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Although gastrointestinal symptoms are not uncommon in PD patients due to several causes, such as infusion volume with early satiety, constipation, or peritonitis, sometimes the differential diagnosis is more challenging for nephrologists. We present the case of a woman with end-stage renal disease due to autosomal dominant polycystic kidney disease on PD who presented with swollen legs and incoercible vomiting. After ruling out constipation and infection, an abdominal CT was done, revealing extrinsic compression of the intrahepatic inferior cava vein (ICV) and massive venous thrombosis from ICV to bilateral iliofemoral deep veins. In addition, CT also showed displacement and extrinsic compression of the stomach, pylorus, and duodenum due to an enlarged liver cyst. Percutaneous drainage and sclerosis of the cyst compressing the stomach was performed, anticoagulation was started, and the patient clinically improved with complete resolution of symptoms.

BACKGROUND AND AIMS Icodextrin is a soluble glucose polymer used widely as an alternative osmotic agent to glucose-only solutions in PD patients. It provides effective net peritoneal ultrafiltration (UF) and nowadays it is only licensed for once-daily dwells. However, in selected patients it has been described its use in two daily dwells (2-ICO). Our aim was to revise our center experience with icodextrin when prescribed as 2-ICO. METHOD We retrospectively analysed all patients with a 2-ICO dwell prescription in our PD unit from January 2018 until June 2021. Clinical data, indication for prescription and outcomes were collected. RESULTS CONCLUSION In selected patients, 2-ICO dwells daily may have a clinical benefit, improving UF significantly and allowing better management of fluid overload and UF failure without relevant adverse events.

BACKGROUND AND AIMS The severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) pandemic has had a massive impact in health systems worldwide, taking an important toll on dialysis patients as they are more comorbid, have higher mortality and an impaired immune system. Vaccines against SARS-Cov-2 proved to reduce mortality and hospitalization, but serological response in the dialysis population is weaker. Therefore, predictors of response would be useful to assess their level of protection and evaluate the need for further booster doses of the vaccine. METHOD RESULTS CONCLUSION In our experience, PD patients have an adequate serological response to the SARS-Cov-2 vaccines, being previous COVID exposure the main predictor of a good response. Conversely, longer duration of PD treatment was a prognostic factor of seroconversion failure. We believe this should be kept in mind to assess the need for booster vaccination doses in those patients.

BACKGROUND AND AIMS Transplantation (KTx) is considered the best renal replacement therapy nephrologists can offer and improving its outcomes remains a primary challenge in our field. KTx ureteral JJ stenting has been used to prevent urological complications, but there is no consensus about its elective removal timing and literature regarding routine US imaging after EJJR to detect complications is lacking. Our aim was to define the incidence of urological complications diagnosed by routine US after EJJR in KTx, determine US utility and best time interval to perform it. METHOD We retrospectively analyzed all routine KTx US performed in our Unit from 2016 until 2020 by an experienced interventional nephrologist. US post EJJR findings were compared with previous patient US. KTx characteristics, treatment and outcomes were recorded. RESULTS CONCLUSION Routine US after EJJR allowed a timely diagnosis and early treatment of urological complications, a key factor for successful transplantation. KTx US is a cost-effective and reproducible test that provides crucial information to guide clinical decisions, being most efficient when performed 10 days post elective removal. Interventional nephrologists could do this examination promptly.

BACKGROUND AND AIMS Patients with end-stage kidney disease (ESKD) are becoming older and more comorbid. We define assisted peritoneal dialysis (aPD) as any PD treatment that needs the help of another person regardless of the age of the patient and the duration of such help. Our aim was to analyse our aPD experience. METHOD RESULTS CONCLUSION aPD should be considered not only in the elder or fragile, but also in cases of variable disability regardless of patient age. It does not imply a higher complication rate or a technique failure, and careful caregiver support should be provided to avoid exhaustion and PD abandonment.

