Mycobacterium abscessus exit-site infection in peritoneal dialysis patients: should we ever aim to salvage the catheter?

Improvements in the exit-site care for peritoneal dialysis (PD) patients have uncovered a trend for increasing incidence of rapidly growing nontuberculous mycobacterium exit-site infections (ESI). Among these, Mycobacterium abscessus is unique in terms of its high morbidity and treatment failure rates. The international society of PD guidelines encourage PD catheter removal in patients with M. abscessus peritonitis but, do not have evidence-based recommendations for the management of ESIs related to this organism. We report an unusual case in which an asymptomatic end-stage renal disease patient with multiple favorable clinical characteristics, i.e., no apparent immunodeficiency, sensitivity pattern showing possibility of treatment with multiple antibiotics, no evidence of peritonitis, and early clinical response, was treated with a 9-month combination antimicrobial regimen administered orally and intraperitoneally. Despite excellent clinical response with a resolution of the ESI, our patient relapsed quickly, within 30 days of stopping antimicrobial therapy and required PD catheter removal. Our case, taken together with available published case reports, highlights the futility of the conservative approach towards the M. abscessus ESI and makes the cases for early PD catheter removal in these patients.

Left Ventricular Assist Device and the Kidney: Getting to the Heart of the Matter.

Left ventricular assist devices (LVADs) are increasingly used for the management of patients with advanced heart failure (AHF) due to their established salutary impact on hemodynamic status and survival benefit. Impairment in kidney function is common in the setting of AHF and is associated with adverse impact on the outcomes. Cardiorenal interactions represent a complex pattern in these patients rendering their care a challenge that needs to be addressed by multidisciplinary approaches. Following LVAD implantation, AHF patients have the potential to achieve marked improvement in kidney function due to increased cardiac output and kidney perfusion as well as reduction in renal venous congestion. However, a subset of these patients is also at risk for acute kidney injury and resurgence of kidney dysfunction on continued mechanical circulatory support. Herein, we provide an overview of various aspects of changes in kidney function pre- and post-LVAD implantation, review potential underlying pathophysiologic mechanisms, and the impact on the outcomes. Moreover, the currently available data on renal replacement therapy of LVAD-treated patients, whether in the acute setting or as a maintenance therapy, are discussed in detail along with areas of high clinical relevance where a clear gap in knowledge exists.

Erroneously High Lactate: A Guide to Diagnosing Ethylene Glycol Poisoning.

A high lactic acid level in critically ill patients is a marker of poor prognosis. However, lactic acidosis in ethylene glycol (EG) poisoning should be interpreted cautiously as analytical interference is observed with EG metabolites.

Expanding the Boundaries of Combined Renal Replacement Therapy for Non-Renal Indications.

Over the last decades, there have been major advancements in the field of renal replacement therapy (RRT) with utilization of newer technologies and advent of various modalities. Once exclusively used for treatment of renal failure and its metabolic consequences, the science of RRT has expanded to include non-renal indications such as treatment of fluid overload in patients with refractory heart failure. Hepatic encephalopathy due to sudden rise in serum ammonia level in the setting of acute liver failure represents an underexplored area in which RRT can potentially be helpful. While the key role of hyperammonemia in the pathogenesis of hepatic encephalopathy in patients with liver failure is well established, emerging data points to distinct pathophysiologic mechanisms underlying chronic alterations in neural metabolic functions and acute changes in cerebral perfusion. In the acute setting, ammonia can cross the blood-brain barrier at high levels leading to sudden formation of strong osmolytes, significant transcellular shift of water, and cerebral edema. Herein, we provide a brief overview of the role of RRT in management of acute hyperammonemia in the setting of acute liver failure and discuss the practical aspects of the available therapeutic modalities. Larger studies are needed to shed light on a number of clinical aspects such as the impact on the outcomes, criteria for selection of the patients that would benefit most from this therapeutic approach, optimal timing of initiation of RRT, and the most appropriate modality.

Renal ultrasonography: a reliable diagnostic tool for pyonephrosis.

Pyonephrosis is a rare purulent infection of the upper urinary tract, which can lead to rapid clinical deterioration. While contrast-enhanced CT scan is a sensitive test, point-of-care renal sonography can serve as a quick and valuable bedside tool for diagnosis, especially when iodinated contrast use is contraindicated.

Acute interstitial nephritis: a multifaceted disease.

Drug-induced acute interstitial nephritis is an important cause of unexplained acute kidney injury in hospitalized patients. It can present with nonspecific clinical features, and renal biopsy should be considered for definitive diagnosis. Removal of the offending agent along with early initiation of corticosteroid therapy is the mainstay of treatment.

Fever in a transplant recipient: think beyond infection.

Immune reconstitution inflammatory syndrome (IRIS) is an exaggerated inflammatory cascade initiated in response to immune recovery during the resolution of an infection. Reduction in calcineurin inhibitor levels in organ transplant recipients due to enhanced metabolism from interaction with rifampin can predispose these individuals to develop IRIS during the treatment of tuberculosis and mimic sepsis.

Renal cyst infection: a diagnostic dilemma.

Cyst infection is a common complication of autosomal dominant polycystic kidney disease. It presents with vague clinical features and imaging findings which make the diagnosis challenging. Imaging findings can be misinterpreted as renal cell carcinoma, and biopsy of the lesion is often required for definitive diagnosis.