Case report: Atenolol overdose successfully treated with hemodialysis

Owing to the drug's favorable hydrophilic and pharmacokinetic characteristics, a number of case reports have demonstrated effective treatment of atenolol overdose with hemodialysis. However, the efficiency of atenolol clearance throughout hemodialysis treatments has not previously been examined. In this report, a patient with impaired renal function was successfully treated with two 5‐hour intermittent high‐flux high‐efficiency hemodialysis therapies after atenolol overdose. Serial atenolol levels were measured during his hemodialysis treatments. We observed an over 50% plasma atenolol concentration reduction after each 5‐hour hemodialysis therapy. Hemodialysis therapy is an effective treatment for atenolol overdose, especially in patients with impaired renal function.     

Marked functional improvement in a pediatric patient treated with hemodialysis for scleroderma related renal failure

Systemic sclerosis (SSc) is a rare autoimmune disease characterized by fibrosis and vasculopathy of the skin and visceral organs. Scleroderma renal crisis (SRC), the most acute and life threatening complication, occurs in 10–20% of adult patients with SSc and has not been reported in children. A 10‐year‐old girl was diagnosed with SSc when she presented with weakness and skin thickening. She had positive ANA and anti‐Scl 70. Renal function, urinalysis, and blood pressure were normal. She was treated with steroids, penicillamin and methotrexate as well as amlodipine for Raynaud's phenomenon, but her diffuse skin thickening and contractures progressed and she became wheelchair bound and had poor growth despite nutrition through a G‐tube. At age 15 (weight 28 kg), when evaluated for abdominal pain, she was found to have acute renal failure (BUN 54 mg/dl, creatinine 2.2 mg/dl) and hypertension. Despite therapy with enalapril, serum creatinine continued to rise and she became oligoanuric, requiring initiation of hemodialysis. BP was controlled with enalapril and dialysis but she remained dialysis dependent. Steroid therapy was discontinued and replaced by low dose cyclosporine. Enalapril was replaced by losartan because of leukopenia and BP remained normal. Over the next 2 years, she was treated with hemodialysis and did not experience any complications. She progressively had an outstanding overall clinical improvement, marked skin softening, and was able to walk independently. Renal function did not improve. 28 months after the SRC, she received LRD renal transplant. Immunosuppression included cyclosporine, mycophenolate and prednisone. Creatinine 2 months post‐transplant is 0.7 mg/dl. SRC in children may progress to end‐stage renal disease but can be treated successfully with dialysis and transplantation without significant complications.     

Heparin‐induced thrombocytopenia in a hemodialysis patient treated with fondaparinux: Nephrologists between two fires

Heparin‐induced thrombocytopenia (HIT) is caused by heparin exposure and presents with reduced platelet count. Patients undergoing hemodialysis (HD) treatment have increased risk of developing HIT due to prolonged exposure to unfractionated heparin or low‐molecular weight heparin. We report a 79‐year‐old male patient with end‐stage renal disease who developed type‐II HIT during maintenance HD. Platelet count of the patient decreased gradually and antiplatelet factor IV antibody was found to be positive. The patient was treated with fondaparinux and continued heparin‐free HD. Unfortunately, despite favorable initial response without any thrombotic episodes, the patient died due to severe sepsis complicated by gastrointestinal hemorrhage.     

Sternal instability in a hemodialysis patient with secondary hyperparathyroidism

A 77‐year‐old man, 11 years under chronic hemodialysis treatment for chronic renal failure of unknown origin, presented with anterior chest pain, dyspnea with paradoxical breathing, and sternal instability after a simple fall from a standing height. Patient underwent three‐vessel coronary artery bypass grafting 31 months ago. Computed tomography with three‐dimensional volume rendering showed sternal nonunion with a great gap between the two halves of the sternum and at least one fracture in the left half of the sternum. A successful surgical repair followed. Patient suffered from severe secondary hyperparathyroidism for many years. Despite treatment with sevelamer, paricalcitol and cinacalcet, intact parathyroid hormone was 1682 pg/mL. During the last 5 years, serum intact parathyroid hormone remained steadily above 1000 pg/mL. Patient refused parathyroidectomy in the past. We assume that long‐lasting severe hyperparathyroidism contributed to this rare and life‐threatening complication of median sternotomy in our patient, due to the detrimental effect of hyperparathyroidism on bone metabolism and its association with increased incidence of bone fractures and defect in bone fracture healing.     

Levofloxacin-induced rhabdomyolysis in a hemodialysis patient

Rhabdomyolysis is a well-known complication of various drug therapies. We report a case of levofloxacin-induced rhabdomyolysis requiring hospitalization in a hemodialysis patient. Physicians should be aware of the risk of this potentially severe adverse drug reaction.     

Unilateral digital clubbing in a hemodialysis patient

We present an unusual case of a chronic hemodialysis patient with moderate diffuse acrocyanosis and prominent unilateral clubbing of his right hand fingers, with classic physical features of hypertrophic osteoarthropathy. The patient's left hand, which had a functioning arteriovenous fistula, did not show any evidence of clubbing. We briefly discuss the different theories in regards to the pathogenesis of clubbing, and the potential role of arteriovenous fistula in preventing its occurrence.     