Within peritoneal dialysis (PD) complications, peritonitis remains a primary challenge for the long-term success of the technique. Proper technique training is essential, since it reduces peritonitis rates, but the adequacy of training has not been standardized. Furthermore, factors influencing training duration have not been well identified. We retrospectively analyzed all consecutive training sessions of incident PD patients in our Unit from January 2001 to December 2018. Our analysis included 135 patients, 25.9% were diabetic and median Charlson index (CCI) was 4 (IQR 2–6). Above 13 sessions was chosen as the cut off between usual and prolonged training, as it was our cohort’s 75th percentile: 23% (31) had an extended training duration as per our study definition and 77% (104) had a usual training duration. The number of training sessions required increased with age (Spearman Rho 0.404; p = 0.000001), diabetic status (p = 0.001), unemployment status (p = 0.046) and CCI (Spearman Rho 0.369; p = 0.00001). Neither gender, cohabitation status, scheduled PD start, education level nor referral origin, were significant factors impacting training duration. Requiring longer training (> 13 sessions) was a significant risk factor for higher peritonitis risk, but extended training was not related to a shorter technique survival. Number of PD training sessions depends on the patient’s age and comorbidities, but is not related to social, educational or employment status. Prolonged training duration was a statistically significant predictor of higher peritonitis risk, but it was not related to shorter permanence in PD in our series. Identifying these patients since the training period would be useful to adapt training schedule as an early prevention strategy to minimize the risk of peritonitis and plan a preemptive retraining.

Grupo de Trabajo en Nefrología Diagnóstica e Intervencionista (GNDI) de la Sociedad Española de Nefrología (SEN)., [ES] La ecografía es una herramienta esencial en el manejo del paciente nefrológico que permite el diagnóstico, el seguimiento y la realización de intervencionismo sobre el riñón. La utilidad de los ultrasonidos en Nefrología no se circunscribe exclusivamente al estudio ecográfico del riñón. Mediante ecografía el nefrólogo puede, además, optimizar el manejo de la fístula arteriovenosa para hemodiálisis, medir el riesgo cardiovascular (grosor íntima-media), implantar catéteres centrales para hemodiálisis ecoguiados y ayudar en la colocación de los peritoneales, así como calcular la volemia del paciente mediante ecografía cardiaca básica, ecografía de la vena cava inferior y pulmonar. Desde el Grupo de Trabajo en Nefrología Diagnóstica e Intervencionista (GNDI) de la Sociedad Española de Nefrología (SEN) hemos elaborado este documento de consenso en el que se resumen las principales aplicaciones de la ecografía en Nefrología, incluyendo los requisitos técnicos básicos necesarios, el marco normativo y el nivel de capacitación de los nefrólogos en esta materia. El objetivo de este trabajo es promover la inclusión de la ecografía, tanto diagnóstica como intervencionista, en la práctica clínica habitual del nefrólogo y en la cartera de servicios de Nefrología con la finalidad de ofrecer un manejo diligente, eficiente e integral al paciente nefrológico., [EN] Ultrasound is an essential tool in the management of the nephrological patient allowing the diagnosis, monitoring and performance of kidney intervention. However, the usefulness of ultrasound in the hands of the nephrologist is not limited exclusively to the ultrasound study of the kidney. By ultrasound, the nephrologist can also optimize the management of arteriovenous fistula for hemodialysis, measure cardiovascular risk (mean intimate thickness), implant central catheters for ultrasound-guided HD, as well as the patient's volemia using basic cardiac ultrasound, ultrasound of the cava inferior vein and lungs. From the Working Group on Interventional Nephrology (GNDI) of the Spanish Society of Nephrology (SEN) we have prepared this consensus document that summarizes the main applications of ultrasound to Nephrology, including the necessary basic technical requirements, the framework normative and the level of training of nephrologists in this area. The objective of this work is to promote the inclusion of ultrasound, both diagnostic and interventional, in the usual clinical practice of the nephrologist and in the Nephrology Services portfolio with the final objective of offering diligent, efficient and comprehensive management to the nephrological patient.

