Kienböck's disease associated with radiocephalic fistula formation in a patient with end‐stage renal disease

Kienböck's disease, which consists of osteonecrosis and collapse of the lunate bone, causes chronic pain and dysfunction of the wrist. Patients on hemodialysis are occasionally present with wrist pain, but Kienböck's disease is rarely reported in dialysis patients. This case study describes Kienböck's disease in a patient with end‐stage renal disease on hemodialysis. A 39‐year‐old male with a 1‐year history of hemodialysis presented with left wrist pain that increased progressively over 6 months. The patient had no history of trauma or any other risk factors known to be associated with Kienböck's disease. Physical examination of the wrist at the site of the arteriovenous fistula showed swelling and tenderness with decreased range of motion. Radiographic examination showed articular collapse and fracture of the body of lunate consistent with stage IIIb Kienböck's disease. An intercarpal arthrodesis with autogenous bone graft was performed.     

In vitro drug release and in vivo human X-ray studies of ileo-cecal targeting budesonide fast disintegrating tablet

Crohn's disease is a type of inflammatory bowel disease that frequently affects the ileo-cecal region of the gastrointestinal tract. For effective treatment of this disease, a site-targeting drug in the ileo-cecal region is essential. Budesonide (BD) is a synthetic, non-halogenated glucocorticoid and is the drug of choice for the treatment of Crohn's disease. The present study is an attempt to develop the dosage form of a BD tablet to achieve targeted drug release in the ileo-cecal region. The BD tablets are coated with Eudragit FS 30 D, which is a polymer that specifically dissolves at and above pH 6.8. The in vitro drug release and in vivo tablet disintegration (using X-ray radiography) were carried out. The coating process was optimized successfully. The in vitro performance of the tablet with coating thickness showed that the tablet did not disintegrate till 4.5 hours, which represents the transit time to the ileo-cecal region. In vivo studies also established that the tablet lasted till 4.5 hours. The tablet containing 0.5%?superdisintegrant and 10%?coating thickness was able to deliver BD effectively to the ileo-cecal region, thus making it a promising drug delivery system for the treatment of Crohn's disease.     

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.     

Case report: Atenolol overdose successfully treated with hemodialysis

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

Post‐hemodialysis dosing of 1 vs. 2 g of ceftazidime in anuric end‐stage renal disease patients on low‐flux dialysis and its pharmacodynamic implications on clinical use

Ceftazidime is a cost‐effective antimicrobial against Gram‐negative pathogens associated with sepsis in end‐stage renal disease (ESRD) hemodialysis patients with potential for wider use with the advent of ceftazidime‐avibactam. Dosing ceftazidime post‐hemodialysis appears attractive and convenient, but limited in vivo data on pharmacodynamic efficacy (PE) attainment, defined as >70% of the interdialytic period drug concentrations exceed susceptible pathogens minimal inhibitory concentrations (MICs) (%TMIC), warrants further assessment. We therefore evaluated PE and tolerability of 1 against 2 g regime in anuric ESRD patients on low‐flux hemodialysis. Two doses of 1 or 2 g ceftazidime were administered post‐hemodialysis prior to 48‐ and 72‐hour interdialytic intervals in ESRD inpatients without active infections. Peak and trough concentrations (mg/L) were assayed using a validated liquid chromatography–tandem mass spectrometry method. Proportion of patients achieving PE for known pathogens with MICs ≤ 8 mg/L and adverse effects were assessed. Six (43%) and eight (57%) adult patients received 1 and 2 g dose, respectively. Median (25th–75th percentile), peak, 48‐ and 72‐hour trough ceftazidime concentrations were 78 (60–98) vs. 158 (128–196), 37 (23–37) vs. 49 (39–71), and 13 (12–20) vs. 26 (21–41) mg/L, respectively, resulting in 100% TMIC for both doses. One patient on the 1‐g dose experienced mild pruritus. Reliable and safe PE attainment over both 48‐ and 72‐hour interdialytic interval was achievable with 1 g of ceftazidime dosed post‐hemodialysis. The 2 g dose was equally effective and well tolerated but may not be necessary. These findings need validation in non‐anuric patients, high‐flux hemodialysis, and during avibactam co‐administration.     

