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Highlights • We describe a new operative technique for creating a radial artery-second dorsal metacarpal vein AVF in the first interdigital space for hemodialysis patients. • This technique involves the creation of the AVF using the most peripheral site and autologous vein in the upper limb. • This technique has several advantages including preserving many future VA options and providing a long segment of arterialized vein for cannulation. • This technique is a worthwhile option in patients with the proper vessels for the creation of the AVF., Introduction The creation of the first arteriovenous fistula (AVF) as far distally in the upper limb as possible is ideal. We developed a new operative technique for creating a radial artery-second dorsal metacarpal vein AVF in the first interdigital space. This technique involves the creation of the AVF using the most peripheral site and autologous vein in the upper limb. Case presentation We herein describe the steps of this technique and its successful performance in a 71-year-old man with end-stage renal disease. Discussion This technique has several advantages including preserving many future vascular access options and providing a long segment of arterialized vein for cannulation. Conclusion We consider this technique to be a worthwhile option and recommend the use in patients with the proper vessels for the creation of the AVF.

A radiocephalic arteriovenous fistula in the anatomical snuffbox (tabatière region) was first described in 1969 as the most peripheral site for arteriovenous fistula in the upper limb. In cases in which the internal diameter of the first dorsal metacarpal vein under avascularization is ⩾2.0 mm, we have adopted a new operative technique for creating a radial artery-first dorsal metacarpal vein arteriovenous fistula in the first interdigital space of the dorsal hand, which lies between the thumb and the index finger. This technique is the creation of the arteriovenous fistula using the first dorsal metacarpal vein and the most peripheral site in the upper limb. To our knowledge, no previous report has described the creation of a radial artery-first dorsal metacarpal vein arteriovenous fistula. We herein describe the steps of the technique and report its successful performance in a patient with chronic renal failure.

Highlights • We describe a one-sheath inverse method in vascular access intervention therapy (VAIVT) for hemodialysis patients. • It allows VAIVT to be performed using one sheath with one approach site in cases in which lesions are present on the upstream and downstream sides. • Because vascular access location is usually superficial, the technique can be utilized with relative ease., Introduction Vascular access intervention therapy (VAIVT) is an essential interventional therapy in the field of hemodialysis therapy that allows for the long-term vascular access functionality to be maintained. The venous approach is often performed in VAIVT for arteriovenous fistula. When lesions are present on the upstream and downstream sides from the approach site, it is likely that two sheaths will be inserted from two facing punctures. However, we have adopted a one-sheath inverse method using a guidewire in such cases. Case presentation We herein describe the steps of the technique that we have performed and report the successful treatment of a 77-year-old woman who developed arteriovenous fistula failure. Discussion To the best of our knowledge, the concrete and detailed technique has not been reported in the English literature to date. The merit of the technique is that it allows VAIVT to be performed using one sheath with one approach site in cases in which lesions are present on the upstream and downstream sides from the approach site. The other benefits include pain reduction, a shortened operation time, and reduced costs. Because vascular access location is usually superficial, the technique can be utilized with relative ease. Conclusion A one-sheath inverse method is useful. We hope that the technique will be more widely recognized, allowing the technique to be applied to more cases.

We experienced a case in which improving the renal damage caused by warfarin‐related nephropathy took a long time. It is important to follow up for a long time after the initiation of dialysis due to warfarin‐related nephropathy.

We previously described the success and usefulness of two operative techniques for creating a radial artery-first or second dorsal metacarpal vein arteriovenous fistula (AVF) in the first interdigital space of the dorsal hand using the most distal site and autologous veins in the upper limb. These techniques utilize the dorsal metacarpal veins on the radial side of the dorsal hand. Developing these ideas, we devised a novel operative technique for creating a transposed radial artery-third metacarpal vein AVF in the first interdigital space of the dorsal hand using the most distal vein on the ulnar side of the upper limb and most distal site in the upper limb. The distinctive advantage of this technique is that it can be applied to patients whose cephalic vein in the forearm and the dorsal metacarpal veins on the radial side of the dorsal hand are of a poor quality. We herein report the steps of this technique and describe its successful performance in a patient who has been on hemodialysis for 14 months without any additional vascular access interventions or postoperative complications. We consider this technique to be a valuable option in select patients who meet the applicable conditions. The creation of the first AVF as distally as possible is ideal, and it offers a further viable option of distal native vascular access that may be overlooked.

