Conversion from Intermittent Hemodialysis to Peritoneal Dialysis in Metastatic Catheter-Related Bloodstream Infection.

Of all complications from central venous catheters (CVC) in end-stage renal disease (ESRD) patients, catheter-related bloodstream infection (CRBSI) is one of the most devastating consequences. The option of catheter salvage is not an effective measure with metastatic infections. However, in patients with severe vasculopathy and/or near end-stage vascular disease, preservation of the venous access should be given utmost importance as the luxury of utilizing another vascular site is markedly limited. Providing adequate renal replacement therapy in this group of patients can be remarkably challenging for nephrologists. We are presenting an ESRD patient with advanced vascular disease who developed metastatic CRBSI with worsening uremia who was successfully converted from intermittent hemodialysis (IHD) to peritoneal dialysis (PD). Our rationale was to minimize repeated intravascular procedures coupled with the presence of another intravascular device. This has led to a complete resolution of persistent bacteremia, with a steady improvement in the uremic state. Conversion from IHD to PD for persistent bacteremia with metastatic complications was seldom addressed in literature. In the absence of a significant contraindication to PD, it can be considered as a valid alternative possibility in order to interrupt this viscous cycle, especially in vasculopathic patients.

Recurrent Hyponatremia in the Setting of Autoimmune Disease with Sicca Syndrome: A Case Report.

Sjogren's syndrome is an autoimmune disease associated with xerostomia and xerophthalmia. The association of Sjogren's with hyponatremia has rarely been reported and has been attributed to syndrome of inappropriate antidiuretic hormone secretion. Here, we report a case of polydipsia secondary to xerostomia as a cause of chronic hyponatremia in the setting of Sjogren's syndrome. Analysis of the patient's medical record, including medication reconciliation and dietary habits, revealed several underlying causes of her recurrent hyponatremia. A thorough review of the patient's clinical history and good bedside examination may reduce prolonged hospitalizations and improve the quality of life of a hyponatremic population of patients who are predominantly elderly.

Discontinuation of Intermittent Hemodialysis in HIV-Associated Nephropathy Following Initiation of Antiretroviral Therapy.

Human immunodeficiency virus (HIV) infection occurs due to the HIV virus. It results in an immunodeficient state and multi-organ system infections and malignancy known as AIDS. HIV-associated nephropathy (HIVAN) is the most common HIV kidney involvement and may present as acute kidney injury (AKI), as well as chronic kidney disease (CKD). HIVAN is a collapsing form of focal segmental glomerulosclerosis (FSGS). HIVAN treatment options include antiretroviral therapy (ART), steroids, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB), and hemodialysis (HD). We herein describe the case of a 40-year-old patient with an established diagnosis of HIVAN who has had partial recovery of end-stage renal failure following the initiation of ART.

Calcific Uremic Arteriolopathy: A Case Series and Review from an Inner-City Tertiary University Center in End-Stage Renal Disease Patients on Renal Replacement Therapy.

MATERIALS AND METHODS: 24 patients with CUA and on RRT were evaluated at Detroit Medical Center from 2007 to 2016. Skin biopsy was used in almost all patients, along with the radiological and clinical findings. The patient's clinical and paraclinical data were retrieved from the electronic medical records. The effect of treatment modalities and the underlying hyperparathyroidism management were compared to the clinical outcomes using appropriate statistical tests. RESULTS: Twenty-one patients were on hemodialysis, two patients received renal transplants, and one patient was on peritoneal dialysis. Diabetes mellitus was the most prevalent cause of ESRD. The parathyroid hormone level (PTH) was elevated in 22 patients. Fifteen patients were diagnosed 2 weeks or more prior to skin lesion onset. Twenty-two and thirteen patients received sodium thiosulphate and cinacalcet, respectively. Patients with lower PTH and the calcium-phosphate product levels had a relatively better outcome of CUA. CONCLUSIONS: A multifaceted approach may play a role in treating CUA. Referral to a nephrologist may aid in the early diagnosis and prompt management of CUA.

Prevalence, Length of Stay, and Hospitalization of Acute Kidney Injury in Patients With and Without Sjogren's Syndrome.