Ultrasound is an essential tool in the management of the nephrological patient allowing the diagnosis, monitoring and performance of kidney intervention. However, the usefulness of ultrasound in the hands of the nephrologist is not limited exclusively to the ultrasound study of the kidney. By ultrasound, the nephrologist can also optimize the management of arteriovenous fistula for hemodialysis, measure cardiovascular risk (mean intimate thickness), implant central catheters for ultrasound-guided HD, as well as the patient's volemia using basic cardiac ultrasound, ultrasound of the Cava Inferior vein and lungs.From the Working Group on Interventional Nephrology of the Spanish Society of Nephrology (G.N.D.I. of the S.E.N.) we have prepared this Consensus Document that summarizes the main applications of ultrasound to Nephrology, including the necessary basic technical requirements, the framework normative and the level of training of nephrologists in this area. The objective of this work is to promote the inclusion of ultrasound, both diagnostic and interventional, in the usual clinical practice of the nephrologist and in the Nephrology Services portfolio with the final objective of offering diligent, efficient and comprehensive management to the nephrological patient. Resumen: La ecografía es una herramienta esencial en el manejo del paciente nefrológico permitiendo el diagnóstico, seguimiento y realización de intervencionismo sobre el riñón. La utilidad de los ultrasonidos en Nefrología no se circunscribe exclusivamente al estudio ecográfico del riñón. Mediante ecografía el nefrólogo puede, además, optimizar el manejo de la fístula arteriovenosa para hemodiálisis, medir el riesgo cardiovascular (grosor íntima media), implantar catéteres centrales para hemodiálisis ecoguiados y ayudar en la colocación de los peritoneales, así como calcular la volemia del paciente medianteecografía cardiaca básica, ecografía de la vena cava inferior y pulmonar.Desde el G.N.D.I. de la S.E.N hemos elaborado este documento de consenso en el que se resumen las principales aplicaciones de la ecografía en Nefrología, incluyendo los requisitos técnicos básicos necesarios, el marco normativo y el nivel de capacitación de los nefrólogos en esta materia. El objetivo de este trabajo es promover la inclusión de la ecografía, tanto diagnóstica como intervencionista, en la práctica clínica habitual del nefrólogo y en la cartera de servicios de Nefrología con el objetivo final de ofrecer un manejo diligente, eficiente e integral al paciente nefrológico.

Background: Relapsing peritonitis due to the development of a biofilm in the catheter’s lumen remains an important complication of peritoneal dialysis therapy that endangers technique continuity. Taurolidine catheter lock has proven efficient reducing infection rates in permanent hemodialysis catheters based on its biocidal activity and biofilm detachment effect. Efficacy evidence on its use in peritoneal dialysis catheters is lacking. Methods: We retrospectively analyzed all relapsing peritonitis episodes from June 2018 until October 2019 in our center. Patients were identified and data were collected from our electronic renal registry and patient’s records. Results: Six patients were identified during the study period. Most patients (66.6%) were on automated peritoneal dialysis and the median duration of peritoneal dialysis before the episode of taurolidine was started was 43.66 ± 29.64 months. Mean taurolidine doses were 10 (range: 9–11) and 83.3% (five patients, with peritonitis caused by Pseudomonas aeruginosa, Staphylococcus aureus, Escherichia coli, and Corynebacterium propinquum) had a favorable response and microbial eradication without relapses after taurolidine treatment. Only one patient relapsed by the same organism ( Corynebacterium amycolatum) due to non-adherence to the antibiotic treatment prescribed. None of the patients experienced any relevant adverse events, with only two out of six presenting mild transient abdominal discomfort. Conclusion: We believe that peritoneal catheter taurolidine lock could be considered in cases of relapsing or refractory peritonitis, as it could prevent catheter removal and permanent switch to hemodialysis in selected cases, although literature is scarce and further studies are needed.

Background Peritoneal dialysis (PD) is the RRT of choice in 15% of patients with CKD and has multiple advantages over hemodialysis. PD leaks can prompt technique failure and dropout. Use of peritoneal scintigraphy (PS) for diagnosis of PD leaks has declined in favor of more complex and expensive tests. We analyzed the utility of PS for PD leak diagnosis in our center. Methods We retrospectively analyzed all PS done in our center from January 2000 until December 2018, inclusive, in all patients on PD with a suspected dialysate leak. Results A total of 39 PS procedures were done in 36 patients on PD in the study period. Of those, 81% were male and 11% had CKD due to polycystic kidney disease. During this period, 23 leaks were diagnosed, showing an incidence of 6% (three episodes per patient per year). In all cases with negative PS, other tests did not confirm a peritoneal dialysate leak. Conclusions PS is a safe, inexpensive, reproducible, and highly effective diagnostic tool for peritoneal dialysate leaks that allows nephrologists to tailor or stop PD therapy if required. In our opinion, it should be the first-line imaging test to diagnose PD leaks with minimum exposure to radiation, contrast, or other substances that could irritate the peritoneal membrane. We believe PS should be considered as the initial test of choice to diagnose this PD complication as soon as possible, minimizing technique failure and dropout due to leaks.

