Spontaneous retroperitoneal hemorrhage in dialysis: a presentation of 5 cases and review of the literature.

BACKGROUND: Spontaneous retroperitoneal hemorrhage (SRH) is a rare but potentially fatal entity. Despite published case reports of SRH in dialysis, little systematic information is available. METHODS: Report of 5 cases and review of MEDLINE database from 1971 until 2008. RESULTS: Incidence of SRH in our unit was 0.86 cases per 100 patients; annual incidence rate 8/10,000 patients. We identified 34 publications, comprising 55 cases. The existing cases and the 5 reported were analyzed: 74.5 % male, average age 53.3 years (range 27-78), average time on dialysis 7.1 years (range 3 weeks-27.5 years), 95% on hemodialysis and 5% on peritoneal dialysis. There was significant heterogeneity in clinical presentation. The kidney was the most commonly reported origin (87.8%), and acquired cystic kidney disease (ACKD) was the most frequent underlying cause. 91.8% received some kind of anticoagulation. Treatment was conservative, included angioembolization or surgery in 33.3%, 17.6% and 49% of the cases respectively. Mortality rate was 18.3%. CONCLUSIONS: More than 85% of SRH in dialysis had a renal cause, ACKD being predominant. The complication occurs mainly in the HD modality, possibly in relation to anticoagulation. There is no evidence that screening of ACKD is of benefit predicting SRH. Therefore, awareness of ACKD as a manifestation of ESRD patients and its risk of bleeding is necessary. Because of the summation of risk factors that appears in the population on dialysis, SRH should be considered in the differential diagnosis of unexplained pain before drop in blood pressure or hematocrit occurs.

A case of endocarditis of difficult diagnosis in dialysis: could "pest" friends be involved?

We report a case of A. xylosoxidans endocarditis of larvate clinical presentation in a central venous catheter-dependent hemodialysis patient of difficult diagnosis and poor evolution despite a high index of suspicion and consequent assessment. A 50-year-old man on hemodialysis presented with inflammatory-malnutrition parameters during the months prior to diagnosis of endocarditis, whilst he was otherwise asymptomatic. No vegetations were detectable on his cardiac valves at repeated echocardiography until third transesophageal echocardiography was performed, and confirmed intraoperatively. On the occasion of positive peripheral blood culture for Alcaligenes (Achromobacter) xylosoxidans, the etiological diagnosis was retrospectively explained given his history of animal exposure - hunting rabbits using his pet ferrets. This bacterium is an emergent and resistant organism, mostly related to nosocomial infections and environmental water sources. Reservoirs include the microflora of the nasal cavity of rabbits and the dentogingival sulcus of ferrets. We presume that A. xylosoxidans endocarditis was transmitted from the patient's pets. It highlights the importance of early recognition of an inflammatory status and investigation of the underlying cause. Additionally, the causative bacterium emphasizes the importance of registering exposure to animals in CVC-dependent patients as well as the need for their awareness of hygienic precautions and the infectious risk associated to catheters.

[Clinical course of high and low immunological risk renal transplant receptors subjected to different immunosuppressive treatments]. / Evolución de receptores de trasplante renal de alto y bajo riesgo inmunológico sometidos a diferente inmunosupresión.

We evaluate the incidence of acute rejection, opportunistic infections and non-dermatological malignancies, graft and recipient survival between a group of high immunological risk renal transplant recipients and a group of patients without immunological risk, who received grafts from the same cadaveric donors since 2001 to 2006. This is a prospective and observational study. The risk group (n= 50) included patients with high rate of antibodies (> 50%), recipients who had lost their first graft due to early rejection, cross match positive, black race or important histoincompatibility. They received thymoglobulin to maintain T-cell around 10 cells/ microl, FK 506 after five days, mycophenolate mofetyl and steroids, with ganciclovir prophylaxis for CMV. The normal risk group (n=50) ,cyclosporine, mycophenolate mofetil and steroids. Recipients who lost their graft due to technical failure were excluded..All CMV seronegative recipients who received seropositive grafts were treated with valganciclovir for 100 days.The mean follow-up was 42,7 months. Both groups were similar respect to donor and recipient gender and age, HLA incompatibility, but the percentage of patients with high rate of performed antibodies and second transplant recipients was higher in the high risk group according to the criteria of the study The incidence of acute rejection histologically diagnosed was higher in the normal risk group (30% against 6 %, p=0.03). There was no difference in opportunistic infections or malignancies, although 2 recipients of the normal risk group developed lymphoproliferative disorders. The recipients survival was 97,9% at 1 and 3 years in both groups, and the graft survival was 89,8% and 84,8% in the high risk group against 93,8 % and 90,4% at 1 and 3 years in the normal group (p=NS). We conclude that the evolution of high risk renal transplant recipients is similar to normal risk patients if a potent enough immunosuppression is used. The incidence of acute rejection was higher in the normal risk group.

[Operation to remove tunnelled venous catheters in a dialysis unit. Is it possible to reverse the trend in their growing use?]. / Operación retirada de catéteres venosos tunelizados en una unidad de diálisis. ¿Es posible cambiar la tendencia en el uso creciente de éstos?

