Assessing the contact‐activation of coagulation during hemodialysis with three different polysulfone filters: A prospective randomized cross‐over trial

Introduction: During hemodialysis (HD) the interaction of the blood with the dialyzer triggers both an inflammatory reaction and an activation of the coagulation cascade. An accepted parameter to quantify the extent of coagulation activation during HD is not available. This study aims to evaluate its amplitude, comparing dialyzers made of different polysulfone polymers, by measuring D‐dimers in the filter‐rinsing fluids (Frf) and to test whether Frf D‐dimers are suitable candidate markers to assess contact coagulation activation during HD. Methods: In a prospective, cross‐over study 41 hemodialysis patients were randomly allocated to nine HD sessions with three types of polysulfone membranes: Filter A: Poliflux®RevaclearMAX; Filter B: Helixone®Fx80, Filter C: Polyflux®H210. Findings: A total of 117 HD sessions were studied. The mean (SD) filter (Frf) D‐dimers were 0.19 µg/L (0.56) for Filter A; 0.66 µg/L (2.81) for Filter B; 0.33 µg/L (1.13) for Filter C. Significant differences were found: A vs. B (P < 0.01), A vs. C (P = 0.01); B vs. C not significant. A large between‐patient variability of D‐dimer filter levels was found. D‐Dimers in blood showed a similar trend but differences were not significant. Discussion: The contact activation of coagulation during HD may also vary among filters made up with similar polysulfones. D‐dimer in the filter rinsing fluid but not in the blood can be considered a candidate marker for the evaluation of thrombogenicity during HD. Further studies are needed to elucidate the mechanism(s) and to confirm the usefulness of filter rinsing fluid D‐Dimers as a clotting activation marker during HD.     

Clearance of FGF‐23 during continuous renal replacement therapy

FGF‐23 is a 32 kDa protein that is a key regulator of phosphorus and vitamin D metabolism. Emerging evidence also demonstrates that FGF‐23 increases within 24 hours of acute kidney injury (AKI) and may be associated with adverse clinical outcomes. We conducted this study to evaluate FGF23 clearance during continuous veno‐venous hemofiltration (CVVH) in critically ill patients with AKI. We demonstrate that plasma clearance of FGF‐23 during CVVH is ～11 mL/min and the mean sieving coefficient is 0.27 ± 0.1. Future studies will need to clarify FGF‐23's role in adverse outcomes among AKI patients, and whether therapies aimed at reducing FGF‐23 levels may be beneficial.     

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 case of anaphylactic shock induced by FX60 polysulfone hemodialyzer but not F6‐HPS polysulfone hemodialyzer

A 75‐year‐old woman was admitted for dyspnea and fever. She underwent emergent dialysis smoothly under F6‐HPS polysulfone hemodialyzer. With two subsequent hemodialysis sessions, severe anaphylactic reaction with cardiopulmonary resuscitation occurred under FX60 polysulfone dialyzer. Further dialysis sessions by F6‐HPS polysulfone dialyzer were uneventful. This rare case demonstrated that dialyzer reaction may be markedly different even with the same material and the same manufacturer.     

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.     

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.     

Outcomes of patients with end‐stage renal disease (ESRD) under chronic hemodialysis requiring continuous renal replacement therapy (CRRT) and patients without ESRD in acute kidney injury requiring CRRT: A single‐center study

In most continuous renal replacement therapy (CRRT) studies, end‐stage renal disease (ESRD) patients were excluded and the outcomes of patients with ESRD treated with chronic hemodialysis (HD) were unknown. The purposes of this study were to (1) evaluate short‐term patient survival and (2) compare the survival of conventional HD patients needing CRRT with the survival of non‐ ESRD patients in acute kidney injury (AKI) requiring CRRT. We evaluated adults (>18 years) requiring CRRT who were treated in the intensive care unit (ICU) at Kosin University Gospel Hospital from January 1, 2009 to December 31, 2010. A total of 100 (24 ESRD, 76 non‐ESRD) patients underwent CRRT during the study period. Patients were divided into two major groups: patients with ESRD requiring chronic dialysis and patients without ESRD (non‐ESRD) with AKI. We compared the survival of conventional HD patients requiring CRRT with the survival of non‐ ESRD patients in AKI requiring CRRT. For non‐ESRD patients, the 90‐day survival rate was 41.6%. For ESRD patients, the 90‐day survival rate was 55.3%. Multivariate Cox proportional hazards analyses demonstrated that conventional HD was not a significant predictor of mortality (hazard ratio [HR]: 0.334, 95% confidence interval [CI]: 0.063–1.763, P = 0.196), after adjustment for age, gender, presence of sepsis, APACHE score, use of vasoactive drugs, number of organ failures, ultrafiltration rate, and arterial pH. The survival rates of non‐ESRD and ESRD patients requiring CRRT did not differ; ESRD with conventional HD patients may be not a significant predictor of mortality.     

