Case Study: The Weighty Issue of Treatment Options for Obese Dialysis Patients.

Obesity is a complex chronic disease and common comorbidity in kidney failure and is the leading causes of death and disability in this population. Guidelines do not specifically address the preferred weight management option(s) for obesity while on dialysis. Large body size is a limiting factor for consideration of a kidney transplantation. We report on a successful bariatric surgery with a young adult after 5.5 years on dialysis with hope for a future transplant. Success was demonstrated with progressive weight loss without adverse changes in renal clinical markers accompanied by improvements in exercise tolerance and health status thereby improving her suitability for a kidney transplant. Further studies and guidelines are needed to address weight loss options for those with obesity on dialysis and want to lose weight.

Renin-Angiotensin-Aldosterone System Blockade (RAASB) After Acute Kidney Injury: The Controversy Thickens on If and When to Discontinue RAASB.

Unquestionably, there is a common consensus regarding cardiorenal protection with renin-angiotensin-aldosterone system blockade (RAASB) in both diabetic and nondiabetic chronic kidney disease (CKD). Nevertheless, there remain conflicting retrospective reports regarding renal and cardiovascular mortality outcomes following discontinuation of RAASB in advanced CKD. We present an editorial on a recent article discussing renal and mortality outcomes among hospitalized veterans who were started back on RAASB versus those who were not started back on RAASB. The controversy surrounding this topic thickens as the analysis unfolds.

A Four-Year Report on Renal Outcomes Following the Elective Withdrawal of Long-Term Renin-Angiotensin-Aldosterone Blockade in a Cohort of Patients With Otherwise Inexplicable New-Onset and Progressive Acute Kidney Injury.

Background Renin-angiotensin-aldosterone (RAAS) blockade is acclaimed, by consensus, to be renoprotective in both diabetic and non-diabetic chronic kidney disease (CKD). Contradictory reports exist regarding renal and cardiovascular outcomes after stopping RAAS blockade in advanced CKD. A few prospective, non-randomized, cohort studies have demonstrated improvement in kidney function after discontinuation of RAAS blockade. In this study, we investigated renal and mortality outcomes following the elective withdrawal of RAAS blockade after otherwise inexplicable acute kidney injury (AKI). Methodology We conducted a retrospective cohort analysis of patients enrolled between February 2018 and May 2021. Kidney function was monitored after elective withdrawal of long-term RAAS blockade in CKD patients presenting with new-onset otherwise inexplicable progressive AKI, defined by a >25% increase in baseline serum creatinine. Results In total, 71 patients, 69 Caucasians, one African American, and one Hispanic, were included in the study, with a male-to-female ratio of 42:29, and a mean age of 69.4 (37-95) years. Through February 2022, 12 patients had died, with eight remaining on hemodialysis for end-stage renal disease. Of the remaining 51 patients followed for 706 (40-1,478) days, baseline serum creatinine was 1.30 ± 0.42 (0.66-2.70) mg/dL, peak enrollment serum creatinine was 2.17 ± 1.06 (1.1-8.3) mg/dL (n = 51, p < 0.0001, t = 6.4872, df = 135), and serum creatinine after four years was 1.58 ± 0.54 (0.84-3.3) mg/dL (n = 50, p < 0.0001, t = 5.1805, df = 119). Death in 11 of 12 (91%) patients was from non-renal causes, and most deaths occurred despite improved kidney function. Conclusions Our results demonstrate clearly improved renal outcomes in most patients following the elective withdrawal of long-term RAAS blockade in CKD patients with new-onset progressive yet otherwise inexplicable AKI without increased cardiovascular mortality.

Chronic Kidney Disease Burden in Low-Resource Settings: Regional Perspectives.

