Use of the Superficialized Brachial Artery as Vascular Access for a Patient with Myasthenia Gravis with a Frequent Need for Plasmapheresis: A Case Report.

A 41-year-old woman diagnosed with seronegative myasthenia gravis struggled to maintain remission for a decade, facing crises every 3 months for several years. After repeated apheresis using a non-tunneled non-cuffed central venous dialysis catheter (NTNCC), complications such as catheter-related thrombus in the internal jugular veins and morbid obesity from steroids made the insertion of NTNCC increasingly difficult, leading to consideration of an alternative permanent vascular access (VA) approach. Thus, we created a subcutaneously superficialized brachial artery as the VA, which allowed the patient to undergo safe and uninterrupted apheresis therapy.

Accidental removal of dialysis central venous catheter inserted for blood purification therapy: a single-center study.

BACKGROUND: Dialysis central venous catheters (DCs) are used for various blood purification therapies. Accidental removal of a DC is a potentially life-threatening event. However, the risk factors associated with accidental removal have rarely been discussed in the literature. METHODS: We performed a 5 year retrospective, single-center, cohort study of patients who were admitted to the ward other than intensive care units and were inserted DCs. We compared patient characteristics between patients who used DCs with and without a history of accidental removal. RESULTS: There were 17 cases of accidental removal (3.5%) out of 489 DC insertions during the observation period. There was no significant difference between patients with and without accidental removal in terms of age, sex, reason for DC insertion, catheter type, or insertion site. The presence of dementia was 35 and 11% (p = 0.006), and that of delirium was 88 and 13% (p < 0.0001) in those with and without accidental removal, respectively. The median days from insertion to accidental removal were 5 (range 0-21) days, and removal occurred mainly at night (71%). One patient with accidental removal developed hemorrhagic shock, but there no deaths occurred due to accidental removal. CONCLUSIONS: The present findings suggest that to prevent accidental removal, sufficient attention should be paid to delirium that occurs after admission as well to pre-existing dementia at the time of admission. As accidental removal occurs most commonly early after insertion and at night, special attention should be paid during these periods.

Paraneoplastic Polymyositis Due to Renal Cell Carcinoma in a Patient with Autosomal Dominant Polycystic Kidney Disease.

We herein report a 70-year-old man with malaise and muscle weakness that had developed within a month. The patient also had abdominal fullness due to polycystic kidney disease. Severe proximal skeletal muscle weakness and mild elevation of creatinine kinase to 301 IU/L were noted. A muscle biopsy of the right bicep showed polymyositis. Computed tomography showed a right renal mass, and an analysis after right nephrectomy identified clear cell carcinoma. The muscle weakness subsided one month after nephrectomy and intravenous immunoglobulin therapy. Therefore, we suspect that the development of polymyositis in this patient was closely related to renal cell carcinoma.

Correction to: A nationwide survey on clinical practice patterns and bleeding complications of percutaneous native kidney biopsy in Japan.

In the original publication, some errors have been found in the alignment of Table 9. The corrected table is given below.

A nationwide survey on clinical practice patterns and bleeding complications of percutaneous native kidney biopsy in Japan.

BACKGROUND: Practice patterns and bleeding complications of percutaneous native kidney biopsy (PNKB) have not recently been investigated and the Japanese Society of Nephrology performed a nationwide questionnaire survey in 2018. METHODS: The survey consisted of nine sections about PNKB: (1) general indications; (2) indications for high-risk patients; (3) informed consent; (4) pre-biopsy evaluation; (5) procedures; (6) sedation; (7) post-biopsy hemostasis, bed rest, and examinations; (8) bleeding complications; and (9) specimen processing. A supplementary survey examined bleeding requiring transcatheter arterial embolization (TAE). RESULTS: Overall, 220 directors of facilities (nephrology facility [NF], 168; pediatric nephrology facility [PF], 52) completed the survey. Indications, procedures, and monitoring protocols varied across facilities. Median lengths of hospital stay were 5 days in NFs and 6 days in PFs. Gauge 14, 16, 18 needles were used in 5%, 56%, 33% in NFs and 0%, 63%, 64% in PFs. Mean limits of needle passes were 5 in NFs and 4 in PFs. The bed rest period was 16-24 h in 60% of NFs and 65% of PFs. Based on 17,342 PNKBs, incidence rates of macroscopic hematuria, erythrocyte transfusion, and TAE were 3.1% (NF, 2.8%; PF, 6.2%), 0.7% (NF, 0.8%; PF, 0%), and 0.2% (NF, 0.2%; PF, 0.06%), respectively. Forty-six percent of facilities processed specimens all for light microscopy, immunofluorescence, and electron microscopy, and 21% processed for light microscopy only. Timing of bleeding requiring TAE varied among PNKB cases. CONCLUSION: Wide variations in practice patterns of PNKB existed among facilities, while PNKBs were performed as safely as previously reported.

Kidney autotransplantation for the treatment of renal artery occlusion after endovascular aortic repair: a case report.