INTRODUCTION: Introduction In an attempt to reduce unnecessary central venous catheters (CVC) dependence in prevalent population, a "CVC removal" programme was initiated in our unit. The objective was to diminish the number of CVC and to analyze the causes of their insertion and maintenance. On 09/01/07, 38 out of 173 prevalent patients on hemodialysis. Methods were CVC dependant (21.9%): 16 incident patients (42,1%) and 22 (57,8%) prevalent patients. All of them were re-evaluated for permanent vascular access utilization, included those previously rejected for surgery. Physical, psychical and vascular aspects regarding each patient were taken into consideration. The following variables were age, Body mass index, time on hemodialysis, Charlson analyzed comorbidity index, DM or vascular comorbidities and number of vascular accesses created prior to CVC placement. In those patients in whom AVF creation was feasible, the following were registered after 18 months of 1.Primary failure rate. 2. Related complications. 3. up follow Percentage of usable AVF or AVG. 4. Percentage of removed CVC. 5. Mortality and hospitalization. The decision of no realization of a new vascular access and? Results maintenance of TVC was performed in 21 patients (55.2%). In 9 of them was decision of the nephrologists and the family. In 11 patients was decision of vascular surgeon due to vascular bed exhaustion. A permanent VA was achieved in 17 patients (44.7%), 50% of them was incident patients and 45% prevalent patients. The primary failure rate was 0%. The TVC was withdrawn in 11/17 (64.7%). Only 4 patients remain without TVC after 18 months of follow-up: 5 patients died (4 with a AVF functioning and 1 VA closure due to steal syndrome) and in 8 patients was mandatory to reintroduce the TVC again. Immediate complications after the surgery were: 1 severe haematoma, 2 infections and 2 severe sequestrations. 3 patients required hospital admission following complications directly related to VA. Mean time of free of TVC was 5.2 months (range: 0.7- 14.3 months). The mortality was 29,4% (5/17) in the group of patients with a new VA and 9,5% (2/21) in the other group(RR 3,19; IC 95%: 0,68-13,98; p: 0,11). No significant differences were observed between patients who transitioned to a permanent vascular access and those who remained TVC dependant in regards to age, gender, BMI, time on dialysis, DM, comorbidity or number of previous VA, Transition from CVC use to hospitalizations or mortality. Conclusions permanent vascular access is possible in prevalent patients in dialysis. Improvement was achieved by a modest amount, and after a prolonged process with gravel complications, some of which proved severe. Need for CVC dependence is confirmed in a high percentage of prevalent patients on dialysis. Comorbidity might have influenced the results. The quality standard should be adequate to reality of current population on hemodialysis.

[Dispositional optimism in patients on chronic haemodialysis and its possible influence on their clinical course]. / Optimismo disposicional en pacientes en hemodiálisis y su influencia en el curso de la enfermedad.

INTRODUCTION: Dispositional optimism is a personality trait significantly associated with the use of positive adaptive coping strategies as well as with perceived psychological and physical well-being, and it appears to be an important predictor of illness. OBJECTIVES: To analyse if dispositional optimism is significantly associated with the number of hospital admissions of our chronic haemodialysis patients, as well as its relationship with perceived state of health. METHODS: We studied 239 patients on chronic haemodialysis. Patients were categorised into two groups according to the variables: hospital admissions/no. of admissions in the last year and dispositional optimism (DO). We used the following variables and questionnaires: 1) Dispositional O/P using the Spanish-validated cross-cultural adaptation of the revised version of the Life Orientation Test (LOT-R) (Scheier, 1994): higher scores mean a higher degree of dispositional optimism. 2) Health-related quality of life (HRQoL) using the different aspects of the COOP/WONCA (CW) charts and its total score. In this case higher scores mean lower HRQoL. 3) Modified Charlson Comorbidity Index (mCCI). 4) Age, gender, and time on dialysis. RESULTS: Mean age was 64.8 ± 14.3 years; median time on dialysis 2.9 years (range: 0-32); and median LOT-R 21 (range 6-30). Patients considered DO had a lower risk of hospital admissions than pessimists (DP) (OR: 0.55; IC 95%: 0.32-0.94; P<.05). PD Patients that were admitted in the last year showed a significantly lower score on LOT-R (they were more pessimistic) than those that had no hospital admissions (19.4 ± 5.7 vs 22.3 ± 4.6; P=.001). We found no significant differences between admitted and not admitted patients in age, gender, time on haemodialysis and comorbidity. Admitted patients showed worse HRQoL (higher scores in total CW) than those that were not (Total CW: 22.37 vs 19.42; P<.001). PD patients had significantly higher scores than OD patients in all COOP-WONCA aspects except in aspect 1 (physical fitness) and 5 (change in health). CONCLUSIONS: Pessimistic personality trait is significantly associated with hospital admissions in chronic haemodialysis patients, regardless of age, gender and comorbidity. Optimistic patients perceived a better state of health.