Effects of hemodialysis on ventricular activation time in children with end‐stage renal disease

Patients with end‐stage renal disease are affected by cardiovascular complications, including disturbances of the heart intraventricular conduction. Body surface potential mapping is a non‐invasive electrocardiographic detection method of initial disturbances in heart activation propagation. A goal of the study was to analyze the effects of single hemodialysis (HD) session on ventricular activation time (VAT) maps obtained from hemodialyzed children. The study group consisted of 13 hemodialyzed children (age: 6–18 years). The control group is composed of 26 healthy subjects. In each HD patient, 12‐lead electrocardiogram and echocardiography examinations were performed. Isochrone heart maps, reflecting body surface distribution of VAT isolines, were recorded from an 87‐electrode HPM‐7100 system for body surface potential mapping, before (group B) and after HD session (group A). The distribution of isochrones and VAT values, as recorded in the HD patients, differed significantly from the reference VAT map for controls. The highest VAT maximal value was noted in group B (Me: 110 vs. 62 ms in the control group; P < 0.001), becoming significantly lower after HD session (Me: 98 ms for group A vs. 110 ms for group B; P < 0.001). Ventricular activation time maps, recorded before HD session, showed significant VAT delays with isochrone arrangement specific for the left bundle branch block. After HD session, VAT maps presented significant changes, suggesting a normalization process. Ventricular activation time maps in children with end‐stage renal disease exhibited disturbances of intraventricular conduction within the left bundle branch block, undetectable on standard electrocardiogram. A single HD session resulted in VAT map improvement related to overall HD treatment duration.     

Approach to prophylactic measures for central venous catheter‐related infections in hemodialysis: A critical review

Vascular access is the major risk factor for bacteremia, hospitalization, and mortality among hemodialysis (HD) patients. The type of vascular access most associated with bloodstream infection is central venous catheter (CVC). The incidence of catheter‐related bacteremia ranges between 0.6 and 6.5 episodes per 1000 catheter days and increases linearly with the duration of catheter use. Given the high prevalence of CVC use and its direct association with catheter‐related bacteremia, which adversely impacts morbidity and mortality rates and costs among HD patients, several prevention measures aimed at reducing the rates of CVC‐related infections have been proposed and implemented. As a result, a large number of clinical trials, systematic reviews, and meta‐analyses have been conducted in order to assess the effectiveness, clinical applicability, and long‐term adverse effects of such measures. In the following article, prophylactic measures against CVC‐related infections in HD patients and their possible advantages and limitations will be discussed, and the more recent literature on clinical experience with prophylactic antimicrobial lock therapy in HD CVCs will be reviewed.     

Split catheters in children on chronic hemodialysis: a single-center experience

Tunneled central venous catheters (CVCs) play an increasing role as vascular access for chronic hemodialysis (HD) in children, but limited data exist about the optimal CVC choice. We analyzed the outcome, efficacy, and complications of tunneled CVCs, placed in our unit in the last 3 years. Nineteen 10 F Split‐Cath CVCs (two separate catheters fused along their length) were placed in 10 children, median age 9.19 years (range 2.15–13.31) and body weight (BW) between 10 and 40 kg. CVCs survival at 1, 3, 6, and 12 months was 94%, 77%, 51%, and 34%, respectively. Catheter survival was higher in children with BW > 20 kg than in smaller patients. Median survival was higher than that of 11 Quinton Permcath CVCs, placed in five children in the preceding 2 years (280 vs. 45 days, P < 0.05). Median blood flow rate and indices of HD adequacy were higher in children with lower BW (<20 kg vs. 20–30 kg vs. >30 kg) than in those with higher BW. Incidence of exit site and bloodstream infections was 2.32 and 0.66/1000 CVC days, respectively. One case of hemothorax due to subclavian artery puncture occurred during CVC placement. In conclusion, Split‐Cath 10 F CVC allows for effective dialysis in children undergoing HD, particularly those between 10 and 30 kg BW. Catheter survival is acceptable, but could be improved in small children.     

Ventricular arrhythmia in dialysis patients: A link with higher hemoglobin levels?

