A Report on 4 New Cases of Nephrogenic Fibrosing Dermopathy in Chronic Hemodialysis Patients

Nephrogenic fibrosing dermopathy (NFD) is a rare entity affecting patients with renal failure, often on chronic dialysis or after transplantation (TXP). The patient profile at risk for this debilitating condition is yet undefined as is the role of renal failure in its etiology. We diagnosed 4 chronic hemodialysis (HD) patients with NFD. A 55-year-old Caucasian male on HD for 5 years, secondary to diabetic nephropathy, developed woody, indurated skin of the extremities, decreased mobility, and wheelchair dependence. He died within 1 year. A 66-year-old African-American male with diabetes, hypertension, and pancreatic cancer developed thick indurated skin on his extremities after being on HD for approximately 20 months. He died 3 months later from sepsis. A 26-year-old Caucasian female on HD for approximately 10 years, secondary to hyperoxaluria-induced renal failure, had undergone combined liver and kidney TXP with primary nonfunction of the renal TXP. She succumbed to cholangitis approximately 1 year after progressive skin thickening and joint contractures were noted. A 75-year-old Caucasian female with renal failure secondary to recurrent hemolytic uremic syndrome and TXP failure was dialysis dependent for 6 years. Over a 3-month period, she developed skin changes consistent with NFD and entered hospice care secondary to marked deterioration in her quality of life. In all of these cases, skin changes were restricted to the extremities, sparing the trunk, face, and internal organs. Skin biopsy findings included thickened dermis with particularly thickened collagen bundles, mucin deposition, and fibroblast proliferation and were distinct from scleromyxedema and scleroderma. Autoimmune disease workup was negative. Indeed, NFD is a novel cutaneous fibrosing disorder of progressively debilitating nature in patients with renal failure that needs further clinical and pathological characterization.     

Risk of major depression in patients with chronic renal failure on different treatment modalities: A matched‐cohort and population‐based study in Taiwan

The influence of different treatment modalities on the risk of developing major depression in patients with chronic renal failure (CRF) is not well understood. We aimed to explore the incidence of major depression among patients with CRF who were on different dialysis modalities, who had received renal transplantation (RT), and those who had not yet received any of the aforementioned renal replacement therapies. We conducted a population‐based retrospective cohort study using a national health insurance research database. This study investigated 89,336 study controls, 17,889 patients with chronic kidney disease on conservative treatment, 3823 patients on hemodialysis (HD), 351 patients on peritoneal dialysis (PD), and 322 patients who had RT. We followed all individuals until the occurrence of major depression or the date of loss to follow‐up. The PD group had the highest risk (hazard ratio [HR] 2.43; 95% confidence interval [CI] 1.26–4.69), whereas the RT group had the lowest risk (HR 0.18; 95% CI 0.03–1.29) of developing major depression compared with the control group. Patients initiated on PD had a higher risk of developing major depression than patients initiated on HD (pairwise comparison: HR 2.20; 95% CI 1.09–4.46). Different treatment modalities are associated with different risks of developing major depression in patients with CRF. Among renal replacement therapies, patients who have had RT have the lowest risk of developing major depression. Patients who initiate renal therapy on PD may have a higher risk of major depression compared with patients who initiate renal therapy on HD.     

Compliance, quality of life, and contributing factors in renal transplantation waiting list patients

Poor patient compliance is common during dialysis therapy. We aimed to study incidence of noncompliance, contributing factors, and effects on quality of life (QOL) among cadaveric renal transplantation waiting list patients. We included 86 renal transplantation waiting list patients (56M/30F). Dialysis duration, previous renal transplantation history, comorbid conditions, interdialytic weight gain, predialysis BUN, creatinine, potassium, and phosphate were recorded. Noncompliance criteria were skipping >1 dialysis session or shortening a dialysis session>10 min in 1 month, interdialytic weight gain>5.7% of body weight, predialysis serum potassium >6 mEq/L, and phosphate level >7.5 mg/dl. There were 49 noncompliant (age: 46.8 ± 21.8 years, HD duration: 83.9 ± 48.7 months) and 37 compliant (age: 42.8 ± 12.1 years, HD duration: 96.5 ± 45.2 months) patients. QOL was evaluated by short form 36 and depression levels by Beck Depression Inventory. Previous renal transplantation was present in 24.4% and comorbid diseases in 31.3% of all patients. In depressed patients, 77.8% had comorbid diseases. No difference was found between the groups considering age, gender, dialysis duration, previous transplantation history, and comorbid diseases (p > 0.05). Noncompliant patients had lower QOL (p < 0.04). Noncompliant patients had higher degree of depression (p = 0.01). QOL and Beck scores were negatively correlated (p = 0.001, r = −0.561). Noncompliance to diet and dialysis therapy is associated with depression, which further decreases QOL in renal transplantation waiting list patients. Early diagnosis of depression, is possible by monitoring noncompliance, and therapeutic intervention may benefit during the transplantation‐waiting period.     