The burden of chronic kidney disease (CKD) has increased exponentially worldwide but more so in low- and middle-income countries. Specific risk factors in these regions expose their populations to an increased risk of CKD, such as genetic risk with APOL1 among populations of West African heritage or farmers with CKD of unknown etiology that spans various countries across several continents to immigrant/indigenous populations in both low- and high-income countries. Low- and middle-income economies also have the double burden of communicable and noncommunicable diseases, both contributing to the high prevalence of CKD. The economies are characterized by low health expenditure, sparse or nonexistent health insurance and welfare programs, and predominant out-of-pocket spending for medical care. This review highlights the challenges in populations with CKD from low-resource settings globally and explores how health systems can help ameliorate the CKD burden.

Pseudohyperkalemia and the Need for Imperative Caution With the Newly Introduced Potent Potassium Binders: Two Cases.

Pseudohyperkalemia was first reported in 1955 by Hartmann and Mellinkoff, as a marked elevation of serum potassium in the absence of clinical evidence of electrolyte imbalance - simultaneous serum potassium exceeds plasma potassium by >0.4 mmol/L. We describe two patients with pseudohyperkalemia who inadvertently received inappropriate potassium binder therapy for weeks to months before the diagnosis of pseudohyperkalemia was entertained and subsequently confirmed. Potassium binders ultimately were promptly discontinued once the diagnosis of pseudohyperkalemia was confirmed. Physicians' attention must be drawn to the availability of the new potent oral potassium binders, patiromer and sodium zirconium cyclosilicate. We strongly advocate for imperative caution with these new binders. Iatrogenic life-threatening hypokalemia remains a real concern and must be avoided. Our patients highlighted the importance of caution in the use of the newer potent potassium binders to mitigate against the causation of iatrogenic hypokalemia. Also as important is the observation that in the same patient, with changing clinical scenarios, a patient might exhibit true hyperkalemia that alternated with pseudohyperkalemia, the first of such a report.

Alternating and Concurrent True Hyperkalemia and Pseudohyperkalemia in Adult Sickle Cell Disease.

Sickle cell disease (SCD) predisposes the patient to recurrent episodes of acute painful hemolytic crisis. Sickle cell nephropathy (SCN) is not uncommon in adult patients, and renal manifestations of SCN include renal ischemia, microinfarcts, renal papillary necrosis, and renal tubular abnormalities with variable clinical presentations. Intravascular hemolysis and reduced glomerular filtration rate with renal tubular dysfunction predispose to true hyperkalemia. Hemolytic crisis can be complicated by sepsis, leading to significant degrees of thrombocytosis, and thrombocytosis is a well-defined cause of pseudohyperkalemia. We describe a 40-year-old African American male patient with sickle cell anemia who exhibited alternating episodes of true hyperkalemia and pseudohyperkalemia, during consecutive hospital admissions. Clearly, true hyperkalemia is a potentially lethal condition. At the same time, the institution of inappropriate and intensive treatment of pseudohyperkalemia leading to severe hypokalemia is also potentially lethal. The need for this caution is most imperative with the recent introduction of the safer and more potent potassium binders, patiromer and sodium zirconium cyclosilicate.

Timed Controlled Repeated Rotation of the CAR-170-C NXSTAGE Chronic Cartridge Hemodialysis Filter: A Novel Approach to Enabling Heparin-Free Frequent Daily Home Hemodialysis.

