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Background: The pro-coagulable state in nephrotic syndrome is due to urinary losses of anti-coagulant proteins, including antithrombin III. Low molecular weight heparin (LMWH) is a common initial treatment for thrombosis and works by activating anti-thrombin III that itself inhibits factor Xa. In thrombosis in nephrotic syndrome, antithrombin levels are only infrequently checked and replacement is uncommon. We describe a case of thromboembolism due to an acquired antithrombin III deficiency and treatment with plasma derived anti-thrombin III (Thrombotrol-VF CSL ltd Australia) and LMWH. Case report: A 21-year-old male with focal segmental glomerulosclerosis, previously managed with rituximab, presented with a relapse of his nephrotic syndrome involving severe oedema and ascites, serum albumin <6 g/L, total cholesterol 17 mmol/L, UPCR 1.99 g/mmol, and right sided chest pain. A perfusion scan confirmed a large right segmental pulmonary embolus. He was commenced on intravenous methylprednisolone and rituximab and later cyclosporin. Given his impaired gut absorption and significant clot burden, his thromboembolism was treated with therapeutic enoxaparin. His initial anti-Xa and anti-thrombin III levels were low at 0.30 IU/mL (target range 0.50-1) and 0.29 IU/mL (normal 0.8-1.20) respectively. To ensure efficacy of LMWH he received Thrombotrol-VF with daily monitoring and replacement to achieve target levels. Owing to urinary losses, his anti-thrombin III levels were intermittently low even after achieving therapeutic anti-Xa levels. He was transitioned to warfarin once his gut absorption improved, evidenced by therapeutic oral cyclosporin drug levels and later his INR. Conclusion(s): Anti-thrombin III losses in severe nephrotic syndrome should be considered when treating its thrombotic complications. When using LMWH it may be prudent to check anti-thrombin III levels and replace as needed.

Aims: To assess the COVID-19 vaccine understanding, attitudes and hesitancy in renal transplant recipients prior to vaccination. Background(s): Transplant recipients are particularly vulnerable to the consequences of COVID-19 infection. COVID-19 vaccine hesitancy is currently a major public health concern. Method(s): An anonymous 'COVID-19 vaccine understanding, and attitudes' online survey was distributed to kidney transplant recipients at our centre. Participants were categorised by intention to have the vaccine: yes, no and undecided. Comparisons were made between the yes and undecided (hesitant) groups. Result(s): Of 876 surveys sent, 473 recipients responded (response rate 54%). 346 (73.15%), and 105 (22.20%) recipients were in the yes and undecided categories respectively (no group 22 (4.65%) are not considered further). Yes and undecided groups were similarly concerned about their risk of COVID-19 infection. Relative to the yes group, the undecided group were younger (mean age 58.53, SD 12.09 vs.54.69, SD 12.49, p = 0.005), but were not different in other characteristics including gender, education level, occupation status, transplant duration or comorbidities (p-value>0.05 for all). The undecided group felt less positive about the vaccine, less relief it was available and had greater concerns about vaccine safety, effectiveness, and potential side effects (p-values all <0.001). The undecided group also felt more need for vaccine specific information and a recommendation from their nephrologist before committing to vaccination (p < 0.001). Recipients ranked mask wearing, handwashing, and social distancing (both individually and collectively) more effective in reducing COVID-19 infection risk than vaccination (p < 0.001). Conclusion(s): Vaccine hesitant recipients had concerns pertaining to vaccine safety and effectiveness. Vaccine specific information and a recommendation from their Nephrologist were identified as mechanisms to increase vaccine acceptance in