New-onset psoriasis in a maintenance hemodialysis patient

New-onset psoriasis is extremely rare in hemodialysis (HD) patients, and several trials of dialysis therapies (HD and peritoneal dialysis) in psoriasis have indicated remarkable improvement in skin lesions and well-being even in patients without renal impairment. We describe a patient who developed severe psoriasis despite undergoing chronic maintenance hemodialysis for 5 years and was treated successfully with oral cyclosporin A.     

Fever of unknown origin in a hemodialysis patient with a failed allograft

Fever of unknown origin (FUO) in hemodialysis (HD) patients represents a diagnostic challenge because differential diagnosis includes diverse etiologies. Causes of FUO in the general population can be classified into 3 diagnostic categories: infections, tumors, and noninfectious inflammatory diseases. Also, chronic HD patients may have additional problems such as infections, the risk for which may be increased by the immunosuppression associated with uremia, vascular access-related infections, and nosocomial infections. Moreover, patients with chronically failed kidney transplants can have low-grade fever and abdominal pain, and if inflammation of the allograft is severe enough, it may result in a spontaneous rupture. Hence, it is important to rapidly recognize, diagnose, and manage these complications. In the present study, we report a case of FUO in an HD patient with a failed graft and discuss clinical approach and management of these patients.     

Cervical tumoral calcinosis with secondary hyperparathyroidism in a chronic hemodialysis patient

Tumoral calcinosis is an uncommon and severe complication of chronic renal failure. It is generally associated with the presence of a high‐serum calcium‐and‐phosphorus product. We report here a case of a patient on maintenance hemodialysis who presented with progressively increasing, solitary, tumor‐like swelling over the nape of the neck. A 50‐year‐old female on thrice weekly maintenance hemodialysis for the last 3 years presented with a small swelling over the nape of the neck that had been progressively increasing over the last 1 year to cricket ball size. The patient was investigated and diagnosed as having tumoral calcinosis. The metastatic calcification occurring in the patient was most likely related to high calcium × phosphate product with coexistent secondary hyperparathyroidism possibly aggravated by vitamin D therapy. The patient was treated with withdrawal of vitamin D therapy, strict control of serum phosphate levels with noncalcemic phosphate binders, and subtotal parathyroidectomy. The neck swelling started decreasing in size after 2 months of parathyroidectomy and there was marked clinical improvement with drop in serum parathormone levels, over a period of 6 months. After 2 years of parathyroidectomy, the neck swelling again started increasing in size with increase in serum parathormone levels. The patient was treated with cinacalcet and the neck swelling gradually decreased in size along with control of serum parathormone and phosphate levels.     

Spontaneous intercostal artery bleeding in a hemodialysis patient

Spontaneous rupture of an intercostal artery (ICA) is a rare but could be a life‐threatening emergency requiring prompt diagnosis and intervention for optimal outcome. We report a patient presented with swelling in his right‐side back which started immediately after scheduled hemodialysis and continued to increase in size. Contrast computed tomography scan revealed soft tissue attenuated lesion with internal enhancing dots which suggested expanding hematoma with active bleeding. Arteriography detected focal contrast extravasation from seventh ICA, and transcatheter arterial embolization was successfully done. To the best of our knowledge, this is the first report describing spontaneous bleeding of ICA in a hemodialysis patient.     

Ventriculo-peritoneal shunt infection in a patient on hemodialysis

Sepsis is an important and serious complication in hemodialysis (HD) patients. Here we report on a case of spina bifida with ventriculo-peritoneal (VP) shunt infection who was on HD and underwent at least 5 months of investigations before a source of the infection was found and eventually treated successfully. We believe this to be the first reported case of VP shunt-associated sepsis in a patient on HD.     

Denosumab treatment for refractory hypercalcemia in a hemodialysis patient with tertiary hyperparathyroidism

The most appropriate surgical procedure for tertiary hyperparathyroidism is still controversial. Medical management may be considered in those patients with failed previous surgical intervention. There are limited medical options for tertiary hyperparathyroidism with renal dysfunction. The monoclonal antibody denosumab has been used in patients with osteoporosis and hypercalcemia of malignancy. We report a case of medically refractory hypercalcemia caused by tertiary hyperparathyroidism treated with denosumab. A 46-year-old female was on hemodialysis for 10 years. She was diagnosed with tertiary hyperparathyroidism due to hypercalcemia with a high level of intact parathyroid hormone (iPTH, 1411 pg/ml). After right parathyroidectomy 6 weeks, her serum calcium remained persistently elevated (Ca, 3.17 mmoL/L). Denosumab (60 mg) was administered subcutaneously, and her serum calcium quickly decreased (from 3.43 to 2.04 mmoL/L within 8 days) and was slightly elevated (Ca, 2.8 mmoL/L) 3 months later. We conclude that denosumab has a significant effect on the reduction of serum calcium for tertiary hyperparathyroidism patients. The long-term treatment effect and safety warrant more studies in the future.     

