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True aneurysmal degeneration of the inflow artery after arteriovenous fistula ligation is extremely rare. Pain is the most common symptom and surgical treatment by an autologous venous bypass is considered as the treatment of choice with good long-term results. We present a patient with peripheral embolism as first and only symptom leading to the diagnosis of a true aneurysmal degeneration of the entire left radial artery. It was discovered 5 years after the ligation of his radiocephalic fistula. As illustrated by this case, a conservative treatment by antiplatelet and anticoagulation therapy should be considered a satisfying alternative to the standard bypass surgery in patients with anatomical variations (e.g. an incomplete arterial palmar arch) since the latter include a higher risk of postoperative ischemic complications.

Introduction Central diabetes insipidus is a heterogeneous condition characterized by decreased release of antidiuretic hormone by the neurohypophysis resulting in a urine concentration deficit with variable degrees of polyuria. The most common causes include idiopathic diabetes insipidus, tumors or infiltrative diseases, neurosurgery and trauma. Temozolomide is an oral DNA-alkylating agent capable of crossing the blood-brain barrier and used as chemotherapy primarily to treat glioblastoma and other brain cancers. Cases Two men (aged 38 and 54 years) suddenly developed polyuria and polydispsia approximately four weeks after the initiation of temozolomide for a glioblastoma. Plasma and urine parameters demonstrated the presence of a urinary concentration defect. Management The clinical and laboratory abnormalities completely resolved with intranasal desmopressin therapy, allowing the continuation of temozolomide. The disorder did not relapse after cessation of temozolomide and desmopressin and relapsed in one patient after rechallenge with temozolomide. Discussion Our report highlights the importance of a quick recognition of this exceptional complication, in order to initiate promptly treatment with desmopressin and to maintain therapy with temozolomide.

Cinacalcet and, more recently, etelcalcetide revolutionized the treatment of chronic kidney disease–mineral and bone disorder (CKD–MBD). Kidney transplant (KT) usually improves CKD–MBD. However, a significant proportion of KT recipients have high serum calcium levels, not requiring any treatment. We report two patients previously treated with etelcalcetide who developed severe (>3.3 mmol/L) hypercalcaemia in the early post-KT course, requiring parathyroidectomy. Pathological studies showed parathyroid adenomas and hyperplasia. One patient had a graft biopsy showing numerous intratubular calcium phosphate crystals. These observations should prompt pharmacovigilance studies and careful follow-up of KT recipients previously treated with etelcalcetide.

BACKGROUND: Pneumocystis jirovecii associated pneumonia is a potentially life-threatening opportunistic infection, occurring most frequently in the first year after renal transplantation, and may be associated with hypercalcemia. CLINICAL PRESENTATION:We report the case of a renal transplant recipient presenting with Pneumocystis jirovecii associated pneumonia and hypercalcemia due to ectopic production of 1,25-dihydroxyvitamin D, 6 years after renal transplantation. Calcemia and 1-25 hydroxyvitamin D levels normalized after our patient was treated by trimethoprim-sulfamethoxazole. DISCUSSION: We review similar cases to delineate the clinical and biological profile of patients with Pneumocystis jirovecii pneumonia associated hypercalcemia. CONCLUSION:Physicians should evoke this diagnosis in renal transplant recipients presenting with pulmonary infection associated with hypercalcemia.

Antibiotic lock therapy (ALT), in conjunction with systemic antibiotics, is recommended by scientific societies as a treatment of uncomplicated catheter-related bloodstream infections (CRBSI) in hemodynamically stable hemodialysis patients for whom catheter salvage is the goal. The rationale for this strategy is the eradication of intraluminal biofilms by the highly concentrated antibiotic used in the lock. However, the available evidence supporting this recommendation is scanty, and only includes small, short-term, observational studies (most of them single-arm), with different definitions of CRBSI cure and variable follow-up periods. Furthermore, the ability of an antibiotic to eradicate a biofilm is not predicted by its inherent spectrum of antibacterial activity, since sessile microorganisms in their biofilm display other mechanisms of resistance to antibiotics than their planktonic counter-parts. Additionally, penetration of some antibiotics frequently used into biofilms produced by common microorganisms appears to be low. In this editorial we provide a critical view on the available evidence regarding the efficacy of ALT on the treatment of CRBSI in hemodialysis patients, as well as the microbiological issues and technical challenges of this strategy.