BACKGROUND: Literature on the outcome of acute kidney injury (AKI) in Sjogren's syndrome (SJS) is quite scanty. Acute kidney injury has emerged as a significant cause of morbidity and mortality in patients with autoimmune diseases such as systemic lupus erythematosus. OBJECTIVE: To examine the outcome of AKI with and without SJS. To achieve this, we examined the prevalence, mortality, outcomes, length of stay (LOS), and hospital charges in patients with AKI with SJS compared with patients without SJS from a National Inpatient Sample (NIS) database in the period 2010 to 2013. DESIGN: A retrospective cohort study using NIS. SETTING: United States. SAMPLE: Cohort of 97 055 weighted patient discharges with AKI from the NIS. MEASUREMENTS: Not applicable. METHODS: Data were retrieved from the NIS for adult patients admitted with a principal diagnosis of AKI between 2010 and 2013, using the respective International Classification of Diseases, Ninth Revision (ICD-9) codes. The study population divided into 2 groups, with and without Sjogren's disease. Multivariate and linear regression analysis conducted to adjust for covariates. We omitted patients with systemic sclerosis and rheumatoid arthritis from the analysis to avoid any discrepancy as they were not meant to be a primary outcome in our study. RESULTS: The study population represented 97 055 weighted patient discharges with AKI. Analysis revealed AKI patients with Sjogren's compared with patients without Sjogren's had statistically significant lower hyperkalemia rates (adjusted odds ratio: 0.65, confidence interval: 0.46-0.92; P = .017. There was no statistically significant difference in mortality, LOS, hospital charges, and other outcomes. LIMITATIONS: Study is not up to date as data are from ICD-9 which are testing data from 2010 to 2013, and data were obtained through SJS codes, which have their limitations. Also, limitations included lack of data on metabolic acidosis, hypokalemia, and not including all causes of AKI. CONCLUSIONS: At present, our study is unique as it has examined prevalence, mortality, and outcomes of Sjogren's in patients with AKI. Patients with Sjogren's had significantly lower hyperkalemia during the hospitalization. Further research is needed to identify the underlying protective mechanisms associated with Sjogren's that resulted in lower hyperkalemia. TRIAL REGISTRATION: Not applicable.

CONTEXTE: La documentation portant sur les issues de l'insuffisance rénale aiguë (IRA) en présence du syndrome de Sjorden (SSJ) est assez peu abondante. L'IRA apparaît comme une cause importante de morbidité et de mortalité chez les patients atteints de maladies auto-immunes telles que le lupus érythémateux systémique. OBJECTIFS: Examiner les issues de l'IRA avec ou sans SSJ. Pour ce faire, nous avons consulté la période entre 2010 et 2013 de la base de données National Inpatient Sample (NIS) pour comparer la prévalence, la mortalité, les issues, la durée des hospitalisations, et les frais d'hospitalisation chez des patients atteints d'IRA avec ou sans SSJ. TYPE D'ÉTUDE: Une étude de cohorte rétrospective utilisant la NIS. CADRE: États-Unis. ÉCHANTILLON: Les congés pondérés de 97 055 patients atteints d'IRA tirés de la NIS. MESURES: Sans objet. MÉTHODOLOGIE: Les codes diagnostic CIM-9 ont servi à l'extraction des données de la NIS pour les adultes admis avec un diagnostic primaire d'IRA entre 2010 et 2013. La population étudiée a été divisée en deux groupes: avec ou sans syndrome de Sjorden. Des analyses par régression linéaire et multivariée ont été conduites pour corriger les covariables. Pour éviter les disparités, les patients atteints de sclérose systémique et de polyarthrite rhumatoïde ont été exclus de l'analyse puisque ces affections ne devaient pas constituer un résultat principal de l'étude. RÉSULTATS: La population étudiée était constituée de 97 055 patients atteints d'IRA et ayant obtenu leur congé de l'hôpital. L'analyse a révélé que les patients atteints d'IRA et du SSJ présentaient des taux d'hyperkaliémie statistiquement plus faibles (rapport de cotes [RC] corrigé: 0,65; IC à 95 %: 0,46-0,92; p =0,017) que les patients sans SSJ. Aucune différence significative n'a été observée entre les deux groupes en ce qui concerne la mortalité, la durée du séjour, les frais d'hospitalisation et les autres résultats. LIMITES: L'étude n'est pas à jour puisque les données sont tirées des codes CIM-9, soit sur des données de 2010 à 2013 obtenues par l'entremise des codes du SSJ, lesquels ont leurs propres limites. L'étude est également limitée par le manque de données sur l'acidose métabolique, l'hypokaliémie et par le fait qu'elle n'inclut pas toutes les causes d'IRA. CONCLUSION: À ce jour, notre étude est la seule qui ait examiné la prévalence, la mortalité et les issues du syndrome de Sjorgren chez les patients atteints d'IRA. Les patients atteints du syndrome de Sjogren ont présenté moins d'hyperkaliémie pendant leur hospitalisation. Des études supplémentaires sont nécessaires pour identifier les mécanismes sous-jacents, associés au syndrome de Sjogren, ayant entraîné moins d'hyperkaliémie. ENREGISTREMENT DE L'ESSAI: Sans objet.