We investigated the frequencies and associated risk factors of cardiac arrhythmias and heart rate variability (HRV) in hemodialysis (HD) patients. One hundred fifty prevalent HD patients underwent 48-hour Holter monitoring. Holter monitoring was analyzed in 4 phases: early post-HD phase (12 hours), late post-HD phase (20 hours), pre-HD phase (12 hours), and HD phase (4 hours). Echocardiography was applied to measure the left ventricular mass index in a subgroup of patients (n: 52). Patients with ventricular premature contraction (VPC) were significantly older, had a longer HD duration, and higher hemoglobin (Hb) levels. Left ventricular mass index was significantly correlated with the frequency of VPC, during the HD and pre HD phases (r: 0.435, 0.312, respectively). In logistic regression analysis, patients with Hb level >11.9 g/dL (high tertile) had a 4.5-fold increased risk of VPC compared with those with Hb levels <10.8 g/dL (P: 0.04). In HRV analysis, age (P<0.001), and diabetes (P: 0.03) were found to be independent predictors of low standard deviation of all mean normal-to-normal RR intervals. Increased left ventricular mass index is associated with a high frequency of VPC in the pre-HD and HD periods. The occurrence of VPC is predicted by older age, longer dialysis duration, and higher Hb levels, while older age and diabetes are the determinants of HRV. The relation between higher Hb levels and the frequency of VPC might provide a clue for the explanation of the detrimental effect of higher Hb levels on HD patients.     

Hemodialysis‐induced bradycardia, “a plumbing issue”: Resolved with catheter repositioning

Sudden cardiac death (SCD) is reported as leading cause of death in patients on chronic hemodialysis. Arrhythmias are proposed to be a major predisposing factor for SCD. However, triggers for potentially lethal arrhythmias are not well understood. Here we describe a case of 72‐year‐old man on chronic hemodialysis via permanent Central venous catheter (CVC) who was admitted for evaluation after unwitnessed fall. Within 10 minutes of his first routine dialysis session in the hospital, he had cardiac‐arrest. He was successfully resuscitated within 3 minutes. The next day, fifteen minutes into the dialysis session, he had bradycardia with telemetry demonstrating long sinus pause and he lost consciousness. After few minutes of Advanced Cardiac Life Support (ACLS) he regained pulse and consciousness. Further review of the chest X‐ray revealed the tip of CVC to be directly touching the distal Superior Vena Cava (SVC) wall. We felt the catheter tip may have migrated after the fall and now is irritating the Sinoatrial node and triggering bradyarrhythmia. Next day, the CVC was exchanged, and the tip was placed higher up in superior vena‐cava. After repositioning, we started him on dialysis under intensive monitoring, and he tolerated well without any arrhythmia. Subsequent dialysis was uneventful. We describe a case of recurrent symptomatic intra‐dialytic bradycardia due to abnormal positioning of CVC that resolved after the repositioning of the catheter. This case in addition to similar case in nondialysis settlings provides additional insights into mechanisms of fatal arrhythmias in hemodialysis patient having CVC.     

Changes in circulating biomarkers during a single hemodialysis session

The hemodialysis (HD) procedure induces an inflammatory response potentially contributing to cardiovascular disease. Here we investigated the acute impact of HD on circulating biomarkers. Circulating biomarkers (small solutes, middle molecular‐sized peptides, and proteins) related to inflammation, oxidative stress, and vascular calcification (VC) were measured before and after a single session of HD in 45 clinically stable patients. Concentrations were corrected for ultrafiltration‐induced hemoconcentration. Among vascular calcification‐related biomarkers, osteoprotegerin and fetuin‐A remained unchanged while fibroblast growth factor‐23 (FGF23) decreased by ?19%. Changes of FGF23 and changes of phosphate correlated (ρ = 0.61, P < 0.001). While C‐reactive protein did not change, interleukin‐6 (IL‐6) increased by 14% and pentraxin 3 (PTX3) increased by 45%. IL‐6 and PTX3 appear to be valid biomarkers of the intradialytic inflammatory response. VC‐related markers were in general not affected by the single HD session; however, the observed correlation between acute changes of FGF‐23 and phosphate during HD warrants further studies.     