Membranous nephropathy (MN) is a common glomerular disease that is characterized by diffuse thickening of the glomerular basement membrane, and a common cause of nephrotic syndrome (NS). MN is often accompanied with malignant disease; The solid tumors are commonly associated with MN, whereas hematological malignancies are rarely found in patients with MN. A 68-year-old man with a history of diabetes mellitus visited a hospital with a chief complaint of general fatigue. He was previously not diagnosed with any complications of diabetes. Computed tomography revealed a pancreatic tumor, and the pathological findings of the biopsied tumor revealed the tumor was diffuse large B-cell lymphoma (DLBCL). Concurrently, he developed severe proteinuria, hypoalbuminemia, systemic edema and hyperlipidemia, consistent with the diagnosis of NS. The biopsied renal specimen revealed minute spike lesions of glomerular basement membrane, and abnormal lymphocytes infiltrated in the kidney interstitially. Anti-glomerular basement membrane antibody, proteinase-3-/myeloperoxidase antineutrophil cytoplasmic antibody and hepatitis B antigenemia, are absent in the patient. Serum anti-phospholipase A2 receptor (PLA2R) antibody (marker for primary MN) was not detected. A diagnosis of secondary MN induced by DLBCL was made. He received rituximab containing chemotherapy for DLBCL, resulting in amelioration of both DLBCL and MN. We report the rare case of a patient co-existing NS and DLBCL. DLBCL might be pathogenesis of NS; the findings are supported by the presence of MN, an underlying malignancy (DLBCL), and the lack of anti-PLA2R antibodies. Although further investigation is warranted, our case suggests that DLBCL is a possible cause of secondary MN.

A brachio-brachial arteriovenous fistula with superficialization of the brachial vein and superficialization of the brachial artery are useful vascular access techniques for hemodialysis patients. However, both typically require a long skin incision from the antecubital fossa toward the axillary fossa. In addition, the brachio-brachial arteriovenous fistula in particular, which is created with not a one-stage but a two-stage procedure, requires a relatively long time of 2–3 months before it can be used for hemodialysis. Furthermore, superficialization of the brachial artery usually requires nonarterialized superficial veins for blood return. In cases where patients have no adequate superficial veins for creating an arteriovenous fistula, we have adopted a one-stage operative technique to create a brachio-brachial arteriovenous fistula with superficialization of not only the brachial vein but also the brachial artery using a short skin incision. This technique of a brachio-brachial arteriovenous fistula with superficialization of the brachial artery has several advantages over traditional approaches, including a minimally invasive procedure and early use for vascular access. To our knowledge, the presently described technique and the related data have not been previously reported in the English literature. We herein report the steps of this technique and the midterm follow-up outcomes.

We examined the thyroid function of non-dialysis-dependent chronic kidney disease (CKD) patients in Japan.Serum-free thyroxine, free triiodothyronine, thyroid-stimulating hormone (TSH), and thyroglobulin (Tg) levels were evaluated in 37 CKD patients. CKD was defined as sustained kidney damage for more than 3 months and was classified as CKD 1+2 (n = 11), 3+4 (n = 10), or 5 (n = 16), which were defined by glomerular filtration rates of ≥ 60, 15 - 59, or 15 mL/min/1.73mThe prevalence of primary hypothyroidism (TSH ≥ 4.83 mU/L) in CKD 1+2, CKD 3+4, and CKD 5 was 9%, 20%, and 56%, respectively (p 0.05). Unexpectedly, elevated serum Tg levels ( 30 ng/mL), a marker of the reversible recovery of the thyroid function, were found in 67% of the CKD 5 patients (p0.05). The serum TSH and Tg levels became lower, without replacement therapy, after the initiation of hemodialysis and iodine restriction, and there was a significant correlation between the serum TSH and Tg levels in the CKD 5 patients (p0.05).The high prevalence of reversible hypothyroidism and the TSH-dependent elevation of the serum Tg levels was suggested in Japanese patients with advanced CKD. The excess ingestion and the impaired urinary excretion of iodine may be responsible for this reversible thyroid dysfunction. .

Difference in thyroid function depending on the etiology of end-stage renal disease (ESRD) was evaluated in 124 Japanese patients on haemodialysis (HD) due to either chronic glomerulonephritis (CGN, n = 82) or lifestyle related systemic disease (non-CGN, n = 42), such as diabetes mellitus (n = 30) or hypertension (n = 12). There was no significant difference in serum free thyroxine, free triiodothyronine and thyroid-stimulating hormone (TSH) level, but serum thyroglobulin (Tg) level was significantly higher in CGN (p = 0.0151). Prevalence of the patients with hypothyroidism (TSH > 4.83 mU/l) was 11 or 13.4% in CGN and 4 or 9.5% in non-CGN (p = 0.017). The most striking finding was the elevated Tg in 38 or 46.3% in CGN and in 11 or 26.2% in non-CGN (p = 0.034). Logistic regression analysis revealed elevated serum TSH level and higher thyroid volume were the significant factors associated with elevated Tg level. Extreme Tg elevation over 100 ng/ml was found only in CGN (12 or 14.6%), and 2 of the patients were overtly hypothyroid but became euthyroid after iodide restriction. Elevated Tg responding to elevated TSH mainly found in CGN suggested the relatively preserved thyroid tissue and reversible recovery of the thyroid function.