Correlation between Dt/V derived from ionic dialysance and blood-driven Kt/V of urea in African-American hemodialysis patients, based on body weight and ultrafiltration volume.

BACKGROUND: The Dt/V obtained by using ionic dialysance (D) as a surrogate for urea clearance (K) is a well-validated adjunct measure of hemodialysis adequacy, with a variable level of correlation with urea-based Kt/V. However, this correlation has not been examined based on patients' body size and ultrafiltration (UF) volume during the dialysis session. METHODS: Simultaneous evaluations of online Dt/V and single-pool variable-volume urea Kt/V were made. Patients were categorized into three subgroups based on their weight (<60, 60-80 and ≥80 kg), body mass index (<25, 25-30 and >30 kg/m2) and UF volume (<1.5, 1.5-3 and >3 L). The correlation between Dt/V and Kt/V was evaluated for the entire cohort per dialysis session in each subgroup. RESULTS: Mean Kt/V was greater than the mean Dt/V (1.72 versus 1.50, P < 0.001), with an overall correlation r value of 0.602. This correlation was stronger in the medium weight group versus lower and higher weights. The correlation between Dt/V and Kt/V was inversely related to the UF volume (r = 0.698, 0.621 and 0.558 for those with UF volume of <1.5, 1.5-3.0 and >3 L, respectively). A total of 99.3% of patients with Dt/V of >1.2 also had Kt/V >1.2 and 9.5% of those with Dt/V <1.2 had their Kt/V <1.2. CONCLUSIONS: There is a moderate degree of correlation between Dt/V and Kt/V in African-American hemodialysis patients, which is impacted by body size and UF volume. A Dt/V of >1.2 strongly predicts adequate dialysis as defined by Kt/V of >1.2.

Coexisting tertiary hyperparathyroidism and severe hypothyroidism in an end-stage renal disease patient on hemodialysis.

INTRODUCTION: The clinical syndrome of uremia is a bedside diagnosis which mimics a wide spectrum of other clinical disorders, most commonly thyroid disease. End-stage renal disease (ESRD), as a disorder, frequently alters thyroid hormone metabolism, and this is not significantly normalized by dialysis. Although the thyroid and parathyroid glands are considered independent organs, their anatomical juxtaposition in the neck, as well as sharing a common embryological origin, might play a role in some of the possible association between thyroid and parathyroid disease. It has been demonstrated in experimental animals that changes in the thyroid gland might lead to pathological changes in the parathyroids and vice versa. CASE PRESENTATION: An incidence of as high as 25% of hypothyroidism has been reported in patients with ESRD on dialysis. We report a patient with ESRD on maintenance hemodialysis (MHDx) who has had a combination of profound tertiary hyperparathyroidism (HPTH) and severe hypothyroidism. CONCLUSIONS: Literature search revealed an increased prevalence of hypothyroidism with secondary HPTH from renal failure. Although there is increased prevalence of hypothyroid state in secondary HPTH from renal failure, the association appears much weaker in primary HPTH and again no conclusive pathological relation has been identified between the two endocrine glands. A closer look and perhaps long-term prospective studies are required in the future to determine this association.

Relationship between bone histology and markers of bone and mineral metabolism in African-American hemodialysis patients.