New-onset psoriasis in a maintenance hemodialysis patient

New-onset psoriasis is extremely rare in hemodialysis (HD) patients, and several trials of dialysis therapies (HD and peritoneal dialysis) in psoriasis have indicated remarkable improvement in skin lesions and well-being even in patients without renal impairment. We describe a patient who developed severe psoriasis despite undergoing chronic maintenance hemodialysis for 5 years and was treated successfully with oral cyclosporin A.     

Multiple metastatic infections in a hemodialysis patient with untunneled internal jugular catheter

We present an end‐stage renal disease patient on dialysis with fever. The primary source was right internal jugular vein catheter which had metastatic infections in the body probably via an arteriovenous communication in a cavity in left lung. Patient had right psoas muscle abscess and a left kidney abscess. An ¹⁸F‐fluorodeoxyglucose‐positron emission spectroscopy scan was done to find out left kidney abscess. A search of literature did not reveal many patients of psoas abscess secondary to infection of hemodialysis access.     

Spontaneous perirenal hemorrhage in hemodialysis patient treated with selective embolization: A case series and review of the literature

Introduction: Spontaneous perirenal hemorrhage (SPH) or Wunderlich syndrome, is a rare but potentially life‐threatening condition. It is characterized by an unexpected bleeding in the kidneys and usually presents as an abdominal pain. Angiography and more recently selective renal arterial embolization are emerging as effective modalities for the diagnosis and treatment of SPH. In this article, we report a total of three cases of SPH in hemodialysis (HD) patients. Methods: This is the experience of diagnosis and treatment of SPH in HD patients. Findings: All three were female, between 37 and 54 years of age and were undergoing HD for end stage renal disease (ESRD). Two of patients presented with left flank or abdominal pain after termination of HD therapy, while the third patient presented with left abdominal pain during the dialysis session. All patients received anti‐coagulation therapy for HD, but no abnormal levels of coagulation index were found. These patients were diagnosed using CT and two of them were diagnosed with acquired cystic kidney disease (ACKD). Selective renal arterial embolization was performed in the case of active bleeding. Discussion: We are aware that HD patients have elevated risk of bleeding related complications, additionally the presence of an acute abdominal pain increases the suspicion of SPH as a possible cause. ACKD can be considered one of the possible risk factors for SPH in long‐term HD patients. Interventional treatment for kidney injury is useful and safe for active bleeding in most cases.     

Telematics Service for Home and Satellite Hemodialysis

Home hemodialysis (HD) for the treatment of end-stage renal disease was first implemented about 30 years ago. In this paper the application of telematics monitoring services for supporting patients who need home HD or satellite HD is described. Two modified HD machines were located in two renal units, and a central control station (CCS, UNIX workstation with multimedia PC terminal) was located in another room of the hospital. Bidirectional communication between the modified HD machines and the CCS was managed using ISDN (Integrated Services Digital Network) links. Nine patients had 150 HD sessions performed using these HD machines over a period of 5 months. This system, called the HOMER-D system, provided on-line, remote supervision of the HD machine-related functions and the clinical condition of the patients through measurement of blood pressure, pulse rate, PO₂ (pulse oxymetry), and ECG from the CCS. Any disturbances in the functioning of the HD machines were both visible and audible in the CCS, and the observer could give teleconsultation to the renal unit staff. No major dialysis-associated complications were observed; all data and alarms were transmitted correctly; and patients received adequate HD treatment.     