Hemodialysis catheter infection with unusual presentation and grave outcome

Bacteremia from central venous catheter (CVC) infection causes morbidity and mortality in patients on hemodialysis (HD). Diagnosis of the infection can be difficult and may require special imaging. A 70-year-old man with diabetic nephropathy was on HD for 11 months through a permanent CVC. Because of symptomatic osteoporosis, he had kyphoplasty in three lumbar vertebrae (L2, L3, L4) 6 months after starting HD. Severe back pain persisted after kyphoplasty. Throughout the HD period, the exit site of the CVC had a clean appearance, there was no fever, and blood leukocyte counts were normal. During the 11th month of HD, he complained of subjective fever at home. Blood count revealed normal leukocyte count with neutrophilic predominance and blood cultures grew methicillin-resistant Staphylococcus aureus (MRSA). Echocardiogram revealed no heart valve vegetations, but irregular thickening of the CVC wall. Fluorodeoxyglucose positron-emission tomography-computed tomography (FDG-PET-CT) revealed severe inflammation of the CVC wall and a picture consistent with osteomyelitis and severe destruction of the body of the 11th thoracic vertebra. He was treated with intravenous vancomycin and removal of the CVC, the wall of which was grossly inflamed and grew in culture MRSA. Three weeks later, he discontinued HD because of persistent severe back pain. CVC infection with bacteremia and remote infectious foci having grave sequelae can develop in HD patients with paucity of clinical manifestations. FDG-PET-CT is a useful imaging tool in establishing the presence and extent of both the CVC infection and remote metastatic infectious foci.     

Optimal fluid control can normalize cardiovascular risk markers and limit left ventricular hypertrophy in thrice weekly dialysis patients

Increased hemodialysis frequency can make fluid overload easier to treat, although most patients are still treated thrice weekly. Chronic fluid overload is associated with left ventricular hypertrophy and elevated serum cardiac biomarkers, recognized as mortality risk factors. Serum cardiac troponin T (cTnT), N‐terminal prohormone brain natriuretic peptide (NT‐proBNP), left ventricular mass index by cardiac magnetic imaging, and ambulatory blood pressure was measured in 30 thrice weekly hemodiafiltration patients. Time‐averaged fluid overload (TAFO) was quantified by bioimpedance spectroscopy. In the study group, left ventricular hypertrophy was found to be 26% by cardiac magnetic resonance. Ambulatory blood pressure was 130 mmHg (112–151) requiring a low equivalent dose of medication of 0.25 units (0–1). Significantly, lower levels of left ventricular mass index (P < 0.05) were associated in those patients with TAFO <1 L or NT‐proBNP <1200 pg/mL or cTnT <0.1 ug/L. In the subgroups, 16 patients had normal cTnT (<0.03 ug/L), 16 patients had NT‐proBNP <400 pg/mL, and 20 patients had TAFO <1 L. Nine patients had both cTnT <0.03 ug/L and NT‐proBNP <400 pg/mL. Normally hydrated thrice‐weekly hemodiafiltration patients can have cardiac biomarker and TAFO levels indistinguishable from the normal healthy population. Obtaining TAFO by bioimpedance monitoring can offer a practical alternative to serum cardiac biomarkers.     