Complication of diagnostic pleural aspiration: Is it of value in hemodialysis patients?

Pleural effusions are common in hemodialysis patients and are associated with significant morbidity. Diagnostic pleural aspiration and subsequent biochemical analysis can be used to differentiate exudates and transudates. In particular, Light's criteria have been validated in the general population although their efficacy in hemodialysis patients is unclear. Furthermore, aspiration is not without risk; we report the case of a life‐threatening thoracic bleed as a complication of diagnostic thoracocentesis in a hemodialysis patient, in whom a transudative effusion was misclassified according to Light's criteria. Retrospective examination of a further 22 aspirations in hemodialysis patients suggests that biochemical analysis of pleural fluid in this group is of limited value. Careful clinical and radiological assessment may be of greater value in determining individuals who may benefit from formal drainage, rather than diagnostic aspiration with its attendant risks.     

Home hemodialysis in Australia and New Zealand: practical problems and solutions

Home hemodialysis, as practiced in Australia and New Zealand, offers patients the return of self-control and self-esteem. It also allows reconnection with family, friends and (re)employment. Though there are emotional and time-related "costs" with home hemodialysis, these center on training time, commitment and patient or family stresses and, if carefully managed and properly resourced, can be overcome for most home-suitable patients. As we believe many center-based hemodialysis patients are home-suitable and that home care is severely under-utilized, assessment techniques to maximize uptake are examined. While patient dropout from home care relates more to staff attitudes than to true home-failure, dropout is minimized by ensuring the patient and not a carer takes full dialysis responsibility with the carer acting as a supporter and not the facilitator. Installation of home equipment is simple and cheap, the financial costs of home hemodialysis being substantially less than those of facility care where salary and infrastructure costs far exceed training, equipment, installation and maintenance costs at home. Home monitoring is not routinely required especially with longer, more frequent regimens-but effective 24-hour on-call nurse and technician cover is essential. Intravenous drug self-administration at home is safe and effective, reducing the need for hospital visits to a 2-3 monthly minimum. The debilitating effects of facility care cannot be over-emphasized while the liberating psychology of a well-supported hemodialysis program is truly satisfying for patient and staff alike.     

When it rains,it pours: Peripartum cardiomyopathy with features of left‐ventricular noncompaction in a hemodialysis patient

Pregnancy and associated pre‐eclampsia carry a high maternal risk in hemodialysis patients, yet no guidelines on how to monitor these patients' cardiovascular function exist. A 34‐year‐old hemodialysis patient presented with peripartum cardiomyopathy after a late second trimester miscarriage. On cardiac magnetic resonance imaging, diagnostic features of left ventricular noncompaction were apparent. Yet, histological and gene panel analyses remained negative. Upon stringent dry weight control and pharmacological heart failure therapy, the pathological changes showed complete regression. As pregnant hemodialysis patients have an excessively increased risk for pre‐eclampsia‐related cardiac disease, thorough screening appears valuable in these patients.     

A question to the physician from a patient on hemodialysis: Would it be safe to run a marathon? A case report

A patient on maintenance hemodialysis asked his physician if it would be safe for him to run a marathon. For healthy persons, studies show that it is relatively safe. Very few data are available on patients on hemodialysis performing out of center endurance exercise. To address this question, we conducted a clinical study to investigate the electrolyte derangements during different running distances. Our main concern was development of hyperkalemia. We present a case of an anuric hemodialysis patient, who ran eight different runs with a maximum distance of 32.2 km. Blood was analyzed before and after the runs. We did not find severe hyperkalemia at any point. According to this study, we found no signs of increased risk.     