Background Restless legs syndrome (RLS) is not a rare condition in patients on long-term dialysis. Pramipexole is a small molecule used in the treatment of idiopathic and uremic RLS. Although some information concerning the efficacy and safety of pramipexole in uremic patients is available, data concerning the pharmacokinetics of pramipexole in hemodialysis (HD) are lacking. Following the occurrence of accidental pramipexole intoxication in a chronic HD patient, we were concerned about the efficacy of HD in removing pramipexole. Our aim was thus to assess plasma pramipexole concentrations and pramipexole clearance in a stable chronic HD patient without any residual kidney function. Materials and methods Our patient was a 63-year-old man on chronic HD for 5 years who had been treated uneventfully with oral pramipexole for uremic RLS since then. During a routine 4-hour high-flux HD session, blood, ultrafiltrate, and dialysate samples were collected every hour to determine pramipexole concentrations over time. Results Pramipexole blood concentrations ranged from 12.1 to 23.9 µg/L. Pramipexole reduction ratio was 32.5%. Mean dialytic clearance of pramipexole was 76.8 mL/min. Postdialysis rebound was 5.6%. Conclusion In the absence of any side effect, pramipexole blood concentrations at steady state were 2- to 4-fold higher than those observed in subjects with normal kidney function. Like other drugs with a high volume of distribution, pramipexole was poorly removed by HD. Therefore, HD is not recommended as a treatment option for pramipexole intoxication in patients with a glomerular filtration rate superior to 30 mL/min/1.73m².

Blood pressure (BP) is routinely measured as a vital sign before, during and/or after dialysis (peridialysis BP). Even if peridialytic measurements are widely used, the agreement with the interdialytic BP is poor and is often biased by many technical errors [1]. Since accurate BP measurements are critical for making decisions and evaluating a patient’s cardiovascular risk, Working Groups from the ERA-EDTA and the European Society of Hypertension (ESH) issued recommendations on standardized BP measurement in dialysis patients [2]. Previous studies have underlined substantial differences between recommendations for BP measurement in general and effective BP measurements performed by medical staff [3], but whether these recommendations are followed in dialysis centres has not been investigated so far. The objectives of this multi-centric, cross-sectional survey were (i) to assess the adherence to current recommendations [4] on BP measurements in dialysis centres both according to physicians’ and patients’ perspectives and (ii) to evaluate the use of out-of-office BP measurements in dialysis patients. [...]

Interpreting evidence in the arteriovenous (AV) access literature is challenged by the heterogeneity in terminology and the lack of standardization in outcomes. Below some of the terms used in this guideline are listed and how they have been interpreted in the context of this document. Because guideline development necessarily relies on aggregate data from systematic reviews and other individual studies, we can only hope to provide the user with conceptual definitions for certain concepts and outcome domains. At present, there is insufficient consensus to go beyond that point and define specific outcome measures or measurements. [...]

