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Background and Aims Hemodialysis (HD) patients represent a risk category for infections and for their possible complications, in particular infective spondylodiscitis. Although this is a serious complication, only few cases have been reported in the literature and it is not clear which is the best clinical management. The aim of this retrospective study was to evaluate the cases of infective spondylodiscitis that occurred among HD patients of our center. Method We collected the cases of spondylodiscitis that occurred at our center between May 2005 and October 2019. We focused in particular on the time interval between onset of symptoms and diagnosis, often delayed. The possible risk factors related to the onset of this disease were also considered. The diagnosis of infective spondylodiscitis was based on clinical data, laboratory results and diagnostic imaging tests. Results Over more than 10 years, there were 9 cases. The mean age was 69 ± 12 years. 55.6% of patients were affected by diabetes mellitus, 55.6% by hypertension, 22.2% by bone diseases, 11.1% by cancer and 11.1% by rheumatoid arthritis in chronic treatment with low-dose steroids and azathioprine (Table 1). All patients had back pain as an initial symptom, 55.6% had fever, while 33.4% had neurological symptoms. At hospital admission 55.6% of patients had leukocytosis and 88.9% of patients had elevated CRP level (Table 2). Six patients (66.7%) had their diagnoses confirmed by magnetic resonance imaging (MRI), while two patients had performed CT prior to MRI and one patient had his diagnosis confirmed by CT (Table 2). The lumbar region was the most common site of infection (77.8%) (Figure 1). The mean dialytic age was 33 ± 38 months. Four patients used an arteriovenous fistula as vascular access for HD, one patient used an arteriovenous graft, three patients used a tunneled cuffed catheter, and one patient used a temporary catheter (Table 3). Two patients had experienced thrombosis of the arteriovenous fistula requiring endovascular surgery. Blood culture were positive in five patients (four for S. aureus and one for S. agalactiae) and negative in four patients. Three of the patients with positive coltures used a catheter for HD and in two cases it was necessary its removal. Bone biopsy (performed in three cases) confirmed the diagnosis of S. aureus spondylodiscitis in one patient (Table 3). The mean time interval between onset of symptoms and diagnosis was 34 ± 42 days (Table 3). All patients received antibiotic treatment for a mean duration of 6 weeks. In most of the cases it was used vancomycin or teicoplanin plus ciprofloxacin as initial antibiotics (Table 4). One patients had recurrent infective spondylodiscitis within 2 years; one patient had long-term neurologic sequelae despite surgical treatment. The others 7 cases underwent resolution after a mean of 3.5 months. Conclusion Infective spondylodiscitis is a disease to be suspected in the presence of back pain among HD patients, even in the absence of fever or traditional risk factors. It is important to get an early diagnosis, to improve the outcome of patients, avoiding diagnostic delays. Close monitoring of vascular access, paying attention to disinfection procedures and aseptic techniques, is important to avoid this complication. Figure 1. MRI of the lumbosacral spine without gadolinium contrast showing discitis at the L4–L5 level (Patient n. 6). Table 1. Characteristics of the patients with infective spondylodiscitis in care at our center. Table 2. Initial clinical presentation, initial laboratory results, diagnostic tools, location of infection. Table 3. Dialytic age, vascular access for hemodialysis, culture results, time interval between onset of symptoms and diagnosis. Table 4. Treatments and outcome of patients.

BACKGROUND Tunnelled femoral catheters with their tip in the lower inferior vena cava (IVC) are proposed only in few cases, but they often provide less than optimal blood flows and frequently have complications. The aim of this prospective observational study is to evaluate the use of 70-cm-long tunnelled cuffed femoral twin Tesio catheters with their tip in the upper IVC for haemodialysis. METHODS Between May 2007 and May 2009, 25 tunnelled femoral catheters (fCVC) have been placed in 25 patients (77.7 +/- 10.8 years) with exhausted thoracic venous accesses or old patients with several comorbidities. Two 10 Fr carbothane 70-cm-long Tesio catheters with a Dacron cuff at 45 cm from the tip were placed in the femoral vein of each patient and then tunnelled; tips were in the upper third of the IVC. fCVCs were removed for either malfunction (Qb < 200 ml/min) or infection that did not resolve with antibiotics. RESULTS Technical success of placement was 100%. The 6- and 12-month assisted primary patency rate were respectively 67 +/- 13% and 54 +/- 17%. The mean session Kt/V was 1.45 +/- 0.19, and the blood flow was 270 +/- 17 ml/min. Six fCVCs have been removed: three for infection, one for accidental damaging and two for the making of a different vascular access. The main complications were 2 catheter tip thrombi, 3 tunnel infections and 11 fCVC-related bacteraemia (1.77 episodes per 1000 CVC-days). CONCLUSION The placement of twin fCVCs with their tip in the high IVC can provide an adequate dialysis and can be considered for patients with no remaining thoracic accesses.

Introduction Although chronic cyclosporine toxicity is mainly characterized by tubular atrophy and interstitial fibrosis, glomerular injury with expansion of mesangial matrix and sclerosis is not uncommon. Tacrolimus is a newer calcineurin inhibitor that has been used in renal transplant recipients as primary or rescue therapy. Clinical trials suggest an improved long-term graft survival among patients treated with tacrolimus. Recently we have shown that tacrolimus and cyclosporine have similar effects on extracellular matrix turnover in cultured cells. The present study was performed to investigate the effects of the calcineurin inhibitors on whole glomeruli extracellular matrix turnover. Methods Human glomeruli isolated from kidney biopsies just before transplantation were incubated with culture media containing either cyclosporine (200 ng/mL) or tacrolimus (10 ng/mL) for 24 hours. Glomeruli incubated only with culture medium were used as control. Results The expressions of (α2)IV collagen, metalloprotease 9 (MMP9), tissue inhibitors of metalloproteases 2 (TIMP-2), and TGFβ were evaluated by in situ reverse transcription and polymerase chain reactions (RT-PCR). β-actin was used as a control gene. Cyclosporine (but not tacrolimus) increased the expression of (α2)IV collagen and TIMP2 in isolated glomeruli. TGF-β was markedly increased by cyclosporine. MMP9 expression was not affected by the calcineurin inhibitors. By light microscopy kidney biopsies did not show pathologic changes. Conclusion Cyclosporine treatment modulates extracellular matrix turnover in isolated human glomeruli, inducing an imbalance between synthesis and degradation. This effect, not observed in tacrolimus-treated human glomeruli, may induce the extracellular matrix deposition and sclerosis characteristic of chronic cyclosporine toxicity.