**1. Introduction**

120 Technical Problems in Patients on Hemodialysis

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Patients receiving hemodialysis (HD) often have complex chronic wounds, which are hard to heal because of complications of other diseases, including DM, calciphylaxis, collagen disease, arteriosclerosis obliterans, chronic anemia, and weakness of the skin (Figures 1-3)1-3). Subsequent infection of necrotic skin tissue is associated with the risk of sepsis, which may be fatal if the blood access shunts become infected 4).

Fig. 1. (A) A 54-year-old woman was referred from an emergency unit for complex necrotic ulcer of the right hand with high fever. She had systemic lupus erythematosus and had been treated with 20 mg/ day of prednisolone for 40 years. She had received hemodialysis because of lupus nephritis for 34 years through a blood access shunt in the right elbow, which also showed inflammation. Debridement of the right hand was immediately performed.

Complex Wounds in Patients Receiving Hemodialysis 123

Fig. 2. (A) A 56-year-old man was referred from an emergency unit for a complex necrotic ulcer caused by a burn to the left foot with high fever. He had received hemodialysis because of diabetes mellitus for 4 years through a blood access shunt in the right elbow, which also showed inflammation. Amputation of the left big and 2nd toes was immediately performed. (B) As soft tissue necrosis progressed after debridement, and osteomyelitis occurred 1 month later, he underwent further amputation. (C) The wound improved over a

Figure 3

Fig. 3. A 65-year-old man was referred from an emergency unit for severe pain and a complex necrotic ulcer of the bilateral feet. He had arteriosclerosis obliterans, and had received hemodialysis because of chronic glomerulonephritis for 34 years. Right below-knee

period of 1 month with favorable granulation.

amputation was performed.

Figure 2A Figure 2B Figure 2C

Fig. 1. (B) As the patient's wound improved over a period of 1 month, she underwent resurfacing surgery using local flap transfer and free skin grafting. The wound had completely resurfaced by 2 weeks after surgery.

Fig. 1. (C) However, the wound aggravated and marked erythema expanded rapidly to the upper arm over the course of one day, which required immediate amputation of the infected hand at the forearm.

Fig. 1. (B) As the patient's wound improved over a period of 1 month, she underwent resurfacing surgery using local flap transfer and free skin grafting. The wound had

Fig. 1. (C) However, the wound aggravated and marked erythema expanded rapidly to the upper arm over the course of one day, which required immediate amputation of the infected

completely resurfaced by 2 weeks after surgery.

Figure 1C

hand at the forearm.

Fig. 2. (A) A 56-year-old man was referred from an emergency unit for a complex necrotic ulcer caused by a burn to the left foot with high fever. He had received hemodialysis because of diabetes mellitus for 4 years through a blood access shunt in the right elbow, which also showed inflammation. Amputation of the left big and 2nd toes was immediately performed. (B) As soft tissue necrosis progressed after debridement, and osteomyelitis occurred 1 month later, he underwent further amputation. (C) The wound improved over a period of 1 month with favorable granulation.

Fig. 3. A 65-year-old man was referred from an emergency unit for severe pain and a complex necrotic ulcer of the bilateral feet. He had arteriosclerosis obliterans, and had received hemodialysis because of chronic glomerulonephritis for 34 years. Right below-knee amputation was performed.

Complex Wounds in Patients Receiving Hemodialysis 125

Study, collecting data from more than 29,000 HD patients, showed that 42% of HD patients experience moderate to extreme itching 15). The impaired skin resistance and stimuli caused by scrunching because of itchy skin cause continuous inflammations, which contribute to local skin ulcers and the general development of malnutrition and cardiovascular disease 16). In addition, disturbed mineral metabolism is associated with skin complaints in dialysis patients17). Other cutaneous manifestations include scaling (9.9%), pressure ulcer (2 .0%),

Regarding cutaneous infection, Bencini *et al.* reported that the incidence of fungal infection in patients undergoing hemodialysis was 67% 20). CRF patients exhibit impaired cellular immunity due to a decreased T-lymphocyte cell count; this could explain the increased prevalence of fungal infections 21). Other cutaneous infections include bacterial (13%) and viral (12%) infections, reportedly common in diabetics 9). Difficulty healing wounds is a frequent problem in patients on HD because of their poor general conditions, including malnutrition, inflammation, and atherosclerosis syndrome 1). Stein and Wiersum, in a retrospective analysis of 22,389 laparotomies, concluded that dysfunction played a significant role in the development and outcome of abdominal wound dehiscence 2). Not only abdominal surgical wounds, but also all surgical sites sometimes develop poor wound adhesion causing a complex ulcer (Figure 5). Mistrík et al. reported at significant decrease in skin blood flow during the HD procedure and concluded that the skin blood flow may be impaired in HD patients, which leads to the development of difficulty in healing skin wounds 3). Consequently, patients with end-stage renal disease were associated with higher resource use, complication rates, and mortality when they

Fig. 5. Development of a complex leg ulcer because of wound dehiscence, following great

**3. Profiles and clinical status of HD-receiving patients who develop extremity** 

Thirty patients receiving HD who had chronic wounds of the limbs underwent surgical treatment in our unit from 2004 through 2010. The ages ranged from 52 to 89 years (mean,

and dermatitis (2%) 18, 19).

were injured 22).

66.5 years).

saphenous vein harvest for vein grafting.

**ulcers because of diabetes mellitus or other diseases** 

The number of patients requiring HD because of obesity-related renal diseases such as diabetes mellitus is increasing 5, 6). This article focuses on the prevalence of complex wounds among patients with chronic renal failure (CRF) undergoing hemodialysis, and shows effective and successive treatments of these wounds.

We report our 6-year experience involving 30 patients receiving HD who had chronic skin ulcers. In addition, we investigated the differences in characteristics between patients receiving HD because of DM and those receiving HD due to other diseases.