Background and Aims Oral cinacalcet (CIN) and IV-administered etelcalcetide (ETEL) are calcimimetics available for the management of secondary hyperparathyroidism (SHPT) in hemodialysis (HD) patients. This pilot study assessed patient adherence to calcimimetic therapy and calcimimetic preference of nephrologists and nurses based on adapted questionnaires. Method A cross-sectional survey was conducted with HD patients currently using a calcimimetic, and nephrologists and dialysis nurses who prescribed/administered calcimimetic in 7 European countries (Belgium, France, Germany, Italy, Spain, Sweden and the United Kingdom). Patient questionnaires were adapted from the Medication Adherence Report Scale (MARS), the Beliefs about Medicines Questionnaire (BMQ-specific Necessity and Concern), and Treatment Intrusiveness Scale (TIS) to understand patterns of adherence and perceptions of medications; questions about gastrointestinal (GI) symptoms were included. Questionnaires for nephrologists and nurses were adapted from the Treatment Rating Scale (TRS), Health Professional Preference Scale (HPPS), and Prescribing Comparator Scale (PCS) to understand calcimimetic preference. Questionnaires were translated and administered in the local language. Results Sixty HD patients (33 CIN and 27 ETEL), 16 nephrologists and 18 dialysis nurses participated in the survey. ETEL patients were younger than CIN patients (mean age: 57 vs. 59 yrs). ETEL patients also had a lower pill burden (mean no. of pills: 6 vs. 11) and had numerically fewer hospitalizations in the last 6 months (mean no. of days: 1.5 vs 3.9) than CIN patients. Self-reported adherence to CIN was high (mean MARS: 4.7±0.7). ETEL and CIN patients did not perceive medications (excluding dialysis, diet and dietary restrictions) as interfering with their life (mean TIS: 1.5±0.5 vs. 1.6±1.6) and neither calcimimetic group had a specific belief in medicines in terms of necessity (mean BMQ CIN: 2.4±0.6 and ETEL: 2.3±0.4) or concerns about potential side-effects (mean BMQ CIN: 3.1±0.6 and ETEL: 3.5±0.7). ETEL patients were less likely than CIN patients to experience GI symptoms in the prior month: nausea (11% vs. 49%), vomiting (11% vs. 24%), and diarrhea (15% vs. 33%). Overall, the adapted patient questionnaires showed good internal consistency for MARS (Cronbach’s α=0.99) and BMQ-Necessity and BMQ-Concerns scales (CIN: α=0.74 and ETEL: α=0.81) but lower consistency for TIS (α=0.3 for both CIN and ETEL). Nephrologists and nurses had been practicing for a mean of 17 yrs. Nephrologists and nurses viewed ETEL to have more efficacy, lower risk of side effects, lower risk of non-adherence, lower burden for patients compared to CIN according to the TRS. According to HPPS, the top 3 treatment attributes for ETEL preference vs. CIN among nephrologists were encouraging patient adherence (93%; n=14/15), minimizing patient burden (87%; n=13/15) and having fewer side effects (80%; 12/15). Similar for nurses, encouraging patient adherence (88%; n=15/17) and minimizing patient burden (94%; n=16/17) were top attributes for ETEL preference as well as improving patient quality of life (82%; 14/17). Based on PCS, the majority of nephrologists agreed that compared to CIN, ETEL will ensure high adherence (100%), achieve better PTH control (93%; 14/15), reduce treatment burden for patients (87%; 13/15), improve patient’s quality of life (80%; 12/15), and improve effectiveness without increasing side-effects (80%; 12/15); they also agreed that ETEL created more work for nursing staff (80%; 12/15). Two thirds of nephrologists (n=10/15) agreed that ETEL would be more efficacious than CIN. Conclusion In this pilot study, CIN patients self-reported high adherence and both calcimimetic groups did not perceive medications to be concerning or intrusive. Nephrologists and nurses showed preference for ETEL than CIN. The questionnaires were validated and will be administered in a large study.

Upon the identification of hepatitis C virus (HCV) over 3 decades ago, HCV infection was recognized as a frequent complication of maintenance hemodialysis (HD), in part owing to high rates of blood transfusion.1 Progressive improvements in testing blood donors by serological tests (and more recently by nucleic acid testing [NAT]), the increasing use of erythropoiesis-stimulating agents, and the improvement of hygienic precautions all contributed over the subsequent 2 decades to a reduction in the incidence and prevalence of HCV in HD patients. [...]

Patients on in-center maintenance hemodialysis (HD) are at potentially high risk of acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (coronavirus disease 2019 [COVID-19]) inside the HD unit, due to social contacts during the frequent HD sessions. Data concerning the dynamics of anti–SARS-CoV-2 antibodies in patients on HD are scarce. [...]

As the worst global pandemic of the past century, coronavirus disease 2019 (COVID-19) has had a disproportionate effect on maintenance dialysis patients and their health care providers. At a virtual roundtable on June 12, 2020, Dialysis Outcomes and Practice Patterns Study (DOPPS) investigators from 15 countries in Asia, Europe, and the Americas described and compared the effects of COVID-19 on dialysis care, with recent updates added. Most striking is the huge difference in risk to dialysis patients and staff across the world. Per-population cases and deaths among dialysis patients vary more than 100-fold across participating countries, mirroring burden in the general population. International data indicate that the case-fatality ratio remains at 10% to 30% among dialysis patients, confirming the gravity of infection, and that cases are much more common among in-center than home dialysis patients. This latter finding merits urgent study because in-center patients often have greater community exposure, and in-center transmission may be uncommon under optimal protocols. Greater telemedicine use is a welcome change here to stay, and our community needs to improve emergency planning and protect dialysis staff from the next pandemic. Finally, the pandemic’s challenges have prompted widespread partnering and innovation in kidney care and research that must be sustained after this global health crisis.

