Pregnancy outcomes for women with pre-existing renal disease and the role of a dedicated joint maternal medicine and renal clinic: A retrospective cohort study.

OBJECTIVE: To reaffirm the value of a joint obstetric and renal clinic on obstetric outcomes in patients with high-risk pregnancies due to chronic kidney disease (CKD). METHODS: This was a retrospective cohort study of patients who attended the clinic between 2005 and December 2021. The hospital is a regional tertiary unit for renal medicine and a maternal medicine hub. The data included all women with pre-existing renal conditions who were cared for in a dedicated renal and obstetric clinic. Datasets were extracted from hospital notes, the renal database, clinical data and maternity electronic health records. The data analyzed included pre-existing renal conditions, biochemical parameters related to the renal condition, pregnancy outcomes included miscarriages, gestation, mode of delivery, postpartum hemorrhage (PPH), loss, birth weight and neonatal admission. RESULTS: The results were as follows: Lupus nephritis: four term deliveries; three had pre-eclampsia; two PPH and two miscarriages. Four estimated glomerular filtration rates (eGFRs) returned to baseline levels within 12 months. With regard to IgA nephropathy there were five live births, four term deliveries, two pre-eclampsia (PE) and five cesarean sections (CS). All eGFRs returned to baseline within 12 months. With regard to patients with adult polycystic kidney disease (APKD), there were six live births, two had pre-eclampsia and there were five term vaginal deliveries. CONCLUSION: Patients with lupus nephritis, APKD, and IgA demonstrated a higher incidence of adverse pregnancy outcomes as compared with our local pregnant population. Our findings reflect those of larger studies and support the role of combined renal/obstetric clinics. More research and larger scale studies are needed into specific CKD conditions and their outcomes.

Severity of COVID-19 after Vaccination among Hemodialysis Patients: An Observational Cohort Study.

BACKGROUND AND OBJECTIVES: Patients receiving hemodialysis are at high risk from coronavirus disease 2019 (COVID-19) and demonstrate impaired immune responses to vaccines. There have been several descriptions of their immunologic responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination, but few studies have described the clinical efficacy of vaccination in patients on hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In a multicenter observational study of the London hemodialysis population undergoing surveillance PCR testing during the period of vaccine rollout with BNT162b2 and AZD1222, all of those positive for SARS-CoV-2 were identified. Clinical outcomes were analyzed according to predictor variables, including vaccination status, using a mixed effects logistic regression model. Risk of infection was analyzed in a subgroup of the base population using a Cox proportional hazards model with vaccination status as a time-varying covariate. RESULTS: SARS-CoV-2 infection was identified in 1323 patients of different ethnicities (Asian/other, 30%; Black, 38%; and White, 32%), including 1047 (79%) unvaccinated, 86 (7%) after first-dose vaccination, and 190 (14%) after second-dose vaccination. The majority of patients had a mild course; however, 515 (39%) were hospitalized, and 172 (13%) died. Older age, diabetes, and immune suppression were associated with greater illness severity. In regression models adjusted for age, comorbidity, and time period, prior two-dose vaccination was associated with a 75% (95% confidence interval, 56 to 86) lower risk of admission and 88% (95% confidence interval, 70 to 95) fewer deaths compared with unvaccinated patients. No loss of protection was seen in patients over 65 years or with increasing time since vaccination, and no difference was seen between vaccine types. CONCLUSIONS: These data demonstrate a substantially lower risk of severe COVID-19 after vaccination in patients on dialysis who become infected with SARS-CoV-2.

Outcome and effect of vaccination in SARS-CoV-2 Omicron infection in hemodialysis patients: a cohort study.

BACKGROUND: Hemodialysis patients are at high risk of Covid-19, though vaccination has significant efficacy in preventing and reducing the severity of infection. Little information is available on disease severity and vaccine efficacy since the dissemination of the Omicron variant. METHODS: In a multi-center study, during a period of the epidemic driven by the Omicron variant, all hemodialysis patients positive for SARS-CoV-2 were identified. Outcomes were analyzed according to predictor variables including vaccination status. Risk of infection was analyzed using a Cox proportional hazards model. RESULTS: SARS-CoV-2 infection was identified in 1126 patients including 200 (18%) unvaccinated, 56 (5%) post first dose, 433 (38%) post second dose, and 437 (39%) at least 7 days beyond their third dose. The majority of patients had a mild course but 160 (14%) were hospitalized and 28 (2%) died. In regression models adjusted for age and comorbidity, two-dose vaccination was associated with a 39% (95%CI: 2%-62%) reduction in admissions, but third doses provided additional protection, with a 51% (95%CI: 25%-69%) further reduction in admissions. Among 1265 patients at risk at the start of the observation period, SARS-CoV-2 infection was observed in 211 (17%). Two-dose vaccination was associated with a 41% (95%CI: 3%-64%) reduction in the incidence of infection, with no clear additional effect provided by third doses. CONCLUSIONS: These data demonstrate lower incidence of SARS-CoV-2 infection after vaccination in dialysis patients during an Omicron dominant period of the epidemic. Among those developing infection, severe illness was less common with prior vaccination, particularly after third vaccine doses.

