Effect of insertion site on tunnelled haemodialysis catheter outcomes: an observational study of 967 catheters.

BACKGROUND: The right internal jugular vein is the preferred approach to tunnelled haemodialysis catheter placement. However, the effect of the insertion site on long-term catheter outcomes remains uncertain. AIMS: We aimed to analyse a large cohort of tunnelled haemodialysis catheter placements to compare short-term and long-term results according to central venous catheter location. METHODS: A retrospective cohort study was performed on consecutive tunnelled catheter insertions at two centres over 7 years. The primary outcome was catheter survival, compared according to the central vein site. We used the Kaplan-Meier curve method and Cox proportional hazards modelling to determine the effect of the catheterisation route on primary patency, adjusted for clinical risk factors for catheter failure. RESULTS: There were 967 tunnelled dialysis catheter placements in 620 patients. The median survival for right internal jugular vein catheters was 569 days. There were no differences in rates of catheter failure between right internal jugular, left internal jugular (adjusted hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.52-1.21), external jugular (HR, 0.79; CI, 0.33-3.13), subclavian (HR, 0.67; CI, 0.58-2.44) and femoral vein (HR, 1.20; CI, 0.36-1.33) catheters following multivariable analysis. There were no major differences in functionality or complications between the groups. CONCLUSIONS: This study identified no statistically significant relationship between tunnelled haemodialysis catheter insertion site and catheter survival. The contemporary approach to dialysis vascular access should be tailored to specific patient circumstances.

Low Posterior Internal Jugular Vein Approach for Tunnelled Haemodialysis Catheter Insertion: A Report on Outcomes at a Single Centre.

AIM: The impact of technical differences in cannulation technique for tunnelled haemodialysis catheter insertion is undetermined. We aimed to assess clinical outcomes of the low posterior approach for internal jugular vein tunnelled catheter placement. METHODS: A retrospective audit was undertaken on consecutive tunnelled catheter procedures performed at a single centre between January 2016 and June 2022. Only catheters specifically placed with a low posterior internal jugular approach were included. The study's primary outcome was 12-month catheter survival, evaluated using the Kaplan-Meier survival curve and log-rank test. Secondary outcomes included catheter performance and procedure-related complications. RESULTS: During the study period, 391 tunnelled internal jugular haemodialysis catheters were inserted in 272 patients using the low posterior technique. The 12-month primary patency rate was 68%. Catheter insertion was successful in 96% of cases. Peri-procedural complications occurred in 4% of cases, most frequently bleeding. The most common reasons for catheter loss were dysfunction (10%) and bacteraemia (6%). The best predictors of catheter failure were advanced age (HR 1.02, 95% CI 1.00-1.04) and in-centre dialysis treatment locality (HR 2.04, 95% CI 1.19-3.45). CONCLUSION: The low posterior approach for internal jugular vein tunnelled catheter insertion is effective and safe. We demonstrated a 12-month catheter survival rate of 68%. Further research comparing the low posterior approach with other internal jugular vein cannulation techniques is warranted.

Urgent-start peritoneal dialysis / Diálisis peritoneal aguda

Peritoneal dialysis is an important form of kidney replacement therapy. Most patients presenting with an unplanned, urgent need for dialysis are prescribed haemodialysis, leading to peritoneal dialysis underutilisation. Urgent-start peritoneal dialysis refers to treatment that is commenced within 2 weeks of catheter placement. Urgent-start peritoneal dialysis represents an efficacious, cost-effective alternative to the conventional approach of commencing dialysis. There is a paucity of evidence to guide management, however experience with the technique is increasing. This article overviews the rationale and practical application of urgent-start peritoneal dialysis. (AU)

La diálisis peritoneal es una forma importante de terapia de reemplazo renal. A la mayoría de los pacientes que presentan una necesidad urgente e imprevista de diálisis se les prescribe hemodiálisis, lo que lleva a la infrautilización de la diálisis peritoneal. La diálisis peritoneal de inicio urgente se refiere al tratamiento que se inicia dentro de las 2 semanas posteriores a la colocación del catéter. La diálisis peritoneal de inicio urgente representa una alternativa eficaz y rentable al enfoque convencional de iniciar la diálisis. Hay escasez de evidencia para guiar el manejo, sin embargo, la experiencia con la técnica está aumentando. Este artículo describe la justificación y la aplicación práctica de la diálisis peritoneal de inicio urgente. (AU)

Tunneled Hemodialysis Catheter Insertion: Technical and Clinical Considerations.

Tunneled hemodialysis catheter insertion is a common and important procedure. Clinicians involved in the placement or maintenance of tunneled catheters require an appreciation of their best clinical application. Although comprehensive guidelines are available, many aspects of the published literature on this subject remain uncertain. This primer offers a concise, evidence-based discussion of 10 fundamental, everyday questions with respect to tunneled hemodialysis catheter insertion.

Obstructive uropathy - acute and chronic medical management.