Heparin-free hemodialysis is often warranted in postoperative states, bleeding diathesis, and critically ill patients. Conventionally, this is achieved through normal saline flushes or regional citrate anticoagulation. An 87-year-old white man with end-stage renal disease and atrial fibrillation, who was taking warfarin and using maintenance home hemodialysis (HHD) with an NxStage machine, underwent laparoscopic appendicectomy. The procedure was complicated by intra-abdominal abscess, sepsis, and tamponade from a bloody pericardial effusion. He needed emergent therapeutic pericardiocentesis. Warfarin was promptly discontinued. He was discharged home with heparin-free HHD. Prior heparin anticoagulation for HHD was an initial bolus of 4000 units of heparin. He continued to clot his extracorporeal system with resultant very high venous pressures and compromised HHD. Heparin anticoagulation was still contraindicated. Flushes with 250-500 mL normal saline, delivered in aliquots every 15-30 minutes, failed to prevent the frequent clotting. The first author, our HD Senior Technician, had astutely observed that the horizontally placed hemodialysis filter exhibited early "clot" formation at the 12-o'clock position, despite the saline flushes. Through trial and error, he discovered that rotating the horizontally placed hemodialysis filter along its long axis, 60 degrees clockwise for 15 minutes, return to the neutral position for 15 minutes, rotating the filter another 60 degrees counterclockwise for 15 minutes, with this repeated cycle of rotations "did the trick." It promptly and consistently resolved the clotting problem. The lines stopped clotting, and he has not needed saline flushes for smooth heparin-free HHD for more than 7 months. To our knowledge, this is the first such report. Further study is justified. We have hypothesized a mechanism and have named this the "Locke-Onuigbo Maneuver."

Clinical Management of Hyperkalemia.

Hyperkalemia is an electrolyte abnormality with potentially life-threatening consequences. Despite various guidelines, no universally accepted consensus exists on best practices for hyperkalemia monitoring, with variations in precise potassium (K+) concentration thresholds or for the management of acute or chronic hyperkalemia. Based on the available evidence, this review identifies several critical issues and unmet needs with regard to the management of hyperkalemia. Real-world studies are needed for a better understanding of the prevalence of hyperkalemia outside the clinical trial setting. There is a need to improve effective management of hyperkalemia, including classification and K+ monitoring, when to reinitiate previously discontinued renin-angiotensin-aldosterone system inhibitor (RAASi) therapy, and when to use oral K+-binding agents. Monitoring serum K+ should be individualized; however, increased frequency of monitoring should be considered for patients with chronic kidney disease, diabetes, heart failure, or a history of hyperkalemia and for those receiving RAASi therapy. Recent clinical studies suggest that the newer K+ binders (patiromer sorbitex calcium and sodium zirconium cyclosilicate) may facilitate optimization of RAASi therapy. Enhancing the knowledge of primary care physicians and internists with respect to the safety profiles of these newer K+ binders may increase confidence in managing patients with hyperkalemia. Lastly, the availability of newer K+-binding agents requires further study to establish whether stringent dietary K+ restrictions are needed in patients receiving K+-binder therapy. Individualized monitoring of serum K+ among patients with an increased risk of hyperkalemia and the use of newer K+-binding agents may allow for optimization of RAASi therapy and more effective management of hyperkalemia.

Page Kidney Complicating Kidney Biopsy after Stopping Apixaban: A Physician's Dilemma.

Page kidney was described by Page, following very elaborate experiments with animal kidneys in 1939, with persistent arterial hypertension from "cellophane perinephritis." Subsequently, it was reported after trauma, from renal cysts and tumors, and from intrarenal hematoma complicating percutaneous kidney biopsy. We describe Page kidney associated with acute kidney injury 26 days after an uncomplicated ultrasound-guided right native kidney biopsy. Patient was on Apixaban, a non-vitamin K antagonist oral anticoagulant (NOAC) for atrial fibrillation which was withheld 3 days before the procedure. It was restarted 3 days after. The evidence-base supporting guidelines and recommendations for the peri-procedural management of the NOACs is inadequate, sparse, and often conflicted. More research is warranted.

Pseudo-arterial Temporary Hemodialysis Catheter Placement in the Left Internal Jugular Vein Ipsilateral to a Preexisting Brachio-axillary Arteriovenous Graft.