Maintenance hemodialysis (HD) patients are at high risk for life-threatening coronavirus disease 2019 (COVID-19). Recent studies have documented a strong humoral response after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination in this population, even in older patients, in contrast to kidney transplant recipients. Previous reports have also shown a poor humoral response after hepatitis B virus (HBV) vaccination in chronic kidney disease patients with comorbidities (e.g. older age, diabetes, immunosuppression). We therefore hypothesized that this weak response to the HBV vaccine could serve as a potential indicator of response to SARS-CoV-2 vaccination. However, data linking humoral responses to both vaccines remains scarce and contradictory [...].

TO THE EDITORS, We recently reported that almost all maintenance hemodialysis (MHD) patients mount specific antibodies within a month of COVID-19 onset. However, evidence concerning the immunogenicity of SARS-CoV-2 vaccines in this immunodeficient population is scarce. [...]

Background. Patients on kidney replacement therapy comprise a vulnerable population and may be at increased risk of death from coronavirus disease 2019 (COVID-19). Currently, only limited data are available on outcomes in this patient population. Methods. We set up the ERACODA (European Renal Association COVID-19 Database) database, which is specifically designed to prospectively collect detailed data on kidney transplant and dialysis patients with COVID-19. For this analysis, patients were included who presented between 1 February and 1 May 2020 and had complete information available on the primary outcome parameter, 28-day mortality. Results. Of the 1073 patients enrolled, 305 (28%) were kidney transplant and 768 (72%) dialysis patients with a mean age of 60 ± 13 and 67 ± 14 years, respectively. The 28-day probability of death was 21.3% [95% confidence interval (95% CI) 14.3–30.2%] in kidney transplant and 25.0% (95% CI 20.2–30.0%) in dialysis patients. Mortality was primarily associated with advanced age in kidney transplant patients, and with age and frailty in dialysis patients. After adjusting for sex, age and frailty, in-hospital mortality did not significantly differ between transplant and dialysis patients [hazard ratio (HR) 0.81, 95% CI 0.59–1.10, P = 0.18]. In the subset of dialysis patients who were a candidate for transplantation (n = 148), 8 patients died within 28 days, as compared with 7 deaths in 23 patients who underwent a kidney transplantation Conclusions. The 28-day case-fatality rate is high in patients on kidney replacement therapy with COVID-19 and is primarily driven by the risk factors age and frailty. Furthermore, in the first year after kidney transplantation, patients may be at increased risk of COVID-19-related mortality as compared with dialysis patients on the waiting list for transplantation. This information is important in guiding clinical decision-making, and for informing the public and healthcare authorities on the COVID-19-related mortality risk in kidney transplant and dialysis patients.

A 33-year-old man on maintenance hemodialysis for 6 years for ESKD secondary to IgA nephropathy presented with acute back pain and loss of sensation in his feet, in the absence of recent trauma. His past medical history included severe hyperparathyroidism, with intact parathyroid hormone levels (iPTH) more than ten times the upper limit of the normal range (80 pg/ml) for 4 years, despite the prescription of phosphate binders, calcitriol, cinacalcet, and—lately—etelcalcetide. Clinical examination was marked by symmetric sensory loss and weakness in the lower extremities, together with deep-tendon hyperreflexia and Babinski signs. Plasma levels of electrolytes were normal. iPTH (855 pg/ml) and alkaline phosphatase (500 IU/L; normal range, 40–130 IU/L) levels were unchanged. Magnetic resonance imaging …

Background Despite long-standing clinical use of sodium polystyrene sulphonate (SPS) for hyperkalaemia management in chronic kidney disease (CKD), its safety profile remains poorly investigated. Methods We undertook an observational analysis of nephrology-referred adults with incident CKD Stage 4+ in Sweden during 2006–16 and with no previous SPS use. We studied patterns of use and adverse events associated to SPS initiation during follow-up. Patterns of SPS use were defined by chronicity of treatment and by prescribed dose. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) associated with SPS initiation (time-varying exposure) for the risk of severe (intestinal ischaemia, thrombosis or ulceration/perforation) and minor (de novo dispensation of laxatives or anti-diarrheal drugs) gastrointestinal (GI) events. Results Of 19 530 SPS-naïve patients with CKD, 3690 initiated SPS during follow-up. A total of 59% took SPS chronically, with an average of three dispensations/year. The majority (85%) were prescribed lower dosages than specified on the product label. During follow-up, 202 severe and 1149 minor GI events were recorded. SPS initiation was associated with a higher incidence of severe adverse events [adjusted HR 1.25 95% CI 1.05–1.49)], particularly in those receiving per label doses [1.54 (1.09–2.17)] and mainly attributed to ulcers and perforations. SPS initiation was also associated with higher incidence of minor GI events [adjusted HR 1.11 (95% CI 1.03–1.19)], regardless of dose, and mainly accounted for by de novo dispensation of laxatives. Conclusions Initiation of SPS in patients with advanced CKD is associated with a higher risk of severe GI complications as well as the initiation of GI-related medications, particularly when prescribed at per label doses.