The 370-Da Inhibitor of the Sodium Pump in the Plasma of Haemodialysis Patients.

BACKGROUND: Previous studies have shown that a molecule of mass 370 Da that inhibits the sodium pump can be extracted from human placentas and from the concentrated plasma or ultrafiltrate of volume-expanded patients. AIM: This study aimed to study the abundance of the 370-Da molecule and its changes across dialysis in a population of patients with renal failure treated by haemodialysis. METHODS: Four millilitres of pre- and post-dialysis blood samples (2 mL plasma) were taken from patients receiving intermittent haemodialysis and analysed by high-performance liquid chromatography coupled to high sensitivity mass spectrometry. RESULTS: In over half of the study population, the 370-Da molecule was present in abundance that exceeded the limit of quantitation. Most patients experienced a marked fall in the abundance of the molecule over a haemodiafiltration session, though exceptions were seen in 2 individuals, both of whom showed clear evidence for the presence of 2 structural isomers of the 370-Da molecule. CONCLUSIONS: Advanced renal failure is frequently accompanied by an increased abundance of a 370-Da inhibitor of the sodium pump and that abundance is strongly impacted by haemodialysis. The technique described here could readily be applied to other clinical situations where sodium pump inhibition might be anticipated, such as hypertension, pregnancy, and foetal medicine, and thereby lead to a better understanding of the physiology and pathophysiology of these conditions.

Fludrocortisone Is an Effective Treatment for Hyperkalaemic Metabolic Acidosis in Kidney Transplant Recipients on Tacrolimus: A Case Series.

BACKGROUND: Hyperkalaemia with metabolic acidosis is common but under-reported following kidney transplantation. Calcineurin inhibitors, such as tacrolimus, are widely used in the management of transplant patients and are associated with the development of hyperkalaemia. We report on 10 renal transplant patients, treated with fludrocortisone, following identification of hyperkalaemic metabolic acidosis. RESULTS: All 10 patients were male aged (mean ± SD) 53.0 ± 13.2 years; 7 were Caucasian and 3 South Asian. Before and after fludrocortisone administration, respective (mean ± SD) serum potassium was 6.1 ± 0.4 mmol/L and 5.3 ± 0.3 mmol/L (p = 0.0002); serum bicarbonate 18.5 ± 1.6 mmol/L and 20.5 ± 2.3 mmol/L (p = 0.002); serum sodium 135 ± 4.6 mmol/L and 137 ± 2.2 mmol/L (p = 0.0728); serum creatinine 181 ± 61 µmol/L and 168 ± 64 µmol/L (p = 0.1318); eGFR 42 ± 18 mL/min and 46 ± 18 mL/min (p = 0.0303); blood tacrolimus 10.1 ± 2.9 ng/mL and 10.4 ± 1.4 ng/mL (p = 0.7975); and blood pressure 129 ± 15/79 ± 25 mm Hg and 126 ± 24/75 ± 7 mm Hg. Pre-fludrocortisone, there were 7 episodes of serum potassium ≥6.5 mEq/L, with 4 patients requiring admission for the treatment of hyperkalaemia. Following fludrocortisone, no patients had hyperkalaemia requiring inpatient management. CONCLUSIONS: Treatment of hyperkalaemic metabolic acidosis in transplant patients on tacrolimus with low-dose fludrocortisone resulted in rapid correction of hyperkalaemia and acidosis without significant effects on blood pressure or serum sodium. Fludrocortisone can be an effective short-term option for the treatment of hyperkalaemic metabolic acidosis in kidney transplant recipients on tacrolimus; however, patient selection remains important in order to reduce to risk of potential adverse effects.

Risk of COVID-19 Disease, Dialysis Unit Attributes, and Infection Control Strategy among London In-Center Hemodialysis Patients.

