Search

Background: Oftentimes, obese dialysis patients develop a viable dialysis access but the access is too deep for cannulation and needs a superficialization procedure.Methods: We present our 14-patient cohort in whom we performed liposuction to superficialize viable but deep vascular accesses. Out of 14 patients, 12 had arteriovenous fistulas and 2 arteriovenous grafts. The primary end points were the ability to superficialize a completely unusable access and to remove the hemodialysis catheter (3patients), or to significantly extend the useful length of a deep access in which only a very short segment was used and to continue to use the access post-surgery without the need to place a dialysis catheter (11 patients).Results: The study goal was met in 13 out of 14 patients. In two of three patients, the catheters were removed and their access usable length was 14 and 13 cm, respectively. The accesses could be used immediately after liposuction in all patients in which this applied—11 patients. The usable access length increased from a mean of 5 to 12.7 cm. The access mean depth decreased from 10.8 mm pre-surgery to 7 mm post-surgery and 5.3 mm 4 weeks after surgery. The mean volume of fat removed was 43.8 cc. We had only one surgical complication: bleeding that was readily controlled with manual pressure. All patients were discharged to home the same day. Postoperative pain was mild.Conclusion: Liposuction is effective, safe, and seems to be the least invasive technique of superficialization.

Background and objectives: We evaluated the location and structure of the fibrous sheath formed after the placement of tunneled, cuffed hemodialysis catheters in large animals, 70 kg pigs. We focused on describing the location of the fibrous sheath in relation to the catheter. Its location explains the fibrous sheath’s ability to cause catheter dysfunction by covering the catheter exit ports located at the catheter’s tip.Design: We used three animals. Each animal had a tunneled, cuffed, 15-French diameter hemodialysis catheter placed in the external jugular vein, with the tip at the junction of the superior vena cava and the right atrium. Two animals were sacrificed at 5 weeks and one animal at 17 weeks after catheter placement. The catheter and surrounding tissues were removed in one block. The fibrous sheath was dissected and longitudinally cut along the catheter to evaluate its extension in relation to the catheter. Relevant portions of the fibrous sheath were sent for pathology examination.Results: The fibrous sheath covered the catheter in its entire length and circumference. It started at the entry site and continued without any interruption along the entire length of the catheter, including the tip. Its average thickness is 1 mm and has an inner cellular/inflammatory layer comprising lymphocytes, plasma cells, neutrophils, macrophages, multinucleated giant cells, and spindled cells and an outer layer comprising a mixture of collagen and fibroblasts.Conclusion: Our model showed that the fibrous sheath forms around all catheters and covers them in their entire length and circumference without any gaps.

Background: Currently, there is insufficient knowledge about the surgical anatomy and surgical techniques in large animals that can be used to test medical devices designed for human use. We encountered this problem in our study requiring the placement of jugular vein, tunneled, cuffed hemodialysis catheter in 70 kg pigs. Despite the operator’s extensive expertise in placing tunneled hemodialysis catheters in humans, the important differences in anatomy made the procedure and choosing the appropriate catheter length challenging.Methods: The following article describes the anatomy and our technique for the placement of tunneled hemodialysis catheter in the pig model.Results: We consider our surgical technique to be sound because in all animals the catheters were placed in the desired location, the procedures were well tolerated by the animals, and there were no immediate or late complications.Conclusion: We present our experience to help other researchers who might encounter the same problem.

Clinical experience with cidofovir in pediatric solid organ transplantation is limited. We assessed the effect of cidofovir use on renal function in pediatric solid organ transplant recipients.

Objective:Higher vancomycin concentrations are thought necessary for treatment of deep-seated methicillin-resistant Staphylococcus aureus(MRSA) infection, yet this may result in greater risk of nephrotoxicity. We evaluated the relationship of serum vancomycin trough concentration with clinical outcomes and nephrotoxicity for patients with deep-seated MRSA infection.Methods:A retrospective cohort study evaluated adults with MRSA pneumonia, endocarditis or osteomyelitis who received vancomycin for ≥ 5 days from June 2005 to June 2007. Patients were stratified by mean vancomycin trough level [low (< 15 mg/l), high (≥ 15 mg/l)]. Outcomes were clinical response, mortality, length of stay (LOS) and nephrotoxicity. Three definitions of nephrotoxicity were used: i) rise in serum creatinine (SCr) ≥ 0.5 mg/dl; ii) 50% increase in SCr; and iii) 25% decrease in estimated creatinine clearance.Results:Fifty-five patients experiencing MRSA pneumonia (n 28), endocarditis (n 9), osteomyelitis (n 20) and multiple infections (n 2) were stratified into low (n 39) and high (n 16) groups. High group patients were more likely to be septic (p 0.01) and have a higher APACHE II score (p 0.01). After adjustment for APACHE II score, clinical response rates among survivors did not differ significantly. Risk of death was not significantly different between the high (19%) and low (5%) group patients (p 0.1). LOS did not differ significantly between groups (p 0.7). Nephrotoxicity occurred in the low and high groups, respectively, for 10 and 31% (p 0.04) with definition 1, 10 and 31% (p 0.04) with definition 2, and 13 and 25% (p 0.1) with definition 3. After adjustment for APACHE II score, odds of nephrotoxicity based on definitions 1 or 2 were increased among the high versus low groups (OR 3.27, 95% CI: 0.7 – 15.25, p 0.1), although not statistically significant.Conclusions:Clinical outcomes did not differ significantly between high and low trough groups for deep-seated MRSA infections. Nephrotoxicity was consistently higher in the high trough group, regardless of the definition used.