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End stage kidney disease (ESKD) patients in the developing countries often present late for dialysis initiation with advanced uremia and life‐threatening complications. Urgent start dialysis in such emergent situations exposes the patient to risk of uremia related complications as well as iatrogenic insults. We report the case of a middle‐aged man with ESKD who presented late with acute pulmonary edema and hyperkalemia and developed osmotic demyelination syndrome following urgent start hemodialysis. Osmotic demyelination syndrome in this patient is noteworthy since there was no accompanying hyponatremia, the most commonly recognized antecedent. We propose that rapid lowering of serum osmolality by aggressive hemodialysis is sufficient to incite osmotic demyelination syndrome in patients who have long‐standing uremia and high blood urea level. Malnutrition resulting from uremia might be a compounding factor in this scenario. Our patient had a characteristic initial presentation of osmotic demyelination syndrome with locked‐in‐state which later progressed to respiratory failure and death. [ABSTRACT FROM AUTHOR]

Background: Accelerated neuropathy is a rare syndrome of rapidly worsening peripheral neuropathy, typically described in end‐stage kidney disease (ESKD) patients undergoing dialysis. In our center, we encountered a surge in the occurrence of accelerated neuropathy among ESKD patients undergoing hemodialysis, which prompted systematic research. Methods: In this case–control study, we present the clinical features, electrophysiologic findings, and outcome of a series of patients who developed accelerated neuropathy after commencing hemodialysis for ESKD. Those who initiated hemodialysis and did not develop accelerated neuropathy were included as controls. We used logistic regression to identify predictors of accelerated neuropathy. Results: Among 436 ESKD patients who initiated hemodialysis over 4 years, 17 were diagnosed with accelerated neuropathy. The median‐time (interquartile range) from hemodialysis initiation to presentation with accelerated neuropathy was 3 weeks (2–6). It typically presented as acute onset of unsteadiness of gait necessitating assistance for ambulation. Electrophysiology revealed length‐dependent symmetric sensorimotor axonal neuropathy. Diabetes mellitus (odds ratio [OR] 4.1, 95% CI 1.2–13.9, p = 0.02), pre‐existing peripheral neuropathy (OR 9.25, 95% CI 2.79–30.6, p < 0.001), and serum alkaline phosphatase (OR 1.2 for every 10 U increase, 95% CI 1.00–1.52, p = 0.04) significantly predicted accelerated neuropathy. With continued dialysis and supportive care, neurologic status improved, total‐neuropathy score (summary score of peripheral nerve dysfunction incorporating clinical and electrophysiological parameters) declined from 26.5 to 18.4 (p < 0.001) and most regained unassisted ambulation. Conclusion: This study presents the largest series of patients with accelerated neuropathy and has identified predictors. However, in view of the unusually high incidence of accelerated neuropathy we speculate that other unidentified factor(s) could be underlying its pathogenesis. [ABSTRACT FROM AUTHOR]

Background and aim: It is feared that among chronic kidney disease patients undergoing hemodialysis, arteriovenous fistula (AVF) itself could contribute to pulmonary hypertension (PH). The impact of AVF location on PH is yet to be assessed. We hypothesize that patients with proximal AVF have higher access blood flow and hence higher pulmonary arterial systolic pressure (PASP) than those with distal AVF. We aimed to compare the PASP between patients with proximal and distal AVF. Methods: In this cross‐sectional study, PASP was estimated using Doppler echocardiography and blood flow in the AVF was assessed by Doppler ultrasound. PASP was modeled by multivariate linear regression. AVF location was the primary exposure of interest. Results: Out of 89 patients undergoing hemodialysis, 72 (81%) had PH defined as PASP >35 mmHg. The mean blood flow in proximal and distal AVF was, respectively, 1240 and 783 mL/min (mean difference 457 mL/min, p < 0.001). Mean PASP in patients with proximal AVF was 16.6 mmHg higher than those with distal AVF (p < 0.001, 95% CI 8.3–24.9). There was a positive correlation between access blood flow and PASP (r = 0.28, p = 0.007). If access blood flow was included as a covariate in the multivariate model, the association between AVF location and PASP ceased to exist. Conclusion: Patients with proximal AVF have a significantly higher PASP than those with distal AVF, and this could be attributed to the higher blood flow in proximal AVF compared to distal AVF. [ABSTRACT FROM AUTHOR]

"Chronic pain" is a commonly reported symptom among hemodialysis patients. Despite its high prevalence and the poor health‐related quality of life associated with it, chronic pain remains an ineffectively assessed and managed entity in dialysis patients. We report a case of a 55‐year‐old gentleman on maintenance hemodialysis who presented with 3 months history of "excruciating flitting and fleeting type" of pain largely involving both lower limbs and occasionally neck, shoulder, chest, and upper limbs. The pain was so intolerable that it even triggered suicidal intentions in the patient. Common causes of chronic pain in dialysis patients were considered, but the initial history and clinical examination remained elusive. The patient was empirically started on oral analgesics, benzodiazepines, calcitriol, and levocarnitine supplementation but had no significant effect on his symptoms. A comprehensive repeat clinical history revealed the nocturnal periodicity of symptoms, specific aggravation of pain with inactivity, and its temporary relief with movement. This helped us narrow down the diagnosis to restless leg syndrome (RLS) amidst the myriad causes of chronic pain in dialysis patients. The "constant urge to move the legs" which is the defining characteristic of RLS was inconspicuous in our patient and excruciating pain was the predominant manifestation. This atypical presentation of RLS with agonizing pain involving multiple sites of the body led to a delay in the diagnosis and initiation of appropriate therapeutic measures. The patient had a dramatic response to therapy with dopamine agonists and withdrawal of the drug led to reappearance of his symptoms which further confirmed the diagnosis of RLS. RLS should be considered in the evaluation of chronic pain in dialysis patients and renal health care providers should familiarize themselves with the varied atypical, forme fruste manifestations of RLS to avoid diagnostic delay of this disabling but treatable condition. [ABSTRACT FROM AUTHOR]

Transplant physicians must be aware of the opportunistic infections that could befall transplant recipients following COVID-19 infection. Coronavirus disease 2019 (COVID-19) infection poses several challenges for transplant recipients including a high risk of severe COVID-19 with attendant organ failure and in-hospital mortality. [Extracted from the article]