Background Percutaneous renal biopsy (PRB) is invasive, and bleeding-related complications are a concern. Desmopressin (DDAVP) is a selective type 2 vasopressin receptor-agonist also used for haemostasis. Aim To evaluate the side effects of intravenous (IV) weight-adjusted desmopressin preceding PRB. Methods This was a retrospective study of renal biopsies performed by nephrologists from 2013 to 2017 in patients who received single-dose DDAVP pre-PRB. Results Of 482 PRBs, 65 (13.5%) received DDAVP (0.3 µg/kg); 55.4% of the PRBs were native kidneys. Desmopressin indications were altered platelet function analyser (PFA)-100 results (75.3% of the patients), urea >24.9 mmol/L (15.5%), antiplatelet drugs (6.1%) and thrombocytopaenia (3%). Of the 65 patients, 30.7% had minor asymptomatic complications, and 3 patients had major complications. Pre-PRB haemoglobin (Hb) 10 g/L, and altered collagen-epinephrine (Col-Epi) time was a significant risk factor for overall complications. Mean sodium decrease was 0.6 ± 3 mmol/L. Hyponatraemia without neurological symptoms was diagnosed in two patients; no cardiovascular events occurred. Conclusion Hyponatraemia after single-dose DDAVP is rare. A single IV dose of desmopressin adjusted to the patient’s weight is safe as pre-PRB bleeding prophylaxis.

Jugular Tesio lines (TesioCaths; MedCOMP, Harleysville, PA, USA) are frequently used as permanent vascular accesses in haemodialysis patients. During the insertion procedure, arrhythmias are a relatively common complication, usually related to an excessively advanced catheter tip, without major consequences. We present two cases of life-threatening arrhythmias triggered by the Tesio catheter eccentric high-velocity jet of blood resolved after reposition of the catheter without further episodes, despite both lines being inserted under real-time ultrasound and fluoroscopic guidance. We believe dialysis lines should be checked for tip position even when long-standing to prevent relevant complications due to catheter sliding.

Causes of non-resuming peritoneal dialysis (PD) after complicated peritonitis requiring peritoneal catheter (PC) removal remain poorly studied. We reviewed all peritonitis episodes in our center between 1997 and 2017. Patients who restarted PD after PC removal (Group 1) were compared to those who did not (Group 2), identifying the causes. Of 284 peritonitis episodes, PC was removed in 48 patients (16.9%). In 18 (37.5%) patients PC was reinserted, and PD successfully resumed in all, with a median duration of PD afterwards of 14.1 months. In other 30 (62.5%) reinsertion of PC was not attempted. Causes of non-reinsertion were: transfer to hemodialysis 76.6% (n = 23), death 16.7% (n = 5) and transplantation 6.7% (n = 2). Hemodialysis switch was due to non-medical reasons in 47.8% (n = 11) including fear of peritonitis, family decision and social dependence. Group 1 was younger (p = 0.041), with lower Charlson index (p = 0.045) and higher men proportion (p = 0.049). Group 1 had a better patient survival than group 2 (survival at 24 months: 67% and 53%, respectively; log-rank test p: 0.01). There were no differences in survival between groups when adjusted for significant basal characteristics. Resuming PD after severe peritonitis requiring PC removal is feasible but a high proportion of patients do not restart PD for non-medical reasons, usually older patients with higher Charlson index. A properly structured interview would be a useful tool that could improve return to technique in these patients.

There are a significant number of mechanical complications related the peritoneal dialysis (PD) catheter and early diagnosis is key. Between them, the spontaneous extrusion of the catheter is quite uncommon but it should be included among the possible complications of the technique, given that it can be related to frequent situations in PD patients like abdominal wall issues, past immunosuppression or PD fluid leakage. In 25 years our Unit had three cases, probably related to peritoneal fluid leakage, exit site infection and past steroid treatment. Careful examination of abdominal wall preimplantation, adequate break-in period to allow maturation and early detection of exit site infection to start treatment in a timely fashion could help to prevent this rare complication. The complete extrusion of the catheter does not preclude from continuing PD treatment.