Obstructive uropathy is an important cause of acute and chronic kidney disease. Decompression of the urinary tract is an essential aspect of treatment. The cause and aetiology of obstruction typically determine the surgical approach. Acute relief of obstruction is frequently complicated by fluid and electrolyte imbalance. Standard therapeutic interventions for acute or chronic renal failure also apply for cases of obstructive uropathy. This narrative review summarises the early and long-term medical management of obstructive uropathy.

Urgent-start peritoneal dialysis.

Peritoneal dialysis is an important form of kidney replacement therapy. Most patients presenting with an unplanned, urgent need for dialysis are prescribed haemodialysis, leading to peritoneal dialysis underutilisation. Urgent-start peritoneal dialysis refers to treatment that is commenced within 2 weeks of catheter placement. Urgent-start peritoneal dialysis represents an efficacious, cost-effective alternative to the conventional approach of commencing dialysis. There is a paucity of evidence to guide management, however experience with the technique is increasing. This article overviews the rationale and practical application of urgent-start peritoneal dialysis.

Clavicular hook: Cuffed haemodialysis catheter insertion using a paramedian tunnel in patients with recurrent tip migration.

Tunnelled, cuffed central venous catheters are commonly used for the provision of haemodialysis. Internal jugular vein catheters are generally tunnelled subcutaneously to the anterolateral chest wall. However, the lateral subcutaneous tract may increase the risk of catheter migration, particularly in the setting of obesity or large breast tissue. Catheter tip migration is an important cause of catheter failure. We describe two cases in which a paramedian tunnel was fashioned in patients experiencing recurrent catheter migration.

Haemodialysis catheters - a review of design and function.

INTRODUCTION: Hemodialysis (HD) catheters are a fundamental form of dialysis access. An appreciation of the principles of catheter design is important for practitioners involved in the insertion and maintenance of hemodialysis access. Although a wide range of styles and brands are available on the market, comparative clinical trials are lacking. AREAS COVERED: This concise review outlines common dialysis catheter characteristics and summarizes their practical relevance. Materials and surface coatings, tip geometry, side holes, and lumen cross-sectional shape are discussed. EXPERT OPINION: HD catheter choice should be at the operator's discretion based on their best clinical judgment and experience. While device selection should be informed theoretic design principles, more important is a concentration on thoughtful catheter insertion and maintenance practices.

Ewing sarcoma: A pictorial review of typical and atypical locations with reference to the updated 2020 WHO classification system.

Ewing sarcoma (ES) is a small round cell sarcoma which usually occurs in the paediatric and young adult age groups. This pictorial review briefly discusses and presents the typical skeletal and extraskeletal locations which ES is encountered, including the metadiaphysis of long bones, pelvis, chest wall and paravertebral regions. Five cases of ES in atypical locations are then presented along with an observation of demographic differences between skeletal and extraskeletal ES. These cases include ES arising from the metatarsal, scapula, breast, intracranial soft tissue and the paranasal sinuses. Presenting symptoms, treatment approach and prognosis are highly variable depending on the location; and multimodal imaging is centrepiece in the management process. Management usually includes any combination of chemotherapy, radiotherapy and surgery. The WHO classification system was updated in 2020 to include some of the rare genetic subtypes of ES. One such case of the BCOR subtype is demonstrated in this review and occurs in an atypical location. Whether these subtypes have distinct radiological features or a propensity to occur in atypical locations is an area for further research.

Dialysis and extracorporeal therapies for enhanced elimination of toxic ingestions and poisoning.

Poisoning and toxic ingestions cause significant morbidity and mortality worldwide. Extracorporeal therapies such as dialysis, hemoperfusion, and plasma exchange are selectively applied to patients with severe intoxications unresponsive to standard interventions and can be lifesaving. Extracorporeal therapies are a complex but fundamental aspect of the practice of nephrology. Without high-quality evidence to guide implementation, an understanding of toxicokinetics and the physiochemical principles of the enhanced elimination techniques is especially important. This review provides a comphrensive, user-friendly outline of the application of extracorporeal therapy in the poisoned patient.

Survey study of trends in adult nephrology advanced training in Australia and New Zealand.

BACKGROUND: There has been considerable growth in nephrology advanced trainee numbers in Australia and New Zealand, with uncertain effects on clinical experience, competence and employment outcomes. AIMS: To review the perceived adequacy and temporal trends of advanced training in nephrology in Australia and New Zealand by evaluating training experiences, personal views on important aspects of training and nephrology, career paths and early employment outcomes. METHODS: An online survey was distributed to members of the Australian and New Zealand Society of Nephrology through email in December 2020. Responses were sought from current trainees and from nephrologists qualifying since 2014. Likert scale proportions were calculated and group comparisons made using the Chi-squared test. RESULTS: A total of 88 participants returned the survey yielding a response rate of 32%, with a representative sample of trainees and consultants from across Australia and New Zealand. Training was reported as adequate in most aspects of clinical nephrology, although 88% of respondents felt poorly prepared for entering private practice and 61% reported inadequate training in kidney histopathology. Exposure to clinical procedures was variable, with adequate training in percutaneous kidney biopsy, but mostly inadequate training in dialysis access insertion. Sixty-nine percent of nephrologists completed their advanced training entirely in large urban centres and 85% worked in an urban area after training. Only 23% of consultants were engaged in full-time clinical employment in their first-year post-training and 78% were undertaking at least one of dual specialty training or a higher degree by research. Demand for subspecialty fellowships was high. CONCLUSION: Trainees and nephrologists in Australia and New Zealand are currently satisfied with their training in most aspects of nephrology; however, some clinical experiences are perceived as inadequate and early career paths after advanced training are increasingly diverse.

