Spontaneous calf hematoma in a patient with diabetic nephropathy receiving maintenance hemodialysis: A case report and review of the literature

We report the outcome of a 52‐year‐old patient with diabetic nephropathy and receiving maintenance hemodialysis (HD) using low molecular weight heparin (LMWH) as an anticoagulant for 2 years. He presented right lower limb pain accompanied with difficulty in walking for 2 months, and had no history of bleeding tendency or trauma. Physical examination revealed marked swelling and tenderness on his right lower limb. By ultrasound and magnetic resonance imaging (MRI) diagnoses, the calf hematoma was diagnosed and identified with venous thrombosis. Following treatment with heparin‐free HD, the swelling regressed and pain subsided, and a follow‐up MRI showed complete dissolution of hematoma. However, similar symptoms recurred in the right upper limb after 2 months without any predisposition, he was just placed on HD with LMWH, and symptoms regressed following the aforementioned therapy. This suggests that HD patients, especially with diabetic nephropathy having extremity hematoma, should be watched for the development of spontaneous hemorrhage that can be differentially diagnosed by imaging tests, such as MRI, and can be effectively treated with heparin‐free HD.     

Successful treatment of carbamazepine poisoning with hemodialysis: a case report and review of the literature

A 48-year-old man was brought to the emergency room after ingesting an unknown amount of carbamazepine. He was unconscious and not responding to the noxious stimuli. He was intubated and was placed on mechanical ventilation because of respiratory insufficiency. Primary detoxification was performed with a gastric lavage and charcoal instillation. His serum carbamazepine level was 25.6 mcg/mL at the time of admission. His computed tomography of the brain was normal. He was managed conservatively but there was no improvement in his neurological status in the next 24 hours. Serum carbamazepine level was repeated and reported to be 28.3 mcg/mL. As there was no improvement in his sensorium and the serum carbamazepine levels remained persistently high, extracorporeal removal of carbamazepine was attempted. As the facility to carry out hemoperfusion was not available immediately, the decision to initiate hemodialysis was taken. After 3 sessions of hemodialysis, his sensorium improved markedly and the carbamazepine level at this time was within the therapeutic range. He was discharged after psychiatry consultation and counseling. We review the literature regarding extra corporeal techniques for the removal of carbamazepine and discuss them in this article.     

Purulent pericarditis and pericardiac tamponade in a pregnant hemodialysis patient: A case report

Bacterial pericarditis is rare in chronic hemodialysis and has poor prognosis. In this case, we report a pregnant hemodialysis patient who developed purulent bacterial pericarditis and pericardiac tamponade in the 28th week of her pregnancy, and who had delivered a healthy living baby.     

Primary brachial vein transposition for hemodialysis access: Report of a case and review of the literature

The superiority of autogenous fistulae in patients with end‐stage renal disease, performing hemodialysis, is well established and largely accepted. However, in case that superficial veins in the upper arm are not available for fistula construction, brachial vein transposition may be a viable alternative prior to graft placement. This transposition could be done as a primary or staged procedure, depending on the vein size. We present the case of a 63‐year‐old male patient with a thrombosed arteriovenous graft in the forearm and a large brachial vein in the ipsilateral upper arm. A one‐stage (primary) brachial vein transposition was performed. The fistula, 10 months after its construction, is still patent. No complications have occurred.     

Chronic fondaparinux use in a hemodialysis patient with heparin‐induced thrombocytopenia type II and extracorporeal circuit thrombosis—A case report and review of the literature

Heparin‐induced thrombocytopenia (HIT) is a potentially life‐threatening condition that can develop after exposure to unfractionated or low–molecular‐weight heparins. Treatment options appear to be limited in patients on concurrent intermittent hemodialysis. We report the case of an 88‐year‐old man newly initiated on high‐flux hemodialysis who developed HIT and extracorporeal circuit thrombosis after 3 weeks of exposure to unfractionated heparin. Our patient was successfully treated with fondaparinux 2.5 mg subcutaneously three times per week and citrate during dialysis sessions. Antifactor Xa levels were measured on several occasions while receiving fondaparinux.     