BACKGROUND: Unintentional renal artery occlusion after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm remains one of the most unfavorable complications. Renal salvage options include percutaneous transluminal renal artery angioplasty (PTRA) and open hepatosplenorenal bypass. However, the usefulness of kidney autotransplantation (AutoTx) remains unclear. CASE PRESENTATION: A 76-year-old woman with a right solitary kidney attributable to a left renal thromboembolism had previously undergone EVAR with a stent graft for an infrarenal aortic aneurysm, which led to ostial occlusion of the right renal artery. In addition, she had undergone PTRA and stenting. Two days before admission, she developed leg edema and hypertension, leading her to visit the hospital. Her serum creatinine level was 2.4 (baseline, 1.0) mg/dL. Acute kidney injury due to renal artery in-stent restenosis was suspected; re-angioplasty was attempted on day 2 of hospitalization, but was unsuccessful. Her renal function did not improve and anuria persisted; thus, hemodialysis was initiated on the same day. The right kidney size (8.6 cm) was preserved relative to her body size, with only mild cortical atrophy. Doppler ultrasonography and mercaptoacetyltriglycine scintigraphy revealed minimal but significant perfusion of the right kidney. Therefore, we considered that kidney perfusion was sustained and renal function could be reversed. On day 25 of hospitalization, right kidney AutoTx to the right iliac fossa was performed to reestablish adequate renal perfusion and reverse the need for dialysis. Soon after the procedure, the patient started passing urine. Her renal function improved; her serum creatinine level decreased to 1.0 mg/dL on day 33 of hospitalization. Hemodialysis was discontinued after the surgery. Zero-hour kidney biopsy showed only mild tubular injury, with neither tubular necrosis nor glomerular abnormalities. CONCLUSIONS: Kidney AutoTx can be performed for patients with renal artery in-stent occlusion after unsuccessful PTRA who previously underwent EVAR. Our case showed successful recovery of renal function nearly 1 month after renal artery occlusion, indicating that revascularization should be considered even if it is delayed, as the kidney might be perfused through collateral circulation.

Clinicopathological analysis of persistent hypercalcemia and hyperparathyroidism after kidney transplantation in long-term dialysis patients.

Deceased donor kidney transplantation in long-term dialysis patients in Japan has been increasing because of a severe lack of donors. Parathyroid glands of long-term dialysis patients often show qualitative morphological changes from diffuse to nodular hyperplasia. Only a few studies have reported the clinicopathological analysis of persistent hyperparathyroidism after kidney transplantation in long-term (>10 years) dialysis patients. This study on consecutive deceased donor kidney transplantation performed from 2002 to 2010 measured biochemical parameters related to bone and mineral disorders and examined parathyroid tissues in parathyroidectomy cases. Thirty-four subjects (22 males; mean age, 53.8 ± 7.9 years; mean dialysis period, 14.4 ± 4.3 years) were enrolled. Multivariate analysis of potential predictors for the hypercalcemia group at 12 months after transplantation showed that pre-transplantation and early post-transplantation calcium and parathyroid hormone levels were significant determinants. Pathological examination showed that a number of glands showed nodular hyperplasia, even in small glands weighing < 100 mg. In long-term dialysis patients, hyperparathyroidism and hypercalcemia developed at an early stage after transplantation and persisted for a long period (>4 years), with nodular hyperplasia being found even in low-weight parathyroid glands. Pre-transplant high calcium and parathyroid hormone levels were the predictors for the prolonged hypercalcemia. Persistent hyperparathyroidism was considered to be caused by remaining nodular hyperplasia, even if the glands were small. Although the best treatment option is to perform a parathyroidectomy in the waiting period before transplantation, we suggest that it be performed in cases with prolonged hypercalcemia of >6 months after transplantation.

Liver transplantation for hepatocellular carcinoma in New Zealand: a prospective intent-to-treat analysis.

UNLABELLED: Liver transplantation (LT) is potentially curative for early hepatocellular carcinoma (HCC) but time spent on the waiting list exposes patients to the risk of tumour progression prior to transplantation. AIMS: We prospectively evaluated the outcome for New Zealand patients listed for LT with a pre-transplant diagnosis of HCC. METHODS: Patients with 1 to 3 tumours, up to 5 cm in diameter, and no vascular invasion or extra-hepatic disease on imaging, were considered eligible for LT. The results were analysed by intention to treat from the time of listing. RESULTS: Fifty-nine patients were listed with a pre-transplant diagnosis of HCC between February 1998 and June 2004. Ten (17%) were de-listed before LT because of tumour progression, and 9 of 45 (20%) who underwent LT have experienced tumour recurrence up to 59 months post-transplant. For patients listed with a diagnosis of HCC, 5-year actuarial survival was 56.1% from the time of listing. For those listed and transplanted with a diagnosis of HCC, 5-year actuarial survival from the time of transplant was 63.5%. This is significantly worse than the 89.8% 5-year survival for patients transplanted without HCC over the same period (p=0.018) and this difference was entirely due to tumour recurrence. CONCLUSIONS: 37% of patients listed according to our criteria were either de-listed due to tumour progression or experienced recurrence after LT. Based on this experience strategies aimed at preventing waiting list drop out have been adopted, however expansion of tumour-related selection criteria cannot be recommended without a concomitant increase in donor organ availability.

A successful liver transplantation for refractory hepatic veno-occlusive disease originating from cord blood transplantation.

An 11-month-old boy with acute lymphoblastic leukemia (ALL) underwent umbilical cord blood transplantation (CBT) from an unrelated donor after a first complete remission. Despite the prophylactic use of low molecular weight heparin, prostaglandin E1 and ursodeoxycholic acid, hepatic veno-occlusive disease (VOD) occurred on the 29th day after CBT. Furthermore, neither defibrotide nor antithrombin-III improved the hepatic coma and coagulopathy due to the hepatic VOD. On the 42nd day after CBT, he underwent living related liver transplantation (LRLT) with a left lateral segment graft from his father. He received tacrolimus for the prevention of rejection and graft-vs.-host disease (GVHD) and also received aggressive antifungal and antiviral prophylaxis. Although he showed signs of acute rejection on postoperative days 5 and 10, the postoperative course was uneventful in general. At present, 17 months after LRLT, the patient shows stable liver function and no signs of either GVHD or a relapse of ALL. In conclusion, LRLT can be seen as a feasible option for the treatment of a hepatic VOD after CBT, though aggressive prophylaxis for infection and the anticipation of acute rejection are of importance.