Meningitis associated with strongyloidiasis in an area endemic for strongyloidiasis and human T-lymphotropic virus-1: a single-center experience in Japan between 1990 and 2010.

Meningitis caused by enteric flora is a known complication of strongyloidiasis, and human T-lymphotropic virus-1 (HTLV-1) predisposes individuals to severe strongyloidiasis. We reviewed the clinical features of bacterial meningitis associated with strongyloidiasis seen at a single center in subtropical Japan, in an area endemic for both strongyloidiasis and HTLV-1. We found 33 episodes in 21 patients between 1990 and 2010. The results were remarkable for the high incidence of meningitis due to Gram-positive cocci (27.3 %), especially Streptococcus bovis, and culture-negative cases (42.4 %). Given the high incidence of Gram-positive meningitis, a modified approach to corticosteroid use would be advisable in areas where strongyloidiasis is endemic, due to the potentially adverse consequences of glucocorticoid therapy.

Pulmonary embolism following successful thrombectomy of an arteriovenous dialysis fistula.

A hemodialysis patient was diagnosed with pulmonary embolism, shortly after successful thrombectomy of an autogenous arteriovenous fistula. Diagnostic testing revealed no alternative source for thromboembolism. Increased recognition of hypercoagulability as a common consequence of end-stage renal disease would suggest that dialysis patients would be at risk for thromboembolic events. A fully developed dialysis fistula may have sufficient luminal diameter to harbor subclinical or clinically significant venous thrombi. Clinicians should be alert to the possibility of venous emboli after fistula manipulation.

Renal replacement therapy in the critical care unit.

Acute renal failure is common in critically ill patients. Many intensive care unit patients require renal replacement therapy (RRT). Hemodialysis can be performed as intermittent treatments or as continuous RRT, which can be customized to clinical goals by the use of carefully designed replacement fluids and hemodialysates. The available forms of RRT are reviewed, with emphasis on the clinical indications that contribute to the choice and design of therapy. Practical issues and troubleshooting are discussed, as are available options for anticoagulation during RRT. Consideration is given to modality choice, hemodynamic issues, costs, and physiologic outcomes.

Pulmonary atheroembolism via an AV shunt.

Although cholesterol crystal embolism can present with diffuse visceral involvement, lung lesions do not occur unless there is left to right circulatory shunting. Pulmonary atheroembolism was confirmed by histology in an elderly male with recent end-stage renal failure (ESRF) due to atheroembolic renal disease, who presented with massive hemoptysis and intractable respiratory failure. At autopsy, atheromatous degeneration of the aorta was observed and acute cholesterol emboli found in the kidneys, spleen, liver, stomach and lung. Cholesterol clefts were seen in pulmonary arterioles, and ischemic alveolar damage was present. The pulmonary arteries had no atheromatous changes. Intrapulmonary, intracardiac, and aortocaval shunting were not present. Pulmonary atheroembolism arising from a dialysis fistula has not been previously reported.

Safety of paracentesis in inpatients.

INTRODUCTION: Prior research has suggested that paracentesis is free from complications such as acute renal failure (ARF) providing albumin is administered. Actual safety of paracentesis > 1,000 ml was assessed at a tertiary care hospital. METHODS: 300 inpatient paracenteses performed between 12/99 and 4/04 were identified by coding records, of which 40 procedures were excluded due to lack of pre- or post-procedure lab values. Charts were reviewed for serum creatinine (Scr) before and after procedures, ascites volume, and clinical outcomes. RESULTS: 44 deaths occurred after 260 paracenteses (16.9%). Among 33 patients with ARF, 13 (39.4%) died. Only 31/227 patients without ARF (13.7%) died (p < 0.001). Serum creatinine (Scr) > 1.6 mg/dl prior to paracentesis predicted a 22.5% rate of ARF, compared to 8% for Scr < 1.0 (p = 0.002). ARF increased as volume increased (9.9%, 12.4%, and 14.9%, for volumes of < 2,300, 2,300 - 3,200, and > 3,200 ml) but this trend did not have statistical significance (p = 0.426). ARF occurred in 11/69 (15.9%) of patients receiving albumin, compared to 22/191 (11.5%) of patients who did not (p = 0.462). CONCLUSIONS: Paracentesis in inpatients has significant rates of ARF and death. Scr > 1.6 prior to paracentesis predicts an increased rate of ARF. Development of ARF is associated with an increased rate of death. No advantage was demonstrated with administration of albumin. Pre- and post-paracentesis labwork should be routine in inpatients.

Long-term outcomes of a fistula initiative: sustaining "fistula culture".

From 1998 to 2003, a low cost fistula initiative at Allegheny General Hospital increased the rate of AV fistulas from 32% to 72%. We present an additional 25 months of vascular access data, with stratification of results by gender and long-term patient survival data. These data show the self-sustaining nature of 'fistula culture' in an urban hemodialysis unit, and the survival benefits that result from increased fistula rates.

Collateralization of the palmar arch by a failing radiocephalic fistula: an underappreciated complication of Cimino fistula anatomy.