Tuberculosis in end-stage renal disease patients on hemodialysis

Recent studies have shown that there is an increase in the incidence of mycobacterium tuberculosis (MBT). This is more prevalent among immune compromised patients (those on dialysis) and recipients of organ transplants. Furthermore, extra-pulmonary presentation appears to be more common and difficult to diagnose. We aimed in this study to assess and evaluate the presentation of MBT in a retrospective study conducted among 256 hemodialysis (HD) patients where 18 of them were diagnosed and managed for tuberculosis over a 10-year period between 1990 and 2000. The mean age of the patients was 38 years (21-75 years). The mean interval between the onset of HD and the time of diagnosis was about 24 months (1-120 months). The diagnosis of tuberculosis was made either by isolation of acid-fast bacilli (AFB), the typical caseating granuloma on biopsy, or by recovery of tubercle bacilli from the culture of the biopsy material. Extra-pulmonary tuberculosis was more common (77.8%) than pulmonary tuberculosis (22.2%). The various extra-pulmonary tuberculosis sites noted were cervical lymphadenitis (16.7%), gastrointestinal (16.7%), genitourinary (11.1%), peritonitis (11.1%), pleural effusion (5.6%), pericardial effusion (5.6%), miliary tuberculosis (5.6%), and pyrexia of unknown origin (5.6%). None of the patients with extra-pulmonary tuberculosis had evidence of pulmonary tuberculosis. The atypical presentation with insidious onset was quite common. Anergy to tuberculin skin test was noticed in 56% of cases. All of our patients received modified antituberculosis treatment for 1 year with adequate response, and without undue side effects. We conclude that a high index of suspicion is required especially in the diagnosis of extra-pulmonary tuberculosis, and when there is a high percentage of anergy to tuberculin skin test. Tissue biopsy both for characteristic histology and demonstration of MTB, either by staining or culture, remains the main criteria for the diagnosis of extra-pulmonary tuberculosis.     

Free dialysis in Nepal: Logistical challenges explored

Nepal's Ministry of Health began offering free lifetime hemodialysis (HD) in 2016. There has been a large growth in renal replacement therapy (RRT) services offered in Nepal since 2010, when the last known data on the subject was published. In 2016, 42 HD centers existed (223% increase since 2010) serving 1975 end stage renal disease patients (303% increase since 2010); 36 nephrologists were registered (200% increase since 2010), 12 were trained in transplantation, and 790 transplants had been performed to date. We estimate the incidence of end stage renal disease to be 2900 patients (100 per million population). With an annual cost of approximately US$2300 per dialysis patient, offering free dialysis could potentially cost the government US$6.7 million per year, suggesting that 2.1% of the annual health budget would be allocated to 0.01% of the population. The geographic zone surrounding the capital city, Kathmandu, contains 50% of HD centers, but only 14.5% of Nepal's population. Forty‐eight percent of the population lives within zones without HD service, therefore infrastructure challenges exist in providing equitable access to RRT. The aim of this article is to summarize the current statistics of RRT in Nepal.     

P-selectin, E-selectin, and CD40L over time in chronic hemodialysis patients

The aim of this study was to measure P-selectin, E-selectin, and CD-4L levels over time in chronic hemodialysis (HD) patients. Thirty stable patients with end-stage renal failure undergoing chronic HD were included in the study. Blood samples were obtained before HD for measurement of P-selectin, E-selectin, and CD-40L. Measurements were performed at month 0 (T0), 3 (T2), 8 (T3), and 13 (T4). The levels of P-selectin, E-selectin, and CD40L were also analyzed according to the occurrence of cardiovascular disease (CVD) and to CVD-related mortality. The levels of CD40L and P-selectin changed significantly over time, decreasing at month 3 and 6 and returning at the T0 levels at month 13. Conversely, E-selectin levels did not. The levels of CD40L, P-selectin and E-selectin over time did not differ significantly between patients with age ≤ 65 or > 65 years, between patients with or without CVD, or between patients who died or who survived during the follow-up. In end-stage renal failure patients undergoing chronic HD, CD40L and P-selectin, but not E-selectin, showed a transient decrease over time, and the serum levels of these molecules were not associated with CVD or with CVD-related mortality.     

Changing patterns of pericardial disease in patients with end-stage renal disease

Pericarditis can occur in patients with chronic renal failure before initiation of dialysis. It is also described in established dialysis patients. Traditionally, the cause of pericarditis in such settings has been attributed to uremia and/or inadequate dialysis and it is consequently thought that intensifying the dialysis process in such patients could improve outcome. We report here 7 cases of acute pericarditis in patients with end-stage renal disease on renal replacement therapy. Only 3 of the patients gave any history of chest pain, and a pericardial friction rub was only noted in 2. Despite a period of intensive dialysis, none of the patients improved and all required pericardial drainage as the definitive curative procedure. The clinical presentation of acute pericarditis in dialysis patients therefore may be atypical and pericardial drainage should be considered early, as intensive dialysis alone may not lead to resolution.     