Recurrent pulseless electrical activity and cardiac arrest caused by baroreceptor failure following neck irradiation.

INTRODUCTION: Baroreceptor damage and hypersensitivity can produce labile autonomic blood pressure control. Neck irradiation for malignancy is a well-known but under-recognised cause of baroreceptor failure. CASE PRESENTATION: We describe a dramatic delayed complication of neck irradiation treatment. Our patient developed recurrent unexplained hypotension and pulseless electrical activity cardiac arrest upon connection to intermittent haemodialysis, which he had previously tolerated uneventfully until exposure to radiotherapy. CONCLUSION: No other cause was identified, and this case thus highlights baroreflex dysfunction as an important differential diagnosis in patients with profound hypotension.

Respiratory Failure: A Rare Complication of Chronic Kidney Disease Mineral and Bone Disorder.

Background: Disordered metabolism of bone and minerals is a problem frequently encountered in patients with chronic kidney disease. Early biochemical changes include altered calcium and phosphate balance, while advanced disease produces reduced bone strength and extraskeletal calcification. The syndrome describing this constellation of findings is termed chronic kidney disease mineral and bone disorder. Case Report: This report details a rare and extreme manifestation of chronic kidney disease mineral and bone disorder in a patient on long-term hemodialysis for end-stage renal failure. Progressive abnormalities of the thoracic skeleton were ultimately severe enough to produce restrictive lung physiology and symptomatic respiratory failure. Conclusion: Cases of chronic kidney disease mineral and bone disorder with pronounced clinical sequelae occur uncommonly in contemporary practice because of early detection and effective therapies. To our knowledge, this report is the first case in the literature of severe thoracic involvement manifesting as respiratory failure.

A Rare Case of Renal Impairment Caused by Primary Hypothyroidism.

An association between hypothyroidism and renal impairment has rarely been reported in the literature. We describe a case of hypothyroidism that was associated with otherwise unexplained acute kidney impairment, which was reversed with treatment. A 21-year-old female patient presented to her family physician with myalgia, and preliminary investigations revealed an elevated level of creatine kinase and poor renal function. Primary hypothyroidism was diagnosed and no other apparent etiology for renal failure could be identified despite extensive investigations by the Nephrology Department. Notably, the patient's renal impairment showed prompt resolution following thyroid hormone replacement.

A Rare Case of Adult Rhabdomyosarcoma.

BACKGROUND: Rhabdomyosarcoma is a rare, soft tissue malignancy, diagnosed particularly in adults. It commonly metastasizes to the bone marrow. We present a rare case of an adult rhabdomyosarcoma which illustrates the importance of magnetic resonance imaging in identifying early changes in the internal bone structure. CASE REPORT: A 50-year-old male presented with acute urinary retention. The patient initially had a CT scan of the lumbar spine which only revealed a protrusion of the L5-S1 intervertebral disc and no apparent cause for the patient's symptoms. One week later, an MRI was performed which showed extensive bone marrow metastases throughout the lumbar spine and a soft tissue mass in the lower sacral region. The bony metastases were not evident on the CT scan and the soft tissue mass was out of the coverage area of the CT. Subsequent biopsy of the soft tissue mass was performed and histopathology concluded the tissue to be a rhabdomyosarcoma. Unfortunately, the patient died one week after diagnosis. CONCLUSIONS: Although adult rhabdomyosarcomas are very rare, this case highlights the advantage of MRI over CT in identifying early changes in the internal bone structure. Therefore, CT should not be relied upon to exclude bony metastases, particularly in the setting of primary cancer with a known tendency to metastasize to the bone marrow.

Confusion, Faciobrachial Dystonic Seizures, and Critical Hyponatremia in a Patient with Voltage-Gated Potassium Channel Encephalitis.

Autoimmune limbic encephalitis is a rare cause of encephalitic disease. It is associated with various target antigens and is difficult to diagnose, and experience with its treatment is limited. This case report describes a 69-year-old man, who presented with life-threatening hyponatremia and confusion, following several months of gradually worsening faciobrachial dystonic seizures. Faciobrachial dystonic seizures are a well-described feature classically observed in voltage-gated potassium channel autoimmune encephalitis. The presence of chronic hyponatremia without cognitive dysfunction, eventually culminating in an acute episode of encephalopathy and severe hyponatremia, is a pattern of natural history not previously documented in this condition.