Hypertriglyceridemia as a Cause of Continuous Renal Replacement Therapy Circuit Clotting: A Case Series.

INTRODUCTION: Hypertriglyceridemia is a rarely reported cause of early continuous renal replacement therapy (CRRT) circuit clotting. METHODS: We have identified and will present 11 published cases in the literature where hypertriglyceridemia has led to CRRT circuit clotting or dysfunction. RESULTS: The majority of cases (8/11) are related to propofol use leading to hypertriglyceridemia. The other cases (3/11) are due to total parenteral nutrition administration. CONCLUSION: Due to the propensity of propofol use for critically ill patients in intensive care units, and the rather common occurrence of CRRT circuit clotting, hypertriglyceridemia may be underappreciated and undiagnosed. The exact pathophysiology behind hypertriglyceridemia-induced CRRT clotting has not been fully elucidated, although there are some hypotheses which include fibrin and fat droplet deposition (identified after electron microscopic examination of the hemofilter), increased blood viscosity, and development of a procoagulant state. Premature clotting poses a multitude of problems including inadequate treatment time, increased costs, increasing nursing workload, and patient blood loss. With earlier identification, discontinuation of the inciting agent, and possible therapeutic management, we could expect improvement in CRRT hemofilter patency and decreased costs.

Pseudohypobicarbonatemia in a patient with amyloidosis.

We report a case of a patient who had critically low serum bicarbonate (HCO3 -) levels ranging from 8 to 11 mmol/L on repeated venous measurements using an enzymatic/photometric assay. This prompted hospitalization and treatment with intravenous sodium bicarbonate (NaHCO3) followed by oral NaHCO3. He was evaluated for potential causes of high anion gap metabolic acidosis without any etiology found. He continued to have low serum HCO3 - levels despite maintenance oral NaHCO3 therapy and was referred for a second opinion where further laboratory work was pursued. An arterial blood gas was obtained, which revealed normal whole blood pH and HCO3 - levels. A different enzymatic/photometric assay revealed a normal serum HCO3 - level at 21 mmol/L. Additional workup revealed paraproteinemia, which was thought to interfere with the enzymatic process by which his serum HCO3 - was measured, resulting in erroneous values.

Delftia acidovorans pseudo outbreak in portable reverse osmosis machines: Interventions to ensure safe and cost-effective hemodialysis.

INTRODUCTION: Reverse osmosis (RO), a major advance in hemodialysis (HD) safety, effectively clears most water organisms. Delftia acidovorans is an environmental water-borne pathogen that is rarely reported to cause human infections. We report a pseudo outbreak caused by colonization of RO machines with D acidovorans with no reported human infections and interventions to improve HD safety. METHODS: Repeated positive RO product water cultures triggered our hospital to initiate an investigation, RO machines were examined for mechanical integrity by biomedical engineers. Cultures of product water as well as RO parts were done. Testing for bacterial relatedness after identification was performed. An investigation was conducted in a systematic fashion to determine the cause and the extent of the problem. RESULTS: Upon formal review of policies and procedures, there were minor deficiencies. Rectifying these deviations from policies did not stop the repeated positive water cultures. A 7-step investigation and correction was successfully conducted. City water testing with filtration and concentration methods was positive for D acidovorans. Major renovation of the HD unit with replacement of all RO machines and a 2-step water filtration resulted in elimination of the pseudo outbreak. CONCLUSION: City water was the source of biofilm formation of D acidovorans in RO machines that was not possible to eradicate. Application of incoming water filters was an effective preventive strategy. Replacement of RO machines after 4 failed disinfection attempts is the most cost-effective strategy as well for persistent positive water cultures. The HD remains RO water culture negative 2 years after changes.

Preoperative Risk Assessment and Management in Adults Receiving Maintenance Dialysis and Those With Earlier Stages of CKD.

With an increasingly aging population and improved mortality in individuals with end-stage kidney disease, more surgeries are being performed on patients with all stages of chronic kidney disease (CKD). This high-risk population carries unique risk factors that have been associated with increased adverse perioperative outcomes, including acute kidney injury, cardiovascular events, and mortality. In this article, we review the literature describing absolute risks associated with common surgeries performed in patients with CKD and patients receiving maintenance dialysis. We also review perioperative optimization with special risk assessment including evaluation of cardiovascular and bleeding risk evaluation, hypertension management, and timing of dialysis. Predictive model scores are reviewed as a method to stratify risk for acute kidney injury, major adverse cardiac events, or other serious complications with elective surgeries. A multidisciplinary approach with individualized counseling is necessary to counsel the patient with advanced CKD or patients treated with maintenance dialysis considering elective surgery.