Resume La granulomatose induite par les agents anti-tumor necrosis factor (anti-TNF) est un effet secondaire rare, mais pas exceptionnel, de ce traitement. Les organes le plus souvent atteints sont les poumons, les ganglions lymphatiques et la peau. L’atteinte renale est exceptionnelle. L’examen histologique montre habituellement des granulomes non caseeux. Certains des signes biologiques decrits habituellement dans la sarcoidose sont tres rares dans la granulomatose induite. Nous rapportons un cas de granulomatose se manifestant par une hypercalcemie severe et symptomatique, associee a une insuffisance renale aigue, chez une femme traitee par etanercept pour une polyarthrite rhumatoide. Sept jours apres l’admission, elle a presente une pneumopathie interstitielle hypoxemiante. Les analyses microbiologiques se sont averees negatives, y compris la recherche de mycobacteries et mycoses. Le tableau etant suggestif de granulomatose secondaire au traitement par etanercept, celui-ci a ete arrete. La biopsie renale, effectuee 30 jours apres l’admission, a revele une nephrite interstitielle aigue avec des depots de cristaux calciques. L’evolution a ete favorable apres arret de l’etanercept et traitement par cortisone, avec une reversibilite des lesions pulmonaires et une recuperation totale de la fonction renale trois semaines apres l’admission. La presentation clinique de la granulomatose secondaire aux agents anti-TNF peut etre extremement variable. Notre observation montre qu’une hypercalcemie symptomatique et potentiellement fatale peut survenir. L’atteinte renale est inhabituelle. Ce cas souligne la difficulte diagnostique de cette entite, ainsi que l’importance d’un suivi rapproche chez les patients recevant ce traitement. L’arret du medicament conduit a la resolution des lesions dans la majorite des cas.

The prevention of catheter-related blood stream infections (CRBSI) in hemodialysis (HD) patients remains a challenge because of high morbidity and mortality associated to CRBSI. Alternative locking solutions (ALS) containing an antithrombotic substance with additional antimicrobial or antibiofilm properties (citrate, ethylenediaminetetraacetic acid [EDTA], 70% ethanol, thrombolytics) with or without the addition of molecules with specific antimicrobial activity (antibiotics, taurolidine, paraben-methylene-blue) has been proposed with the aim to prevent or eradicate intraluminal biofilm colonization and subsequent CRBSI. In this review, we examine the available evidence concerning their efficacy and potential side effects, in order to determine whether ALS should be implemented widely or only in selected cases.

In their recent study comparing different assays to measure albumin level, van de Logt et al.1 show that the use of bromocresol green (BCG) (but not bromocresol purple [BCP]) leads to a substantial overestimation of plasma and serum albumin concentration (mean bias: 6.2 g/l), in comparison to the reference immunonephelometric assay in patients with hypoalbuminemia (including patients with membranous nephropathy, liver cirrhosis, or sepsis) and in chronic kidney disease patients with albumin concentrations within reference values. The investigators pointed out that up to 59% of patients with membranous nephropathy would receive inappropriate prophylactic anticoagulant therapy on the basis of albumin measured by BCG assay. [...]

Dialysis-related infections (vascular access or peritonitis) are the main source of infections (24%) in dialysis patients, followed by infections below the knee (19%), and pneumonia (13%). Chronic viral hepatitis is much less frequent but entails important organizational implications and is discussed in elsewhere in this book.

Drug-induced sarcoidosis-like disease is a rare, but not exceptional, side effect of anti-tumor necrosis factor (anti-TNF) agents. The organs most commonly involved are lungs, skin and lymph nodes. Kidney involvement is exceptional. Histology usually reveals non-caseating granulomas. Some of the biological features usually described in sarcoidosis are very infrequent in drug-induced granulomatosis. We report a case of sarcoid-like granulomatosis manifesting as life-threatening hypercalcemia and acute kidney injury in a woman treated with etanercept for a rheumatoid arthritis. Seven days after admission, she developed hypoxemic interstitial pneumonia with negative mycobacterial and fungal analysis. This picture suggested sarcoid-like disease induced by tumor necrosis factor blockers and prompted etanercept cessation. Kidney biopsy performed 30 days after admission revealed significant acute interstitial nephritis and intratubular calcium crystals. Staining for acid-fast bacilli and fungi was negative. Clinical picture improved gradually after etanercept withdrawal and cortisone treatment. Three weeks after admission, serum creatinine and calcium levels were normal. Clinical presentation of sarcoidosis-like disease induced by anti-tumor necrosis factor agents may be extremely variable. Our observation shows that severe, life-threatening hypercalcemia may occur. Renal involvement is very unusual. This case highlights this diagnostic difficulty and the importance of a close clinical monitoring in patients treated with these drugs. Cessation of the anti-tumor necrosis factor agent leads to resolution of this condition in most cases.