Background: Diagnostic and Interventional Nephrology has been a rising field in recent years worldwide. Catheter insertion, renal biopsy, renal ultrasound, and peritoneal dialysis catheter or permanent dialysis catheter insertion are vital to our specialty. At present, many of these procedures are delegated to other specialties, generating long waiting lists and limiting diagnosis and treatment. Methods: An online survey was emailed to all Nephrology departments in Spain. One survey response was allowed per center. Results: Of 195 Nephrology departments, 70 responded (35.8%). Of them, 72.3% (52) had ultrasound equipment, 77.1% insert temporary jugular catheters, and 92.8% femoral. Up to 75.7% (53 centers) perform native renal biopsies, of which 35.8% (19) are real-time ultrasound guided by nephrologists. Transplant kidney biopsies are done in 26 centers, of which 46.1% (12) by nephrologists. Tunneled hemodialysis catheters are inserted in 27 centers (38.5%), peritoneal catheter insertion in 18 (31.6%), and only 2 centers (2.8%) perform arteriovenous fistulae angioplasty. In terms of ultrasound imaging, 20 centers (28.5%) do native renal ultrasound and 16 (22.8%) transplanted kidneys. Of all units 71.4% offer carotid ultrasound to evaluate cardiovascular risk, only in 15 centers (21%) by nephrologists. AVF ultrasound scanning is done in 55.7% (39). Conclusion: Diagnostic and Interventional Nephrology is slowly spreading in Spain. It includes basic techniques to our specialty, allowing nephrologists to be more independent, efficient, and reducing waiting times and costs, overall improving patient care. Nowadays, more nephrologists aim to perform them. Therefore, appropriate training on different techniques should be warranted, implementing an official certification and teaching programs.

With aging population and chronic kidney disease burden increasing worldwide, the need for renal replacement therapy is rising and our patients are getting more complex due to comorbidities and long-standing kidney disease. Deteriorated vascular capital is a frequent feature we have to deal with these days, making even obtaining routine blood tests a hard task. We present two case reports of peritoneal dialysis patients without a peripheral vein access were a Port-a-Cath (Port-a-Cath® Deltec® Smiths Medical) was placed to sort out long-term access. Port-a-Cath manipulation was simple, safe and had no complications neither at implantation nor during its use. We believe that Port-a-Cath placement is an option to be considered when coping with end-stage venous access.

Ultrasound is an essential tool in the management of the nephrological patient allowing the diagnosis, monitoring and performance of kidney intervention. However, the usefulness of ultrasound in the hands of the nephrologist is not limited exclusively to the ultrasound study of the kidney. By ultrasound, the nephrologist can also optimize the management of arteriovenous fistula for hemodialysis, measure cardiovascular risk (mean intimate thickness), implant central catheters for ultrasound-guided HD, as well as the patient's volemia using basic cardiac ultrasound, ultrasound of the cava inferior vein and lungs. From the Working Group on Interventional Nephrology (GNDI) of the Spanish Society of Nephrology (SEN) we have prepared this consensus document that summarizes the main applications of ultrasound to Nephrology, including the necessary basic technical requirements, the framework normative and the level of training of nephrologists in this area. The objective of this work is to promote the inclusion of ultrasound, both diagnostic and interventional, in the usual clinical practice of the nephrologist and in the Nephrology Services portfolio with the final objective of offering diligent, efficient and comprehensive management to the nephrological patient.

Supplemental material, Online_Appendix for Diagnostic and Interventional Nephrology in Spain: A snapshot of current situation by R Haridian Sosa Barrios, Jose Ibeas, Ramon Roca Tey, Manuel Ceballos Guerrero, Angels Betriu Bars, Ignacio Cornago Delgado, Manuel Lanuza Luengo, Vicente Paraíso Cuevas, Pedro L Quirós Ganga and Maite E Rivera Gorrín in The Journal of Vascular Access

Background Percutaneous renal biopsy (PRB) is an important technique providing relevant information to guide diagnosis and treatment in renal disease. As an invasive procedure it has complications. Most studies up to date have analysed complications related to bleeding. We report the largest single-center experience on routine Doppler ultrasound (US) assessment post PRB, showing incidence and natural history of arteriovenous fistulae (AVF) post PRB. Methods We retrospectively analysed 327 consecutive adult PRB performed at Ramon Cajal University Hospital between January 2011 and December 2014. All biopsies were done under real-time US guidance by a trained nephrologist. Routine Doppler mapping and kidney US was done within 24 h post biopsy regardless of symptoms. Comorbidities, full blood count, clotting, bleeding time and blood pressure were recorded at the time of biopsy. Post biopsy protocol included vitals and urine void checked visually for haematuria. Logistic regression was used to investigate links between AVF, needle size, correcting for potential confounding variables. Results 46,5% were kidney transplants and 53,5% were native biopsies. Diagnostic material was obtained in 90,5% (142 grafts and 154 native). Forty-seven AVF’s (14.37%) were identified with routine kidney Doppler mapping, 95% asymptomatic (n = 45), 28 in grafts (18.4%) and 17 natives (9.7%) (p-value 0.7). Both groups were comparable in terms of comorbidities, passes, cylinders or biopsy yield (p-value NS). 80% were