were super-aged (≥80 years). In super-aged patients (≥80 years) and aged patients (70-79 years), dialysis initiation with CVC was correlated with a significantly poorer survival rate than dialysis initiation with AVF. The survival rates were comparable between the low CRP group (<1.8 mg/dL) using CVC or AVF., Conclusions: The initiation of dialysis with temporary CVC is not a risk factor of death in nonelderly patients (<70 years). On the other hand, in elderly (≥70 years) and super-aged (≥80 years) patients, dialysis initiation with CVC increased the risk of death, but they had to start dialysis with CVC on an emergency basis because of their clinical condition, that is, inflammations.

Peritoneal dialysis solution (PDS) plays a role in functional and morphological damage to the peritoneum. This study aimed to clarify the effect of neutral PDS in preventing morphological changes by assessing peritoneal damage and comparing morphological alterations between PD patients treated with neutral PDS and acidic PDS. Sixty-one patients participated from seven hospitals. All patients were treated with neutral PDS excluding icodextrin, during their entire PD treatment, and experienced no episode of peritonitis. The thickness of submesothelial compact (SMC) zone and the presence of vasculopathy in the anterior parietal abdominal peritoneum were assessed. The impact of icodextrin, hybrid therapy, and peritoneal rest and lavage in morphological alterations were determined. There was no significant difference in the average SMC thickness between neutral and acidic PDS. The vessel patency in patients using neutral PDS was significantly higher compared to that in acidic PDS at any time during PD. There were no significant suppressive effects from interventions or use of icodextrin with respect to peritoneal morphological injury. A monolayer of mesothelial cell was observed in approximately half the patients, especially in their receiving lavage patients. Neutral PDS, accompanied by other preventive approaches against peritoneal injury, might suppress the development of peritoneal morphological alterations.

Purpose: Both high-flow vascular access (VA) and dialysis-associated steal syndrome are serious complications requiring a flow reduction technique. We adopted the minimally invasive limited ligation endoluminal-assisted revision (MILLER) banding procedure with some modifications to control the high blood flow and steal syndrome during VA procedures and retrospectively assessed the outcome., Methods: Seven patients with high-flow access (access flow >1400 ml/min) and five patients with steal syndrome (with pain, coldness, or cyanosis) were treated using the MILLER banding method. Flow volume of the brachial artery was monitored using Doppler ultrasonography during the banding procedure. In patients with steal syndrome, the finger probe of a pulse oximeter was attached to a finger on the ipsilateral side, and the peripheral oxygen saturation (SpO2) was monitored., Results: In the high-flow group, the mean access blood flow (Qa) decreased from 2043 ± 463 ml/min (mean ± SD) to 1248 ± 388 ml/min (p<0.001). In the steal syndrome group, the SpO2 value improved in all steal syndrome patients after banding. Symptoms were almost relieved in two steal syndrome patients. The Qa in the steal group decreased from 997 ± 867 to 548 ± 376 ml/min (p = 0.12). The secondary patency rates of the high-flow and steal groups at 6 months were 83.3% and 50%, respectively., Conclusions: The MILLER banding procedure with intraoperative access flow monitoring is effective to treat high-flow VA and steal syndrome.

Renal cell carcinoma (RCC) in a kidney allograft is rare. We report the successful diagnosis and treatment of a de novo RCC in a nonfunctioning kidney transplant 20 years after engraftment. A 54-year-old man received a kidney transplant from his mother when he was 34 years old. After 10 years, chronic rejection resulted in graft failure, and the patient became hemodialysis-dependent. Intravenous contrast-enhanced computed tomography (CT) for the evaluation of gastrointestinal symptoms revealed a solid 13 mm tumor in the kidney graft. The tumor was confirmed on ultrasound examination. This tumor had not been detected on a surveillance noncontrast CT scan. Needle biopsy showed that the tumor was an RCC. Allograft nephrectomy was performed. Pathological examination showed that the tumor was a Fuhrman Grade 2 RCC. XY-fluorescence hybridization analysis of the RCC showed that the tumor cells were of donor origin. One year after the surgery, the patient is alive and has no evidence of tumor recurrence. Regardless of whether a kidney transplant is functioning, it should periodically be imaged for RCC throughout the recipient's lifetime. In our experience, ultrasonography or CT with intravenous contrast is better than CT without contrast for the detection of tumor in a nonfunctioning kidney transplant.