Background Although superior vena cava (SVC) stenosis may be a life-threatening complication of haemodialysis (HD) catheters, its prevalence and risk factors in HD patients are unknown. Our aim was to assess the prevalence and risk factors for SVC stenosis in HD patients with a tunnelled cuffed catheter (TCC) and to describe its clinical presentation. Methods In this single-centre, retrospective cohort study, all in-centre chronic HD patients carrying a TCC (1 January 2008-31 December 2012) were included (n = 117 patients, 214 TCC, 80 911 catheter-days). SVC stenosis was defined as a diameter reduction >50% on phlebography or computed tomography. Imaging was triggered by clinical SVC stenosis syndrome or vascular access (VA)-related concerns. We recorded demographics, conditions potentially influencing catheter permeability (medications, carriage of thoracic devices), number of TCCs, total duration of TCC carriage, previous arteriovenous VA and last (in use at time of stenosis detection) TCC details (location, diameter and length). VAs created while a TCC was still used were also recorded. Results An SVC stenosis was found in 11 patients (9.4%, 0.14/1000 catheter-days), which represents almost one-quarter of patients undergoing imaging, whatever the cause (11/45). Only two presented with clinically obvious SVC stenosis. The number of TCCs per patient was 2.64 ± 1.8 in the SVC stenosis group versus 1.75 ± 0.94 in the negative group (P = 0.13). On multivariate analysis (Poisson), diabetes {incidence rate ratio [IRR] 4.63 [confidence interval (CI) 1.2-17.8]; P = 0.02} and total duration of TCC carriage [IRR 1.47 (CI 1.2-1.8) per year; P = 0.001] were associated with SVC stenosis, whereas age had a slightly protective effect [IRR 0.96 (CI 0.91-1.01); P = 0.01]. Limitations are the retrospective design, detection and survivor bias. Conclusion SVC stenosis is not a rare condition, is mostly asymptomatic in the absence of a peripheral VA, is strongly associated with diabetes and is promoted by long TCC carriage. Age is slightly protective.

To the Editor: In a recent single-blind, randomized controlled trial, Winnicki et al.1 showed that the use of taurolidine-based catheter lock solutions (taurolidine-citrate-heparin twice weekly and taurolidine-citrate-urokinase once weekly) significantly reduced the incidence of catheter-related bacteremia (CRB) (incidence risk ratio, 0.25; 95% confidence interval, 0.10–0.73; P = 0.009) and catheter malfunction (P = 0.001 for both reversal of catheter lines and need for thrombolytics) compared with citrate 4%. […]

Objective:We previously reported results of a European survey suggesting that standard recommendations for blood pressure (BP) measurement are poorly followed in dialysis centres. The objectives of the current sub-study were (i) to compare adherence to office BP measurement guidelines in dialysis ce

In HD patients, the optimal choice of dialysate K concentration is of paramount importance. Recent large observational studies have documented an association between low dialysate K concentration (< 2 or even

Potential advantages of buttonhole (BH) cannulation over the standard rope-ladder technique have been claimed on the basis of small sized, potentially biased observational studies with a relatively short follow-up. On the contrary, randomized controlled trials (RCTs) show inconclusive or conflicting results. The uncertain benefit must thus be weighed against a definite increase in the infectious risk with the BH technique, which may not be completely abolished by preventative strategies. Awaiting the results of long-term studies (2-3 years follow-up), the widespread use of the BH technique is not warranted, especially in busy in-centre haemodialysis (HD) settings with many rotating nurses. In our experience, the BH technique has been implemented safely in a self-care HD unit, presumably because of the limited number of cannulators and, in the case of self-cannulating patients, direct supervision by a small team of nurses. Units (and patients) willing to use the BH technique should be aware that BH is an extremely demanding technique and requires constant and strict adherence to the protocol. Regular monitoring of infection rates is recommended. Additional RCTs are clearly warranted, together with large-sized observational studies with multivariable adjustment.