Hemodialysis does not impair ventricular functions over 2 years

We aimed to evaluate the long-term effect of hemodialysis (HD) treatment on left and right ventricular (LV and RV) functions in patients with end-stage renal disease. The study population consisted of 22 patients with newly diagnosed end-stage renal disease. Before an arteriovenous fistula was surgically created for HD, the patients were evaluated by echocardiography for systolic and diastolic functions. After the first HD session (mean 24.22 ± 2.14 months), the second echocardiographic evaluations were performed. Left ventricular and RV functions before and after long-term HD treatment were compared. The mean age was 55 ± 13 years and 10 (45%) of the patients were female. After long-term HD treatment, the isovolumic relaxation time was significantly decreased; however, the peak early (E) and late (A) diastolic mitral inflow velocities, E/A ratio, and deceleration time of E wave were not significantly different from the baseline measurements. Also, there was no significantly change in the early diastolic velocity (Ea) of the lateral mitral anulus and the E/Ea ratio. Pulmonary vein peak diastolic velocity, peak atrial reversal velocity, and peak atrial reversal velocity duration remained almost unchanged even though the pulmonary vein peak systolic velocity and the pulmonary vein peak systolic velocity/pulmonary vein peak diastolic velocity ratio were significantly lower after long-term HD treatment. In addition, LV systolic functions, LV diameters, LV mass index, left atrium size, and RV diastolic functions were not statistically different after long-term HD treatment. The myocardium is exposed to hemodynamic, metabolic, and neuro-humoral abnormalities during HD treatment; however, the long-term effects of HD on ventricular functions are not clearly known. The present study showed that the long-term effects of HD on LV and RV functions were insignificant in patients with end-stage renal disease. We have demonstrated that the LV and RV functions did not change significantly after long-term HD treatment. We suggest that this result may be due to regulated blood pressure levels of the patients, treatment of anemia and other metabolic disorders during the HD period and the prevention of weight gain and hypervolemia.     

Does the presence of an arteriovenous fistula alter changes in body water following hemodialysis as determined by multifrequency bioelectrical impedance assessment?

Multifrequency bioelectrical impedance assessments (MFBIAs) aid clinical assessment of hydration status for hemodialysis (HD) patients. Many MFBIA devices are restricted to whole body measurements and as many patients dialyze using arteriovenous fistulas (AVFs), we wished to determine whether AVFs affected body water measurements. We reviewed pre‐ and post‐HD segmental MFBIA measurements in 229 patients attending for midweek HD sessions. Up to 144 were dialyzed with a left arm AVF (L‐AVF), 42 with a right arm AVF (R‐AVF), and 43 by central venous access catheter (CVC). Water content and lean tissue were greater in the left compared to right arm in those patients with L‐AVFs both pre and post dialysis (pre 2.1 ± 0.7 vs. 2.0 ± 0.7 L, and post 1.9 ± 0.6 vs. 1.8 ± 0.6 L and pre 2.65 ± 0.9 vs. 2.56 ± 0.8 kg, and post 2.34 ± 0.8 vs. 2.48 ± 0.8 vs. 2.34 ± 0.8 kg, respectively) and were also greater in the right compared to left arm for those patients dialyzing with R‐AVFs (pre‐HD 1.92 ± 0.5 vs. 1.86 ± 0.6 L and post‐HD 1.79 ± 0.5 vs. 1.7 ± 0.5 L, and pre‐HD 2.47 ± 0.6 vs. 2.38 ± 0.7 kg and post‐HD 2.3 ± 0.74 vs. 1.28 ± 0.7 kg, respectively), all Ps < 0.05. There were no significant differences in arm volumes or composition pre or post dialysis in those dialyzing with CVCs. Segmental MFBIA detects differences in arm water and lean mass in patients with AVFs. The presence on an AVF increases the water content in the ipsilateral arm both pre and post HD. This increased water content of the fistula arm will not be detected by whole body bioimpedance devices.     

Maintenance of blood flow rate on dialysis with self‐centering CentrosFLO catheter: A multicenter prospective study

Introduction Chronic central venous catheters (CVC) for dialysis lose patency and deliver lower blood flow over time, often due to fibrous sheathing that covers the lumen tips. The CentrosFLO central venous catheter has a shape that directs the arterial and venous tips away from the walls of the vena cava and right atrium, making sheathing of the tips less likely. Methods A prospective, multicenter, single arm, non‐controlled, observational study was conducted at eight sites in the United States. All consenting dialysis patients receiving CentrosFLO catheters through the right or left internal jugular veins were accepted in the study, as long as the catheter was expected to be used for 45 days and was not an over‐the‐wire replacement for a previous CVC. Data were automatically collected on initial and average dialysis blood flow rate and initial arterial and venous pressures, for up to 26 weeks of dialysis therapy. Findings 75 patients were enrolled. Kaplan‐Meier analysis indicated that 87% of patients maintained blood flow rate over 300 mL/min throughout 26 weeks of follow‐up. There was no decline in average dialysis blood flow rate and no significant change in hydraulic resistance of the arterial or venous lumens of the catheters during the study. Discussion The CentrosFLO catheter demonstrates long term patency with good flow rates on dialysis, which, by comparison with previous studies, shows a clinically significant improvement in blood flow rate vs. other catheters. Stable hydraulic resistance of the catheter lumens showed no evidence of tip encroachment by fibrous sheaths.     