BACKGROUND AND OBJECTIVES: Patients receiving in-center hemodialysis treatment face unique challenges during the coronavirus disease 2019 (COVID-19) pandemic, specifically the need to attend for treatment that prevents self-isolation. Dialysis unit attributes and isolation strategies that might reduce dialysis center COVID-19 infection rates have not been previously examined. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We explored the role of variables, including community disease burden, dialysis unit attributes (size and layout), and infection control strategies, on rates of COVID-19 among patients receiving in-center hemodialysis in London, United Kingdom, between March 2, 2020 and May 31, 2020. The two outcomes were defined as (1) a positive test for infection or admission with suspected COVID-19 and (2) admission to the hospital with suspected infection. Associations were examined using a discrete time multilevel time-to-event analysis. RESULTS: Data on 5755 patients dialyzing in 51 units were analyzed; 990 (17%) tested positive and 465 (8%) were admitted with suspected COVID-19 between March 2 and May 31, 2020. Outcomes were associated with age, diabetes, local community COVID-19 rates, and dialysis unit size. A greater number of available side rooms and the introduction of mask policies for asymptomatic patients were inversely associated with outcomes. No association was seen with sex, ethnicity, or deprivation indices, nor with any of the different isolation strategies. CONCLUSIONS: Rates of COVID-19 in the in-center hemodialysis population relate to individual factors, underlying community transmission, unit size, and layout.

Mycobacterium abscessus - an uncommon, but important cause of peritoneal dialysis-associated peritonitis - case report and literature review.

BACKGROUND: Peritoneal dialysis (PD) is a form of therapy for end-stage kidney disease (ESKD), and peritonitis is a known complication. Mycobacterium (M) species associated peritonitis in PD patients is uncommon. Our experience of managing PD associated peritonitis caused by M abscessus in a middle-aged man with ESKD due to focal segmental glomerulosclerosis is shared in this article with a review of the literature on this condition. CASE PRESENTATION: A 49-year old man presented to our unit with symptoms of peritonitis and cloudy PD effluent. Initial analysis of PD fluid showed Gram stain was negative, with no organism grown. Empirical PD peritonitis treatment with intra-peritoneal antibiotics did not improve his symptoms and he required intravenous antibiotics, PD catheter removal and a switch to haemodialysis. Cultures of the PD fluid later grew M abscessus, and the antibiotic regimen was changed appropriately, leading to clinical improvement. CONCLUSION: M abscessus associated peritonitis in PD patients is rare. It needs to be borne in mind when clinical improvement is not seen with standard broad-spectrum antibiotics, especially in situations where the PD fluid is initially deemed to be culture negative. PD fluid samples should be sent for acid-fast bacillus and if detected, should be further analysed with genome-wide sequencing to confirm the species of the Mycobacterium. Prompt removal of the catheter with peritoneal washout is critical for clinical improvement.

The Characteristics, Dynamics, and the Risk of Death in COVID-19 Positive Dialysis Patients in London, UK.

Background: Patients on dialysis with frequent comorbidities, advanced age, and frailty, who visit treatment facilities frequently, are perhaps more prone to SARS-CoV-2 infection and related death-the risk factors and dynamics of which are unknown. The aim of this study was to investigate the hospital outcomes in patients on dialysis infected with SARS-CoV-2. Methods: Data on 224 patients on hemodialysis between February 29, 2020 and May 15, 2020 with confirmed SARS-CoV-2 were analyzed for outcomes and potential risk factors for death, using a competing risk-regression model assessed by subdistribution hazards ratio (SHR). Results: Crude data analyses suggest an overall case-fatality ratio of 23% (95% CI, 17% to 28%) overall, but that varies across age groups from 11% (95% CI, 0.9% to 9.2%) in patients ≤50 years old and 32% (95% CI, 17% to 48%) in patients >80 years; with 60% of deaths occurring in the first 15 days and 80% within 21 days, indicating a rapid deterioration toward death after admission. Almost 90% of surviving patients were discharged within 28 days. Death was more likely than hospital discharge in patients who were more frail (WHO performance status, 3-4; SHR, 2.16 [95% CI, 1.25 to 3.74]; P=0.006), had ischemic heart disease (SHR, 2.28 [95% CI, 1.32 to 3.94]; P=0.003), cerebrovascular disease (SHR, 2.11 [95% CI, 1.20 to 3.72]; P=0.01), smoking history (SHR, 2.69 [95% CI, 1.33 to 5.45]; P=0.006), patients who were hospitalized (SHR, 10.26 [95% CI, 3.10 to 33.94]; P<0.001), and patients with high CRP (SHR, 1.35 [95% CI, 1.10 to 1.67]) and a high neutrophil:lymphocyte ratio (SHR, 1.03 [95% CI, 1.01 to 1.04], P<0.001). Our data did not support differences in the risk of death associated with sex, ethnicity, dialysis vintage, or other comorbidities. However, comparison with the entire dialysis population attending these hospitals, in which 13% were affected, revealed that patients who were non-White (62% versus 52% in all patients, P=0.001) and those with diabetes (54% versus 22%, P<0.001) were disproportionately affected. Conclusions: This report discusses the outcomes of a large cohort of patients on dialysis. We found SARS-CoV-2 infection affected more patients with diabetes and those who were non-White, with a high case-fatality ratio, which increased significantly with age, frailty, smoking, increasing CRP, and neutrophil:lymphocyte ratio at presentation.

