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Transcript of interview with Wilena Peterson.

The differential diagnosis of heavy proteinuria presenting early after kidney transplantation has generally included de novo or recurrent glomerulonephritis (GN), whereas proteinuria is thought to be an unusual presentation of acute allograft rejection. We retrospectively analyzed the characteristics of 7 patients who presented with early (median 9 days post-transplant) heavy proteinuria with or without renal failure, in association with the development of new donor anti-HLA antibody. End Stage Renal Disease (ESRD) was due to primary GN in three patients. Mean proteinuria at presentation was 7.46 ? 2.44 gm/24 hours. Donor specific anti-HLA antibody was associated with each episode. Diffuse peritubular C4d staining was noted in three cases. Response to therapy with intravenous immunoglobulin G (IVIg) was good, with mean creatinine of 1.48 ? 0.13 mg% at last follow-up of 2-78 months with resolution of proteinuria, and no graft loss. Based on this series, we recommend screening for proteinuria post transplant in all allograft recipients, not only to detect de-novo or recurrent GN in the allograft, but also to detect antibody mediated rejection., Pub. in the Open Transplantation Journal, v3, p26-30, 2009.

A spectrum of derangements of potassium homeostasis have been reported on patients undergoing transfusion with cell-based transfusion products, specifically, packed red blood cells (PRBCs) and fresh whole blood. In both adults and children, hypokalemia has been reported more frequently than hyperkalemia. The largest reported series of which we are aware, retrospective in nature, reported an incidence of hypokalemia of 72% in children undergoing liver transplantation; hyperkalemia occurred in less than 5% of patients. Others have likewise observed hypokalemia to be more common after transfusion. In the few, small studies describing hyperkalemia after transfusion of blood products, elevations of serum potassium levels have been described alternatively as transient and clinically insignificant. We have previously reported an independent association between the number of transfused blood products, both cell and noncell-based, and the development of hyperkalemia in a noncrush trauma population undergoing acute resuscitation after major penetrating trauma. In this population, hyperkalemia was common, often severe, but transient; however, there was a trend toward higher mortality in those patients who developed hyperkalemia compared with those who did not. To better delineate the role of cell-based transfusion, specifically PRBCs and fresh whole blood, in the development of hyperkalemia, we retrospectively analyzed data for a cohort of trauma patients undergoing acute resuscitative interventions after admission to a combat support hospital in central Iraq., Published in the Jnl. Trauma Injury, Infection, and Critical Care Feb Supplement 2008, v64, n2, p586-591.

Jeanne C Patzkowski1, Frank P Hurst1,2, Robert T Neff1,2, Kevin C Abbott1,21Uniformed Services University of the Health Sciences F. Edward Hebert School of Medicine, Bethesda, MD, USA; 2Nephrology Service, Walter Reed Army Medical Center, Washington, DC, USAAbstract: Proper management of infected tunneled-cuffed catheters (TCC) is essential in order to avoid catastrophic consequences for the patient. Hematogenous dissemination of infection can result in serious secondary infections, including infective endocarditis, osteomyelitis, and epidural abscess. Pelvic osteomyelitis is an extremely rare condition in adults with no reported cases of infection localized to more than one pelvic bone at a time. We present a case of a hemodialysis patient who developed osteomyelitis of the entire right hemipelvis due to MRSA bacteremia after repeated attempts at TCC salvage.Keywords: pelvic osteomyelitis, indwelling catheter, staphylococcus aureus, catheter-related bacteremia

Jacob F Collen, Nealanjon P Das, Jonathan M Koff, Robert T Neff, Kevin C AbbottWalter Reed Army Medical Center, Washington, DC, USAAbstract: Acute hyperammonemia is a medical emergency requiring rapid recognition and treatment to prevent devastating neurologic sequelae. Its varying etiologies include primary hepatic failure, drug toxicity, infection, and inherited disorders of metabolism. Ornithine transcarbamylase (OTC) deficiency is the most common inherited urea cycle disorder and can result in hyperammonemic encephalopathy and coma, often presenting in the newborn or early childhood. Partial deficiencies of the enzyme can present later in adulthood with protean neuropsychiatric signs and symptoms. Early recognition and management of metabolic encephalopathy is crucial to avoid neurologic damage, and may require hemodialysis for rapid removal of ammonia, with adjunctive medications and dietary modifications to decrease endogenous nitrogen production and activate alternate pathways of nitrogen excretion. We present the case of an adult patient with partial OTC deficiency who presented with encephalopathy, coma, and seizures, accompanied by hyperammonemia and treated acutely with hemodialysis.Keywords: ornithine transcarbamylase deficiency (OTC), hemodialysis, hyperammonemia, urea cycle, ammonul

