Arteriovenous fistulas thrombosis in hemodialysis patients with COVID-19.

BACKGROUND: The current Coronavirus disease 2019 (COVID-19) outbreak is associated with significant mortality, especially in patients suffering from end stage renal disease (ESRD) and hemodialysis patients. Several previous studies reported an over-risk of arterial and venous thrombosis, in particular pulmonary embolism and venous thrombosis of catheter in COVID19 patients in intensive care unit. However, arteriovenous fistula (AVF) thrombosis has rarely been reported yet in these patients. AVF thrombosis is a serious complication that impacts significantly patients outcome. Here, we aim to describe characteristics and prognosis of a cohort of COVID-19 hemodialysis (HD) patients presenting with AVF thrombosis. METHODS: In the Ile de France region (Paris area) during the March 11th-April 30th 2020 period, fistula thrombosis cases were collected among COVID-19 hemodialysis patients in seven dialysis units and in interventional vascular departments. These patients' characteristics were analyzed through a review of the patient's medical records. RESULTS: Seventeen patients were included in our study (median age 69 years). Ten patients (59%) were men. Ten patients (59%) were diabetic and 88% had a high blood pressure. The mortality rate in these patients was 47%. All thrombosis treated with a declotting procedures (64%) were successfully cleared, but with early relapse in 36%. CONCLUSION: Our study highlights AVF thrombosis as a severe complication in COVID-19 hemodialysis patients that contributed to the severity and accelerated death.

COVID-19 in Patients Undergoing Hemodialysis: Prevalence and Asymptomatic Screening During a Period of High Community Prevalence in a Large Paris Center.

RATIONALE & OBJECTIVE: Due to extensive comorbid conditions, coronavirus disease 2019 (COVID-19) has a poor prognosis in people receiving maintenance hemodialysis. In this article, we describe our experience with 200 maintenance hemodialysis patients in a hemodialysis center that used universal reverse transcriptase-polymerase chain reaction testing, including 38 COVID-19-positive patients. STUDY DESIGN: Descriptive observational cohort, including the time line of patient diagnoses along with contextual events including precautions, testing, screening algorithms, clinical diagnostics and therapy, and the clinical course of COVID-19-infected patients and their final outcomes. SETTING & PARTICIPANTS: 200 patients within a single hemodialysis center with 2 dialysis clinics in Paris. RESULTS: Among 200 maintenance hemodialysis patients, 38 (19%) had COVID-19 diagnosed; of these, 15 (39.5%) were admitted to the hospital, including 4 who required intensive care unit (ICU) care. There were 8 (21%) deaths. The most common symptom was fever, followed by dry cough, fatigue, and dyspnea. All COVID-19-infected patients had lymphopenia and an increase in C-reactive protein levels. Median time from the onset of respiratory symptoms to ICU admission was 1 to 2 days. Durations of non-ICU hospitalizations and ICU stays were 7 and 13 days, respectively. LIMITATIONS: Retrospective study, single hemodialysis center. CONCLUSIONS: Dialysis patients are a highly susceptible population and hemodialysis centers are a high-risk area in a COVID-19 epidemic. "Unexplained" lymphopenia and/or an increase in C-reactive protein level should lead physicians to the diagnosis of COVID-19 and should, when possible, be followed by diagnostic testing with universal reverse transcriptase-polymerase chain reaction, as well as the reinforcement of contamination barrier measures.

[Intravenous iron during predialysis period improves anemia management and cardiovascular parameters in incident hemodialysis patients]. / La prise en charge de l'anémie et de ses conséquences chez les patients débutant l'hémodialyse : importance du fer intraveineux en prédialyse.

Individualized use of iron therapy (IT) and erythropoiesis-stimulating agents (ESA) may effectively correct anemia and its symptoms in CKD patients (Pts). The aim of this retrospective study was to precise the anemia management (AM) in incident HD Pts, and to compare Pts treated by intravenous (i.v.) IT and ESA during predialysis to those treated by oral IT and ESA on AM and cardiovascular parameters during the first year of HD. One hundred and two Pts performed their first dialysis in the unit, mean age 58.5 (15.9) years, 70% males, 27% diabetes. Ninety Pts started with a native arteriovenous fistula. Charlson comorbidity index was 7.3 (3.5). Mortality rate was 3% at one year. Hb level was at start 10.6 (1.7) and at one year 11.7 (1.1) g/dL (P<0.0001). DA injected every 2weeks was at the beginning at 107 (56) µg and then at 61 (46) (P<0.0001). i.v. IT injected every week was at the dosage of 87 (23) mg and then at 57 (40mg) per injection (P<0.001). Out of 102 Pts, 33 received i.v. IT during predialysis. These Pts started dialysis with a better Hb level: 11.1 (1.3) versus 10.4 (1.55) g/dL (P<0.01), had a TSAT at 50.0 (19.2) versus 30.1 (15.2) % (P<0.001), received less ESA 0.58 (0.28) versus 0.82 (0.37) µg/kg per week (P<0.01). More important were the changes on the cardiovascular functions: left ventricular mass at 116 (34) versus 134 (39) g/m(2) (P<0.02), left ventricular ejection fraction at 64.7 (4.4) versus 61.4 (8.7) % (P<0.02) and mean arterial pressure at 104.7 (80) versus 109 (13.2) mmHg (P<0.02). These Pts were also less hospitalized. This study revealed the importance of i.v. IT during predialysis care not only on AM but also on cardiovascular status in HD Pts starting dialysis.