Enterococcus faecalis endophthalmitis as a metastatic complication of hemodialysis vascular access‐related sepsis: A case report and review of the literature

Catheter and/or arteriovenous (A‐V) graft‐related bacteremia is an important cause of morbidity and mortality among hemodialysis (HD) patients. Endocarditis, septic arthritis, epidural abscess, septic embolism, and osteomyelitis are the most common complications of catheter and/or A‐V graft‐related bacteremia; however, endogenous endophthalmitis is rarely seen. To the best of our knowledge, Enterococcus faecalis is the first case report in this population. We hereby report a case of endogenous endophthalmitis caused by E. faecalis as a complication of catheter and/or A‐V graft‐related bacteremia in a diabetic patient, who was undergoing HD for 5 years. We also discuss the etiology, clinical features, and outcomes of endogenous endophthalmitis in HD patients with a brief review of the literature. Although broad‐spectrum parenteral (intravenous and intravitreal) antibiotics were used for 4 weeks, evisceration of the left eye could not be avoided. Endogenous endophthalmitis is a rare but rapidly blinding complication of catheter and/or A‐V graft‐related bacteremia in HD patients. It can develop as a result of silent catheter and/or A‐V graft infections, which may lead to recurrent bacteremia. E. faecalis should be considered as a pathogen in this population who had recent history of catheter or A‐V graft procedure.     

Piperacillin/tazobactam‐induced neurotoxicity in a hemodialysis patient: A case report

Antibiotics are potentially a cause of neurotoxicity in dialysis patients, the most common are the beta‐lactams as ceftazidime and cefepime, and few cases have been reported after piperacillin/tazobactam use. This report presents a case of a hypertensive and diabetic 67‐year‐old woman in regular hemodialysis, which previously had a stroke. She was hospitalized presenting pneumonia, which was initially treated with cefepime. Two days after treatment, she presented dysarthria, left hemiparesis, ataxia, and IX and X cranial nerves paresis. Computed tomography showed no acute lesions and cefepime neurotoxicity was hypothesized, and the antibiotic was replaced by piperacillin/tazobactam. The neurologic signs disappeared; however, 4 days after with piperacillin/tazobactam treatment, the neurological manifestations returned. A new computed tomography showed no new lesions, and the second antibiotic regimen withdrawn. After two hemodialysis sessions, the patient completely recovered from neurological manifestations. The patient presented sequentially neurotoxicity caused by two beta‐lactams antibiotics. This report meant to alert clinicians that these antibiotics have dangerous neurological effects in chronic kidney disease patients.     

A rare case of Actinomyces skin and soft tissue infection in an end‐stage kidney disease patient with a review of the literature

End‐stage kidney disease (ESKD) patients are a commonly overlooked immunocompromised population that places them at risk for rare infections. We describe the case of a 78‐year‐old man with a history of ESKD managed with thrice weekly in‐center hemodialysis who had a prolonged episode of left elbow pain and drainage and was eventually found to have a skin and soft tissue infection from Actinomyces radingae. We review the bacteriology of Actinomyces spp. and the experiences of other providers who have treated actinomycosis in individuals with ESKD. The anatomic sites and demographics of these individuals are heterogeneous, but they all generally require a long antibiotic course with a beta‐lactam and portend to a good prognosis. High index of suspicion is needed to identify rare and atypical infections in the ESKD population.     

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.     

Correction of pulmonary hypertension with intensive hemodialysis: A case report

Pulmonary hypertension (PH) defined as a mean pulmonary arterial pressure ≥25 mmHg is a common complication in hemodialysis occurring in up to 58% of patients. PH is classified according to its etiology. We report in a patient with severe PH of mixed etiology (connective tissue disease and left‐sided heart failure) who improved after initiation of intensive home hemodialysis. We postulated that the use of a frequent mode of hemodialysis may ameliorate PH via enhanced volume control. Thereby, an intensive hemodialysis schedule may be preferred renal replacement modality in this patient population.     

Late‐onset Pompe's disease in a hemodialysis patient: A first case report

A 37‐year‐old hemodialysis patient appeared with unusual somnolence during 2 successive hemodialysis sessions. Blood gas analysis revealed hypercapnic respiratory failure and spirometry restrictive lung disease. After exclusion of other causes of restrictive lung disease with chest CT‐scan and cerebrum MRI, electrophysiological study revealed myopathy. Because besides lordosis and limb‐girdle gait the patient was ambulant the possibility of late‐onset Pompe's disease was set and confirmed with evaluation of α‐glucosidase activity and genetic analysis. Enzyme replacement therapy (ERT) with aglucosidase alfa was started. Due to inaccessibility of veins in the arm without the arteriovenous fistula, during the last 1 year, the patient received the ERT through the venous line of the hemodialysis circuit. Three years later the patient remains ambulant without the need of any assistant device and preserved his pulmonary function. This is the first described case of late‐onset Pompe's disease in a hemodialysis patient treated with ERT.     

