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.     

Role of peritoneal dialysis in the era of the resurgence of home hemodialysis

In recent years, there has been a resurgence of home hemodialysis (HHD) therapies. Given the small percentage of prevalent patients in the United States currently on home dialysis, an appropriate question is: What is the role of peritoneal dialysis (PD) in this era? Data suggest that in centers that are promoting the growth of HHD, their PD programs also tend to be very active. Furthermore, our experience and other data suggest that one should not worry about cannibalizing PD in order to grow HHD. Most HHD patients come from in‐center hemodialysis or those patients transitioning from PD to another therapy. In fact, data suggest that in order to promote the growth of HHD, a certain minimal infrastructure is needed in terms of staff. An active PD program not only supports a robust infrastructure that allows for HHD growth but also fosters profitability of a home program.     

Challenges of providing maintenance hemodialysis in a resource poor country: Experience from a single teaching hospital in Lagos,Southwest Nigeria

Providing maintenance hemodialysis is associated with high costs and poor outcomes. In Nigeria, more than 90% of the population lives below the poverty line, and patients with end‐stage renal disease (ESRD) pay out‐of‐pocket for maintenance hemodialysis. To highlight the challenges of providing maintenance hemodialysis for patients with ESRD in Nigeria, we reviewed records of all patients who joined the maintenance hemodialysis program of our dialysis unit over a 21‐month period. Information regarding frequency of hemodialysis, types of vascular access for dialysis, mode of anemia treatment and frequency of blood transfusion received were retrieved. One hundred and twenty patients joined the maintenance hemodialysis program of our unit during the period under review. Seventy‐two (60%) were males and the mean age of the study population was 47 + 14 years. The mean hemoglobin concentration at commencement of dialysis was 7.3 g/dL + 1.6 g/dL. The initial vascular access was femoral vein cannulation in all the patients. A total of 73.5% of the patients required blood transfusion at some point with 33% receiving five or more pints of blood. Only 3.3% of the patients had thrice weekly dialysis, 21.7% dialyzed twice weekly, 23.3% once weekly, 16.7% once in two weeks, 2.5% once in three weeks and 11.7% once monthly. At the time of review, 8.3% of the patients had died while 38.3% were lost to follow‐up. Majority of patients with ESRD on maintenance hemodialysis in our unit were poorly prepared for dialysis, were under‐dialyzed, and were frequently transfused with blood with resultant poor outcomes.     

Creation of arteriovenous fistulae for hemodialysis in octogenarians

Elderly patients, defined as octogenarians and nonagenarians, are an increasing population entering renal replacement therapy. Advanced age appears as an exclusive factor negatively influencing dialysis practice. Elderly patients are referred late for the initiation of hemodialysis and more likely are offered catheters rather than arteriovenous fistulae (AVF), which increase mortality and negatively affect quality of life. We present our approach to the creation of vascular access for hemodialysis in this demanding population. In 2006–2012, 39 patients aged 85.9 ± 2.05 with end‐stage renal disease, mainly resulting from ischemic nephropathy, were admitted to the Department of Nephrology to establish permanent vascular access for hemodialysis: preferably AVF. Temporary dialysis catheters were implanted in uremic emergency to bridge the time to fistula creation/maturation. AVF was attempted in 87.2% of the patients. Primary AVF function was achieved in 54% of the patients. Cumulative proportional survival of AVF at months 12 and 24 was 81.5%. Ninety‐four percent of AVF were localized on the forearm: 74% in the distal and 20% in the proximal part. Mean duration of hemodialysis therapy was 20.80 ± 19.45 months. The mean time of AVF use was 15.9 ± 20.2 months. Until present, 38% have been dialyzed using AVF for 31.0 ± 18.8 months. Five patients died with functioning fistula. Eight patients initiated hemodialysis therapy with fistula. During further observation, the use of AVF increased to 62%. Elderly patients should not be denied creation of AVF as a rule. The outcome of AVF benefits more from acknowledging individual vascular conditions rather than age of the patient.     

