Hydroxocobalamin supplementation and erythropoisis stimulating agent hyporesponsiveness in haemodialysis patients.

BACKGROUND: Long-term haemodialysis patients may be at risk of hydrosoluble vitamin deficiencies. This study aimed to test the hypothesis that in patients with serum B12 < 300 pmol/L, intramuscular hydroxocobalamin reduces erythropoietin requirements whilst maintaining haemoglobin concentrations (Hb). METHODS: Study design was prospective, non-randomized, open label, with single group assignment. In 61 patients hydroxocobalamin 1000 µg was given weekly for 3 weeks and erythropoietin dose adjusted to target a Hb of 11-12 g/L. The primary outcome was the change in erythropoietin requirements at 2 years. Secondary outcomes included assessment of change in biochemical or clinical parameters. RESULTS: The erythropoietin dose reduced from 11 000 ± 7000 (10 000) IU to 5000 ± 6000 (3000) IU per week (P < 0.001) with no change in Hb 116 ± 16 (117) g/L before and after 114 ± 15 (113) g/L (P = 0.488) hydroxocobalamin supplementation. Serum albumin rose from 35 ± 4 (35) g/L to 36 ± 4 (36) g/L (P = 0.03). A significant rise in red cell folate (RCF) and serum vitamin B12 levels was observed. Serum ferritin rose despite a reduction in intravenous iron usage and no significant change in c-reactive protein or transferrin saturation. CONCLUSIONS: In HD patients with B12 < 300 pmol/L, following treatment with hydroxocobalamin there was reduced erythropoietin requirements, maintained Hb and a small but significant rise in the serum albumin. RCF may be low in haemodialysis patients with metabolic cobalamin deficiency and rises significantly after supplementation. Hydroxocobalamin supplementation may have the potential to reduce the cost of anaemia management.

Percutaneous maintenance and salvage of dysfunctional arteriovenous fistulae and grafts by nephrologists in Australia.

AIM: Percutaneous endovascular procedures can maintain and salvage dysfunctional arteriovenous fistulae and grafts used in haemodialysis. The aim of this study is to report the experience of nephrologists from a single centre in Australia with these procedures. METHODS: A total of 187 consecutive percutaneous vascular procedures (angioplasty, angioplasty±thrombolysis, stent placement and accessory vein ligation) were performed in 100 haemodialysis patients with dysfunctional arteriovenous fistulae and grafts between January 2006 and July 2009 in a single centre. All relevant clinical and radiological data collected during this period were reviewed retrospectively. Post patency rates were estimated using the Kaplan-Meier method. RESULTS: The clinical and anatomic success rates were 93% (172 of 184 interventions) and 91% (169 of 184 interventions), respectively. The overall complication rate was 5.9%. A major complication leading to access loss occurred in one patient (0.5%). The primary patency rates at 6, 12 and 18 months were 72%, 55% and 47%, respectively. The secondary patency rates at 6, 12 and 18 months were 96%, 93% and 90%, respectively. The mean cumulative patency was 36.8 months±SE 1.27 (95%CI 36.8-39.3). The mean fluoroscopy screening time was 11.5±8.5 min. CONCLUSION: This study demonstrates that high anatomic success and excellent patency rates can be obtained with percutaneous endovascular procedures and that appropriately trained interventional nephrologists can perform these procedures safely and effectively.

Non-candidal fungal peritonitis in Far North Queensland: a case series.

BACKGROUND: Fungal peritonitis is a recognized complication in patients with end-stage renal failure treated with peritoneal dialysis (PD). Most infections are attributable to Candida species. In approximately one third of cases, the causative fungus is a non-Candida species. Recent reports in the literature show a rising incidence of non-candidal fungal peritonitis (NCFP). We report a case series of NCFP, together with two hitherto unreported species of fungi causing peritonitis, from a tropical geographic area (Far North Queensland). METHODS: This series of 10 cases of NCFP was identified from the PD peritonitis database in Far North Queensland between 1998 and 2010. All 10 patients were from the Aboriginal and Torres Strait Islander ethnic group, 8 of whom lived in remote locations. All but 1 patient had type 2 diabetes mellitus. Of the 10 cases, 7 occurred while the patients received continuous ambulatory PD. Only 1 patient avoided catheter removal, and 5 patients were permanently transferred to hemodialysis. No patient died as a result of the fungal infection. All 10 fungi represented different species. Most (6 of 10) were saprophytic; only 2 were normal skin flora. Two of the causative species (Chaetomium and Beauveria) have rarely been associated with any form of human infection. In 7 patients, the infection occurred during the wet season (November - April). All cases met clinical criteria for peritonitis. DISCUSSION AND CONCLUSIONS: The NCFP cases described in this series involved a variety of previously known fungal species and also two new species that have not been reported to cause disease in humans. Indigenous patients from Far North Queensland are particularly predisposed to infection with these exotic fungi as a result of environmental and social factors. Further understanding is desirable to help devise preventive strategies to avoid the consequences of catheter failure.