Adrenal insufficiency in hemodialysis patients-An under-recognized problem: A case series.

Adrenal insufficiency is an uncommon disorder and presents with non-specific symptoms. Identifying adrenal insufficiency in patients with chronic kidney disease requiring dialysis is increasingly difficult as there is a significant overlap of the signs and symptoms of adrenal insufficiency with those seen in chronic kidney failure. We highlight this diagnostic uncertainty in a case series of three patients with chronic kidney disease requiring hemodialysis as renal replacement therapy from a single center identified as hypoadrenal. Steroid replacement improved symptoms and hemodynamic parameters. Increased vigilance for adrenal insufficiency in dialysis patients is necessary. It is likely under recognized in hemodialysis patients given their multi-morbidity.

Effect of centre- and patient-related factors on uptake of haemodiafiltration in Australia and New Zealand: A cohort study using ANZDATA.

BACKGROUND: The use of haemodiafiltration (HDF) for the management of patients with end-stage kidney failure is increasing worldwide. Factors associated with HDF use have not been studied and may vary in different countries and jurisdictions. The aim of this study was to document the pattern of increase and variability in uptake of HDF in Australia and New Zealand, and to describe patient- and centre-related factors associated with its use. METHODS: Using the Australian and New Zealand Dialysis and Transplant Registry, all incident patients commencing haemodialysis (HD) between 2000 and 2014 were included. The primary outcome was HDF commencement over time, which was evaluated using multivariable logistic regression stratified by country. RESULTS: Of 27 433 patients starting HD, 3339 (14.4%) of 23 194 patients in Australia and 810 (19.1%) of 4239 in New Zealand received HDF. HDF uptake increased over time in both countries but was more rapid in New Zealand than Australia. In Australia, HDF use was more likely in males (odds ratio (OR) 1.13, 95% confidence interval (CI) = 1.03-1.24, P = 0.009) and less likely with older age (reference <40 years; 40-54 years OR = 0.85; 95% CI = 0.72-0.99; 55-69 years OR = 0.79; 95% CI = 0.67-0.91; >70 years OR = 0.48; 95% CI = 0.41-0.56); higher body mass index (body mass index (BMI) < 18.5 kg/m2 OR = 0.62; 95% CI = 0.46-0.84; 18.5-29.9 kg/m2 reference; >30 kg/m2 OR = 1.46; 95% CI = 1.33-1.61), chronic lung disease (OR = 0.84; 95% CI = 0.76-0.94; P < 0.001), cerebrovascular disease (OR = 0.76; 95% CI = 0.67-0.85; P < 0.001) and peripheral vascular disease (OR = 0.77; 95% CI = 0.70-0.85; P < 0.001). No association was identified with race. In New Zealand, HDF use was more likely in Maori and Pacific Islanders (OR = 1.32; 95% CI = 1.05-1.66) and Asians (OR = 1.75; 95% CI = 1.15-2.68) compared to Caucasians, and less likely in males (OR = 0.76; 95% CI = 0.62-0.94; P = 0.01). No association was identified with BMI or co-morbidities. In both countries, centres with a higher ratio of HD to peritoneal dialysis (PD) were more likely to prescribe HDF. Larger Australian centres were more likely to prescribe HDF (36-147 new patients/year OR = 26.75, 95% CI = 18.54-38.59; 17-35/year OR = 7.51, 95% CI = 5.35-10.55; 7-16/year OR = 3.00; 95% CI = 2.19-4.13; ≤6/year reference). CONCLUSION: Haemodiafiltration uptake is increasing, variable and associated with both patient and centre characteristics. Centre characteristics not explicitly captured elsewhere explained 36% of variability in HDF uptake in Australia and 48% in New Zealand.

Patient survival on haemodiafiltration and haemodialysis: a cohort study using the Australia and New Zealand Dialysis and Transplant Registry.

Background: It is unclear if haemodiafiltration improves patient survival compared with standard haemodialysis. Observational studies have tended to show benefit with haemodiafiltration, while meta-analyses have not provided definitive proof of superiority. Methods: Using data from the Australia and New Zealand Dialysis and Transplant Registry, this binational inception cohort study compared all adult patients who commenced haemodialysis in Australia and New Zealand between 2000 and 2014. The primary outcome was all-cause mortality. Cardiovascular mortality was the secondary outcome. Outcomes were measured from the first haemodialysis treatment and were examined using multivariable Cox regression analyses. Patients were censored at permanent discontinuation of haemodialysis or at 31 December 2014. Analyses were stratified by country. Results: The study included 26 961 patients (4110 haemodiafiltration, 22 851 standard haemodialysis; 22 774 Australia, 4187 New Zealand) with a median follow-up of 5.31 (interquartile range 2.87-8.36) years. Median age was 62 years, 61% were male, 71% were Caucasian. Compared with standard haemodialysis, haemodiafiltration was associated with a significantly lower risk of all-cause mortality [adjusted hazard ratio (HR) for Australia 0.79, 95% confidence interval (95% CI) 0.72-0.87; adjusted HR for New Zealand 0.88, 95% CI 0.78-1.00]. In Australian patients, there was also an association between haemodiafiltration and reduced cardiovascular mortality (adjusted HR 0.78, 95% CI 0.64-0.95). Conclusion: Haemodiafiltration was associated with superior survival across patient subgroups of age, sex and comorbidity.

