Nivolumab exposure in a hemodialysis patient with metastatic melanoma.

The effect of intermittent hemodialysis (IHD) on nivolumab serum concentrations in patients with severe renal impairment is largely unknown. Here, we present a 79-year-old patient with metastatic melanoma and end-stage renal disease on IHD three times a week, treated with 480 mg nivolumab every 4 weeks. A serum trough concentration of nivolumab was determined before the start of the third cycle, and two samples were taken immediately before and after a hemodialysis session during this cycle. All nivolumab serum concentrations were within a similar range as those previously measured among patients without renal insufficiency, after a comparable duration of nivolumab treatment. Therefore, we conclude that IHD does not influence nivolumab exposure. Furthermore, nivolumab treatment was continued without complications and appears to be well tolerated for patients on IHD.

[Endovascular arteriovenous fistulas: percutaneous creation of vascular access for hemodialysis]. / Endovasculair aangelegde arterioveneuze fistels.

A novel endovascular technique allows percutaneous creation of arteriovenous fistulas for hemodialysis. The proximal radial artery is cannulated through the perforating vein in the cubital fossa using ultrasound guidance. A fused anastomosis between these blood vessels is created using heat and pressure. This results in an arteriovenous fistula that can be regarded as an alternative for a surgically created brachiocephalic fistula. In our early experience, this new technique is safe and successful. Moreover, no complications due to high-flow fistulas have been reported with this technique to date. Nevertheless, the intervention rate and the cost effectiveness of the new endovascular technique need to be compared to traditional open surgery before it can be considered standard clinical care.

Biological Variation of Creatinine, Cystatin C, and eGFR over 24 Hours.

BACKGROUND: Estimated glomerular filtration rate (eGFR) is widely used in clinical practice. This study assessed the within-subject biological variation (CVI) of different eGFR equations in people with chronic kidney disease (CKD) and people without CKD. The aims of this study were (a) to determine the 24-h biological variation profiles of creatinine, cystatin C, and eGFR and (b) to determine whether CVI of creatinine, cystatin C, and eGFR changes on deterioration of glomerular filtration. METHODS: Hourly blood samples were analyzed from 37 individuals (17 without CKD, 20 with CKD) during 24 h. Creatinine (enzymatic method) and cystatin C were measured using a Cobas 8000 (Roche Diagnostics). eGFR was estimated using the Modification of Diet in Renal Disease and the Chronic Kidney Disease Epidemiology Collaboration based on creatinine and/or cystatin C. Plasma samples were stored at -80 °C before analysis. Outlier and homogeneity analyses were checked before performing a nested ANOVA to determine biological variation. RESULTS: CVI of creatinine was higher in people without CKD than in those with CKD (6.4% vs 2.5%) owing primarily to the more profound effect of meat consumption on creatinine variability in individuals with lower baseline creatinine concentrations. Unlike creatinine, cystatin C concentrations were unaffected by meat consumption. Cystatin C showed some diurnal rhythmic variation and less in people with CKD. Reference change values (RCVs) of all eGFR equations were within 13% to 20% in both study groups. CONCLUSIONS: Despite differences in CVI of creatinine, the CVI and RCV of the eGFR equations were relatively similar for people with or without CKD.

Peritoneal dialysis in centenarian patients: no age limitation?

BACKGROUND: The majority of dialysis patients are elderly, and the trend towards even more elderly people with end-stage renal disease (ESRD) will further determine the dialysis field in the future. METHOD: If these elderly ESRD patients do not opt for conservative ESRD care, they may still qualify for peritoneal dialysis (PD), which may be assisted or unassisted. RESULTS: Although they may be more frail and have a greater co-morbidity burden compared to their younger counterparts, elderly patients with ESRD may still be able to maintain a good functionality level with adequate quality of life by performing PD, which may be assisted (treatment performed or supported e.g. by partner or nurse) or unassisted (without support). PD may indeed further contribute to maintaining autonomy, and enhance quality of life compared to in-center conventional hemodialysis. In order to illustrate this strategy, we hereby describe a centenarian patient with ESRD who received assisted PD successfully. CONCLUSIONS: With appropriate management and infrastructure, (very) high age is not a contra-indication for PD.