Background: Fungal peritonitis is associated with significant morbidity and mortality and commonly leads to peritoneal dialysis (PD) technique failure. Candida albicans and Candida parapsilosis are the most common fungal organisms causing PD peritonitis. Clinical experience with rare candida species is important to inform practice because with clinical data lacking, recommendations are largely based on laboratory data. We present a case of Candida guilliermondii PD peritonitis. Case Report: A 70-year old male was admitted for an elective arteriovenous fistula ligation. During his admission he developed a cloudy dialysate but remained clinically well with no fevers, abdominal pain or systemic symptoms. His peritoneal fluid microscopy revealed a white cell count of 1410 x 106/L, the gram stain showed no growth, and his culture isolated Candida guilliermondii. The fluconazole, voriconazole, amphotericin B and caspofungin minimum inhibitory concentrations (MIC) were 4 mg/L, 0.06 mg/L, 0.25 mg/L, and 0.5 mg/L respectively. The European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints data suggests fluconazole resistance with MIC > 4 mg/L for C. albicans and C. parapsilosis. The susceptibility data for C. guilliermondii is not yet clearly established. The patient underwent a removal of his Tenkhoff catheter and was successfully treated with a two-week course of oral fluconazole 200 mg daily despite the potentially reduced in vitro susceptibility, as inferred from other common candida species' resistance patterns. Conclusion(s): C. guilliermondii PD peritonitis is rare. It is reportedly a more resistant candida species with a diminished susceptibility to fluconazole and echinocandins. Lack of clinical experience may make interpreting susceptibility data of rare fungal pathogens unreliable. Although in vitro results suggested potentially reduced fungal susceptibility, our case demonstrates that clinical cure is achievable with short course fluconazole

Objective: To identify barriers and enablers to COVID-19 vaccination in renal transplant recipients who are undecided about vaccination. Method(s): An online survey was distributed to 876 adult kidney transplant recipients at a tertiary referral service, who had not been vaccinated against COVID-19. The survey assessed willingness to be vaccinated, attitudes toward COVID-19 vaccines, and barriers and enablers to proceeding with vaccination. Result(s): The survey response rate was 54% (473/876). Three hundred and forty-six (73.1%) participants planned to receive vaccination (yes group), 105 (22.2%) were undecided, and 22 (4.7%) refused vaccination. The undecided group were younger but were not different in other demographic characteristics to the yes group. The undecided group were less positive toward (34.29% vs. 91.3%, p <.001) and more concerned about (93.3% vs. 25.1%, p <.001) vaccination than the yes group. Their concerns related to vaccine safety (including harm to their transplant), poor efficacy, and a lack of rigorous testing in transplant recipients. Undecided recipients had received less vaccine-specific information from medical specialists than the yes group. Most undecided participants (95.1%) were willing to proceed with vaccination with appropriate supports. The most desired supports were information and a recommendation to proceed with vaccination from their treating transplant specialist and team. Conclusion(s): Concerns about vaccine safety (including harm to transplant), poor vaccine efficacy, and lack of rigorous testing were barriers to vaccine uptake. Most undecided recipients would proceed with vaccination with specific recommendations and vaccine information provided by their transplant specialist/team. These simple interventions can be readily implemented to optimize vaccine uptake.Copyright © 2021 Wiley Periodicals LLC

Haemolysis in haemodialysis, although rare in current times, is associated with significant mortality and morbidity. As such prompt recognition, treatment, analysis of root cause and correction of underlying causative factors is crucial. Dialysate, extracorporeal circuit and patient related factors all contribute to haemolysis risk. Haemolysis can manifest with non-specific signs and symptoms including but not restricted to hypertension, nausea, pain (abdominal, chest, back) and dyspnoea. It may present acutely during the dialysis session or may take a protracted course. Potential life threating consequences include; hyperkalaemia induced cardiac arrhythmias, profound anaemia and associated acute coronary events and respiratory distress, and severe necrotizing pancreatitis. Chronic haemolysis results in impaired endothelial function thus contributing to the long-term cardiovascular risk profile in haemodialysis patients. Stringent national and international standards, technological advancements in membrane and dialysis equipment design, dialyser purification methods and water treatment systems have greatly reduced the incidence of haemolysis. Despite these improvements recognition of haemolysis risk and ongoing clinical vigilance is important.Copyright © 2017 Asian Pacific Society of Nephrology