N‐acetylcysteine may improve residual renal function in hemodialysis patients: A pilot study

Clinical outcomes in chronic dialysis patients are highly dependent on preservation of residual renal function (RRF). N‐acetylcysteine (NAC) may have a positive effect on renal function in the setting of nephrotoxic contrast media administration. In our recent study, we showed that NAC may improve RRF in peritoneal dialysis patients. The aim of the present study was to investigate the effect of NAC on RRF in patients treated with chronic hemodialysis. Prevalent chronic hemodialysis patients with a residual urine output of at least 100 mL/24 hours were included. The patients were administered oral NAC 1200 mg twice daily for 2 weeks. Residual renal function was assessed at baseline and at the end of treatment using a midweek interdialytic urine collection for measurement of urine output and calculation of residual renal Kt/V and glomerular filtration rate (GFR). Residual GFR was measured as the mean of urea and creatinine residual renal clearance. Each patient served as his own control. Twenty patients were prospectively enrolled in the study. Administration of NAC 1200 mg twice daily for 2 weeks resulted in significant improvement in RRF: urine volume increased from 320 ± 199 to 430 ± 232 mL/24 hours (P < 0.01), residual renal Kt/V increased from 0.19 ± 0.12 to 0.29 ± 0.14 (P < 0.01), and residual GFR increased from 1.6 ± 1.6 to 2.4 ± 2.3 mL/minute/1.73 m² (P < 0.01). N‐acetylcysteine may improve RRF in patients treated with chronic hemodialysis.     

Fallacies of High‐Speed Hemodialysis

Chronic hemodialysis sessions, as developed in Seattle in the 1960s, were long procedures with minimal intra‐ and interdialytic symptoms. Financial and logistical pressures related to the overwhelming number of patients requiring hemodialysis created an incentive to shorten dialysis time to four, three, and even two hours per session in a thrice weekly schedule. This method spread rapidly, particularly in the United States, after the National Cooperative Dialysis Study suggested that time of dialysis is of minor importance as long as urea clearance multiplied by dialysis time and scaled to total body water (Kt/V_urea) equals 0.95–1.0. This number was later increased to 1.3, but the assumption remained unchanged that hemodialysis time is of minimal importance as long as it is compensated by increased urea clearance. Patients accepted short dialysis as a godsend, believing that it would not be detrimental to their well‐being and longevity. However, Kt/V_urea measures only removal of low molecular weight substances and does not consider removal of larger molecules. Besides, it does not correlate with the other important function of hemodialysis, namely ultrafiltration. Whereas patients with substantial residual renal function may tolerate short dialysis sessions, the patients with little or no urine output tolerate short dialyses poorly because the ultrafiltration rate at the same interdialytic weight gain is inversely proportional to dialysis time. Rapid ultrafiltration is associated with cramps, nausea, vomiting, headache, fatigue, hypotensive episodes during dialysis, and hangover after dialysis; patients remain fluid overloaded with subsequent poor blood pressure control, left ventricular hypertrophy, diastolic dysfunction, and high cardiovascular mortality. Short, high‐efficiency dialysis requires high blood flow, which increases demands on blood access. The classic wrist arteriovenous fistula, the access with the best longevity and lowest complication rates, provides “insufficient” blood flow and is replaced with an arteriovenous graft fistula or an intravenous catheter. Moreover, to achieve high blood flows, large diameter intravenous catheters are used; these fit veins “too tightly,” so predispose the patient to central‐vein thrombosis. Longer hemodialysis sessions (5–8 hrs, thrice weekly), as practiced in some centers, are associated with lower complication rates and better outcomes. Frequent dialyses (four or more sessions per week) provide better clinical results, but are associated with increased cost. It is my strong belief that a wide acceptance of longer, gentler dialysis sessions, even in a thrice weekly schedule, would improve overall hemodialysis results and decrease access complications, hospitalizations, and mortality, particularly in anuric patients.     

Can twice weekly hemodialysis expand patient access under resource constraints?

