Sodium bicarbonate catheter lock solution reduces hemodialysis catheter loss due to catheter-related thrombosis and blood stream infection: an open-label clinical trial.

BACKGROUND: There is no ideal lock solution that prevents hemodialysis (HD) catheter loss due to catheter-related thrombosis (CRT) and catheter-related bloodstream infection (CRBSI). Catheter loss is associated with increased hospitalization and high inpatient costs. Sodium bicarbonate (NaHCO3) demonstrates anti-infective and anticoagulation properties with a good safety profile, making it an ideal lock solution development target.The objective of this study was to determine the safety and efficacy of using sodium bicarbonate catheter lock solution (SBCLS) as a means of preventing HD catheter loss due to CRT and CRBSI. METHODS: The study took place in a community hospital in Brooklyn, NY, USA. All admitted patients ≥18 years of age who needed HD treatment through CVC were included in the study. 451 patients included in the study were provided SBCLS or NSCLS post-dialysis. Catheter loss due to CRT or CRBSI was evaluated over a period of 546 days. RESULTS: A total of 452 patients met the criteria; 1 outlier was excluded, 226 were in the NSCLS group and 225 were in the SBCLS group. There were no significant differences between groups in comorbidities at the outset. The NSCLS group had CRT and CRBSI rates of 4.1 and 2.6/1000 catheter days (CD), respectively, compared with 0.17/1000 CD for both outcomes in the SBCLS group. SBCLS patients had a significantly reduced catheter loss rate due to CRT (P < 0.0001) and CRBSI (P = 0.0004). NSCLS patients had higher odds of losing their catheter due to CRT {odds ratio [OR] 26.6 [95% confidence interval (CI) 3.57-198.52]} and CRBSI [OR 15.9 (95% CI 2.09-121.61)] during the study period. CONCLUSION: The novel approach of using SBCLS was found to be safe and was statistically superior to normal saline in preventing HD catheter loss due to CRT and CRBSI. NaHCO3 solution is inexpensive, readily available in various settings and holds the potential to decrease hospitalization, length of stay and dialysis-related costs. TRIAL REGISTRATION: Maimonides Medical Center Investigational Review Board, Study IRB 2015-06-25-CIH. ClinicalTrials.gov identifier: NCT03627884.

Initial presentation in psychiatry emergency room led to diagnosis of many urinary bladder stones in a male patient.

The first case of man who presented to psychiatry emergency room for evaluation of abnormal behavior because of urinary stones was reported. Careful evaluation of patient led to a diagnosis of 37 urinary bladder stones in an Egyptian man with obstructive uropathy and metabolic defects in the form of hyperoxaluria and hypocitraturia. Knowledge of the differential diagnosis of metabolic defects can lead to successful outcome in preventing reformation of urinary tract stones after surgery. A 61-year-old Egyptian man presented to psychiatry emergency room because he was found lying on floor in bathroom to urinate by his wife who thought her husband needed psychiatric evaluation. Patient gave history of frequent urination and dysuria on and off for 3 years. In the last 3 months before his presentation to emergency room, he got into a habit of lying down on his left side when he went to bathroom to urinate because it was easier for him to pass urine. Renal consultation requested because of presence of red blood cells in urinalysis. Computed tomography of the abdomen and pelvis showed bilateral hydronephrosis and multiple bladder stones. Twenty-four-hour urine collection showed low urinary citrate and high oxalate. Patient underwent open vesicolithotomy and removal of 36 stones. Stone analysis showed 75% uric acid and 25% calcium oxalate. Patient did very well after surgery, and 1 month later, he underwent transuretheral resection of prostate without any complications. Now patient has no difficulty passing urine and he has no recent attack of urinary tract infection. Knowledge of the differential diagnosis of metabolic defects in men with urinary bladder stones would hopefully provide clinicians with the proper diagnostic tools to more specifically treat such patients with improved success in preventing reformation of urinary tract stones after surgery.

A selected controlled trial of supplementary vitamin E for treatment of muscle cramps in hemodialysis patients.

