Correlation between Dt/V derived from ionic dialysance and blood-driven Kt/V of urea in African-American hemodialysis patients, based on body weight and ultrafiltration volume.

BACKGROUND: The Dt/V obtained by using ionic dialysance (D) as a surrogate for urea clearance (K) is a well-validated adjunct measure of hemodialysis adequacy, with a variable level of correlation with urea-based Kt/V. However, this correlation has not been examined based on patients' body size and ultrafiltration (UF) volume during the dialysis session. METHODS: Simultaneous evaluations of online Dt/V and single-pool variable-volume urea Kt/V were made. Patients were categorized into three subgroups based on their weight (<60, 60-80 and ≥80 kg), body mass index (<25, 25-30 and >30 kg/m2) and UF volume (<1.5, 1.5-3 and >3 L). The correlation between Dt/V and Kt/V was evaluated for the entire cohort per dialysis session in each subgroup. RESULTS: Mean Kt/V was greater than the mean Dt/V (1.72 versus 1.50, P < 0.001), with an overall correlation r value of 0.602. This correlation was stronger in the medium weight group versus lower and higher weights. The correlation between Dt/V and Kt/V was inversely related to the UF volume (r = 0.698, 0.621 and 0.558 for those with UF volume of <1.5, 1.5-3.0 and >3 L, respectively). A total of 99.3% of patients with Dt/V of >1.2 also had Kt/V >1.2 and 9.5% of those with Dt/V <1.2 had their Kt/V <1.2. CONCLUSIONS: There is a moderate degree of correlation between Dt/V and Kt/V in African-American hemodialysis patients, which is impacted by body size and UF volume. A Dt/V of >1.2 strongly predicts adequate dialysis as defined by Kt/V of >1.2.

Collapsing glomerulopathy associated with hemophagocytic syndrome in a patient with NK/T cell lymphoma.

Hemophagocytic syndrome (HPS) is a rare condition caused by dysregulated activation of the immune system leading to infiltration of bone marrow and organs by nonmalignant macrophages that phagocytose blood cells. Primary HPS is caused by inherited immune dysregulation whereas secondary HPS is triggered by neoplastic, infectious or autoimmune diseases. Clinically, the syndrome presents with continuous high-grade fever in association with multi-organ involvement. Few data are available regarding renal manifestations of HPS. We report a 60-year-old patient with NK/T cell nasopharyngeal extranodal lymphoma who presented with acute kidney injury and nephrotic range proteinuria in association with fever and pancytopenia. A kidney biopsy was consistent with collapsing glomerulopathy. A final diagnosis of HPS was made on the basis of clinical, laboratory, and bone marrow biopsy findings in accordance with established diagnostic criteria. Steroid therapy was initiated. However, the patient failed to recover his renal function and remained hemodialysis-dependent. Key diagnostic and therapeutic challenges and strategies used to overcome those challenges are discussed.

Coagulopathy and spontaneous hemorrhage in a patient with nephrotic syndrome.

Patients with nephrotic syndrome, particularly those with membranous nephropathy tend to be in a hypercoagulable state and often present with thromboembolic phenomena. The association of nephrotic syndrome with a bleeding diathesis however is much less common and the etiologies less well recognized. We report a patient who presented with coagulopathy and recurrent spontaneous hemorrhage in association with nephrotic syndrome. The case highlights key diagnostic and therapeutic challenges and strategies: 1) work up to establish a unifying etiology for both nephrotic syndrome and the bleeding disorder; 2) decision making to obtain a tissue biopsy, select the site of biopsy and understand the relative yields for each site; 3) recognizing the risk and managing peri-procedural bleeding; and 5) developing a treatment strategy with the lowest risk of possible complications. Our patient underwent a kidney biopsy without any complications and a definitive diagnosis of AL amyloidosis was reached. He was treated with anti-plasma cell chemotherapy followed by autologous stem cell transplant with resultant complete hematologic response, improved coagulation parameters, and no further bleeding.

Downhill varices secondary to HeRO graft-related SVC syndrome.

Tunneled hemodialysis catheters are well-documented causes of benign central vein stenosis, which can be associated with proximal or downhill esophageal varices due to shunting of blood flow from the upper portion of the body through the esophageal venous plexuses. A majority of these cases remain asymptomatic. As a result, studies are largely limited to symptomatic patients, with incidence rates ranging from 16% to 29%. Recently, Hemodialysis Reliable Outflow (HeRO) graft has been introduced as an effective alternate hemodialysis access in catheter-dependent patients, especially in the presence of significant central venous occlusion. It differs from a conventional arteriovenous graft (AVG) by the fact that its venous outflow end is in the right atrium via one of the central veins, bypassing any significant occlusion upstream. Lower intervention rates and reduced incidence of bacteremia make it comparable to conventional tunneled catheters. However, the incidence of central vein occlusion and associated complications with HeRO grafts is unknown. We present the first case of gastrointestinal bleeding from downhill esophageal varices secondary to HeRO-graft-related SVC occlusion.