BACKGROUND AND OBJECTIVES: Racial differences in mineral metabolism exist in the chronic kidney disease population, especially as it relates to intact parathyroid hormone (iPTH) levels. Few data exist on the relationship of these markers to bone biopsy findings in African-American (AA) hemodialysis patients across the spectrum of renal osteodystrophy (ROD). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In prevalent AA hemodialysis subjects, we prospectively evaluated subjects by performing transiliac bone biopsy and correlating biochemical and clinical data to bone histology. RESULTS: Study patients (n = 43) had an average age of 53.7 (11.6) yr, with dialysis vintage of 40.4 (24.5) mo, 30% with diabetes, and 51% male. Bone histology revealed adynamic bone disease (ABD) (16%), mild to moderate hyperparathyroidism (HPT) (72%), severe (12%) HPT, and no osteomalacia or mixed uremic osteodystrophy. At the time of biopsy, mean corrected calcium was 9.1, 8.9, and 9.4 mg/dl (P = 0.344); calcium-phosphorus (Ca X PO4) product was 42, 55, and 62 mg(2)/dl(2) (P = 0.002); phosphorus was 4.6, 6.2, and 6.7 mg/dl (P = 0.005); and iPTH was 225, 566, and 975 pg/ml (P = 0.006), respectively. Median values for bone-specific alkaline phosphatase (BS-AP) were 16, 34, and 64 ng/ml (P < 0.0001) among the three groups. CONCLUSIONS: These data demonstrate that across the spectrum of ROD, iPTH levels are higher than expected in AA hemodialysis subjects. iPTH, PTH peptides, and bone-specific alkaline phosphatase correlated directly with histomorphometric measurements of bone turnover and when subjects were grouped by histologic diagnosis. Only 9.5% of subjects were simultaneously within suggested Kidney Disease Outcomes Quality Initiative (K/DOQI) ranges for Ca X PO4, phosphorus, and iPTH, of which 75% demonstrated ABD on biopsy.

Effect of intravenous ascorbic acid in hemodialysis patients with EPO-hyporesponsive anemia and hyperferritinemia.

BACKGROUND: Although erythropoietin (EPO)-hyporesponsive anemia in hemodialysis patients most commonly results from iron deficiency, the contributory role of chronic inflammation and oxidative stress in its pathogenesis is poorly understood. We conducted an open-label prospective study to assess the effect of vitamin C, an antioxidant, on EPO-hyporesponsive anemia in hemodialysis patients with unexplained hyperferritinemia. METHODS: Forty-six of 262 patients in an inner-city hemodialysis center met the inclusion criteria (administration of intravenous iron and EPO for > or = 6 months at a dose > or = 450 U/kg/wk, average 3-month hemoglobin [Hb] level < or = 11.0 g/dL [< or = 110 g/L], ferritin level > or = 500 ng/mL (microg/L), and transferrin saturation [TSAT] < or = 50%). Patients were excluded if they had a clear explanation for the EPO hyporesponsiveness. Four patients refused to participate. The remaining patients were randomly assigned; 20 patients to receive standard care and 300 mg of intravenous vitamin C with each dialysis session (group 1) and 22 patients to receive standard care only (group 2). Study duration was 6 months. During the study, 1 patient from group 1 was removed (upper gastrointestinal bleeding) from final analysis. Monthly assessment included Hb level, mean corpuscular volume, iron level, iron-binding capacity, ferritin level, TSAT, and Hb content in reticulocytes. In addition, biointact parathyroid hormone, aluminum, C-reactive protein (CRP), and liver enzymes were measured every 3 months. RESULTS: Age, sex, race, and time on dialysis therapy were similar in both groups. At 6 months, Hb levels significantly increased from 9.3 to 10.5 g/dL (93.0 to 105.0 g/L) in group 1, but not group 2 (9.3 to 9.6 g/dL [93.0 to 96.0 g/L]; P = 0.0001). Similarly, TSAT increased from 28.9% to 37.3% in group 1, but not group 2 (28.7% to 29.3%; P = 0.0001). EPO dose (477 to 429 versus 474 to 447 U/kg/wk), iron-binding capacity (216 to 194 versus 218 to 257 microg/dL [38.7 to 34.7 versus 39 to 46 micromol/L]), and CRP level (2.8 to 0.9 versus 2.8 to 2.2 mg/dL) decreased significantly in group 1, but not in controls. Changes in Hb content in reticulocytes and ferritin level also were statistically significant in group 1. There was no change in biointact parathyroid hormone levels. Although serum iron levels and intravenous iron doses changed within each group, changes were equal between the 2 groups. CONCLUSION: In hemodialysis patients with refractory anemia and hyperferritinemia, vitamin C improved responsiveness to EPO, either by augmenting iron mobilization from its tissue stores or through antioxidant effects.