Experience with continuous venovenous hemodiafiltration in four newborns: A case series and review of the literature

When conventional methods for treating complicated problems such as acute and chronic renal failure or metabolic diseases fail, the therapy of choice is peritoneal dialysis (PD) in neonatal period. However, in cases that involve technical difficulties, such as bulky lesions in the abdomen or complications from previous abdominal surgeries, it is not always possible to place a peritoneal catheter. In such situations, continuous venovenous hemodiafiltration (CVVHDF) can be effective. This case series presents our experience in 2013 with the administration of CVVHDF to four patients in our neonatal intensive care unit who could not undergo PD for various reasons.     

Remission of refractory Crohn's disease with anti-IL-12/23 therapy in a patient undergoing hemodialysis: A case report

Crohn's disease is a relapsing chronic inflammatory condition of the intestine with increasing prevalence around the world. Biologic therapies are currently widely used and have proved safe and effective in treating moderate to severe Crohn's disease. However, contemporary bibliography contains little information about the use of these drugs in patients with end-stage renal disease undergoing hemodialysis. Here we present a case of a 47-year-old female patient with treatment-refractory Crohn's disease on hemodialysis. In this patient, treatment with the anti-IL-12/23 receptor antibody ustekinumab was effective in inducing and maintaining remission while being safe in administering throughout hemodialysis.     

Left ventricular assist device patient maintained on home hemodialysis: A novel class of patients to the home dialysis population

Severe heart failure is increasingly being managed by cardiac transplantation, and in some cases mechanical support devices serve as destination therapies. Left ventricular assist devices (LVADs) were approved for destination therapy for end stage heart failure patients before the more advanced total artificial heart modality became available. One common complication of mechanical assist device placement is acute kidney injury. Historically, patients with mechanical support devices have had to have inpatient hemodialysis until combined heart kidney transplant. Though, some units have started accepting LVAD patients in outpatient dialysis clinics. The cost of in center hemodialysis remains high and home dialysis modalities are becoming increasingly popular. We report the first patient with an LVAD to undergo training and successful home hemodialysis while awaiting combined heart kidney transplantation.     

Recurrent heparin‐induced thrombocytopenia due to heparin rinsing before priming the machine in a hemodialysis patient: A case report

Heparin has remained the most commonly used anticoagulant for patients undergoing hemodialysis. It is usually safe to use but can have severe adverse effects in some cases. Heparin‐induced thrombocytopenia (HIT) is a life‐threatening complication of exposure to heparin. It results from an autoantibody directed against endogenous platelet factor 4 (PF4) in complex with heparin, which activates platelets and can cause catastrophic arterial and venous thromboses. Here, we present the case of an 80‐year‐old woman with a recent diagnosis of chronic renal failure who developed acute HIT (platelet count nadir, 15 × 10⁹/L) on day 7 of hemodialysis performed with routine heparin anticoagulation, who despite subsequent heparin‐free hemodialysis (with argatroban and warfarin) developed recurrent HIT (complicated by acute cerebral infarction) on day 11 that we attributed to “rinsing” of the circuit with heparin‐containing saline (3,000 units of unfractionated heparin, with subsequent saline washing) performed pre‐dialysis as per routine. After stopping heparin rinsing, the platelet count recovered completely, without further thrombotic or other sequelae. Our experience indicates that for patients with acute HIT, besides the well‐known practice of using non‐heparin anticoagulation during dialysis and avoiding heparin “locking” of dialysis catheters, it is also important to avoid inadvertent rinsing of the circuit with heparin during preparation for hemodialysis.     