A few single cases of Mycobacterium chelonae skin infection have been reported in haemodialysis patients. We report three additional cases that share peculiar clinical characteristics, pointing to diagnostic clues. All three cases presented as erythematous nodules developing distally to a proximal arteriovenous fistula (AVF). This presentation was identical to that of two published cases. A survey of all Belgian haemodialysis units during the period 2007-11 yields an estimated incidence of ∼0.9/10 000 patient-years. Although the source of M. chelonae remains unclear, this specific clinical presentation should be added to the listing of potential complications of an AVF and should be recognized, as it is fully treatable if diagnosed by culture and tissue biopsy.

Oral manifestations of severe secondary hyperparathyroidism include maxillary and mandibular deformities, brown tumors, dental abnormalities, and metastatic calcification of soft tissues. We report on a chronic hemodialysis (HD) woman with severe, uncontrolled secondary hyperparathyroidism and a painful, nontender mass in the floor of her mouth. The most likely clinical diagnosis was a bone tumoral lesion of the oral cavity, secondary to renal osteodystrophy. Unexpectedly, pathological examination showed characteristic features of ossifying fibroma (OF) of the jaw, a rare, benign fibroosseous lesion characterized by the replacement of normal bone by collagen and fibroblasts containing varying amounts of mineralized substance. The occurrence of an OF in chronic HD patients is exceptional. Differential diagnosis must be made with bone tumoral lesions secondary to renal osteodystrophy. Surgical removal is the treatment of choice. The pathogenesis of OF in the setting of secondary hyperparathyroidism remains unknown. Parathyroidectomy may not be necessary to avoid OF recurrence after surgical removal.

Nephrology Section, Department of Internal Medicine, University Hospital, Gent, Belgium, Nephrology, Dialysis and Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France, Department of Renal Medicine, Royal Derby Hospital, Derby, UK, Nephrology, Cliniques Universitaires Saint-Luc, Universite Catholique de Louvain, Brussels, Belgium, Nephrology Department, Consorcio Hospital General Universitario, Valencia, Spain and Vascular Surgery, Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands

There is a progressive increase in community and nosocomial infections caused by Gram-positive pathogens, which often result in bacteraemia resistant to antibiotics. Many Gram-positive bacteria, including coagulasenegative staphylococci, Staphylococcus aureus and enterococcus species, may colonize the skin, mucous membranes (particularly anterior nares) and lower bowel of most normal subjects. In general, these bacteria do not incur consequences to the host, as the intact cornified squamous epithelium can prevent their access to subcutaneous tissues and blood. Only when the skin or mucous membranes are disrupted, may staphylococci give rise to localized superficial abscesses. Cutaneous infections are often self-limited, because normal subjects can organize a primary defence based on neutrophils and opsonophagogytosis. Nevertheless, if bacteria invade the lymphatics and the blood, they can cause a number of life-threatening complications such as septic shock, endocarditis, pneumonia, osteomyelitis, etc. The leading pathogens are coagulase-negative staphylococci and S. aureus, followed by enterococcus species [1]. The coagulase-negative staphylococci such as Staphylococcus epidermidis have been considered as avirulent commensals in the past. However, in the last 30 years, they have been recognized to be one of the most frequent pathogens responsible for nosocomial infection, with a high rate of mortality. The development of bacteraemia is largely influenced by factors such as (i) the use of catheters that can disrupt the cutaneous barrier to Gram-positive pathogens; (ii) a heavy colonization at mucocutaneous sites, that is favoured by wounds, traumas, ulcers, etc; (iii) the virulence of the pathogen including its ability to produce enzymes