[Renal transplantation in the elderly: a survey]. / Transplantation rénale du sujet âgé.

For ten years, an increase in the number of elderly patients on renal transplant waiting lists has occured. In an attempt to close the widening gap between supply and demand and because the demand for kidneys for younger patients already surpasses the supply, transplant physicians nowadays accept organs from older donors that might have been deemed inappropriate in the past. Programs of age matching between donors and recipients and of dual-kidneys transplantation have emerged. The initial results of these programs are encouraging with excellent patient and graft survival at one and three years.

Intracranial granuloma and skull osteolysis: complication of a primary cutaneous cryptococcosis in a kidney transplant recipient.

Cryptococcosis is the third most common invasive fungal infection in organ transplant recipients after candidiasis and aspergillosis. It occurs almost exclusively in the late posttransplantation period (>6 months after the initiation of immunosuppression). Subclinical onset of meningitis is the usual clinical presentation. Despite initiation of therapy, the mortality rate associated with this infection in this patient population remains high. To the best of our knowledge, this report describes one of the first cases of a rare entity: a primary cutaneous cryptococcosis in a renal transplant recipient disclosed by skull osteomyelitis and pseudotumoral intracranial extension. Surgical debridement and azole antifungal therapy were performed. Ten months after the onset of treatment, the patient feels good, clinical examination findings are normal, and no sign of evolutive cryptococcosis is noted.

Haemodialysis increases QT(c) interval but not QT(c) dispersion in ESRD patients without manifest cardiac disease.

BACKGROUND: HD has been reported to determine an increase in QTc interval and QTc dispersion (QT(max)-QT(min))-risk factors that predispose to severe ventricular arrhythmias and sudden death. However, most studies have included end-stage renal disease (ESRD) patients with significant heart pathology. We therefore aimed to study the impact of a single HD session in subjects without manifest cardiac disease. METHODS: Sixty-eight stable, non-diabetic HD patients (47.1% males, age 40.2+/-12.7 years, HD duration 57+/-36 months and 37% hypertensive), with normal maximal ECG stress test and sub-endocardiac viability index and without ECG left ventricular hypertrophy were included. QT interval was calculated 10 min pre- and post-HD, as an average of three consecutive complexes, and corrected for heart rate using Bazett's formula (QTc=QT/(R-R)(1/2)). Na(+), K(+), Ca(2+), PO(4), pH and BP levels were also determined pre- and post-HD. RESULTS: The QTc interval increased significantly post-HD to 434+/-29 from 421+/-26 ms pre-HD (P=0.005); an abnormally prolonged QTc (>440 ms) was recorded in 34% cases pre-HD and in 46% post-HD, i.e. 1.5-2.3 times higher than in the high risk EURODIAB IDDM population. However, this effect was not homogeneous. Only 47 subjects had an increase in QTc duration after a dialysis session, while in 21 a decrease in QTc duration was recorded. The increase in QTc post-HD correlated with Ca(2+) homeostasis. Patients with greater increases in QTc after dialysis had higher baseline plasma calcium levels (r=0.47, P<0.001); also, a larger decrease in Ca(2+) post-HD correlated with higher increases in QTc interval (r=0.33, P<0.05). In contrast with QTc behaviour and with data from the literature, in this young HD population without manifest cardiac disease and with a low prevalence of HTA, post-HD QTc dispersion was similar to pre-HD values, increasing in only 39 patients. Furthermore, changes in QTc dispersion were not related to changes in electrolytes and BP following dialysis. However, changes in QTc dispersion and in QTc interval were directly correlated (r=0.37, P=0.42). There were no relationships between pre-HD measured echocardiographic variables, including: LV ejection fraction, internal diameters, wall thickness, mass and mass index and baseline or changes in QTc or QTc-d. CONCLUSIONS: Haemodialysis increases the QTc interval in ESRD patients, mainly related to rapid changes in electrolyte plasma concentrations. However, the impact on QTc dispersion is less important in the absence of significant coexisting cardiac disease.