A radio-cephalic arteriovenous fistula (AVF) in the anatomical snuffbox is the most distal site of AVF in the upper limb. When the cephalic vein distal to the wrist is in poor condition or thrombosed, creating the typical radio-cephalic AVF in the distal forearm just proximal to the wrist will likely be considered. However, we have adopted an operative technique for creating a transposed radial artery-dorsal metacarpal vein AVF (RDAVF) in the anatomical snuffbox when possible in such cases. RDAVF is AVF using the most peripheral autologous vein in the upper limb. To our knowledge, the creation of an RDAVF has not been previously reported. We herein describe the steps of the technique and report the successful treatment of a hemodialysis patient who developed occlusion of a radio-cephalic AVF in the anatomical snuffbox.

症例は67歳，女性．IgA腎症による慢性腎不全で，全身浮腫を認めたため透析に導入．透析は特に問題なく施行できたが，著明な心拡大を認め，心エコーにて左室駆出率の低下（24％）と中等量の心嚢水貯留と右房のcollapse所見を認め，心タンポナーデの状態と診断．原因疾患の検索では特に異常所見は得られず，まずは連日透析と徹底した16 kgに及ぶ除水を行った．しかし，心拡大や心エコー所見は軽度の改善に止まったため，心嚢穿刺を敢行し，約500 mLの粘稠性で非血性の滲出液を排出した．心嚢液からは菌の検出はなく，その後の持続ドレナージは施行しなかったが，心拡大は速やかに軽快し，心エコー所見も改善した．尿毒症性心外膜炎は，近年経験することがまれになってきたが，致死的な疾患としての認識が必要な疾患である．今回われわれの経験した症例は，循環動態が安定していたため，まず連日の強化透析を行い大量の除水も行ったが，それだけでは大きな改善が得られず，その後1回の心嚢穿刺排液したのみで著明な改善を認めるに至り，このような症例における対応への一つの示唆を与える症例であった．

It is thought that a large amount of albumin leaking from the glomerulus in nephrotic syndrome (NS) is reabsorbed at the proximal tubule and catabolized. Therefore, it is possible the final quantity of urinary protein does not always reflect the amount of leakage of protein from the glomerulus. We experienced two cases without nephrotic range proteinuria thought to involve hypoproteinemia due to the same pathophysiology as NS. On these patients, we performed protein leakage scintigraphy with technetium-99m human serum albumin diethylenetriamine pentaacetic acid (99mTc-HSAD) to exclude a diagnosis of protein-losing gastroenteropathy and observed diffuse positive accumulation in the kidneys with more intense uptake in the kidney than the liver on the anterior view 24 hours after 99mTc-HSAD administration. In healthy adults intravenously given 99mTc-HSAD, the same dynamics are observed as in albumin metabolism, and the organ radioactivity of the liver and kidneys after 24 hours is equal. Therefore, we thought it was possible that the renal uptake 24 hours after 99mTc-HSAD administration was a characteristic finding of NS. In order to confirm it, the subjects were divided into two groups: the NS group (n = 10) and the non-NS group (n = 7). We defined more intense uptake in the kidney than the liver on the anterior view 24 hours after 99mTc-HSAD administration as Dense Kidney (+). Furthermore, we designed regions of interest in the right and left kidneys and liver on anterior and posterior images, then calculated the kidney-liver ratio. Nine of the ten patients had Dense Kidney (+) in the NS group, compared to none in the non-NS group. And the kidney-liver ratio was significantly higher in the NS group than in the non-NS group on each view in the bilateral kidneys. In conclusion, our results suggest that the renal uptake 24 hours after 99mTc-HSAD administration is a characteristic finding of NS.

A 38-year-old female presenting with a high fever of 39 °C developed severe liver dysfunction and acute renal failure (ARF). In tests for a hepatitis associated virus, an Immunoglobulin M-anti-hepatitis B virus core antibody was the only positive finding. Moreover, the progression of ARF coincided with the pole period of liver damage and all the other assumed causes for the ARF were unlikely. Therefore, this case was diagnosed as ARF caused by acute hepatitis B. ARF associated with non-fulminant hepatitis has been infrequently reported, usually in association with acute hepatitis A. This case is considered to be an extremely rare and interesting case.