A case of gabapentin‐induced rhabdomyolysis requiring renal replacement therapy

Gabapentin is commonly used for controlling convulsions, restless pain syndrome, and pain in diabetic neuropathy. Common side effects include dizziness, somnolence, ataxia, peripheral edema, and confusion; gabapentin‐induced rhabdomyolysis is rarely reported. To date, the reported cases of gabapentin‐induced rhabdomyolysis have been associated with patients with multiple underlying diseases and assuming multiple medicines for various reasons. In this report, we describe a case of gabapentin‐induced rhabdomyolysis in a 32‐year‐old woman with no medical history. We also review related literature and discuss the possible mechanism and the association with other factors. This case shows that gabapentin can induce rhabdomyolysis in healthy patients and that clinicians must consider the possible association between gabapentin and rhabdomyolysis.     

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.     

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.     

Assessment of subjective and hemodynamic tolerance of different high‐ and low‐flux dialysis membranes in patients undergoing chronic intermittent hemodialysis: A randomized controlled trial

Clinical experience and experimental data suggest that intradialytic hemodynamic profiles could be influenced by the characteristics of the dialysis membranes. Even within the worldwide used polysulfone family, intolerance to specific membranes was occasionally evoked. The aim of this study was to compare hemodynamically some of the commonly used polysulfone dialyzers in Switzerland. We performed an open‐label, randomized, cross‐over trial, including 25 hemodialysis patients. Four polysulfone dialyzers, A (Revaclear high‐flux, Gambro, Stockholm, Sweden), B (Helixone high‐flux, Fresenius), C (Xevonta high‐flux, BBraun, Melsungen, Germany), and D (Helixone low‐flux, Fresenius, Bad Homburg vor der Höhe, Germany), were compared. The hemodynamic profile was assessed and patients were asked to provide tolerance feedback. The mean score (±SD) subjectively assigned to dialysis quality on a 1–10 scale was A 8.4 ± 1.3, B 8.6 ± 1.3, C 8.5 ± 1.6, D 8.5 ± 1.5. Kt/V was A 1.58 ± 0.30, B 1.67 ± 0.33, C 1.62 ± 0.32, D 1.45 ± 0.31. The low‐ compared with the high‐flux membranes, correlated to higher systolic (128.1 ± 13.1 vs. 125.6 ± 12.1 mmHg, P < 0.01) and diastolic (76.8 ± 8.7 vs. 75.3 ± 9.0 mmHg; P < 0.05) pressures, higher peripheral resistance (1.44 ± 0.19 vs. 1.40 ± 0.18 s × mmHg/mL; P < 0.05) and lower cardiac output (3.76 ± 0.62 vs. 3.82 ± 0.59 L/min; P < 0.05). Hypotension events (decrease in systolic blood pressure by >20 mmHg) were 70 with A, 87 with B, 73 with C, and 75 with D (P < 0.01 B vs. A, 0.05 B vs. C and 0.07 B vs. D). The low‐flux membrane correlated to higher blood pressure levels compared with the high‐flux ones. The Helixone high‐flux membrane ensured the best efficiency. Unfortunately, the very same dialyzer correlated to a higher incidence of hypotensive episodes.     

Two additional cases of metformin‐associated encephalopathy in patients with end‐stage renal disease undergoing hemodialysis

We report on two additional cases of metformin‐associated encephalopathy in patients with end‐stage renal disease (ESRD) undergoing hemodialysis. Two patients were seen at our hospital with abnormal neurological signs and symptoms. Magnetic resonance imaging (MRI) revealed the same pattern of high signal intensity in both basal ganglia in T2‐weighted images in the two patients. The two patients had started taking metformin 5 and 6 weeks earlier at the same dose of 1000 mg per day. Metformin was immediately stopped, and regular hemodialysis was conducted. Their signs and symptoms resolved completely after these measures. The high signal intensity in both ganglia in T2‐weighted MRI also disappeared. We should suspect metformin‐induced encephalopathy and withdraw the drug when presented with diabetic patients with chronic kidney disease and neurological signs and symptoms of unknown cause.     

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.     

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.     

Safety of arteriovenous fistulae and grafts for continuous renal replacement therapy: The Michigan experience

Introduction: Arteriovenous fistula or graft (AVF/AVG) use is widely considered contraindicated for continuous renal replacement therapy (CRRT), yet insertion of hemodialysis (HD) catheters can carry high complication risk in critically ill end‐stage renal disease (ESRD) patients. Methods: Single‐center analysis of 48 consecutive hospitalized ESRD patients on maintenance HD who underwent CRRT using AVF/AVG from 2012 to 2013. Primary outcome was access‐related complications. Findings: Mean age was 60 years, 48% were male, and 88% required vasopressor support. Median duration of AVF/AVG use for CRRT was 4 days (range 1–34). Ten (21%) patients had access complications (5 bleeding, 5 infiltration, 1 thrombosis); 5 (10.4%) required catheter placement. Overall 31 (65%) patients survived to hospital discharge and AVF/AVG access was functional at the time of discharge in 29 (94%) patients. Discussion: In our experience, use of AVF/AVG for CRRT can be performed with a low serious complication rate and low risk of access loss, potentially avoiding catheter‐related complications.     

Hemothorax caused by replacement of hemodialysis catheter: A case report

Central venous catheters (CVC) are widely used in clinics to gain vascular access, but the risk and prevalence of catheter‐related complications remains a serious issue. We report a long‐term dialysis catheter accidentally inserted into the mediastinum via the right jugular vein in a hemodialysis patient. We also review complications associated with vascular catheterization and propose immediate therapeutic interventions for such cases.     

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.