Infections specifically related to peritoneal dialysis include peritonitis on the one hand, and exit-site and tunnel infections on the other hand.The diagnosis of peritonitis rests on the classical triad of cloudy dialysate, abdominal pain, and presence of < 100 white-cells (including < 50 % polymorphonuclear cells) within the dialysate effluent. Because peritonitis is associated with high mortality and morbidity rates, empiric antibiotics should be initiated without delay, covering both Gram-positive and Gram-negative organisms. Most regimens include vancomycin or a first-generation cephalosporin for the former, and a third-generation cephalosporin or an aminoglycoside for the latter. Antibiotics are usually administered via the intraperitoneal route. Prophylaxis with an anti-fungal agent has to be considered in diabetic patients and in those who just received prolonged antibiotic administration. Cure is obtained in up to 80 % of the cases ; treatment failure however may occur with refractory or relapsing peritonitis episodes. This is especially common in fungal or fecal associated peritonitis, and will require catheter withdrawal. The incidence of peritonitis has dramatically decreased in recent years with the advent of new connectology systems, and both adequate preventive measures and improved patients’ education. Still it is not clearly documented that new biocompatible dialysate fluids have a favorable effect on peritonitis incidence.Exit-site and tunnel infections are defined by the presence of a purulent discharge around the catheter and by erythema, oedema and tenderness of the subcutaneous pathway of the catheter, respectively. Antibiotics are recommended in case of documented infection. Cuff shaving may sometimes be required, as well as catheter removal in case of unfavourable evolution.

From the early days of hemodialysis, viral hepatitis has been recognized as common in dialyzed patients.The prevalence and incidence of HBV infection have decreased markedly over the last decades in HD units. Still, the infectivity of HBV is very high. Vaccinating HD patients, preferably prior to starting dialysis, together with the strict application of hygienic precautions and adequate screening of blood donors remains required, together with the segregation of infective (HBV+) patients in a separate dialysis ward. The level of aminotransferases is markedly lower in HD patients than in the general population: any level above the normal range should thus trigger the suspicion of acute hepatitis (viral or not). The treatment of HBV infection in HD patients is rarely required, unless they are scheduled for a kidney transplant.Screening for HCV infection usually relies on a modern ELISA test. The prevalence and incidence of HCV infection in HD patients has also decreased substantially but remains higher than in the general population. The risk of post-transfusional HCV is currently extremely low, at least in western countries. The actual application of basic hygienic precautions is crucial if nosocomial transmission of HCV is to be prevented. These include optimal hand hygiene practices (hydroalcoholic solution use before contact with patient and after gloves withdrawal), the systematic wearing of gloves, to be changed between patients/stations, an adequate separation of the clean and contaminated items and circuits within the HD unit, and regular cleaning/disinfection of potentially contaminated surfaces. The necessity and usefulness to isolate HCV positive patients in a separate dialysis ward has not been demonstrated and is not recommended by current KDIGO guidelines. The field of the treatment of HCV infection is changing rapidly with many orally active drugs, some of which can be used even in dialysis patients.

Infective endocarditis (IE) and small-vessel vasculitis may have similar clinical features, including glomerulonephritis. Furthermore the association between IE and ANCA positivity is well documented, making differential diagnosis between IE- and ANCA-associated vasculitis particularly difficult, especially in case of culture-negative IE. We report on one patient with glomerulonephritis secondary to culture-negative IE caused byBartonella henselaewhich illustrates this diagnostic difficulty.

Background Buttonhole cannulation (BHC) has been associated with a greater risk of arteriovenous fistula (AVF)-related infections and septicemia than the rope ladder cannulation (RLC) in in-center hemodialysis (HD). Such infections have never been studied in satellite HD units. Study Design Retrospective single center study. Setting and Participant All patients in our satellite HD unit using a native AVF from 1 January, 1990, to 31 December, 2012. Study Period Two different kinds of cannulation have been used during the study period: From 1 January, 1990 to 1, January, 1998 RLC was used in the unit (period 1). After 1 January, 1998 onwards, all the patients were switched within 3 months to BHC (period 2). Outcomes Three different infectious events were observed during the two periods: local AVF infection, bacteremia, and combined infection. The aim of this study was to evaluate the incidence of AVF-related infections in our low-care HD unit and to determine whether BHC is associated with an increased risk of infection in this population. Results 162 patients were analyzed; 68 patients participated to period 1 and 115 to period 2. Sixteen infectious events occurred. Incidences of AVF-related infectious events were 0.05 [95% CI, 0.02–0.16] and 0.13/1000 AVF-days [95% CI, 0.0.8–0.23], for period 1 and 2 (p = 0.44) respectively. Recurrence of AVF-related infection was observed only during period 2. Unadjusted incidence rate ratio (IRR) of all infections was 0.39 (95%CI 0.12–1.37). Two complicated infections occurred during the study period: one in period 1 and one in period 2. Limitations Observational retrospective single centre study Conclusions BHC is not associated with an increased infectious incidence in our HD population from a satellite dialysis unit. In the rare patients with AVF-related infection it seems necessary to change cannulation sites as recurrence of infection might be an event more frequent with BHC.