Myocardial stunning in hemodialysis: What is the overall message?

Heart failure and cardiovascular events are common in chronic renal failure. Hemodialysis (HD) causes significant hemodynamic changes and hypotension. New evidence based on intradialytic echocardiography demonstrates transient cardiac dysfunction or stunning in majority of chronic HD patients. Over time, this group may progress to chronic heart failure and appears to predict higher cardiovascular events and mortality. Although the exact etiology is unclear, alterations in HD technique and cardiac medications may reduce this complication. We review the current understanding of acute cardiac stunning during HD and present a systematic management algorithm to optimizing overall outcomes in this high-risk population.     

Intensive dialysis and pregnancy

Pregnancy in women with end stage renal disease on renal replacement therapy is uncommon due to the physiologic changes associated with renal failure as well as the complexities and risk involved in managing these patients. As most of these women had long periods of illness with chronic kidney disease, the effects of their chronic illness together with the current societal trends to delay child bearing to a more advanced maternal age can hamper fertility. For those able to conceive, intensified hemodialysis (HD), through longer and/or more frequent dialysis sessions, offers improved maternal and neonatal outcomes. Intensified HD is most conveniently offered in the patient's home, where possible. This review expands the scope of the Implementing Hemodialysis in the Home website and associated supplement published previously in Hemodialysis International and includes information tailored to women of reproductive age. We describe the necessary counseling that women should receive before conception and before intensification of HD, and provide a detailed management strategy that includes nephrologic and obstetric care, should pregnancy occur.     

The relevance of convection in clinical practice: a critical review of the literature

Convective treatments (high-flux hemodialysis (HD), hemodiafiltration and hemofiltration) are characterized by enhanced removal of middle and large molecular weight solutes compared with conventional low-flux HD. As these molecules are claimed to play an important role in the genesis of many complications of chronic HD, the availability of these techniques represented an intriguing innovation and a possible means to improve the still poor prognosis of HD patients. Here we will critically review the most important published studies comparing convective treatments with low-flux HD on chronic morbidity, preservation of residual renal function, and long-term survival.     

Fatal neck pain in a patient on maintenance hemodialysis

Infectious spondylodiscitis (IS) is defined as the pathogenic invasion of the vertebrae and intervertebral disks. It is a serious condition that can lead to many complications such as chronic pain, permanent neurological deficits, and even death. Vertebral surgical procedures, invasive urinary tract manipulations, and central line-associated bloodstream infection are the primary methods by which microorganisms reach the vertebrae and intervertebral disks. Hemodialysis (HD) patients are regularly exposed to bloodstream infections due to long-term catheter utilization or repeated vascular puncturing in patients with arteriovenous fistula. Due to the high risk of blood stream infections, HD patients have a higher risk of developing IS. Despite advanced diagnostic methods, diagnosis of spondylodiscitis is often delayed due to insidious and nonspecific symptoms, allowing dissemination of the infection, which explains the high level of mortality due to spondylodiscitis in HD patients. The infectious process typically occurs in the thoracic or lumbar region, although cervical IS does occur. We herein report the case of a 67-year-old man on HD who developed infectious cervical spondylodiscitis. The diagnosis was established a few days after symptom onset, but the issue was unfortunately fatal despite a well-conducted antibiotic treatment.     

Transmetallation and gadolinium: Do low iron stores prevent the development of nephrogenic systemic fibrosis in high‐risk end‐stage renal disease patients?

Nephrogenic systemic fibrosis (NSF) is a systemic disorder that occurs in patients with renal failure and manifests as a thickening of the skin and flexion contractures of the joints. The etiology may involve an exposure to a gadolinium (Gd)‐based magnetic resonance contrast agent. It has been proposed that in hemodialysis (HD) patients, iron mobilization (decreased total iron‐binding capacity, increased iron level, and transferrin oversaturation) causes a transmetallation reaction and the release of free Gd from its chelator with the deposition of both Gd and iron in the affected tissues leading to fibrosis. The objective of this study was to investigate whether the use of gadopentetate dimeglumine leads to iron mobilization and to the development of NSF in HD patients. A retrospective chart analysis of 236 HD patients was performed and patients who had received a Gd‐containing contrast agent were selected for analysis of their iron studies before and after the Gd exposure. A total of 25 patients were identified as having had a magnetic resonance imaging study and all were administered gadopentetate dimeglumine and no patients had any signs or symptoms suggestive of NSF. Six patients had the appropriate iron studies, which showed no statistically significant difference in the serum iron, total iron‐binding capacity, ferritin, or transferrin saturation before and after exposure to gadopentetate dimeglumine. Our data suggest that the use of gadopentetate dimeglumine in HD patients did not cause iron mobilization and transmetallation therefore may partially explain the lack of development of NSF seen in our patient population.     