Daily dialyses decrease plasma levels of brain natriuretic peptide (BNP), a biomarker of left ventricular dysfunction

Brain natriuretic peptide or B-type natriuretic peptide (BNP) is a sensitive marker of heart disease. Plasma levels of BNP increase in left ventricular failure and determination of plasma BNP has become a useful tool in the diagnosis of heart failure. Hemodialysis (HD) patients may have elevated plasma levels of BNP, particularly predialysis, that correlate with echocardiographic signs of left ventricular dysfunction. High BNP levels are also a strong predictor of mortality in both nonrenal and HD patients. We studied plasma BNP levels in patients who changed from conventional thrice-weekly dialysis to daily dialysis 6 times a week while maintaining a total weekly time on dialysis of 12 hr. Twelve HD patients, mean age 55 years, had 4 hr of conventional thrice-weekly treatment for 4 weeks. Predialysis and postdialysis blood samples were obtained at the last dialysis. Patients were then dialyzed for 2 hr, 6 times weekly, for 4 weeks (daily dialysis). Again, predialysis and postdialysis blood samples were collected at the last HD. Brain natriuretic peptide plasma concentrations were determined by immunoradiometric assay. Predialysis BNP levels decreased from 194+/-51 ng/L (68+/-19 pmol/L; mean+SE) during thrice-weekly HD to 113+/-45 ng/L (41+/-18 pmol/L; p = 0.001) after 4 weeks on daily dialysis. With thrice-weekly HD, predialysis BNP levels were higher than postdialysis levels: 120+/-26 ng/L (39+/-8 pmol/L; p = 0.059). With daily dialysis, predialysis BNP levels did not differ significantly from postdialysis levels. Elevated predialysis plasma levels of BNP, considered sensitive and early markers of left ventricular dysfunction, decreased when patients were changed from conventional thrice-weekly HD to daily dialysis maintaining total hours of dialysis per week constant. Given the accumulated evidence that BNP is a biomarker of left ventricular dysfunction and can be used for risk stratification and guidance in pharmacotherapy of heart failure, daily dialysis appears to lead to less cardiac distress.     

Black hole on film following catheter insertion

Vascular accesses both permanent and temporary play an essential role in the procedure of hemodialysis (HD). The double lumen catheter (DLC) is one form of temporal vascular access which may produce different complications based on where the DLC is inserted. Here, we report a case of a cirrhotic patient receiving HD. The DLC was inserted through the left femoral vein. Later on, an unusual catheter position, mimicking a perforation in the iliac vessel, was noted in the incidental image finding. After venography, we concluded that this DLC had entered the dilated left gonadal vein, and was working well. This condition may be explained by portal hypertension leading to increased frequency of collateral branches and easy dilatation of the left gonadal vein. This condition may develop in a cirrhotic patient with portal hypertension, but there is no harm to a patient. However, this condition leads to an interesting computed tomography image, which may result in misinterpretation of the imaging reports and a clinical misdiagnosis.     

