Fatal cerebritis and brain abscesses following a nontraumatic subdural hematoma in a chronic hemodialyzed patient

Staphylococcus aureus is the leading cause of bacteremia in hemodialysis‐dependent patients that can lead to metastatic abscesses with poor outcome. We report a case of a 65‐year‐old chronic hemodialyzed male patient who developed cerebritis and brain abscesses complicating a spontaneous subdural hematoma, following Staphylococcus aureus bacteremia related to infected arteriovenous fistula. In spite of adequate antibiotherapy and several surgical brain drainages, our patient did not survive. Prevention of S. aureus is highly important in hemodialysis patients.     

Type I (sporadic) porphyria cutanea tarda in a hemodialysis patient: a case report

A hemodialysis patient with hepatitis C virus infection developed painful blisters on her hands that burst spontaneously. She was found to have serum porphyrin levels >2000 nmol/L. A punch biopsy revealed subepidermal blistering with festooning of dermal papillae associated with a mixed inflammatory infiltrate. Based on the clinical, biochemical, and histologic findings, a diagnosis of porphyria cutanea tarda was made. Treatment was started with twice-weekly phlebotomy and oral hydroxychloroquine and significant clinical improvement resulted.     

Bilateral quadriceps and triceps tendon rupture in a hemodialysis patient

This paper presented a 58‐year‐old hemodialysis patient who had bilateral quadriceps and triceps tendon rupture, whereby the role of rehabilitation in functional parameters has been highlighted.     

Beneficial effects of nocturnal hemodialysis in a hemodynamically unstable patient with AL‐amyloidosis

We present a patient with primary systemic AL‐amyloidosis, who stabilized hemodynamically on nocturnal hemodialysis (NHD). The NHD allowed a significant reduction in ultrafiltration rates which likely underlies the procedural tolerability. It also provided an increase in urea clearance, better control of serum phosphorus levels without the use of any binders, and normalization of blood pressure despite the discontinuation of all antihypertensive agents. Given the autonomic derangements associated with AL‐amyloidosis pathophysiology and the clinical benefits of NHD on hemodynamic stability, the use of intensive hemodialysis may be considered for the management of patients with unstable hemodynamic profiles.     

Catheter‐related fungal endocarditis caused by Candida parapsilosis in a hemodialysis patient

Fungal endocarditis (FE) is commonly regarded as a rare but fatal disease. The incidence of infective endocarditis (IE) in hemodialysis (HD) patients is thought to be obviously higher than that in the general population. Moreover, IE occurs more likely in HD patients with catheters. With the increase of HD population and extensive use of catheters in HD patients, FE, as a special form of IE, may increase and bring new challenges to clinicians. We reported a case of FE associated with catheter infection in a 44‐year‐old woman on HD. The risk factors and treatment strategies of FE in HD patients were discussed.     

Polycythemia due to obstructive sleep apnea in a patient on hemodialysis

Both anemia and sleep disordered breathing are common in patients with dialysis‐dependent stage 5 chronic kidney disease. Erythrocytosis resulting from obstructive sleep apnea (OSA) is rare in the general population and has never been described in the hemodialysis population. We present a case of asymptomatic isolated erythrocytosis and elevated serum erythropoietin level in an otherwise well and previously erythropoietin‐dependent chronic hemodialysis patient with chronic kidney disease secondary to ischemic nephropathy. There was no history or symptoms of cardio‐pulmonary or hepatic diseases nor any relevant family history. Screening work‐up for malignancies was negative. The clinical history was highly suggestive of OSA and severe OSA (respiratory disturbance index of 59) was confirmed by polysomnographic studies. Successful treatment of the OSA with continuous positive airway pressure resulted in permanent stabilization of the hemoglobin to levels below 13 g/dL without the need for repeated phlebotomies and in dramatic lowering of serum erythropoietin levels. To our knowledge, this is the first case of OSA mediated erythrocytosis in a dialysis patient documented in the literature.     