Recruitment of renal transplant patients into patrolling police roles using orthotic shields.

Renal allografts are transplanted to an anatomically unnatural site where they are exposed to trauma, and may fail if damaged. Individuals with renal allografts have been excluded from patrolling police roles as these often necessitate confrontation. We describe two patients with renal allografts who have been recruited by the Metropolitan Police Service, using bespoke orthotic shields to protect the grafts.

Aortic abnormalities in males with Alport syndrome.

BACKGROUND: There have been isolated case reports of arterial disease in males with Alport syndrome (AS), a systemic disorder of Type IV collagen. In this paper, we describe five new cases of AS associated with significant aortic disease including dissection and aneurysm. METHODS: We present brief clinical descriptions of five males with AS and aortic disease. We performed immunohistochemical analysis of the expression of the α5 chain of Type IV collagen in skin basement membranes from a previously reported family with AS and associated aortic disease and in the aortic media of male mice with X-linked Alport syndrome (XLAS) due to a nonsense mutation in the COL4A5 gene. RESULTS: Three of the five patients exhibited aneurysm and dissection of the thoracic aorta, occurring at 25-32 years of age, while one had aortic dilatation and another had aortic insufficiency. All five men required renal replacement therapy by age 20. Immunohistochemistry of skin biopsy specimens in previously reported male siblings with aortic disease confirmed that they had XLAS. We further found that the α5 chain of Type IV collagen is abnormally absent from aortic media of transgenic mice with XLAS. CONCLUSIONS: Early onset aortic disease may be an unusual feature of AS. Screening of men with AS for aortic abnormalities may be clinically indicated in some families.

Pseudoachalasia of the esophagus caused by encapsulating peritoneal sclerosis.

Encapsulating peritoneal sclerosis is a severe complication of peritoneal dialysis. Progressive sclerotic thickening of the peritoneum results in tethering and cocooning of the bowel, leading to chronic bowel obstruction, malabsorption, malnutrition, and high mortality. Conservative treatment is often unsuccessful and a surgical enterolysis is required for management. Pseudoachalasia is a rare condition that mimics the clinical and radiological features of achalasia of the cardia. Pseudoachalasia is most commonly caused by infiltrating or metastasizing cancers. In this report, we present a case of pseudoachalasia associated with encapsulating peritoneal sclerosis. The clinical symptoms settled after peritonectomy and enterolysis.

Serum cystatin is not a marker of glomerular filtration rate in pregnancy.

The role of cystatin C (Cys-C) as a marker of glomerular filtration rate (GFR) in pregnancy is undetermined. Measurements of Cys-C and creatinine (Cr) were taken at 14-17(+6), 18-23(+6), 27-31(+6) weeks' gestation, at delivery and 2-6 weeks postpartum in a prospective observational study of 27 women. There was no difference between Cys-C levels in early and late second trimester, but they were significantly higher in early third trimester (P < 0.001) than second trimester, despite no concurrent increase in Cr. Cys-C was also significantly higher at delivery than at all other times in pregnancy (P < 0.001) and fell to postpartum values higher than second trimester measurements (P < 0.01), but lower than delivery (P<0.001). In conclusion, changes in Cys-C may be influenced by pregnancy-related changes in glomerular filtration and therefore we would advise against their use as a marker of GFR in pregnancy.

Hemodialysis access-related survival and morbidity in an elderly population in South West Thames, UK.