The convention of prescribing hemodialysis on a thrice weekly schedule began empirically when it seemed that this frequency was convenient and likely to treat symptoms for a majority of patients. Later, when urea was identified as the main target and marker of clearance, studies supported the prevailing notion that thrice weekly dialysis provided appropriate clearance of urea. Today, national guidelines on hemodialysis from most countries recommend patients receive at least thrice weekly therapy. However, resource constraints in low‐ and middle‐income countries (LMIC) have resulted in a substantial proportion of patients using less frequent hemodialysis in these settings. Observational studies of patients on twice weekly dialysis show that twice weekly therapy has noninferior survival rates compared with thrice weekly therapy. In fact, models of urea clearance also show that twice weekly therapy can meet urea clearance “targets” if patients have significant residual function or if they follow a protein‐restricted diet, as may be common in LMIC. Greater reliance on twice weekly therapy, at least at the start of hemodialysis, therefore has potential to reduce health care costs and increase access to renal replacement therapy in low‐resource settings; however, randomized control trials are needed to better understand long‐term outcomes of twice versus thrice weekly therapy.     

Survival of End-Stage Renal Disease Diabetic Patients on Hemodialysis

Purpose: To analyze survival and causes of mortality in end‐stage renal disease (ESRD) diabetic patients treated by hemodialysis. Methods: Data of 1203 ESRD hemodialyzed patients between 1975 and 2002 were analyzed, 116 patients were excluded and 1087 patients included in the study. We studied the prevalence of the diabetic nephropathy, the rate of survival and causes of death by comparing diabetic patients with a control group of patients without diabetes. Results: Among the 1087 patients requiring dialysis, 272 (25%) were diabetic and 815 non‐diabetic whose causal nephropathy was nephroangiosclerosis 32%, glomerulonephritis 15%, chronic interstitial nephropathy 14%, and others 14%. The diabetics were older at the beginning of dialysis than non‐diabetic patients: 60.33 ± 11.39 years vs. 52.23 ± 17.20 years, p < 0.001. Average time on dialysis is more important in non‐diabetic than diabetic group [5.90 ± 5.73 years vs. 2.71. ± 2.48 years, p < 0.001]. The rate of death was higher in diabetics than in control group [71.7% vs. 55.8%, respectively, p < 0.003]. The difference in survival between the two groups remains significant for the same age. Death caused by cardiovascular disorders is higher in diabetics (68.8%) than non‐diabetics (31.2%) (p < 0.05). Among death causes, stroke is the most frequent cause in diabetics (18.4% vs. 11.6%) in non‐diabetics, p < 0.05. Death by heart failure and infections is higher in diabetics but the difference is not statistically significant (12.3% in diabetics vs. 9.4% in non‐diabetics for heart failure and 13.8% vs. 11.4% for infections). Death due to neoplasms is higher in non‐diabetics (4.39% vs. 1.02% in diabetics, p < 0.05). Conclusion: In our cohort, mortality in diabetic patients is higher than in non‐diabetic patients. Cardio‐vascular disorders are the most cause of death in diabetics and above all stroke, whereas mortality due to neoplasms is higher in non‐diabetic patients. Diabetes is an important risk factor of mortality in hemodialysis patients.     

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.     

Quality of water in hemodialysis centers in Baghdad,Iraq

Dialysis water quality is one of the important parameters all over the world because of its direct influence on the health of kidney patients. In Iraq, there are more than 20 dialysis centers; most of them contain identical units for the production of dialysis water. In this work, the quality of water used for dialysis in six dialysis centers located within Baghdad hospitals was evaluated. Samples of product water from each of the six dialysis centers were examined for total heterotrophic bacteria, endotoxin, and chemical contaminants. Endotoxin was measured on‐site using a portable instrument. Bacteriological and chemical examinations were done in the laboratory after collecting samples from each dialysis center. The results showed a fluctuation in the produced water quality that makes the produced water unaccepted when compared with international standards. Bacterial counts for 60% of the analyzed samples were above the action level (50 colony‐forming units[CFU]/mL), while five out of the six dialysis centers showed values higher than the maximum value (100 CFU/mL). Chemical analysis showed that the dialysis water quality suffers from elevated aluminum concentration for all dialysis centers. All hemodialysis centers need thorough monitoring and preventive maintenance to ensure good water quality. In addition, it is important to revise the design of the water treatment units according to the feed and product water quality.     