Stenosis at the anastomosis of an arteriovenous dialysis fistula can cause fistula failure due to venous thrombosis. Three cases are presented in which anastomotic stenosis in radiocephalic fistulas resulted in radial artery occlusion with collateralization of ulnar artery flow across the palmar arch. Hand ischemia did not occur, and reductions in fistula efficiency were clinically subtle. Urea kinetics were compromised, and a characteristic palmar bruit was heard.

AV fistula rates: changing the culture of vascular access.

PURPOSE: Data from the United States Renal Data System show about 30% of prevailing hemodialysis (HD) patients use arteriovenous fistulae (AVF), which falls far short of the Kidney Disease Outcomes Quality Initiative (K/DOQI) goals of 40-50%. Recent initiatives to increase the use of AVF in HD patients have been criticized as unachievable under realistic practice conditions. METHODS: A multidisciplinary effort to increase AVF use was undertaken at an outpatient HD center beginning in 1998. Strategies focused on education and recruitment of patients in both inpatient and outpatient settings, preservation of veins, pre-operative vein mapping, and education of staff. RESULTS: AVF rates increased from 32%, to 72% over 6 years. The percentage of prosthetic grafts decreased from 40% to 13%. Central venous catheters fell from 28% to 15%. Among residual patients with catheters, 77% had maturing fistulae, as well. Infection rates in the dialysis unit decreased by 39%. Bacteremia declined by 47%. These improvements have been sustainable over the past 12 months. CONCLUSIONS: Adherence to a strategic program similar to the Fistula First Initiative can increase fistula rates under ordinary practice conditions. High fistula rates can be achieved in male and female patients. Unanimous commitment among all members of the health care team is needed. Reduction in the risks of infection, bacteremia, endocarditis, and death may be derived from achievable changes in practice.

Cancer chemotherapy administered via hemodialysis fistulas.

End-stage renal failure (ESRF) patients can develop cancer before or after kidney disease occurs. Cancer chemotherapy often needs to be administered via the sort of central venous catheter that is normally avoided in ESRF care. Three cases are presented in which ESRF patients received chemotherapy for cancer via existing hemodialysis fistulas, and the consequences of central venous access in a fourth patient are discussed.

Ascites reinfusion dialysis (ARD) for renal failure with refractory ascites.

BACKGROUND: Dialysis is difficult for patients who have simultaneous liver and kidney failure. Effective mobilization of ascites is rare, and hypotension is common. Combining repeated paracentesis with continuous renal replacement therapy can achieve effective volume removal with hemodynamic stability, but requires intensive care unit resources. Large amounts of albumin are lost from the body in the drained ascites. Combining ascites reinfusion with hemodialysis is a potential alternative therapy. METHODS: Eight treatments were undertaken in 3 patients with refractory ascites in the setting of acute onset renal failure. Hemodialysis was unsuccessful due to hypotension in each case. Two patients were treated twice, and 1 patient was treated 4 times. Each patient underwent hemodialysis with reinfusion of ascites directly into the blood inlet of the dialysis machine. Weight, blood urea nitrogen, albumin and platelet counts were measured before and after treatment. Hemodynamic tolerance was assessed, and patients were observed for the development ofencephalopathy, disseminated intravascular coagulation, infection and hemodynamic decompensation. RESULTS: All patients survived. There was 1 episode of transient hemoperitoneum, but no encephalopathy, GI bleeding or infection. One patient recovered renal function, and the other 2 were discharged ambulatory to chronic hemodialysis programs. Blood pressure was supported easily during therapy, despite removal of 3-8 kg of fluid. Platelet counts decreased by 27,000 +/- 13,000, and albumin increased by 0.5 +/- 0.2 g/dl. All values returned to baseline over the next 1-4 days. CONCLUSIONS: Ascites recirculation with dialysis is a safe and effective therapy for patients with refractory ascites and severe renal failure, which can be carried out in routine inpatient and outpatient settings. Hemodynamic tolerance was good and thrombocytopenia was modest.

Specific disruption of renal function and gene transcription by cyclosporin A.

The effects of cyclosporin A (CsA) are cell-specific, ranging from its immunosuppressive action on cells of the immune system to a variety of nonimmunologic toxic side effects. The predominant undesirable side effects of CsA occur in the kidney. Although many toxic renal effects of CsA have been described, the molecular basis of the nephrotoxicity is unknown. Elucidation of the molecular basis for the renal action of CsA may shed light on the function of cyclophilin in nonimmune cell types. The present study demonstrates that CsA selectively reduces the gluconeogenic capacity of rat proximal tubules via a decrease in activity of phosphoenolpyruvate carboxykinase (GTP:oxaloacetate carboxy-lyase (transphosphorylating), E.C. 4.1.1.32; PEPCK). The decrease in renal PEPCK activity occurs within 3 days and reflects a corresponding reduction in renal PEPCK mRNA abundance. This, in turn, is due to a selective inhibition of renal PEPCK gene transcription. Expression of several other renal genes is unaffected by CsA, as is expression of the PEPCK gene in liver. Thus, the effects of CsA are organ-specific and do not represent a general cytotoxic effect on proximal tubule cells. These results suggest that selective inhibition of the activity of a transcription factor(s) required for expression of specific genes in renal tubules may play a role in CsA-induced nephrotoxicity.