Elderly patients form the most rapidly expanding group of hemodialysis (HD) patients in Europe and the United States. There are initiatives to promote an increase in arteriovenous fistula (AVF) formation. There are concerns that elderly patients may have lower rates of surgical vascular access compared with younger patients due to risks of higher co-morbidities, surgical complications, and higher AVF nonuse rates. The aim of this study was to compare access-related survival and morbidity for dialysis catheters and AVFs and to evaluate the AVF nonuse rate in an elderly population. We have performed a retrospective analysis of access survival and morbidity in patients > or = 70 years of age, either on maintenance HD or predialysis with preemptive formation of surgical access. One hundred and forty-six patients had permanent HD access created during the 18-month study period, from 1 January 2006 to June 2007. There were 89 male and 57 female patients in whom 78 AVFs and 137 tunneled venous catheters were inserted. There was a significantly greater loss of vascular access due to infection in the catheter group compared with the AVF group (P<0.016). Access survival was also significantly prolonged in the AVF group (446 days, 95% confidence interval 405-487) compared with the catheter group (276 days, 95% confidence interval 240-313), P=0.001. The rate of nonuse of AVFs was low (16%). We conclude that an AVF is the preferred form of vascular access in elderly HD patients.

Comparison of Tinzaparin and unfractionated heparin as anticoagulation on haemodialysis: equal safety, efficacy and economical parity.

BACKGROUND: The European Best Practice Guidelines on anticoagulation in chronic haemodialysis recommend the use of low-molecular-weight heparins (LMWH) over unfractionated heparin (UFH), based on previous small-scale studies and a meta-analysis which demonstrated equal efficacy of anticoagulation without an increase in hemorrhagic events. METHOD: We performed a prospective single-centre study where all stable patients on chronic in-hospital haemodialysis were converted from UFH to Tinzaparin. Patients were monitored for 2 months before and 2 months after the switch. Access failures due to thrombosis, clotted circuits and hemorrhagic events were recorded. RESULTS: 1,489 and 1,823 dialysis sessions took place on UFH and LMWH, respectively, in 108 patients (65 male). The total number of clotted circuits tended to decrease after the switch to LMWH (34 vs. 13) but was not statistically significant. There were four minor non-access-related episodes of haemorrhage while on treatment with UFH and none with Tinzaparin, and the length of bleeding time post needle removal was shorter with Tinzaparin than UFH. The cost-analysis demonstrated parity of Tinzaparin with UFH; using a median of 10,000 U of UFH versus 2,500 U of LMWH, each therapy cost GBP 10,783 (EUR 15,942; USD 20,446) per annum. CONCLUSION: Our findings suggest comparable safety and efficacy of Tinzaparin, parity of cost in comparison with UFH.

Development of a self-management package for people with diabetes at risk of chronic kidney disease (CKD).

Kidney disease progression in diabetes can be slowed by strict blood pressure and blood sugar control, prescription of medicines that modify the renin-angiotensin system and lifestyle changes, such as smoking cessation. This paper describes the development of a self-management package for people with diabetes at risk of kidney damage. This multi-method study entailed a literature review, case-finding of all patients with diabetes and microalbuminuria in six family practitioner (FP) surgeries and interviews with 15 patients at high-risk of progressive kidney disease. Results identified 23% of the study population (n = 1946) at risk of kidney damage, within a population with 3.14% incidence of diabetes. The most important finding from the interviews was that although most people had some understanding of the possible risk of kidney disease, they had little idea of exactly how they could control the condition themselves. This study highlights the importance of incorporating self-management tools in the care and management of patients with diabetes in primary care.

Complex bypasses and fistulas for difficult hemodialysis access: a prospective, single-center experience.

The purpose of this article is to describe several complex vascular access procedures and the outcomes achieved with them in 24 patients (mean age 60 years) undergoing hemodialysis in whom all other accesses had failed and neither peritoneal dialysis nor transplantation was possible. Patients underwent either a necklace bypass (n = 5), axillary loop (n = 1), contralateral internal jugular vein bypass (n = 6), femorofemoral crossover bypass (n = 1), superficial femoral vein transposition (n = 5), axillary artery to popliteal vein bypass (n = 5), or femoral artery to right atrium bypass (n = 1). All grafts implanted were 6 mm, internally reinforced prostheses made of expanded polytetrafluoroethylene (Gore-Tex Intering Vascular Graft). Postoperatively patients had bimonthly clinical examinations in which the thrill, bruit, skin, cannulation sites, and adequacy of dialysis were reviewed. A bimonthly ultrasound dilution assessment that included estimation of the graft inflow rate, recirculation rate, and cardiac output was also performed. There was one serious postoperative complication: rapid-onset severe steal syndrome that required immediate tie off of the fistula. During the median follow-up time of 22 months, three patients died of causes unrelated to their vascular access. Nineteen dilatations and 10 surgical revisions were done. Primary patency rates were 83%, 63.5%, and 63.5%, respectively, at 6 months, 1 year, and 2 years; secondary patency rates were 91%, 77%, and 77%. Complex vascular access procedures can provide patients some additional good-quality time on hemodialysis.

