An unusual case of nephrotic syndrome and glucosuria.

We report a case of a 57-year-old man with hypertension and smoking history who presented with decreased glomerular filtration rate, nephrotic-range proteinuria, and persistent glucosuria. He underwent a kidney biopsy that showed nodular glomerulosclerosis. We discuss the clinicopathologic entities of idiopathic nodular glomerulosclerosis and primary renal glucosuria.

A comparison of transposed brachiobasilic fistulae with nontransposed fistulae and grafts in the Fistula First era.

This retrospective study compares outcomes of transposed brachiobasilic fistulae (avf), nontransposed avf, and grafts (avg). There were 161 (21%) transposed avf, 321 (42%) nontransposed avf, and 285 (37%) avg placed and followed over a 3-year period. Of the nontransposed avf, 203 (63%) were forearm radiocephalic avf and 118 (37%) were upper arm brachiocephalic avf. Grafts were able to be used in shorter time than avf and had a lower primary failure rate. However, avg had a significantly higher infection rate (0.23/patient/year vs. 0.07/patient/year) and required more procedures over the life of the access than avf (2.90/patient/year vs. 0.51/patient/year). Despite a higher primary failure rate, avf had better overall patency. Among nontransposed avf, brachiocephalic avf had significantly better primary patency than radiocephalic avf (p < 0.0001). Transposed avf had better cumulative patency than either nontransposed avf or grafts (p < 0.0001). Cumulative patency was best for transposed avf, intermediate for brachiocephalic avf, and worst with radiocephalic avf and avg. There was no difference in cumulative patency between radiocephalic avf and grafts (p = 0.5601). This analysis supports the current recommendation to prefer transposed avf over avg. In addition, the data suggest that both nontransposed brachiocephalic avf and transposed brachiobasilic avf outcomes may be superior to radiocephalic fistulae.

Benzocaine and lidocaine induced methemoglobinemia after bronchoscopy: a case report.

INTRODUCTION: Methemoglobinemia is a rare cause of hypoxemia, characterized by abnormal levels of oxidized hemoglobin that cannot bind to and transport oxygen. CASE PRESENTATION: A 62-year-old male underwent bronchoscopy where lidocaine oral solution and Hurricaine spray (20% benzocaine) were used. He developed central cyanosis and his oxygen saturation was 85% via pulse oximetry. An arterial blood gas revealed pH 7.45, PCO2 42, PO2 282, oxygen saturation 85%. Co-oximetry performed revealed a methemoglobin level of 17.5% (normal 0.6-2.5%). The patient was continued on 15 L/minute nonrebreathing face mask and subsequent oxygen saturation improved to 92% within two hours. With hemodynamic stability and improved SpO2, treatment with methylene blue was withheld. CONCLUSION: Methemoglobinemia is a potentially lethal condition after exposure to routinely used drugs. Physicians should be aware of this complication for early diagnosis and treatment.

Sodium citrate 4% locking solution for central venous dialysis catheters--an effective, more cost-efficient alternative to heparin.

BACKGROUND: Thrombosis of the central venous haemodialysis catheter compromises dialysis adequacy and catheter survival. Heparin containing catheter-locking solution has been associated with bleeding, interferes with INR (prothrombin time/international normalized ratio) measurements and is costly. Sodium citrate has been used successfully as a catheter-locking solution, but long-term experience with its use as the exclusive locking solution has not been published. METHODS: Our haemodialysis unit converted to locking all central venous haemodialysis catheters with sodium citrate 4% instead of heparin 10 000 U/ml. A retrospective analysis compared the outcomes of the year prior and after the conversion. Flow-related catheter exchange rate, prevalence of INR assay interference, tissue plasminogen activator (rt-PA) utilization rate, rate of bacteraemias and annual cost of locking agent were examined. RESULTS: During the study period, 30 925 and 37 139 catheter days were identified during the heparin and citrate years, respectively. The rate of flow-related catheter exchange was not different during the two periods (1.81 vs 1.88 per 1000 catheter days, P = 0.89). Falsely elevated INR values were eliminated with citrate and the rate of rt-PA treatments was similar during the two periods (4.1 vs 3.23 per 1000 catheter days respectively, P = 0.07). The number of bacteraemias was similar during the two periods (0.77 vs 0.94 per 1000 catheter days respectively, P = 0.36) There was an 85% reduction in the costs associated with catheter-locking therapy during the citrate period. CONCLUSIONS: The pharmaco-economic benefits of sodium citrate 4% are well supported by this analysis. Furthermore, citrate offers several clinical advantages over concentrated heparin: citrate lock avoids heparin-associated bleeding complications, improves reliability of INR assays and provides an effective alternative for patients with suspected or confirmed heparin-induced thrombocytopenia.