**5. Wound bed preparation for patients receiving HD**

After the debridement of necrotic tissue, the wound bed needs to be prepared to receive either a graft or flap. 31) The resurfacing of wounds is one of the most important procedures, because such wounds will cause further infection, exudates, odors, and bleeding, which decrease the patient's quality of life. Chronic ulcers may sometimes prevent the patient from living at home. 32) Wound bed preparation has allowed uncomplicated wounds to heal quickly. 23, 33-37) The management of chronic wounds has progressed from assessing the

Complex Wounds in Patients Receiving Hemodialysis 137

Fig. 17. (A) An 86-year-old female suffered from a bone-exposed wound due to a pressure ulcer on the heel. She had received hemodialysis because of chronic glomerulonephritis for 2 years. (B) She underwent reversed sural flap surgery. (C) The wound was completely

**6. Several adjuvant and devices in the management of hard-to-heal wounds**  In this section, several adjuvant and devices are presented, including growth factor, bioengineered tissues, and a negative pressure system, which are combined for the

Firstly, several growth factors have been used clinically to prepare favorable wound beds. Of these growth factors, basic fibroblast growth factor (bFGF) is the only angiogenic cytokine currently available in Japan.39) Treatment with bFGF allows chronic ulcers to heal more quickly (Figure 18). 40) Secondly, artificial dermis, which is composed of atelocollagen sponge and a silicone membrane, is beneficial for these wounds because of its unique characteristics (Figure 19). Atelocollagen sponge allows the early infiltration of mononuclear cells and fibroblasts, leading to the rapid resolution of inflammatory reactions and more favorable growth of granulation tissue. On the other hand, the silicone membrane protects against a loss of fluid, protein, and electrolytes, which helps maintain a suitable environment for wound healing. 41, 42) Formerly, resurfacing tendon- or bone-exposed wounds required vascularized flaps, showing high morbidity at the donor site, skilful micro- or plastic surgeons, microsurgical instruments, and much time, because a free skin graft would not take on unfavorable wound beds, such as in the presence of infected granulation and low-vascular tissues. 41) Artificial dermis is beneficial for the reconstruction of these wounds because it promotes the early infiltration of mononuclear cells and

fibroblasts and better growth of connective tissue strands and epithelium. 41-43)

resurfaced. She regained the ability to walk.

improved clinical treatment of complex wounds. 24)

status of a wound to understanding the underlying molecular and cellular abnormalities that prevent the wound from healing. The concept of wound bed preparation offers a systematic approach to remove barriers to healing such as tissue (non-viable), infection/inflammation, moisture (imbalance), and edge (non-advancing or undermining) and enhancing the effects of advanced therapies. 35, 36) Wound bed preparation is an essential element of wound management that advances endogenous healing as well as the efficacy of topical and other wound therapy.38) Wound bed preparation techniques will allow complex wounds to grow abundant granulation tissue. When a wound is covered with suitable granulation and no contamination is observed, free skin grafting should be performed as soon as possible (Figure 16). In cases of bone- or tendon-exposed wounds, some flaps are required to resurface the wounds, because grafted skin will not take directly on tendon or bone (Figure 17).

Fig. 16. (A) A 86-year-old female suffered a hematoma due to falling on a step. She had received hemodialysis because of chronic glomerulonephritis for 43 years. (B) Three weeks after the treatment of the wound bed, abundant granulation tissue was observed. She underwent a free skin graft, and the wound resurfaced favorably.

status of a wound to understanding the underlying molecular and cellular abnormalities that prevent the wound from healing. The concept of wound bed preparation offers a systematic approach to remove barriers to healing such as tissue (non-viable), infection/inflammation, moisture (imbalance), and edge (non-advancing or undermining) and enhancing the effects of advanced therapies. 35, 36) Wound bed preparation is an essential element of wound management that advances endogenous healing as well as the efficacy of topical and other wound therapy.38) Wound bed preparation techniques will allow complex wounds to grow abundant granulation tissue. When a wound is covered with suitable granulation and no contamination is observed, free skin grafting should be performed as soon as possible (Figure 16). In cases of bone- or tendon-exposed wounds, some flaps are required to resurface the wounds, because grafted skin will not take directly on tendon or

Fig. 16. (A) A 86-year-old female suffered a hematoma due to falling on a step. She had received hemodialysis because of chronic glomerulonephritis for 43 years. (B) Three weeks after the treatment of the wound bed, abundant granulation tissue was observed. She

B

A

underwent a free skin graft, and the wound resurfaced favorably.

bone (Figure 17).

Fig. 17. (A) An 86-year-old female suffered from a bone-exposed wound due to a pressure ulcer on the heel. She had received hemodialysis because of chronic glomerulonephritis for 2 years. (B) She underwent reversed sural flap surgery. (C) The wound was completely resurfaced. She regained the ability to walk.