Vascular imaging for hemodialysis vascular access planning

Introduction: Central venous catheters (CVC) increase risks associated with hemodialysis (HD), but may be necessary until an arteriovenous fistula (AVF) or graft (AVG) is achieved. The impact of vascular imaging on achievement of working AVF and AVG has not been firmly established. Methods: Retrospective cohort of patients initiating HD with CVC in 2010–2011, classified by exposure to venography or Doppler vein mapping, and followed through December 31, 2012. Standard and time‐dependent Cox models were used to determine hazard ratios (HRs) of death, working AVF, and any AVF or AVG. Logistic regression was used to assess the association of preoperative imaging with successful AVF or AVG among 18,883 individuals who had surgery. Models were adjusted for clinical and demographic factors. Findings: Among 33,918 patients followed for a median of 404 days, 39.1% had imaging and 55.7% had surgery. Working AVF or AVG were achieved in 40.6%; 46.2% died. Compared to nonimaged patients, imaged patients were more likely to achieve working AVF (HR = 1.45 [95% confidence interval [CI] 1.36, 1.55], P < 0.001]), any AVF or AVG (HR = 1.63 [1.58, 1.69], P > 0.001), and less likely to die (HR = 0.88 [0.83‐0.94], P < 0.001). Among patients who had surgery, the odds ratio for any successful AVF or AVG was 1.09 (1.02–1.16, P = 0.008). Discussion: Fewer than half of patients who initiated HD with a CVC had vascular imaging. Imaged patients were more likely to have vascular surgery and had increased achievement of working AV fistulas and grafts. Outcomes of surgery were similar in patients who did and did not have imaging.     

Acute hemodialysis complications in end‐stage renal disease patients: The burden and implications for the under‐resourced Sub‐Saharan African health systems

Little is known about the challenges of routine renal replacement therapy in Sub‐Saharan Africa. We investigated the fatal and nonfatal acute hemodialysis (HD) complications in patients with end‐stage renal disease (ESRD) in two main dialysis centers in Cameroon. 1000 consecutive HD sessions incurred over a 4‐month period by 129 patients (96 men, 74%) with ESRD, receiving two weekly HD sessions of 4 hours each, were considered. Personal and clinical profiles before, during, and within 24 hours after HD sessions were used to diagnose complications. Participants were aged 7 to 80 years (mean 46 years). In all, 452 acute complications were recorded in 411 (41%) of the 1000 HD sessions. Of the 11 types of complications, hypotension (25%), muscular cramps (22%), hypertensive crisis (14%), pruritus (10%), and fever (7%) were the most frequent. Three hundred and six complications (67.7%) occurred during understaffed nighttime. The vascular access was the main bleeding site with 64%. Being diabetic and ultrafiltration rate >1000 mL/h were associated with hypotension and muscle cramps. The shorter duration in dialysis was associated with the risk of bleeding and the disequilibrium syndrome while longer duration was associated with muscle cramps. Four deaths (three from bleeding and one from disequilibrium syndrome) occurred, all during nighttime. Nearly half of dialysis sessions in these settings are associated with acute complications, some of which are fatal. Those complications occurred mostly during understaffed periods. Urgent strategies are needed to quickly solve the human capital crisis in the health care sector.     

Safety analysis of intermittent hemodialysis in patients with continuous flow left ventricular assist devices

Dialysis centers adopt a cautious approach when it comes to performing intermittent hemodialysis (HD) on patients with continuous flow (CF) left ventricular assist devices (LVADs) because of the potential for volume flux‐related complications and absence of pulsatile blood pressure for monitoring. Many patients have to remain hospitalized because of the inability of the dialysis centers to accept them for outpatient dialysis. In this study, the effect of HD was observed in such patients. Between June 2009 and October 2012, 139 patients received LVADs, of which 10 patients (7%) required intermittent HD postoperatively. The mean age of the patients was 53 ± 14 years and 90% were men. A total of 281 dialysis sessions were administered amounting to 1025 hours of dialysis. The mean systolic blood pressure monitored with Doppler device was 97 ± 18 mmHg. Dialysis durations averaged 218 ± 18 minutes. Mean blood flow rate was 334 ± 38 cc/min, and 2.6 ± 1.1 L was ultrafiltrated during each session. Only 15 (5.3%) sessions were interrupted or terminated in six patients. The reasons for termination were symptomatic hypotension—6 (2.1%), asymptomatic hypotension—3 (1%), ventricular tachycardia—1 (0.36%), dialysis machine malfunction—2 (0.7%), low phosphorus—2 (0.7%), and abdominal cramps—1 (0.36%). Volume expansion was necessary on three occasions. Low‐flow device alarms were registered during two (0.71%) sessions. The results showed no serious adverse effects or deaths.     