Vascular access in hemodialysis patients with central venous obstruction or stenosis: one center's experience.

The purpose of this study was to evaluate the value of complex hemodialysis access procedures among patients with central venous obstruction who were running out of access sites. Between September 2002 and December 2003 we performed a total of 640 new hemodialysis access procedures in 3 renal units. Ten of these patients presented central vein stenosis or obstruction and were not suitable for peritoneal dialysis. Each of the 10 patients had 3 or 4 previous failed access procedures and numerous infected central lines and their dialysis catheters were not functioning adequately. Nine patients presented with a severely stenosed or occluded superior vena cava and 1 had both subclavian veins occluded. Three patients were diabetics, 2 were obese and 6 had hypertension. We performed 12 procedures on these 10 patients. Saphenous veins were used 6 times, twice as a loop to the femoral artery and 4 times as a transposition to the popliteal artery above the knee. Femoral vein transposition to the popliteal artery was carried out in 2 cases. We performed 3 axillary artery to popliteal vein polytetrafluoroethylene (PTFE) bypasses, 1 on an obese woman who had no saphenous vein and was not suitable for a femoral vein transposition, 1 on a diabetic woman whose saphenous vein loop clotted after 5 months and 1 on a female patient with severe peripheral vascular disease. The patient with bilateral subclavian vein occlusion had a brachial artery to internal jugular vein PTFE graft. The PTFE graft to the jugular vein has been patent and regularly needled with a follow-up of 4 months. Four saphenous vein fistulae were regularly used for dialysis; 2 were never used. Five saphenous fistulae clotted after an average life span of 4 months (range 3 weeks-9 months) and 1 is still patent and in use (5 months). Both femoral vein transpositions have been patent and have been needled 3 times a week with a follow-up of 10 and 4 months; one had to be revised surgically after 9 months. Of the 3 axillary artery to popliteal vein grafts, 1 had to be tied off after a week because of severe steal syndrome and 2 have been patent (20 months follow-up) and have been needled regularly ever since. Seventy percent of these patients have been dialyzed line-free through their fistula despite severe central vein stenosis or obstruction for periods of 9-18 months when this review was undertaken. Although the follow-up needs to be longer, we discuss the surgical, radiologic, and dialysis features of these patients and propose a management pathway for central vein stenosis or occlusion.

Tumor necrosis factor alpha blockade with infliximab for refractory uveitis and scleritis.

OBJECTIVE: To assess the efficacy and safety of the anti-tumor necrosis factor alpha agent infliximab in treatment-resistant uveitis and scleritis. DESIGN: Retrospective, noncomparative interventional case series. PARTICIPANTS: Seven patients with noninfectious ocular inflammatory disease that was refractory to alternative immunosuppression. These included one patient with idiopathic retinal vasculitis and panuveitis, one patient with intermediate uveitis, one patient with chronic juvenile anterior uveitis, three patients with scleritis, and one patient with scleritis and peripheral ulcerative keratitis. Four patients had an underlying systemic disease that was in remission in three cases. INTERVENTION: Infusions of infliximab, 200 mg, were given at 4-week to 8-week intervals, depending on the clinical response. MAIN OUTCOME MEASURES: Clinical response, including symptoms, visual acuity, degree of scleral vascular engorgement, corneal thinning, anterior chamber activity, and posterior segment inflammation, reduction in concomitant immunosuppression, and adverse effects. RESULTS: The mean patient age was 47 years (range, 24-78), and four patients were female. The mean number of infliximab infusions was seven (range, 2-19), and the mean follow-up period was 12 months (range, 4-22 months). Six patients experienced a clinical improvement, with five achieving remission and significant reduction in immunosuppression. One patient showed an initial response but developed a delayed hypersensitivity response that precluded further treatment. No other adverse effects occurred. CONCLUSIONS: Infliximab seems to be an effective and safe treatment for noninfectious uveitis and scleritis and may be indicated as rescue therapy for relapses of ocular inflammation or as maintenance therapy when conventional immunosuppression has failed. Further investigation of infliximab for treatment-resistant scleritis and uveitis is warranted.