Early use of PEPA dialyzer for light chains removal and for the recovery from myeloma cast nephropathy: A case report

Chemotherapy and extracorporeal treatment reduce serum free light chains (FLCs) allowing the recovery of acute kidney injury (AKI) caused by myeloma cast nephropathy (MCN). We report the first case of recovery from AKI in a patient with MCN who underwent the removal of FLCs using the PEPA filter, with an undisclosed cut‐off, combined with chemotherapy for multiple myeloma (MM).     

Evaluation of neopterin levels in patients undergoing hemodialysis

Neopterin is a diagnostic or a prognostic biomarker for several pathologies including renal diseases. However, the association between neopterin status and causative main reasons such as diabetes and hypertension for renal disease remains unclear. The aim of the study was to evaluate neopterin levels in diabetes and hypertension patients treated with/without hemodialysis. According to primary renal disorders, the patients undergoing hemodialysis were classified into 4 groups as diabetic nephropathy, hypertensive nephropathy, reflux nephropathy or interstitial nephritis, and others. The controls consisted of healthy subjects, hypertensive subjects, and diabetic individuals without any renal disorder. In the study, both urinary and serum neopterin levels were measured using high performance liquid chromatography and enzyme‐linked immunosorbant assay in patients undergoing regular hemodialysis therapy (n=71). The effects of the duration of hemodialysis and treatment of erythropoietin and/or iron on neopterin levels were also evaluated. Neopterin levels were found to be higher in hemodialysis patients than in the healthy controls (P<0.05). A significant difference in neopterin levels was also found between diabetic control patients and diabetic nephropathy patients (P<0.05). A similar significant difference was detected in neopterin levels between hypertensive patients with/without nephropathy (P<0.05). Neopterin may be an early critical marker for progression of nephropathy in diabetic and hypertensive patients in early stages.     

Understanding barriers to home‐based and self‐care in‐center hemodialysis

Despite superior outcomes and lower associated costs, relatively few patients with end‐stage renal disease undergo self‐care or home hemodialysis. Few studies have examined patient‐ and physician‐specific barriers to self‐care and home hemodialysis in the modern era. The degree to which innovative technology might facilitate the adoption of these modalities is unknown. We surveyed 250 patients receiving in‐center hemodialysis and 51 board‐certified nephrologists to identify key barriers to adoption of self‐care and home hemodialysis. Overall, 172 (69%) patients reported that they were “likely” or “very likely” to consider self‐care hemodialysis if they were properly trained on a new hemodialysis system designed for self‐care or home use. Nephrologists believed that patients were capable of performing many dialysis‐relevant tasks, including: weighing themselves (98%), wiping down the chair and machine (84%), clearing alarms during treatment (53%), taking vital signs (46%), and cannulating vascular access (41%), but thought that patients would be willing to do the same in only 69%, 34%, 31%, 29%, and 16%, respectively. Reasons that nephrologists believe patients are hesitant to pursue self‐care or home hemodialysis do not correspond in parallel or by priority to reasons reported by patients. Self‐care and home hemodialysis offer several advantages to patients and dialysis providers. Overcoming real and perceived barriers with new technology, education and coordinated care will be required for these modalities to gain traction in the coming years.     

In‐center hemodialysis attendance: Patient perceptions of risks,barriers, and recommendations