Relationship between non‐alcoholic fatty liver disease and MIA syndrome

Non‐alcoholic fatty liver disease (NAFLD) is an important factor in the pathogenesis of cardiovascular diseases in the general population. Recently, it has been shown that NAFLD is highly prevalent in chronic kidney disease (CKD) patients. Ninety‐four hemodialysis (HD) patients were followed for a time period of 18 months or until death. Patient's survival rate was determined in relation to their nutritional and inflammatory state, and the presence of NAFLD. We also investigated the association between the presence of NAFLD and the patients' nutritional and inflammatory state. We did not find any significant association between the clinical parameters of nutritional status and the mortality rate. However, the mortality rate was statistically significantly higher in patients with low serum albumin and high high‐sensitive C‐reactive protein (hs‐CRP) levels and in those who had NAFLD. Surprisingly, patients who had received enteral nutrition did not have a better survival rate. The severity of liver steatosis was negatively correlated with the serum albumin levels, while it was positively correlated with hs‐CRP values. Furthermore, serum albumin levels showed a negative correlation with hs‐CRP levels. We did not find any significant association between the presence of NAFLD and clinical parameters of nutrition. We have shown that NAFLD could be one more possible example of reverse epidemiology in patients undergoing HD. NAFLD may be the missing link that causally ties malnutrition, inflammation, and atherosclerosis syndrome to the morbidity and mortality in patients undergoing HD.     

A complication of double lumen hemocatheter guide wire entrapment in a hemodialysis patient

Double lumen hemocatheter is commonly used for temporary hemodialysis patient and various complications have been documented but few reports of guide wire‐related complications. We report a complication of double lumen hemocatheter guide wire entrapment in a 43‐year‐old female of type 1 diabetes mellitus and hemodialysis patient. She was admitted for left arteriovenous shunt dysfunction and right internal jugular vein hemocatheter chamber clotting was found while on hemodialysis, so a new hemocatheter was changed over guide wire. Guide wire was introduced without any resistance and the clotting hemocatheter was removed. During the procedure, the J‐tipped guide wire could not be withdrawn and portable chest radiography revealed the J‐tip of the guide wire was in the right ventricle near the region of tricuspid valve. Fluoroscopy was arranged and it also confirmed the J‐tip was lying in the ventricle near the tricuspid valve where it was stuck. Snare catheter kit was inserted through the 10 Fr sheath and the cardiologist untied the knot by endovascular snare and removed the guide wire smoothly. This report emphasizes the importance of awareness on guide wire entrapment while inserting double lumen hemocatheter. When a guide wire became hard to withdraw, extracting an entrapped guide wire with fluoroscopy guide and snare catheter is a preferable and minimal invasive approach.     

Inverse association between docosahexaenoic acid and mortality in patients on hemodialysis during over 10 years

We have previously conducted a cohort study to investigate n‐3 polyunsaturated fatty acids (PUFAs) in red blood cells (RBCs) and risk of all‐cause mortality in hemodialysis (HD) patients over 5 years and found that n‐3 PUFAs, especially docosahexaenoic acid (DHA), might be an independent predictor of all‐cause mortality. In the present study, we extended the study for another 5 years to determine whether DHA levels in RBCs still predict the mortality of HD patients during a 10‐year study period. The study cohort consisted of 176 patients (64.1 ± 12.0 [mean ± standard deviation] years of age, 96 men and 80 women) under HD treatment. The fatty acid composition of patients' RBCs was analyzed by gas chromatography. During the study period of 10 years, 97 deaths occurred. After adjustment for 10 confounding factors, the hazard ratio of all‐cause mortality of the HD patients in the highest DHA tertile (>8.1%) was 0.52 (95% confidence interval 0.30–0.91) compared with those in the lowest DHA tertile (<7.2%). However, other n‐3 PUFAs such as eicosapentaenoic acid and docosapentaenoic acid (n‐3) did not reveal any significant correlations. The level of DHA in RBCs could be an independent predictor of all‐cause mortality in HD patients even during a long period of follow‐up.