Heparin‐induced thrombocytopenia due to heparin lock in a hemodialysis patient: A case report

Heparin‐induced thrombocytopenia (HIT) is a potentially fatal clinical condition which can develop after exposure to unfractionated or low‐molecular‐weight heparins. Even small doses of heparin such as heparin flushes in hemodialysis catheter can induce the development of HIT. However, the true incidence of heparin lock‐related HIT is unknown. We report a 58‐year‐old woman with acute kidney injury because of obstructive uropathy who developed HIT after heparin‐free hemodialysis. She was found to have severe thrombocytopenia with deep vein thrombosis of left lower limb and arterial thrombosis of the right anterior and middle cerebral arteries. The heparin‐platelet factor 4 antibody was positive and she was put on plasmapharesis. However, her condition further deteriorated and succumbed shortly. Heparin lock solution in the hemodialysis catheter was believed to be the cause of HIT in our patient.     

Acquired reactive perforating collagenosis and pseudoporphyric bullous dermatosis in a hemodialysis patient

Hemodialysis patients present with a broad spectrum of specific and nonspecific skin disorders, which rarely coexist. We report an exceptional case of a hemodialysis patient that developed acquired reactive perforating collagenosis and pseudoporphyric bullous dermatosis on the basis of common skin disorders which include hyperpigmentation, pruritus, xerosis cutis, and Linsday's nails. Interestingly, our patient presented with two unusual but distinctive cutaneous dermopathies on the background of other commonly seen skin alterations. The patient was successfully treated with allopurinol and N‐acetylcysteine. Avoidance of potentially triggering factors such as alcohol, sunlight exposure and certain medication was recommended. Thus, increasing clinical awareness, assiduous investigation and early treatment of skin disorders are required to improve the prognosis and quality of life in this patient population.     

Necrotizing fasciitis and infective endocarditis caused by Escherichia coli in a hemodialysis patient

Patients with uremia are often immunocompromised and uremia patients undergoing maintenance dialysis are often vulnerable to uncommon infections. We report a 40‐year‐old man who was undergoing maintenance hemodialysis and was initially diagnosed with monomicrobal necrotizing fasciitis of the lower limbs, based on blood and pus cultures that yielded Escherichia coli. His condition improved after surgical debridement and antibiotic therapy. However, he eventually died of intracranial hemorrhage related to septic emboli. Concurrent infective endocarditis was diagnosed based on an echocardiogram that indicated vegetation in the left ventricular region. Escherichia coli‐related necrotizing fasciitis and infective endocarditis is rarely seen in clinical practice. There should be a high index of suspicion for multiple infections when a hemodialysis patient presents with an uncommon infection.     

Secondary sternal Aspergillus osteomyelitis in a diabetic hemodialysis patient with previous allograft rejection

A 29-year-old diabetic woman who had a previously failed renal allograft on maintenance hemodialysis developed sternal aspergillosis with Aspergillus terreus following a pericardiectomy. She was successfully treated with surgical debridement and a combination of antifungal agents including amphotericin B, caspofungin, and voriconizole. The diagnostic difficulties and management are discussed.     

Digital infarction in a hemodialysis patient due to embolism from a thrombosed brachial arteriovenous fistula

Acute onset of digital ischemia and infarction is an unusual complication in patients undergoing hemodialysis. This is a report of a patient on regular hemodialysis who presented with acute distal extremity ischemia, progressing to digital infarction and on evaluation was found to have thrombosis of brachial arteriovenous fistula with embolization to the distal arteries causing digital artery occlusion.     

Dilator venotomy technique for placement of hemodialysis catheter following recanalization of occluded central vein

Recanalization of occluded central veins for insertion of hemodialysis catheter is a particular attractive option in patients who are catheter dependent for hemodialysis, as it delays exhaustion of conventional venous accesses. Literature detailing techniques for catheter placement in recanalized veins remain sparse. We hereby describe a safe and economical technique of using dilator venotomy to allow catheter placement following successful recanalization.     

Lactic acidosis induced by metformin in a chronic hemodialysis patient with diabetes mellitus type 2

Metformin is a biguanide group oral antidiabetic drug used for the treatment of type 2 diabetes mellitus. Nausea, vomiting, diarrhea, abdominal pain, and anorexia are the most common adverse effects encountered during treatment. Lactic acidosis is a serious side effect seen with metformin use, and while the incidence of lactic acidosis is similar to other oral antidiabetics, metformin is not recommended to patients with certain risk factors, such as cardiovascular, pulmonary, and renal and liver failure. We describe a chronic hemodialysis patient treated with metformin, presenting to the nephrology department with altered mental status.     