Many studies have reported poor vital prognosis in hepatitis C virus (HCV)-infected dialysis patients. The rate of HCV-infected dialysis patients in Japan is as high as 9.8%, and antiviral therapy is believed to be important for improving vital prognosis. We conducted a multicenter study to examine the administration method for pegylated interferon α-2a (PEG-IFNα-2a) monotherapy in HCV-infected dialysis. We studied 56 patients: 14 with low viral loads (HCV RNA < 5.0 log IU/mL) were treated with 90 μg PEG-IFNα-2a weekly, 42 with high viral loads (HCV RNA ≥ 5.0 log IU/mL) were treated with 135 μg PEG-IFNα-2a weekly. We examined the sustained virological response (SVR), factors affecting the SVR, and treatment safety. The overall SVR rate was 39% (22/56); that for genotype 1, genotype 2, low viral loads, and high viral loads was 29%, 67%, 93%, and 21%, respectively. From receiver operating characteristic (ROC) analysis, the HCV RNA cutoff values likely to achieve SVR for genotypes 1 and 2 were <5.7 log IU/mL (SVR rate: 64% 9/14) and <6.5 log IU/mL (SVR rate: 88% 7/8), respectively. If there was HCV RNA negativation at 4 weeks (rapid virological response), the SVR rate was 94% (16/17), whereas it was 6% (1/16) if there was HCV RNA positivity at 24 weeks. The rate of treatment discontinuation from adverse events or aggravated complications was 25% (14/56). High SVR rates can potentially be achieved with PEG-IFN monotherapy by identifying the target patients, based on virus type and viral load before initiating treatment and by modifying therapy during treatment according to responsiveness., (© 2014 The Authors. Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis.)

Purpose: Increased vascular access flow after percutaneous transluminal angioplasty (PTA) for central venous stenosis and occlusion (central venous disease, CVD) can affect cardiac function in hemodialysis (HD) patients. We evaluated the cardiac function, etiology, and treatment in HD patients with CVD., Methods: HD patients with CVD treated by PTA between June 2006 and February 2013 were studied., Results: Of the 26 patients, 22 had left arteriovenous fistulas (AVFs), 1 left arteriovenous graft (AVG), 2 right AVFs, and 1 right AVG. CVD sites were the left brachiocephalic vein (LBCV; n=13), left subclavian vein (LSCV; n=7), both LBCV and LSCV (n=3), right BCV (n=2), and right SCV (n=1). Computed tomography findings indicated a high extrinsic compression rate for the LBCV (91%) and LSCV (50%). The success rate of PTA was 96%. The primary patency rates at 3, 6, 9, and 12 months were 81%, 73%, 65%, and 57%, respectively. The post-PTA brachial artery flow volume was significantly increased compared with the pre-PTA volume (1306 vs. 957 ml/min; p=0.005). The post-PTA left ventricular ejection fraction and expiration inferior vena cava diameter were the same as the pre-PTA values (57% versus 60%, p=0.2 and 17 versus 17 mm, p=0.9, respectively)., Conclusions: Our findings suggest that increased vascular access flow after PTA for CVD has no relation to cardiac function.

The incidence of acute massive hemorrhage in hemodialysis (HD) patients is thought to be higher than in healthy individuals, and a large, expanding subcutaneous hematoma can result in necrosis of the overlying skin. We evaluated the efficacy of intra-arterial treatment for acute massive subcutaneous hemorrhage in HD patients. Seven HD patients with subcutaneous hemorrhage following minor blunt trauma were treated using superselective transarterial embolization, between July 2005 and October 2012. After examining the site of the hemorrhage using contrast-enhanced computed tomography (CT), embolizations were performed using microcoils, gelatin sponges, or N-butyl cyanoacrylate. Hematoma evacuation or skin grafting was performed as needed. Four men and three women with a mean age of 70 years (range, 63-82 years) comprised the study population. Sites of bleeding were as follows: lower leg (N = 3), upper leg (N = 1), buttock (N = 1), precordia (N = 1), and forearm (N = 1). Blood transfusions were administered to five cases. All patients were successfully salvaged using transarterial embolization. Six patients underwent hematoma evacuation after transarterial embolization, and two patients underwent split-thickness skin grafting for skin necrosis. We established a treatment strategy for HD patients with acute subcutaneous hemorrhage. Immediate confirmation of the site and the degree of bleeding with contrast-enhanced CT and early treatment using the transarterial embolization and as needed, hematoma evacuation are effective for preventing skin necrosis in HD patients with acute subcutaneous hemorrhage., (© 2013 The Authors. Therapeutic Apheresis and Dialysis © 2013 International Society for Apheresis.)