Complications of home hemodialysis

Home hemodialysis is regaining popularity as a treatment choice for end-stage kidney disease. This trend is fueled by numerous reports of better survival and improved quality of life with primarily home-based more frequent and/or longer hours of hemodialysis. Home hemodialysis in the contemporary era is generally very safe. Advances in machine technology have reduced technical complications and longer and more frequent treatments have reduced the risk of hypotension and cardiovascular instability. A successful home hemodialysis program must focus on patient safety to prevent serious hemorrhage from needle dislodgement and enable an aseptic cannulation technique. In addition, vigilance in relation to machine maintenance procedures and attention to water quality are key skills that patients must acquire for optimal outcomes. The possibility of increased septic events with longer and more frequent hemodialysis regimens performed in the home, the long-term psychosocial effects of home hemodialysis, and the best methods for maintaining compliance of patients in the long term are of particular contemporary interest.     

Anti‐thrombotic therapy for atrial fibrillation in patients with chronic kidney disease: Current views

Chronic kidney disease (CKD) occurs in approximately one‐third of patients with non‐valvular atrial fibrillation (AF). The presence of CKD, particularly advanced CKD, confers increased risk of both thromboembolism and major bleeding in this group of patients who are already at risk for ischemic stroke and systemic embolism and at risk of bleeding due to anticoagulation. Studies assessing the effect of warfarin on risk of ischemic stroke, systemic embolism, and major bleeding have produced disparate results, particularly in patients with advanced CKD including those treated with hemodialysis. The direct oral anticoagulants (DOAC's) have been studied in patients with stage III (moderate) CKD and appear to be as effective or more effective (dabigatran 150 mg twice daily) than warfarin in preventing ischemic stroke or embolism in this group. Two of the DOAC's, apixaban and edoxaban, confer lower risk of major bleeding than warfarin with appropriate dose adjustments. Substantial gaps exist in our knowledge of anti‐thrombotic therapy in patients with AF and CKD, primarily due to exclusion of patients with advanced CKD from randomized controlled trials comparing DOAC's with warfarin.     

Challenges and limitations of maintenance hemodialysis in urban South India

Maintenance hemodialysis is a treatment modality available to few patients reaching end-stage renal disease in India. However, the morbidity and outcome of such treatment remains largely unknown. A retrospective cohort of patients commencing hemodialysis in a secondary care institution in India between January 1, 2002 and December 31, 2004 was studied. Patient demographics, cardiac status, access, hospitalizations, and emergency room visits were assessed and outcomes determined. During the study period, 95 patients (66 males, 29 females) commenced maintenance hemodialysis. The underlying cause of chronic kidney disease was diabetic nephropathy in 66.3% of patients. Cumulative follow-up was 676+9.1 patient months. The mean serum creatinine (+SD) at initiation of dialysis was 8.39+3.28 mg%. Thirty-six percent of patients had a functioning arteriovenous fistula at commencement of dialysis, while the remaining 64% of patients required temporary access. The mean number of comorbidities was 1.9+1.0/patient; diastolic dysfunction was deemed to be present in 20.4% of the patients. The hospitalization rate was 3.9/patient year; the number of visits to the emergency room was 4.9/patient year. Cardiac pathology was the most common cause leading to hospitalization and emergency room visits. Diabetic patients were older and had higher cardiac morbidity (p<0.01). The outcome was as follows: 39% transferred to other units; 27% died; 9% switched to CAPD; 8% lost to follow-up; 1% transplantation: Kaplan-Meier survival analysis showed a median survival of 410 days. Patients commencing hemodialysis in an urban dialysis center in South India are predominantly male and have significant comorbidity including diabetes and cardiac disease. Outcome is generally poor. Hence, a huge opportunity for improvement exists.     