An unusual case of an irretrievable hemodialysis catheter in a patient with end stage renal disease

Hemodialysis catheters are associated with higher risks of complications compared to arteriovenous fistulas and grafts. Some common complications of dialysis catheters include infection, thrombus formation, central venous stenosis, and mechanical dysfunction. Rarely, catheters can become firmly adhered to a vessel wall. Catheter adhesion is a serious complication that can impact the delivery of safe and effective dialysis to affected patients. Adherent catheters commonly present insidiously with no overt diagnostic signs and symptoms or antecedent catheter malfunction. Prognosis is variable, but can be potentially fatal depending on the severity of adhesion, and sequelae of complications. There are no standardized methods of therapy and treatment strategies are anecdotally reported by interventional radiology, vascular, and cardiothoracic surgery. We hereby describe a case of hemodialysis catheter that has become firmly embedded within the superior vena cava wall. We review the available literature on the epidemiology, risk factors, long‐term sequelae, and known management strategies of adherent catheters. The development of preventative measures will be of great importance given serious complications and limited treatment options. Clinical awareness and understanding of this rare condition is imperative to the prevention and management of adherent catheters.     

Worsening of soft tissue calcifications in a hemodialysis patient following parathyroidectomy

Hemodialysis patients with soft tissue calcifications present unique challenges to nephrologists who play an integral role in their long‐term management. Although disorders of soft tissue calcification are rare in the general population, calciphylaxis and tumoral calcinosis are encountered in up to 4% of the end‐stage renal disease population. Although they are both associated with the deposition of calcium in the soft tissue, they are distinct entities that differ markedly in respect to their clinical presentation, morbidity, and mortality. It is therefore exceedingly important that the nephrologist be aware of these disorders, be able to recognize them, and be able to differentiate them from each other to diagnose and treat patients appropriately. To achieve this it is necessary that the nephrologist be familiar with the diagnostic tools and the treatment modalities that are available. A case of a patient with soft tissue calcifications is presented followed by an overview of these disorders including a comparison of the clinical, laboratory, radiologic, and histologic findings, as well as treatment.     

Heparin albumin priming in a clinical setting for hemodialysis patients at risk for bleeding

Introduction: Intermittent hemodialysis (IHD) is sometimes necessary in patients with a bleeding risk, i.e., before/after surgery or brain hemorrhage. In such case IHD has to be modified to limit the conventional anticoagulation used to avoid clotting of the extracorporeal circuit (ECC). We evaluated if priming using a heparin and albumin (HA) mixture could minimize the exposure to heparin. Methods: Retrospective data from 1995 to 2013 were collected from 1408 acute dialysis treatment protocols that included 321 patients. Comparisons were made between IHD patients that had increased risk for bleeding and were treated by standard anticoagulation (Group‐S), and patients at increased risk of bleeding (Group‐HA). The ECC in Group‐HA was primed with a solution of unfractioned heparin (UFH) (5000 Units/L) and albumin (1 g/L) in saline that was discarded after priming. There were 16 different dialyzers in the material. Findings: Comparing Group‐S (n = 883) with Group‐HA (n = 221), the mean age was 61.6 vs. 62.2 years (P = 0.8), dialysis time was 197 vs. 190 minutes (P = 0.002), and total dose of intravenous anticoagulant/IHD was at median 5000 Units vs. 1200 Units (P = 0.001). Twenty‐four percent of patients were treated without any additional heparin. Clotting resulting in interrupted dialysis was similar in both groups (0.8% for Group‐S vs. 1.0% for Group‐HA, P = 0.8). No secondary bleeding was reported in either group. Discussion: HA priming minimized the risk of clotting and enabled acute IHD in vulnerable patients without increased bleeding, thus allowing completion of IHD to the same extent as for standard HD.     

Cognitive impairment in a patient with COVID-19 on hemodialysis: Too dangerous to neglect!

Neurological manifestations of coronavirus disease 2019 (COVID-19) often have tragic repercussions. Although many reports of neurological complications of severe acute respiratory syndrome coronavirus 2 infection exist, none of them are of patients on hemodialysis, who have a fivefold greater risk of stroke than the general population. In this report, we emphasize the importance of being vigilant for mild stroke in high risk populations—such as patients on hemodialysis—with COVID-19, since these conditions have overlapping symptoms.