The impact of arteriovenous fistula creation in pulmonary hypertension: Measurement of pulmonary pressures by right heart catheterization in a patient with respiratory failure following arteriovenous fistula creation

Pulmonary hypertension (PHT) is frequent in patients receiving hemodialysis (HD) and carries a high mortality. While it has been suggested that arteriovenous fistulae (AVF) may exacerbate PHT in HD patients, it has also been observed that creating AVF in patients with chronic lung disease and normal renal function may lead to improved exercise tolerance. Most of the observations regarding HD patients using echocardiography demonstrated that temporary closure of AVF improved pulmonary pressures. We present the case of a 45‐year‐old patient with chronic obstructive pulmonary disease on HD who experienced respiratory failure following AVF formation and underwent right heart catheterization. Severe PHT was diagnosed but transient occlusion of the fistula failed to improve the PHT. This case supports the theory that fistula creation does not exacerbate pre‐existing PHT and that AVF can be the access of choice in patients with known chronic lung disease and pulmonary hypertension.     

Oxidative DNA damage correlates with carotid artery atherosclerosis in hemodialysis patients

Oxidative stress is accepted as a nonclassical cardiovascular risk factor in chronic renal failure patients. The aim of this study was to evaluate the relation between oxidative DNA damage (8‐hydroxy‐2′‐deoxyguanosine/deoxyguanosine [8‐OHdG/dG] ratio), oxidative stress biomarkers, antioxidant enzymes, and carotid artery intima‐media thickness (CIMT) in hemodialysis (HD) patients. Forty chronic HD patients without known atherosclerotic disease and 48 age‐ and sex‐matched healthy individuals were included in the study. Plasma malondialdehyde (MDA) levels and 8‐OHdG/dG ratio were determined as oxidative stress markers. Superoxide dismutase (SOD) and glutathione peroxidase (GPx) activities were measured as antioxidants. CIMT was assessed by carotid artery ultrasonography. 8‐OHdG/dG ratios and MDA levels were higher; SOD and GPx activities were lower in HD patients compared to controls. HD patients had significantly higher CIMT compared to controls (0.61 ± 0.08 vs. 0.42 ± 0.05, p < 0.001). There was a significant positive correlation between CIMT and 8‐OHdG/dG ratio (r = 0.57, p < 0.01) and MDA levels (r = 0.41, p < 0.01), while there was a significant negative correlation between CIMT and SOD (r = ?0.47, p < 0.01) and GPx levels (r = ?0.62, p < 0.01). It is firstly demonstrated that CIMT is positively correlated with oxidative DNA damage in HD patients without known atherosclerotic disease.     

Late acceleration of glomerular filtration rate decline is a risk for hemodialysis catheter use in patients with established nephrology chronic kidney disease care

Chronic kidney disease (CKD) patients with established nephrology care have a high rate of tunneled dialysis catheters (TDC) as first vascular access when transitioning to hemodialysis (HD). We sought to identify factors associated with this problem. Patients who started HD and had prior CKD care within our renal clinic were categorized according to access type at incident HD. Clinical factors, all estimated glomerular filtration rates (eGFR), renal clinic attendance records, hospital admissions in the 6 months preceding HD start, and patient participation in predialysis education course were analyzed. Three hundred thirty‐eight patients initiated HD, 107 received pre‐HD CKD care within our clinics. Seventy patients started with a TDC. All groups started HD at similar eGFR values. The trajectory of eGFR decline in the 6 months prior to HD start was significantly more rapid in the TDC group. Patients in the TDC group had more acute health events in the prior 6 months. Multivariate modeling showed that failure to attend a predialysis education course and having a more rapid rate of eGFR decline in the 6 months prior to dialysis initiation were both associated with TDC use. Patients with CKD nephrology care who initiated HD with a TDC as first vascular access had a more rapid rate of decline in eGFR in the months preceding dialysis start and were less likely to have attended our predialysis education course. This appears to correspond with the observed increased number of emergency and hospital visits in the 6 months prior to end‐stage renal disease.