Pulmonary embolism following thrombolysis of dialysis access: is anticoagulation really necessary?

Vascular access thrombosis frequently complicates maintenance hemodialysis (HD) therapy. It is costly and time consuming to patients and practitioners. Alternatives to surgical thrombectomy have been developed using percutaneous thrombolysis (PT) with pharmacologic lysis, mechanical destruction of thrombus, or a combination of the two. These techniques have been used to successfully restore blood flow through thrombosed HD arteriovenous grafts (AVG), but there is a risk of dislodging thrombi into the venous circulation resulting in pulmonary embolism (PE); it is usually clinically insignificant. We examined our practice and reviewed three cases of dialysis access thrombosis treated with PT complicated by symptomatic PE. Two important questions arose: what is the risk of symptomatic PE after PT, and do patients benefit from systemic anticoagulation?

Recurrent membranous nephropathy and leiomyosarcoma in the renal allograft of a lupus patient.

The frequency of membranous lupus nephritis recurrence (World Health Organization (WHO) class V) in the allograft after renal transplantation is unknown, but it appears uncommon (only two reported cases in the literature). Despite the increased incidence of sarcomas in organ transplant recipients (compared to the general population), non-Kaposi's sarcoma is an uncommon malignancy, and primary tumor involvement of a renal allograft is a rare occurrence. Our patient is a 28 year old female with end-stage renal disease (ESRD) secondary to membranous lupus nephritis who received a living related transplant from her mother. At 26 months post-transplant, she presented with proteinuria and a rise in creatinine (Cr). Allograft biopsy was consistent with recurrent membranous nephropathy. Five weeks later, she was found to have a high-grade leiomyosarcoma originating within the allograft. We reviewed the literature on recurrent post-transplant membranous nephropathy and the possible role of the Epstein-Barr virus (EBV) infection in smooth muscle tumors occurring in organ transplant recipients. We also considered the association of membranous nephropathy and malignancy.