Internal jugular vein (IJV) cannulation was originally described by English et al. in 1969 as the safest approach. Carotid artery puncture had an incidence rate of 4-6% before ultrasound guidance. We encountered an unexpected sequence of events following the ultrasound-guided placement of a temporary HD catheter in the left IJV. The postprocedure chest radiograph was misinterpreted as an arterial misplacement, the blood return was correspondingly bright red, and simultaneous blood gas analyses from the left IJV catheter and a right radial artery were near mirror images. Subsequently, a transducer to the catheter showed a clearly venous waveform with a pressure of 40 mmHg. Thus, it was realized that the cacophony of missteps, misjudgments, and misinterpretations was due to the contiguous presence of a functional left brachio-axillary arteriovenous (AV) graft. To our knowledge, this is the first such report of this phenomenon of a pseudo-arterial central venous catheter placement in the IJV.

Post-Renal Biopsy Acute Kidney Injury and Page Kidney from Intra-Renal Hematoma Aggravated by Reversible Contrast-Induced Nephropathy Following Renal Arterial Embolization.

BACKGROUND Page kidney was described by Dr. Irving Page in animal kidneys in 1939 with renal failure and persistent arterial hypertension from "cellophane perinephritis". By 2009, about 100 cases of Page kidney had been reported. Bleeding complications after percutaneous kidney biopsy has, however, been well described. Moreover, the perioperative management of the recently introduced non-vitamin K antagonist anticoagulants (NOACs) remains uncertain due to inadequate evidence. Current guidelines to determine the appropriate duration of withholding NOACs before a surgical procedure, and when to restart NOACs safely after a procedure, however, cognizant of the implications of renal dysfunction, and levels of risk of the procedure are still unclear and sometimes conflicted. CASE REPORT We describe a case of Page kidney from an intrarenal hematoma complicating ultrasound-guided percutaneous right native kidney biopsy with acute kidney injury after withholding apixaban, a NOAC, for 3 days. Computed tomography evidence of continuing intrarenal bleeding from a renal pseudoaneurysm was treated with super-selective renal artery embolization; the case was further complicated by superimposed acute kidney injury from contrast-induced nephropathy. CONCLUSIONS We reviewed the vagaries of Page kidney with respect to the presence, or otherwise, of hypertension and how to explain worsening renal failure despite only unilateral involvement of a single kidney in a patient with 2 kidneys. Furthermore, we revisit the risks of contrast-induced nephropathy following iodinated contrast exposure. We explored the alternative management options for a post-biopsy renal pseudoaneurysm, that would avoid the use of iodinated contrast that could have potentially mitigated, if not fully prevented, the ensuing contrast-induced acute kidney injury.

A Novel Diagnostic Approach for Suspected Icodextrin Pleural Effusion in a Peritoneal Dialysis Patient.

Symptomatic pleural effusion secondary to pleuroperitoneal communication in patients undergoing peritoneal dialysis (PD) occurs in approximately 2% of patients undergoing continuous ambulatory PD. The classic presentation is that of a low-protein, high-glucose pleural aspirate consistent with the high dextrose concentrations present in standard PD fluids, hence the name sweet hydrothorax. Nevertheless, the increasing use of icodextrin calls for an innovative bedside diagnostic approach because icodextrin does not contain high concentrations of dextrose after all. We describe a patient with newly symptomatic right pleural effusion 2 months after starting continuous ambulatory PD with 2 exchanges every 12 hours. Prompt relief was achieved with therapeutic thoracentesis, but the pleural aspirate had less than 2 g/dL of protein (to convert to g/L, multiply by 10) and a glucose level of 108 mg/dL (to convert to mmol/L, multiply by 0.0555), lower than the blood glucose level of 139 mg/dL in the emergency department earlier the same night. The patient was allergic to iodinated contrast. We, therefore, used an innovative approach with biochemical fingerprint analysis of simultaneous pleural and peritoneal fluids for electrolytes, urea, creatinine, and measured osmolality. With the increasing use of icodextrin in contemporary PD worldwide, this innovative tactic is cheap, is easily available, and does not require sophisticated, expensive, and often unavailable options, such as isotope studies, dye studies, and iodinated contrast-enhanced computed tomography. To our knowledge, this is the first time that biochemical fingerprint analysis of simultaneous pleural and peritoneal fluids has been reported in the literature.