The incidence of IgG4-positive plasma cells staining TIN in patients with biopsy-proven tubulointerstitial nephritis.

AIM: IgG4 disease is rare. However, IgG4 tubulointerstitial nephritis (TIN) is the most common renal manifestation. IgG4 disease is usually associated with elevated serum IgG4 levels and other organ involvement, low-density renal lesions on enhanced CT imaging and immune activation. The incidence of IgG4-TIN may be underestimated, as staining for IgG4 is not routine. This study sought to describe the prevalence of previously undiagnosed IgG4-TIN. Due to the complexity of the diagnosis, we only attempt to look at IgG4-positive plasma cell TIN as a potential indication for IgG4 renal disease. METHODS: A retrospective review of native renal biopsies performed between 2002 and 2012 with a primary diagnosis of TIN was selected. Samples for which interstitial nephritis was secondary to a glomerular disease were excluded. The tissues were stained for IgG4 and scored by two blinded observers. Demographic and follow-up details were collected. This study was approved by the local ethics committee. RESULTS: 82 cases of interstitial nephritis from a total of 1238 renal biopsies (2002-2012) were available after staining for further assessment. 12 samples demonstrated staining consistent with the criteria for IgG4-positive plasma cell TIN, of which 3 had mildly positive staining, 7 moderately positive staining and 2 had markedly positive staining. There were no statistically significant differences in the baseline characteristics between the positive and negative staining groups. CONCLUSIONS: A number of cases of IgG4-positive plasma cell TIN were observed histologically that had been previously diagnosed as non-specific chronic TIN. IgG4-positive plasma cell TIN made up 1% of all renal biopsies performed over 10 years and 13% of all biopsies demonstrating TIN not related to glomerular disease. IgG4 staining should be considered routinely in biopsies demonstrating primary TIN.

Modern Intermittent Haemodialysis (IHD) is an Effective Method of Removing Salicylate in Chronic Topical Salicylate Toxicity.

INTRODUCTION: There are limited data on modern intermittent hemodialysis (IHD) efficacy on salicylate elimination from topical poisoning. CASE REPORT: A 54-year-old male sought treatment for dyspnea but was then diagnosed with salicylate toxicity from topical application of Dencorub Extra Strength Heat Gel® for 1 week. Each tube contained 100 g with 26 % methylsalicylate (26 g). Laboratory workup was remarkable for an elevated anion gap of 30 and salicylate concentration of 78.7 mg/dL [5.7 mmol/L (N < 0.4 mmol/L)]. Treatment with urinary alkalinization was followed by hemodialysis for 5 h. Extraction ratios were 0.44 with clearance rates of 78.5 mL/min. Salicylate concentrations fell rapidly following initiation of hemodialysis with no rebound observed. DISCUSSION: Modern high flux IHD is an effective method of removing salicylates in the treatment of chronic topical poisoning.

Cefepime induced acute interstitial nephritis--a case report.

BACKGROUND: Nephrotoxicity due to drugs especially beta lactams and cephalosporins has been well recognised. Cefepime is a fourth-generation cephalosporin that is widely prescribed with few severe adverse reactions reported. Although cefepime induced neurotoxicity has frequently been reported, there is yet no reported case of acute interstitial nephritis caused by this drug. We report a biopsy proven case of acute kidney injury due to acute interstitial nephritis associated with use of cefepime for treatment of mastoiditis and temporal bone osteomyelitis. CASE PRESENTATION: A 62-year-old Caucasian female presented with symptoms of right sided mastoiditis. A brain Magnetic Resonance Imaging scan revealed presence of right sided mastoiditis with concurrent temporal bone osteomyelitis. Microbiological specimen isolated an Escherichia coli. Therapy was commenced with intravenous cefepime. After 4 weeks of therapy with intravenous cefepime she developed acute kidney injury. No other medications were taken by the patient. Urine analysis revealed non-nephrotic range proteinuria. There was no red cell casts or white cell casts. Renal biopsy confirmed acute interstitial nephritis as cause of acute kidney injury. Cefepime therapy was ceased and treatment with ciprofloxacin was given to complete the treatment course. Renal function improved only partially with conservative management without any corticosteroid use. To our knowledge this is the first report of cefepime induced interstitial nephritis. CONCLUSIONS: Although cefepime has been considered to be a safe antibiotic from nephrotoxicity point, like other cephalosporins this adverse effect can occur rarely. Physicians need to be mindful of nephrotoxicity associated with its use and careful monitoring of renal parameters should be performed in patients on prolonged therapy with cefepime.