A 60-year-old man, who had undergone mitral valve repair with quadrangular resection of the posterior mitral leaflet and ring annuloplasty with a Cosgrove-Edwards ring, developed severe mechanical hemolytic anemia. Doppler echocardiography showed only mild residual mitral regurgitation, but turbulent jet was directed toward the annuloplasty ring. Because of unremitting hemolysis requiring multiple transfusions and the occurrence of renal dysfunction, he underwent replacement of the mitral valve with a St. Jude Medical valve. Inspection of the annuloplasty ring at operation showed no evidence of dehiscence, but the area of the annuloplasty ring adjacent to the posteromedial commissure showed no endothelization. After the reoperation, the hemolysis and general condition immediately improved. This experience made us realize the possibility that a high-velocity regurgitant jet toward the cloth-covered annuloplasty ring, even if it mild, can cause severe hemolysis.

With an increasing number of patients suffering from chronic renal failure, the question of how to prolong the period before starting hemodialysis therapy has been attracting great attention. Kremezin^® and Daio-Kanzo-To, which have been reported to produce good clinical results, were administered to two patients with chronic renal failure in the preservation phase. When the treatment started, renal function tended to deteriorate, and hemodialysis had to be introduced in both patients. We investigated possible causes of this deterioration, and the effect of the combined use of Kremezin^® and Daio-kanzo-To the renal function could not be denied. This combination therapy needs to be studied very carefully.

It is suggested that in the use of tacrolimus for treatment of ulcerative colitis, it is important to achieve and maintain a high trough level as soon as possible. We examined two cases, with a starting initial dose higher than that recommended in the package insert, and adjusted the dose by daily therapeutic drug monitoring. Improvement of symptoms was observed by maintaining a high trough level of 10 to 15 ng/mL in these 2 cases. This improvement was observed from 9 days after achieving the high trough level, and it took the same number of days as stated in the mode of administration in the package insert.