End of Life, Withdrawal, and Palliative Care Utilization among Patients Receiving Maintenance Hemodialysis Therapy.

BACKGROUND AND OBJECTIVES: Withdrawal from maintenance hemodialysis before death has become more common because of high disease and treatment burden. The study objective was to identify patient factors and examine the terminal course associated with hemodialysis withdrawal, and assess patterns of palliative care involvement before death among patients on maintenance hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We designed an observational cohort study of adult patients on incident hemodialysis in a midwestern United States tertiary center, from January 2001 to November 2013, with death events through to November 2015. Logistic regression models evaluated associations between patient characteristics and withdrawal status and palliative care service utilization. RESULTS: Among 1226 patients, 536 died and 262 (49% of 536) withdrew. A random sample (10%; 52 out of 536) review of Death Notification Forms revealed 73% sensitivity for withdrawal. Risk factors for withdrawal before death included older age, white race, palliative care consultation within 6 months, hospitalization within 30 days, cerebrovascular disease, and no coronary artery disease. Most withdrawal decisions were made by patients (60%) or a family member (33%; surrogates). The majority withdrew either because of acute medical complications (51%) or failure to thrive/frailty (22%). After withdrawal, median time to death was 7 days (interquartile range, 4-11). In-hospital deaths were less common in the withdrawal group (34% versus 46% nonwithdrawal, P=0.003). A third (34%; 90 out of 262) of those that withdrew received palliative care services. Palliative care consultation in the withdrawal group was associated with longer hemodialysis duration (odds ratio, 1.19 per year; 95% confidence interval, 1.10 to 1.3; P<0.001), hospitalization within 30 days of death (odds ratio, 5.78; 95% confidence interval, 2.62 to 12.73; P<0.001), and death in hospital (odds ratio, 1.92; 95% confidence interval, 1.13 to 3.27; P=0.02). CONCLUSIONS: In this single-center study, the rate of hemodialysis withdrawals were twice the frequency previously described. Acute medical complications and frailty appeared to be driving factors. However, palliative care services were used in only a minority of patients.

Hospital Readmission among New Dialysis Patients Associated with Young Age and Poor Functional Status.

BACKGROUND/AIMS: Over one-third of hospital discharges among dialysis patients are followed by 30-day readmission. The first year after dialysis start is a high-risk time frame. We examined the rate, causes, timing, and predictors of 30-day readmissions among adult, incident dialysis patients. METHODS: Hospital readmissions were assessed from the 91st day to the 15th month after the initiation of dialysis using a Mayo Clinic registry linkage to United States Renal Data System claims during the period January 2001-December 2010. RESULTS: Among 1,727 patients with ≥1 hospitalization, 532 (31%) had ≥1, and 261 (15%) had ≥2 readmissions. Readmission rate was 1.1% per person-day post-discharge, and the highest rates (2.5% per person-day) occurred ≤5 days after index admission. The overall cumulative readmission rate was 33.8% at day 30. Common readmission diagnoses included cardiac issues (22%), vascular disorders (19%), and infection (13%). Similar-cause readmissions to index hospitalization were more common during days 0-14 post-discharge than days 15-30 (37.5 vs. 22.9%; p = 0.004). Younger age at dialysis initiation, inability to transfer/ambulate, serum creatinine ≤5.3 mg/dL, higher number of previous hospitalizations, and longer duration on dialysis were associated with higher readmission rates in multivariable analyses. Patients aged 18-39 were few (8.3%) but comprised 17.7% of "high-readmission" users such that a 30-year-old patient had an 87% chance of being readmitted within 30 days of any hospital discharge, whereas an 80-year-old patient had a 25% chance. CONCLUSIONS: Overall, 30-day readmissions are common within the first year of dialysis start. The first 10-day period after discharge, young patients, and those with poor functional status represent key areas for targeted interventions to reduce readmissions.

