Objectives: Diagnosing the bladder lesions associated with interstitial cystitis/painful bladder syndrome (IC/PBS) is sometimes difficult for general urologists. We therefore aimed to develop an IC/PBS diagnosis method using a cystoscope with a narrow-band imaging (NBI) system that can detect mucosal angiogenic lesions. Methods: Fifty-two subjects suspected of having IC between October 2006 and June 2007 were included in this study. There were 49 women and three men, ranging in age from 19 through 85 with an average age of 59. First, conventional cystoscopy under spinal anesthesia was performed to examine the ulcerative lesions by a urological specialist. Then, other health care professionals made a separate observation of capillary-rich areas of the superficial layer of the bladder mucosa by cystoscopy with the NBI system. Results: Among the 52 patients, 37 cases were found to have ulcers by conventional cystoscopy, which were also recognized as capillary-rich brownish areas using the NBI system (100% accuracy); 13 cases were found to have NBI-positive areas without ulcer, which were coincided with those with petechial hemorrhages and glomerulations following subsequent hydrodistention; and two cases of normal mucosa were detected. Furthermore, six cases of bladder cancer (carcinoma in situ) were detected by biopsies that were obtained from the ulcerative lesions positively identified by NBI cystoscopy. Conclusions: Examining the urinary bladder mucosa with a flexible cystoscope with the NBI system makes it possible to easily detect ulcers of bladder mucosa and areas with angiogenesis. Therefore, it is considered that the use of a flexible cystoscope with the NBI system is highly practical for the IC/PBS diagnosis.

Introduction: Patients aged 60 years and older stand for the fastest growing group of patients with end-stage renal disease worldwide, and the need for kidney transplants among this population is rising. In Japan, living donor kidney transplantation is mainly performed to deal with the severe shortage of deceased donors, and the number of spousal transplants is currently increasing. Patients and Methods: A total of 164 patients with ESRD underwent living donor kidney transplantation at our institution, of whom 21 patients aged 60 years and older had spousal kidney transplantation. ABO-incompatible kidney transplantation was performed in 5 of the 21 cases. We analyzed these recipients. Results: Patient and graft survival rates were 100%. The incidence of acute rejection was 23.8%. Eight patients experienced cytomegalovirus viremia, two patients experienced Pneumocystis jiroveci infection, and one experienced bacterial pneumonia. Two patients developed cancers and underwent curative operation after transplantation. Conclusions: Elderly kidney transplantation from spousal donors is associated with age-related immune dysfunction, which may develop infections and malignancies and could be immunologically high risk due to the high rate of ABO-incompatibility and poor histocompatibility. An effort to minimize the adverse effect of immunosuppression and to reduce the risk of acute rejection may be needed for an excellent long-term outcome.

Background: Venous hypertension is one of the critical complications of arteriovenous fistula (AV fistula). Here, we report an unusual variation of venous hypertension which was caused by retrograde outflow through a perforating vein of the elbow. Case presentation: A 79-year-old man with diabetic nephropathy had an AV fistula created at his left proximal forearm 2 years before referral. Shortly after the creation of the AV fistula, he developed swelling of the left hand and forearm. Six months prior to the referral, persistent pain of the left hand developed, and he visited the nephrology unit. An anastomosis of the AV fistula was located 5 cm distal to the elbow. Inspection, palpation, and auscultation did not suggest outflow stenosis. Ultrasound showed mature upper arm venous outflow without stenosis. His proximal radial artery had been anastomosed side-to-end to a nearby proximal forearm superficial vein. Color Doppler analysis revealed a retrograde outflow through an antecubital perforating vein, which drained into the deep portion of the forearm and then disappeared. Superficial veins of the left forearm had been exhausted due to a previous attempt to create a wrist AV fistula. Given the above, it was suspected that the unusual retrograde outflow through the perforating vein caused venous hypertension by interfering with the venous return of the forearm, which had been dependent on deep veins. The patient subsequently underwent ligation of the perforating vein. The day after the operation, the pain disappeared and swelling improved. The dialysis treatments were continued without problems. Conclusions: Retrograde outflow through a perforating vein can be a cause of venous hypertension in a patient with an AV fistula created using the proximal radial artery. Close sonographic examination of antecubital vessels should be done if a practitioner encounters unilateral whole forearm edema without apparent proximal outflow stenosis.

Key words：simulation education, ultrasound-guided central venous catheterization, simulator, reflection, portfolio 〈Abstract〉 Purpose：To help novice doctors perform ultrasound-guided central venous access insertion, we introduced a novel simulation program. Participants and methods：Between April 2008 and April 2012, 10 novice doctors performed ultrasound-guided central venous access insertion in our nephrology department. The training program was as follows：1)Lecture on the theory of ultrasound-guided puncture, 2)Repeated watching of an instructional DVD showing an instructorʼs performance with a patient, 3)Training using a self-made simulator and catheter kit, 4)On-the-job training with the instructor after watching the instructorʼs performance with patients：the instructor held an ultrasound probe together with the trainee, and directed the trainee on how to proceed for introducing the needle. The ultrasound image was recorded with a digital video recorder. 5)The trainee reflected with the instructor while watching the video after the on-the-job training. The recorded

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