Gustatory sweating recurring on peritoneal dialysis but resolving during periods of hemodialysis

Gustatory sweating is a rare disorder characterized by profuse sweating on the forehead, face, scalp, and neck occurring soon after ingesting food, which has been reported in diabetic patients. The mechanism is thought to be triggered by taste buds and not gastric stimulation. We report a case where gustatory sweating repeatedly developed on peritoneal dialysis that resolved on periods of hemodialysis. A 32-year-old woman with diabetic end-stage renal disease developed gustatory sweating shortly after beginning continuous ambulatory peritoneal dialysis despite excellent clearances. After 5 months, she changed to hemodialysis for 2 months and noticed complete resolution of her gustatory sweating; however, after her return to peritoneal dialysis 2 months later, her gustatory sweating recurred. While on peritoneal dialysis, she was treated with clonidine, which resulted in improvement but not resolution of her symptoms as had occurred on hemodialysis. Another period on hemodialysis resulted in the resolution of her symptoms that returned again after restarting peritoneal dialysis. Clonidine provided incomplete relief while topical glycopyrrolate was effective and without complications. We report recurrent gustatory sweating on peritoneal dialysis that resolved with hemodialysis. We have no data to suggest that intra-abdominal stimulation played a role, but rather that despite excellent clearances neuropathy may have played a role. Treatment with topical glycopyrrolate may be safe and effective given every third day if clonidine is ineffective.     

One patient,two malpositioned hemodialysis catheters, (hepatic vein and ascending lumbar vein), no fluoroscopy

Cuffed-tunneled hemodialysis catheter (CTHC) application via the femoral vein is a safe and effective alternative when peripheral vascular routes are exhausted for hemodialysis in patients with end-stage renal disease. Also, imaging methods have become more important for the diagnosis or prevention of the possible complications that may develop during or after catheter placements. Here, we present a case of hemodialysis catheter dysfunction due to the insertion of a CTHC tip into the hepatic vein, and into the left ascending lumbar vein at the next attempt. We think that the use of fluoroscopy, whether in the first catheter intervention or catheter change, is extremely important in preventing possible complications that may develop, or detecting them as soon as possible.     

Can a renal nurse assess fluid status using ultrasound on the inferior vena cava? A cross‐sectional interrater study

Introduction: Ultrasound of the inferior vena cava (IVC‐US) has been used to estimate intravascular volume status and fluid removal during a hemodialysis session. Usually, renal nurses rely on other, imprecise methods to determine ultrafiltration. To date, no study has examined whether renal nurses can reliably perform ultrasound for volume assessment and for potential prevention of intradialytic hypotension. This pilot study aimed to determine if a renal nurse could master the skill of performing and correctly interpreting Point of Care Ultrasound on patients receiving hemodialysis. Methods: After receiving theoretical training and performing 100 training scans, a renal nurse performed 60 ultrasound scans on 10 patients. These were categorized by the nurse into hypovolemic, euvolemic, or hypervolemic through measurement of the maximal diameter and degree of collapse of the IVC. Scans were subsequently assessed for adequacy and quality by two sonologists, who were blinded to each other's and the nurse's results. Findings: The interrater reliability of 60 scans was good, with intraclass correlation 0.79 (95% confidence interval (CI) =0.63–0.87) and with a good interrater agreement for the following estimation of intravascular volume (Cohen's weighted Kappa κ_w = 0.62), when comparing the nurse to an expert sonographer. Discussion: A renal nurse can reliably perform ultrasound of the IVC in hemodialysis patients, obtaining high quality scans for volume assessment of hemodialysis patients. This novel approach could be more routinely applied by other renal nurses to obtain objective measures of patient volume status in the dialysis setting.     

The History of Home Hemodialysis: A View From Seattle

Home hemodialysis was first used for the treatment of end-stage renal disease in the early 1960s, primarily as a means of reducing the cost of treatment. It was soon found to be an effective form of treatment that provided patient independence, greater opportunity for rehabilitation, and better survival. In 1973, when the Medicare End-Stage Renal Disease Program began, some 40% of all U.S. dialysis patients were on home hemodialysis, but since then the percentage of patients on this treatment has steadily decreased. There are several reasons for this, one in particular being the lack of availability of suitable equipment. There is now renewed interest in home hemodialysis sparked by the knowledge that new equipment specifically designed for this is being developed, that this is the modality with the best survival rate, greatest opportunity for adequate dialysis and best quality of life, and an interest in the use of daily (or nightly) home hemodialysis. Consequently, more than 30 years later, it appears that home hemodialysis may again become the preferred treatment for many more patients.     