Clearance of myoglobin by high cutoff continuous veno‐venous hemodialysis in a patient with rhabdomyolysis: A case report

Continuous veno‐venous hemodialysis using high cutoff filters (HCO‐CVVHD) is a promising technique, which may be effective to decrease the extremely high level of circulating myoglobin in patients with rhabdomyolysis (RM). Here, we report a patient with RM caused by heat stroke who was successfully treated by HCO‐CVVHD. A male patient received HCO‐CVVHD with 4 L/h dialysate for 5 days and then pre‐dilution continuous veno‐venous hemofiltration (CVVH) at a dose of 4 L/h until recovery of renal function. The clearance of myoglobin and albumin at 5 minutes, and at 4, 12, and 24 hours were calculated. The serum myoglobin level decreased from a peak of 25,400 ng/mL on admission to 133 ng/mL at discharge. During HCO‐CVVHD, the mean clearances of serum myoglobin at four timepoints were 61.3 (range, 61.0–61.6), 52.3 (38.9–65.8), 47.3 (46.8–47.9), and 43.7 (39.5–48.0) mL/min, respectively, and the mean clearances of albumin were 12.4 (range, 11.8–13.1), 3.1 (2.5–3.8), 1.2 (1.0–1.4), and 0.8 (0.6–1.0) mL/min, respectively. During CVVH, the clearance rates of myoglobin at 5 minutes and 24 hours were 17.0 and 3.8 mL/min, respectively, with a negligible clearance of albumin. HCO‐CVVHD can effectively decrease serum myoglobin in patients with RM because of much higher clearance of myoglobin than CVVH. However, attention should be paid to albumin loss during HCO‐CVVHD.     

Hemolysis‐induced acute kidney injury following cardiac surgery: A case report and review of the literature

Acute kidney injury is a common complication following cardiac surgery. Even small increases in creatinine levels are associated with increases in morbidity and mortality. Numerous factors such as hemolysis can contribute to the development of acute kidney injury after cardiac surgery. We present a rare case of severe hemolysis related to cardiopulmonary bypass resulting in kidney injury and requiring dialysis. The patient's renal function gradually recovered when hemolysis was improved. After follow‐up for 3 months, his creatinine levels returned to normal. We discussed the pathogenesis of this hemolysis‐related kidney dysfunction, the causes of hemolysis during cardiac surgery, and a new treatment option.     

Endotoxemia after high cutoff hemodialysis for treatment of patient with multiple myeloma can be prevented by using ultrapure dialysate: A case report

To report endotoxemia presented in a case with multiple myeloma (MM) treated by high cutoff hemodialysis (HCO‐HD) being prevented by using ultrapure dialysate. A female inpatient with MM received six times HCO‐HD (HCO 2100 dialyzer) within 3 weeks after initiation of a chemotherapy based on vincristine + epirubicin + dexamethasone protocol. Conventional dialysate was used in the first three times and then changed to ultrapure dialysate due to elevation of body temperature after HCO‐HD. Free light chains (FLC) and endotoxin levels in blood and dialysate were monitored. After six times HCO‐HD, her serum FLC λ decreased from 4689 mg/L to 492.7 mg/L, with a trend of decline of serum creatinine. The clearance, reduction ratio, and removal amount of FLC λ was 38.4 mL/min, 71.0–85.2%, and 9.06–18.02 g, respectively, in the setting of dialysate flow rate 500 mL/min, while in the setting of dialysate flow rate 200 mL/min, the removal efficacy of FLC λ was lower than the former. A rise of body temperature up to 38.5°C after treatment and endotoxemia (endotoxin levels 0.122 EU/mL) was found when using conventional dialysate (endotoxin levels 0.112–0.145 EU/mL), but not seen after changing to ultrapure dialysate. Combined with appropriate chemotherapy, HCO‐HD can effectively remove and reduce blood FLC. Attention should be paid to the endotoxemia and the rise of temperature after treatment when conventional dialysate is used, which can be prevented by using ultrapure dialysate.     

Pulmonary sarcoidosis as a cause of intermittent fever of unknown origin in a hemodialysis patient with renal cell carcinoma: A case report and literature review

Hemodialysis patients have weakened immune systems and can exhibit fever due to various causes. Herein, we describe the case of a 61‐year‐old hemodialysis patient who exhibited intermittent low‐grade fever after a pacemaker had been implanted 2 months before due to sick sinus syndrome. She had a medical history of subcutaneous sarcoidosis and uveitis. Active pulmonary sarcoidosis was diagnosed based on elevated soluble interleukin‐2 receptor, elevated lysozyme level, and gallium‐67 scintigraphy uptake in hilar and mediastinal lymph nodes. She was also diagnosed with renal cell carcinoma via contrast computed tomography. However, because her C‐reactive protein level remained normal, the possibility of neoplastic fever was considered low. After the initiation of prednisolone administration, her fever gradually disappeared. Her serum soluble interleukin‐2 receptor and lysozyme level improved in parallel with the enlargement of the mediastinal lymph node and gallium‐67 scintigraphy uptake.