Muscle cramps are not uncommon complications of hemodialysis (HD) treatments and lead to early termination of HD sessions and are therefore a significant cause of under-dialysis. The etiology of cramps in dialysis patients remains a matter of debate. Many reports suggested that vitamin E (vit. E) may be effective for the prevention of HD-associated cramps. We decided to perform a selected controlled trial of supplementary vit. E for treatment of patients on HD who experience frequent attacks during and between HD sessions. The goal was to compare the number of attacks of muscle cramps with the patient's baseline over a specific period of time. In this study, 19 HD patients were randomly selected of different age groups and ethnicity. Patient must have had at least 60 attacks of muscle cramps during and between HD sessions over a 12-week period. All selected patients received vit. E at a dose of 400 international units daily for 12 weeks, and the number of attacks of muscle cramps was recorded. The frequency of muscle cramps decreased significantly during vit. E therapy, and, at the end of the trial, vit. E led to cramp reductions of 68.3%. The reduction in number of attacks of muscle cramps had no significant correlation with age, sex, etiology of end-stage renal disease, serum electrolytes, or HD duration, and it showed a statistically positive correlation (P = 0.0001) with vit. E therapy. No vit. E-related adverse effects were encountered during the trial. Short-term treatment with vit. E is safe and effective in reducing number of attacks of muscle cramps in HD patients, as shown in our study.

Emphysematous pyelonephritis presenting as gastroenteritis.

Emphysematous pyelonephritis (EPN) is a serious and often life-threatening condition due to a gas-producing and necrotizing infection involving the renal parenchyma and perirenal tissue. The infection is almost exclusively seen in diabetic patients, and the main feature of its presence is finding gas within the kidney. Patients usually present with fever, chills, flank pain, and dysuria. Laboratory testing usually reveals hyperglycemia, leukocytosis, pyuria, an elevated blood urea nitrogen (BUN) level, and high serum creatinine level. Other, nonspecific symptoms such as abdominal pain, nausea, vomiting, and diarrhea can accompany acute pyelonephritis, as found in the reported case. The appropriate management of such serious infection requires combined medical and surgical treatment. In severe infection, nephrectomy should not be delayed. We report a case of EPN in a diabetic patient who presented with gastrointestinal symptoms. A high index of suspicion, coupled with a good imaging study [preferably computed tomography (CT) scanning] of the abdomen can lead to early diagnosis. Appropriate medical and surgical management have resulted in a successful outcome.

Thyrotoxic hypokalemic periodic paralysis triggered by high carbohydrate diet.

Thyrotoxic hypokalemic periodic paralysis is an uncommon disorder characterized by elevated thyroid hormone, muscle weakness or paralysis, and intracellular shifts of potassium leading to hypokalemia. This article presents a case of thyrotoxic hypokalemic periodic paralysis in a 22-year old Hispanic man with nonfamilial thyrotoxic hypokalemic periodic paralysis triggered by a high carbohydrate diet. Laboratory studies showed elevated thyroid hormone, decreased thyroid-stimulating hormone, and hypokalemia. Rapid reduction in thyroid hormone levels by giving antithyroid drugs such as propylthiouracil and prompt potassium therapy with frequent measurements of serum potassium levels during therapy to avoid catastrophic hyperkalemia when potassium starts to shift back from intracellular to extracellular compartments can lead to successful outcome.

Metformin-associated lactic acidosis precipitated by diarrhea.

Metformin-associated lactic acidosis (MALA) is a serious metabolic complication that occurs because of metformin accumulation in patients who become dehydrated or developed acute renal failure. Bicarbonate hemodialysis treatment should take place early in the course of management, especially in patients with severe metabolic acidosis who fail to respond to intravenous bicarbonate therapy or in whom renal failure is present. We report a case of MALA in which acute renal failure resulting from dehydration secondary to diarrhea and poor oral intake likely caused MALA. Early recognition of this condition and initiation of effective treatment can improve outcome.