The trauma patient is exposed to physiologic processes and life-saving interventions that predispose to hyperkalemia. Severe elevations in potassium levels subject this compromised patient to additional cardiac risks in the periresuscitative period. Recent advances in the care of the massively traumatized patient may or may not increase the risk for hyperkalemia. This prospective, observational study was undertaken to define the period prevalence of hyperkalemia (plasma potassium level >5.5 mmol/L) in a noncrush trauma population during the initial resuscitative period and to identify potential risk factors for the development of hyperkalemia. A total of 131 patients were studied during the initial 12 h after admission for noncrush trauma. The period prevalence of hyperkalemia was 29.0%. Hyperkalemic patients had dramatic shifts in plasma potassium levels compared with nonhyperkalemic patients. Five patients, all from the hyperkalemic group, died. By multivariate logistic regression analysis, independent risk factors for hyperkalemia were an emergency department plasma potassium level of 4.0 mmol/L or higher (relative risk 3.40; 95% confidence interval 1.17 to 9.84; P 0.024 versus baseline potassium level <4.0 mmol/L) and transfusion of cell- or plasma-based products (relative risk 10.56; 95% confidence interval 3.62 to 30.78; P < 0.001 per log-transformed unit). The prevalence of hyperkalemia during trauma resuscitation was not reported previously. Given the arrhythmic risks of hyperkalemia, particular caution is necessary with trauma patients who present with plasma potassium levels >4.0 mmol/L and require aggressive transfusion support., Pub. in Clinical Journal American Society Nephrology, v2, p1-7, 4 Dec 2006.

The epidemiology of maintenance dialysis patients and heart failure patients has striking similarities. Both groups have a high prevalence of comorbid conditions, a high hospitalization rate, a low self-reported quality of life, and an excessively high mortality risk, mostly because of cardiovascular causes. Observational studies in both dialysis and heart failure patients have indicated the lack of a significant association between the traditional cardiovascular risk factors and mortality, or the existence of a paradoxic or reverse association, in that obesity, hypercholesterolemia, and hypertension appear to confer survival advantages. The time discrepancy between the 2 sets of risk factors, that is, overnutrition (long-term killer) versus undernutrition (short-term killer) may explain the overwhelming role of malnutrition, inflammation, and cachexia in causing the reverse epidemiology, which may exist in more than 20 million Americans. We have reviewed the opposing views about the concept of reverse epidemiology in dialysis and heart failure patients, the recent Die Deutsche Diabetes Dialyze study findings, and the possible role of racial disparities. Contradictory findings on hyperhomocysteinemia in dialysis patients are reviewed in greater details as a possible example of publication bias. Additional findings related to intravenous iron and serum ferritin, calcium, and leptin levels in dialysis patients may enhance our understanding of the new paradigm. The association between obesity and increased death risk in kidney transplanted patients is reviewed as an example of the reversal of reverse epidemiology. Studying the epidemiology of dialysis patients as the archetypical population with such paradoxic associations may lead to the development of population-specific guidelines and treatment strategies beyond the current Framingham cardiovascular risk factor paradigm.

In the general population, a high body mass index (BMI; in kg/m(2)) is associated with increased cardiovascular disease and all-cause mortality. However, the effect of overweight (BMI: 25-30) or obesity (BMI: >30) in patients with chronic kidney disease (CKD) undergoing maintenance hemodialysis (MHD) is paradoxically in the opposite direction; ie, a high BMI is associated with improved survival. Although this "reverse epidemiology" of obesity or dialysis-risk-paradox is relatively consistent in MHD patients, studies in CKD patients undergoing peritoneal dialysis have yielded mixed results. Growing confusion has developed among physicians, some of whom are no longer confident about whether to treat obesity in CKD patients. A similar reverse epidemiology of obesity has been described in geriatric populations and in patients with chronic heart failure (CHF). Possible causes of the reverse epidemiology of obesity include a more stable hemodynamic status, alterations in circulating cytokines, unique neurohormonal constellations, endotoxin-lipoprotein interaction, reverse causation, survival bias, time discrepancies among competitive risk factors, and malnutrition-inflammation complex syndrome. Reverse epidemiology may have significant clinical implications in the management of dialysis, CHF, and geriatric patients, ie, populations with extraordinarily high mortality. Exploring the causes and consequences of the reverse epidemiology of obesity in dialysis patients can enhance our insights into similar paradoxes observed for other conventional risk factors, such as blood pressure and serum cholesterol and homocysteine concentrations, and in other populations such as those with CHF, advanced age, cancer, or AIDS. Weight-gaining interventional studies in dialysis patients are urgently needed to ascertain whether they can improve survival and quality of life.