Anaphylaxis in Association with Heparin-Induced Thrombocytopenia

Heparin is almost universally used as an anticoagulant during hemodialysis. Rare but serious side effects of heparin therapy include heparin‐induced thrombocytopenia (HIT) and anaphylaxis, and these may lead to significant mortality and morbidity if left unrecognized. We are reporting a patient who developed HIT followed by an anaphylactoid reaction. This 8‐year‐old girl with Joubert's syndrome developed end‐stage renal disease secondary to nephronophthisis. She had a Permacath double‐lumen hemodialysis catheter placed in the right internal jugular vein and was started on hemodialysis using an Asahi B10 65 Dialyzer on 1/28/03. The platelet count at that time was 246 × 10³/mL. Beef lung heparin was used for anticoagulation. She was admitted for living related donor renal transplant on 2/10/03 but was found to be thrombocytopenic with a platelet count of 49 × 10³/mL. The transplant was postponed, a sepsis work‐up was performed, and she was started on antibiotics pending culture results. Hemodialysis was continued with heparin anticoagulation, and despite an improvement in the platelet count she had an acute anaphylactoid reaction 2 days later. The reaction occurred 20 min after starting her hemodialysis treatment and presented as acute onset of bronchospasm, agitation, and chest discomfort. She improved with nebulized albuterol and subcutaneous epinephrine. A review of her records revealed that she had received 6 hemodialysis treatments. The platelet count on 2/3/03, after 3 hemodialysis treatments, had been 242 × 10³/mL and on 2/8/03 after 5 treatments the platelet count was 72 × 10³/mL. HIT with anaphylaxis was suspected. Heparin was discontinued and the platelet count had returned to normal within 2 days. The diagnosis was confirmed by a positive heparin‐associated antibody test. While HIT is recognized as a complication in 1–5% of patients treated with heparin and has been well described in the literature, we could only find 2 reported cases of heparin‐induced anaphylaxis and in both cases there was accompanying thrombocytopenia. This patient further illustrates a possible linkage between these two phenomena. HIT is an important cause of thrombocytopenia in a patient on hemodialysis and continued exposure to heparin may induce anaphylaxis.     

Refractory orthostatic hypotension after creation of a brachio‐basilic arteriovenous fistula

Arteriovenous fistulas (AVFs) are preferred vascular access in patients with end‐stage renal disease (ESRD) undergoing hemodialysis (HD). However, AVFs, can occasionally lead to clinically significant complications. Of these, cardiovascular complications have been well described in the literature. In this report, we describe a case of a 78‐year‐old Caucasian male with ESRD who presented with severe debilitating dizziness and orthostatic hypotension that started soon after the creation of left brachiobasilic AVF. The patient had no significant cardiovascular history apart from essential hypertension. His symptoms persisted despite extensive evaluation and interventions, and abated only after banding of the AVF. This report describes the timeline of the patient's clinical course beginning from the day of creation of his AVF, through the course of his hospitalization leading to AVF banding and ending with postoperative recovery phase with resolution of symptoms. We will also review the pathophysiologic effects of AVF on cardiovascular system, as well as the potential causes of our patient's clinical presentation.     

Hemodialysis for infants,children, and adolescents

Children with chronic kidney disease stage 5 requiring dialysis can be treated by peritoneal or hemodialysis. In the United Kingdom nearly twice as many children receive peritoneal dialysis compared with hemodialysis. Technical aspects of pediatric hemodialysis are challenging and include the relative size of extracorporeal circuit and child's blood volume, assessment of adequacy,technical and complications of vascular access. Alternatives to standard hospital‐based hemodialysis are also increasingly available. Optimizing nutritional status with the support of specialist pediatric dietitians is key to the management of children receiving hemodialysis. The effects of chronic illness on growth and school achievement, as well as the psychological, emotional, and social development of the child should not be underestimated. This review focuses on the above elements and highlights common pediatric practice in the United Kingdom.