Missed hemodialysis treatments lead to increased morbidity and mortality in the end‐stage renal disease population. Little is known about why patients have difficulty attending their scheduled in‐center dialysis treatments. Semistructured interviews with 15 adherent and 15 nonadherent hemodialysis patients were conducted to determine patients' attitudes about dialysis, health beliefs and risk perception regarding missed treatments, barriers and facilitators to hemodialysis attendance, and recommendations to improve the system to facilitate dialysis attendance. Average time on dialysis was 2.5 years for the nonadherent group and 7.3 years in the adherent group. In both groups, patients felt that dialysis is life‐saving and a necessity. A substantial number of patients in both groups understood that missing hemodialysis treatments is dangerous and several patients could clearly communicate the risk of skipping. The most common barriers to hemodialysis were inadequate or unreliable transportation (mentioned in both groups) and a lack of motivation to get to dialysis or that dialysis is not a priority (typically mentioned by the nonadherent group). Facilitators to hemodialysis attendance included explanations from the health care team regarding the risk of skipping and relationships with other dialysis patients. Patient recommendations to improve dialysis attendance included continued education about the risk of poor attendance and more accessible transportation. Patients did not feel that home dialysis would improve adherence. Hemodialysis patients must adhere to a complex and burdensome regimen. Through the elucidation of barriers and facilitators to hemodialysis attendance and through specific patient recommendations, at least three interventions may be further investigated to improve hemodialysis attendance: Improvement of the transportation system, education and supportive encouragement from the health care team, and peer support mentorship.     

The Decline in Residual Renal Function in Hemodialysis Is Slow and Age Dependent

Background: Persons on peritoneal dialysis and hemodialysis with preserved residual renal function experience lower mortality rates than those without. Previous studies have shown slower rates of decline of residual renal function for peritoneal dialysis (PD)(2 to 3% decrease/month), compared with hemodialysis (HD)(6 to 7% decrease/month). However, our clinical observations suggested a lower rate of decline in hemodialysis patients. Methods: We evaluated data in 174 hemodialysis patients cared for from January 2000 through October 2001. Eighty‐seven (50%) patients had at least two timed quarterly urine collections to estimate the rate of change of residual renal function over time (urea clearance, or KrU). All patients underwent thrice‐weekly hemodialysis using polysulfone dialyzers with formaldehyde reprocessing. The rate of decline of residual renal function and the effect of KrU on laboratory variables were estimated using a random effects (MIXED) model, adjusting for the effects of age, sex, race, diabetes, and dialysis vintage. Results: The mean KrU at baseline was 3.5 mL/min. Men (P < 0.001) and persons of shorter vintage (P < 0.0001) had more residual renal function at baseline. The estimated rate of decline of residual renal function was ? 0.07 mL/min/month (? 1.9% decrease/month). The rate of decline in residual renal function was unaffected by sex, race, diabetes, or vintage, although the rate of decline was significantly attenuated among older individuals (age x time interaction, P = 0.01). Serum phosphorus (P = 0.03) and the calcium x phosphorus product (P = 0.009) increased over time and were influenced by the level of residual renal function (P = 0.06 and P = 0.006, respectively). Residual renal function did not influence the rate of change of other laboratory variables. Conclusions: In an ethnically diverse cohort of hemodialysis patients, the rate of decline of residual renal function was relatively slow and age dependent, as well as consistent with values others have reported for patients on peritoneal dialysis. Universal use of biocompatible dialyzers and bicarbonate dialysate may have contributed to differences discussed in prior reports. Residual renal function attenuated the increase in calcium–phosphorus product over time. A better understanding of the determinants of the rate of decline in residual renal function, and the specific benefits afforded to patients via maintenance of residual renal function, would help to inform the debates on timing of initiation and various dosing strategies in hemodialysis.     

Tailoring dialysis and resuming low‐protein diets may favor chronic dialysis discontinuation: Report on three cases

Renal function recovery (RFR), defined as the discontinuation of dialysis after 3 months of replacement therapy, is reported in about 1% of chronic dialysis patients. The role of personalized, intensive dialysis schedules and of resuming low‐protein diets has not been studied to date. This report describes three patients with RFR who were recently treated at a new dialysis unit set up to offer intensive hemodialysis. All three patients were females, aged 73, 75, and 78 years. Kidney disease included vascular‐cholesterol emboli, diabetic nephropathy and vascular and dysmetabolic disease. At time of RFR, the patients had been dialysis‐dependent from 3 months to 1 year. Dialysis was started with different schedules and was progressively discontinued with a “decremental” policy, progressively decreasing number and duration of the sessions. A moderately restricted low‐protein diet (proteins 0.6 g/kg/day) was started immediately after dialysis discontinuation. The most recent update showed that two patients are well off dialysis for 5 and 6 months; the diabetic patient died (sudden death) 3 months after dialysis discontinuation. Within the limits of small numbers, our case series may suggest a role for personalized dialysis treatments and for including low‐protein diets in the therapy, in enhancing long‐term RFR in elderly dialysis patients.     

