Reverse Epidemiology for Lipid Disorders in Hemodialysis-Dependent Patients: Role of Dilutional Hypolipidemia.

Introduction: Atherosclerotic cardiovascular disease is a major cause of mortality and morbidity in dialysis patients. Compared to general population, dialysis patients have lower lipid levels and higher vascular events. This paradox is popularly known as reverse epidemiology. Present study is an attempt to understand reasons for low lipids in dialysis patients. Subjects and Methods: This was a prospective observational multicentric study involving three stages across six dialysis units with Care Hospitals, Hyderabad. Maintenance hemodialysis patients were studied with fasting lipid profiles [TC, LDL-c, HDL-c, and TG], pre- and post-dialysis blood lipids and effluent water lipid profiles. Other parameters studied were use of statins, interdialytic weight gain, and ultrafiltration. All patients had uniform dialysis protocols regarding filter used and dialysis duration. Results: Of the 91 patients studied, we observed significant rise in post-dialysis TC, LDL, and HDL [P < 0.01] and lower lipids [P < 0.01] just before the next dialysis. Lipids were least filtered across the membrane except HDL, which was found in effluent water for more than 60% of patients. Single use of dialyser was associated with higher rise in post dialysis lipids as well as HDL getting filtered in effluent [P = 0.24]. Rosuvastatin was associated with lower lipid values [P = 0.08] and BMI [P = 0.19]. Conclusions: Low lipid levels in dialysis patients are due to dilutional hypolipidemia and needs correction with an equation proposed in present study. Corrected lipids should be used for risk stratification and deploying treatment.

Isolated Penile Calciphylaxis Diagnosed by Ultrasound Imaging in a New Dialysis Patient: A Case Report.

RATIONALE: The recognition of calciphylaxis often eludes practitioners because of its multiple ambiguous presentations. It classically targets areas of the body dense with adipose tissue. A heightened suspicion for the disorder is therefore required in the case of penile calciphylaxis, given its unconventional location. The diagnosis of calciphylaxis is also challenging as the gold standard for diagnosis is biopsy which can often yield equivocal results. Unfortunately, in penile calciphylaxis, the utility of biopsies is further debated due to their potential to precipitate new lesions and their decreased sensitivity due to the limited depth of tissue that can be sampled. For these reasons, it is important that practitioners recognize other accessible and accurate investigative tools which can aid in their diagnosis. PRESENTING CONCERNS OF THE PATIENT: We present the case of a 49-year-old man who presented to the emergency room with penile pain in the context of known chronic kidney disease secondary to diabetic nephropathy. The pain had been present for about a week, was exquisitely tender, and was initially associated with a faint violaceous lesion. This gentleman had just recently initiated peritoneal dialysis and had no other lesions on his body. DIAGNOSIS: His pain was determined by ultrasound and plain radiograph to be secondary to calciphylaxis after two biopsies were nondiagnostic. INTERVENTIONS: The patient had already made changes to his diet to reduce phosphate and calcium intake, and had been on phosphate-lowering therapy with both calcium and phosphate being within their respective target range. Following his diagnosis, this patient was promptly converted from peritoneal dialysis to hemodialysis with sodium thiosulphate and initiated hyperbaric oxygen therapy. This patient continues to be followed by nephrology and urology specialists.

OUTCOMES: At the time of publication there has been no amputation of the appendage although there has been presumably permanent loss of function. TEACHING POINTS: This case should reinforce the high index of suspicion needed to make a timely diagnosis of calciphylaxis, and the broad variety of ways in which the disorder may present. The findings advocate for the utility of alternative diagnostic modalities, including imaging with plain radiograph and ultrasound, for calciphylaxis diagnosis. JUSTIFICATION: Les multiples présentations cliniques de la calciphylaxie, une affection qui cible habituellement des régions du corps denses en tissu adipeux, font en sorte que sa détection échappe fréquemment aux praticiens. La calciphylaxie pénienne, en raison de son emplacement inhabituel, devrait faire l'objet d'une suspicion clinique accrue. La calciphylaxie est en outre difficile à diagnostiquer puisque la biopsie, l'étalon-or pour sa détection, mène souvent à des résultats équivoques. Dans le cas de la calciphylaxie pénienne, la pertinence de la biopsie fait d'autant plus débat puisqu'elle est susceptible de précipiter de nouvelles lésions et qu'elle présente une sensibilité réduite compte tenu de la profondeur limitée des tissus pouvant être obtenus. Il est donc important que les praticiens connaissent d'autres outils d'investigation accessibles et plus précis pouvant les aider dans leur diagnostic. PRÉSENTATION DU CAS: Nous présentons le cas d'un homme de 49 ans s'étant présenté aux urgences avec une douleur au pénis. Le patient était connu pour une insuffisance rénale chronique découlant d'une néphropathie diabétique. La douleur, initialement associée à une lésion légèrement violacée, était présente depuis environ une semaine et le membre était extrêmement sensible. Le patient venait tout juste d'amorcer des traitements de dialyze péritonéale et ne présentait aucune autre lésion sur le corps. DIAGNOSTIC: Après deux biopsies non diagnostiques, une échographie et une radiographie standard ont permis d'associer la douleur à la calciphylaxie. INTERVENTIONS: Le patient avait déjà apporté des changements à son alimentation afin de réduire son apport en phosphore et en calcium, et recevait déjà un traitement de chélateur de phosphate. Les taux de calcium et de phosphore se situaient dans leur plage cible respective. À la suite du diagnostic, le patient est rapidement passé de la dialyze péritonéale à l'hémodialyse, a été traité avec du thiosulfate de sodium et a entrepris une oxygénothérapie hyperbare. Le patient continue d'être suivi par des spécialistes en néphrologie et en urologie. RÉSULTATS: Au moment de la publication, le patient n'avait toujours pas subi d'amputation, malgré une vraisemblable perte de fonction permanente. ENSEIGNEMENTS TIRÉS: Ce cas devrait renforcer l'indice élevé de suspicion qui est nécessaire pour poser rapidement un diagnostic de calciphylaxie, en plus de montrer les très nombreuses présentations cliniques de ce trouble. Ces résultats plaident en faveur de modalités alternatives pour le diagnostic de la calciphylaxie, notamment le recours à l'échographie et à la radiographie standard.

Renal infarct in a COVID-19-positive kidney-pancreas transplant recipient.

The novel coronavirus disease 2019 (COVID-19) is associated with increased risk of thromboembolic events, but the extent and duration of this hypercoagulable state remain unknown. We describe the first case report of renal allograft infarction in a 46-year-old kidney-pancreas transplant recipient with no prior history of thromboembolism, who presented 26 days after diagnosis of COVID-19. At the time of renal infarct, he was COVID-19 symptom free and repeat test for SARS-CoV-2 was negative. This case report suggests that a hypercoagulable state may persist even after resolution of COVID-19. Further studies are required to determine thromboprophylaxis indications and duration in solid organ transplant recipients with COVID-19.