Extreme hyperglycemia with ketoacidosis and hyperkalemia in a patient on chronic hemodialysis

A patient on hemodialysis for end-stage renal disease secondary to diabetic nephropathy was admitted in a coma with Kussmaul breathing and hypertension (232/124 mmHg). She had extreme hyperglycemia (1884 mg/dL), acidosis (total CO(2) 4 mmol/L), hyperkalemia (7.2 mmol/L) with electrocardiographic abnormalities, and hypertonicity (330.7 mOsm/kg). Initial treatment with insulin drip resulted in a decrease in serum potassium to 5.3 mmol/L, but no significant change in mental status or other laboratory parameters. Hemodialysis of 1.75 hours resulted in rapid decline in serum glucose and tonicity and rapid improvement of the acidosis, but no change in mental status, which began to improve slowly after the hemodialysis was stopped, but with ongoing treatment with continuous insulin infusion. The rate of decline in tonicity during hemodialysis (14.5 mOsm/kg/h) was high, raising concerns about neurological complications. In this case, extreme hyperglycemia with ketoacidosis, hyperkalemia, and coma developing in a hemodialysis patient responded to insulin infusion. Monitoring of the clinical status and the pertinent laboratory values is required to assess the need for other therapeutic measures including volume and potassium replacement and emergency dialysis. The indications for and risks of emergency dialysis in this setting are not clearly defined.     

Multiple metastatic infections in a hemodialysis patient with untunneled internal jugular catheter

We present an end‐stage renal disease patient on dialysis with fever. The primary source was right internal jugular vein catheter which had metastatic infections in the body probably via an arteriovenous communication in a cavity in left lung. Patient had right psoas muscle abscess and a left kidney abscess. An ¹⁸F‐fluorodeoxyglucose‐positron emission spectroscopy scan was done to find out left kidney abscess. A search of literature did not reveal many patients of psoas abscess secondary to infection of hemodialysis access.     

Alirocumab in a high cardiovascular risk patient on hemodialysis with liver abnormalities

We present a male diabetic type 2 patient on hemodialysis (HD) with high cardiovascular (CVD) risk and hyperlipidemia. The patient was under cholesterol‐lowering therapy with statin and ezetimibe but he was obligated to discontinue due to chronic hepatitis C virus infection. Statins and ezetimibe may exert a potential hepatotoxic effect and for this reason, we attempted to find an alternative treatment to prevent CVD. Given that a potential hepatotoxic effect has not been reported for Abs SPCK9, we administered alirocumab 150 mg every 2 weeks for a total of 8 weeks. Low‐density lipoprotein levels have decreased and no side effects have been observed. In conclusion, alirocumab is a safe and efficient alternative therapy approach for HD patients with high CVD risk and liver abnormalities. We suggest that SPCK 9 inhibitors should be considered as a first line treatment for lowering cholesterol in this specific patient group.     

Infective endocarditis in a hemodialysis patient: a dreaded complication

Infection is the most common cause of death in hemodialysis patients, after cardiovascular disease. Dialysis access infections, with secondary septicemia, contribute significantly to patient mortality. The most common source is temporary catheterization. Bacteremia occurs commonly in patients receiving hemodialysis, with infective endocarditis being a relatively uncommon, but potentially lethal complication. Valvular calcification is the most significant risk factor. The diagnosis of infective endocarditis is made clinically and confirmed with the echocardiographic modified Duke's criteria. The most common pathogen is Staphylococcus aureus and the mitral valve is the most common site. Staphylococcus aureus infective endocarditis is commonly associated with embolic phenomenon. A high index of suspicion is critical in the early recognition and management of infective endocarditis. However, prevention of bacteremia is undoubtedly the best strategy with the early placement of arteriovenous fistulae. In the case of temporary catheterization, the use of topical mupirocin or polysporin and gentamicin and/or citrate locking is beneficial. Although catheter salvage has not been studied in randomized trials, catheter removal remains standard therapy during bacteremia.     

Cloxacillin‐induced seizure in a hemodialysis patient

We are reporting a cloxacillin‐induced seizure in a patient with stage 5 chronic kidney disease requiring hemodialysis. To our knowledge, there are no published case reports of seizures induced by parenteral cloxacillin in hemodialysis patients. A young hemodialysis female was admitted to the hospital with decreased level of consciousness. Blood cultures revealed methicillin‐sensitive Staphylococcus aureus where cloxacillin 2 g intravenously every 4 hours was initiated. Head computed tomography (CT) was not significant. After 14 hours of cloxacillin therapy (4 doses), the patient demonstrated tonic/clonic seizure activity, where phenytoin and lorazepam were initiated. The anti‐seizure medications partially reduced seizure activity. Once the cloxacillin was discontinued, the seizures stopped. Two weeks later, all anti‐seizure medications were stopped with no further seizure activity. Cloxacillin elimination in hemodialysis patients is similar to patients with normal kidney function. Although cloxacillin does not significantly cross the blood–brain barrier, the correlation between the start of seizures and cloxacillin initiation was confirmed by the negative CT and blood chemistry laboratory results. Moreover, seizure activity was terminated upon discontinuation of cloxacillin. Although further investigation for the cause of such seizures is warranted, clinicians should use caution when giving high doses of cloxacillin in hemodialysis patients.