All-cause costs increase exponentially with increased chronic kidney disease stage.

OBJECTIVE: To evaluate the economic impact of chronic kidney disease (CKD) on US health plans. STUDY DESIGN: A retrospective analysis identified patients with a renin-angiotensin-aldosterone system inhibitor (RAASi) prescription from an electronic medical record (EMR) database (Humedica); those with =90 days in =1 CKD stage were selected based on estimated glomerular filtration rate or diagnosis code, and a cohort on RAASi medications without CKD was selected. Costs for specific services obtained from OptumInsight were applied to services in EMR data of patients aged <65 years (commercial) and =65 years (Medicare). Dialysis costs were excluded. RESULTS: The study included 106,050 patients with CKD and 56,761 no-CKD controls (90,302 commercial and 72,509 Medicare overall). Mean annualized all-cause costs increased exponentially with advancing stage, from $7537 (no CKD) to $76,969 (CKD stages 4-5) in the commercial group, and $8091 (no CKD) to $46,178 (CKD stages 4-5) in the Medicare group (P <.001; all comparisons with preceding disease stage). Mean costs for end-stage renal disease (ESRD) patients were $121,948 and $87,339 in the commercial and Medicare groups, respectively. Inpatient costs were the largest contributor to total costs, and their relative contribution increased with advancing CKD. CONCLUSIONS: Cost to US health plans increases exponentially with each CKD stage progression. ESRD costs are even higher. Because readmissions lead to higher costs, efforts to reduce readmissions would result in cost reductions. Furthermore, healthcare reengineering paradigms that manage increasing comorbidities with advancing CKD, including heart failure, diabetes, and hyperkalemia, should offer additional potential for cost reductions.

A Mayo Clinic 13-year investigation of the syndrome of rapid onset ESRD among renal transplant recipients: An analysis of the implications of renal allograft biopsy results.

INTRODUCTION: We first described the syndrome of rapid onset end stage renal disease (SORO-ESRD), acute yet irreversible renal failure, in 2010. OBJECTIVE: The impact of SORO-ESRD renal allograft survival remains speculative and we plan to study this question. METHODS: A retrospective analysis of individual adult patient-level serum creatinine trajectories of ESRD patients on maintenance hemodialysis for >90 days at Mayo Clinic, Rochester, 2001-2013. RESULTS: Of 1461 ESRD patients, 149 (10%) patients including 13 renal transplant recipients (RTRs) satisfied the diagnosis of SORO-ESRD - 4 males, 9 females, 12 Caucasians/one other, age 45 (18-83) years. Serum creatinine was 1.4 (0.8-1.7) mg/dL in the last year before hemodialysis initiation. Initial hemodialysis access was a dialysis catheter in all 13 patients. AKI precipitating SORO-ESRD followed acute rejection (4), postoperative (2), tubulo-interstitial nephritis (2), unknown (2), infection/sepsis (1), contrast nephropathy (1), BKV nephropathy (1), and cardio-renal syndrome (1). Renal allograft survival was 1469 (277-4939) days (4 years). Renal allograft biopsies were available in 9/14 (69%) RTRs - Four showed acute rejection, two of which followed interruption of immunosuppression, three revealed acute tubular necrosis and four others also showed chronic transplant glomerulopathy. Time on hemodialysis was 856 (129-1630) days (2.4 years). 5/13 RTRs with SORO-ESRD (38%) died - 3 (60%) following cardiac arrest, 2 (40%) after stopping hemodialysis. 4/13 (31%) were re-transplanted in the period of this study. CONCLUSION: SORO-ESRD contributed significantly to late renal allograft loss and return to hemodialysis with 100% initial dialysis catheter rate. Potentially preventable causes of AKI leading to SORO-ESRD were identified. The application of experience gained from such studies would help reduce late renal allograft loss and the need for re-transplantation. This would further help reduce the yawning gap between need and availability of donor kidney organs both here in the United States and around the world. Larger studies are warranted.