Hypertension and left ventricular mass index (L.VMI) in patients on regular hemodialysis (RDT)

Background:  Because of high incidence of acquired renal cyst and renal malignancy, it is suggested that spontaneous renal rupture more frequently occurs in patients receiving long‐term hemodialysis than in the general population. This study was performed to evaluate the clinical characteristics of spontaneous renal rupture in hemodialysis patients. Methods:  This retrospective study enrolled 12 hemodialysis patients who developed spontaneous renal rupture. We investigated primary renal disease, duration of dialysis, clinical symptoms and signs, radiologic findings, treatment modalities, and histologic findings. Result:  The mean age of the patients was 54 ± 10 years old and the number of male was 9. Primary renal disease consisted of autosomal dominant polycystic kidney disease (PCKD)(n = 5), chronic glomerulonephritis (n = 2), diabetic nephropathy (n = 1), hypertensive nephropathy (n = 1), unknown cause (n = 3). Presenting symptoms and signs were sudden onset of flank pain in 9 patients and gross hematuria with mild flank pain in 3 patients. Mean duration from initiation of hemodialysis to development of spontaneous renal rupture was 53 ± 36 months. Abdominal computed tomography showed subcapsular or perinephric hematoma in all patients. Of the 7 non‐PCKD patients, 6 patients had multiple acquired renal cysts. Surgical exploration was undertaken in 9 patients. Pathologic examination demonstrated small sized renal cell carcinoma in 2 of 9 patients. Three patients were only treated with conservative management including blood transfusion. All 12 patients recovered without recurrence. Conclusion:  This study demonstrated that genetic or acquired renal cyst was an important cause of spontaneous renal rupture in hemodialysis patients and presenting manifestations were sudden onset of flank pain and gross hematuria.     

Renal replacement therapy in Nepal

Renal replacement therapy in Nepal fulfills only a small part of the current needs, with 97 hemodialysis machines available for the general population of 29 million. Transportation difficulties to dialysis centers preclude many of the patients from end-stage renal disease care, due to the rural nature of the population. Peritoneal dialysis (PD) organized into rural sub segments, considering the Mexican model of PD and government funding appear to offer some solution to provision of care for this mountainous rural country. We review the current statistics of dialysis patients, hemodialysis numbers, and renal transplantations within Nepal and offer suggestions regarding possibilities for increasing renal care within the country.     

Outbreak of nonfermentative Gram‐negative bacteria (Ralstonia pickettii and Stenotrophomonas maltophilia) in a hemodialysis center

We report a case series of seven patients with nonfermentative Gram‐negative bacteria infections in a single dialysis center; four patients with Ralstonia pickettii and three patients with Stenotrophomonas maltophilia. Two of the seven patients were admitted to hospital for intravenous antibiotic treatment, while the rest were treated with oral antibiotics at home. Both the admitted patients had temporary vascular catheter infections from the aforementioned pathogens. We conclude that the outbreak is due to colonization of treated reverse osmosis water, presumably through contamination via polluted filters and compounded by the usage of reprocessed dialysers in the dialysis center. This is especially relevant because contaminated treated water is directly introduced into the blood compartment of the dialysers during reprocessing. In addition, there seems to be a propensity for both organisms to cause prolonged febrile reactions in patients with temporary vascular catheters, likely through the early development of biofilm. Intensification of general sterilization procedures, servicing and replacement of old decrepit components of the water treatment system and temporary cessation of dialyser reuse practice seem to have halted the outbreak. Due to the virulent nature and difficult resistant profile of nonfermentative Gram‐negative bacteria, we strongly recommend meticulous vigilance in the surveillance of culture isolates in routine microbiological specimens from dialysis centers, especially if there is a senescent water treatment system and a practice of reprocessing dialysers.