Adrian Sequeira

Bile cast nephropathy: An often forgotten diagnosis

High bilirubin levels are nephrotoxic. Bilirubin can cause a functional proximal tubulopathy or may precipitate into casts associated with acute tubular injury. This condition is known as bile cast nephropathy. The kidney injury is generally reversible if bilirubin levels are decreased early. We present a case wherein an alcoholic patient presented with high bilirubin levels and anuric acute kidney injury. The initial urine analysis suggested intrinsic renal disease. A kidney biopsy, performed a few days after the initiation of dialysis, demonstrated the presence of bile casts along with acute tubular injury. The patient however continued to be dialysis dependent inspite of initiating prednisolone to treat acute alcoholic hepatitis.

Complications of a High-flow Access and Its Management

A high‐flow access has been defined as one with a flow >1–1.5 l/minute or as one where the access flow is >20% of the cardiac output. Although it may be asymptomatic, it can be associated with cardiopulmonary complications, aneurysms, central vein stenosis and the distal hypoperfusion ischemic syndrome in some patients. The decision for surgical intervention should be made after careful medical optimization especially in patients with high output cardiopulmonary compromise. In this review, we present a summary of current knowledge about the pathophysiology of a high‐flow fistula, followed by a concise, comprehensive synopsis of current medical and surgical therapy.

Calcific mitral stenosis in the hemodialysis patient

The dialysis patient is prone to elevations in the calcium phosphorus product and hyperparathyroidism, which contributes to valvular and vascular calcification. We present the case of a young lady on chronic dialysis that developed mitral calcification complicated by severe mitral stenosis, caseous calcification and retinal embolization. She subsequently required mitral valve replacement.

Stent Strut Protrusion – An Uncommon Complication of Stent Placement in a Fistula

Stent strut protrusion through the skin is a rare and a potentially dangerous complication from the cannulation of stents placed within arterio‐venous fistulas and grafts. Such cases are usually managed surgically. We present a case wherein strut penetration of an arterio‐venous fistula was noted at the distal (uncovered) end of a Fluency Plus® tracheo bronchial stent graft. After analyzing the various reasons why this may have happened, a nonsurgical approach was taken to preserve the access and manage strut protrusion.

Peritoneal Dialysis Catheter Placement Techniques

The success of catheter placement is critically important for the ability to stay on peritoneal dialysis over the long-term. Nephrologists have used percutaneous placement with or without fluoroscopic guidance and placement using peritoneoscopic guidance to place these catheters. Complications can be divided into early, within 14 days, and late complications, those arising more that 14 days after the procedure. The main post-procedure complications are infection, leakage, and obstruction. Results of non-invasive placement have been comparable to surgical placements. The non- invasive technique is simple with minimal intra-operative morbidity, and a post-placement complication rate better than surgical placements. Comparing percutaneously placed catheters to laparoscopically and peritoneoscopically placed catheters shows that the laparoscopic technique has a better one year survival rate. In deciding which technique is best for the patient, it is important to identify advantages of percutaneous placement, such as use of local anesthesia, lower rates of complications, the fact that it is a bedside or office procedure, versus the limitations in that the percutaneous method is not suited for obese patients or those patients likely to have peritoneal adhesions. Peritoneal catheters can be placed in a timely manner without delays associated with surgical scheduling. This offers an added option, both to the neprhologist and the patient and may avoid starting dialysis using a central venous catheter. The placement of peritoneal dialysis catheters by nephrologists has been shown to increase utilization of peritoneal dialysis as a dialysis modality, and this is an important advantage of the procedure.

Testicular angina during hemodialysis: An unusual complication of ultrafiltration

During hemodialysis, the development of hypotension or symptoms suggestive of ischemia is used as a surrogate marker for the establishment of dry weight. These symptoms manifest commonly as muscle cramps, chest pain or abdominal pain. Hemodialysis patients are also prone to vascular calcification which may be medial or intimal. We report the case of a 68‐year‐old male who developed testicular pain while attempting to establish dry weight. Computerized tomography scan of his abdomen showed extensive vascular calcification. The end result in this case was bilateral orchiectomy. Histopathology revealed hyperplastic arteriolosclerosis with intimal calcification contributing to ischemia.

An Approach to Heparin and Lidocaine Hypersensitivity for the Interventional Nephrologist

The general and interventional nephrologist may occasionally encounter a situation where the patient may state that he/she has an allergy to lidocaine or heparin. Heparin hypersensitivity is usually either a delayed type hypersensitivity reaction or an immune‐mediated thrombocytopenia. While a number of alternative drugs are available, many of them are subject to local availability, food and drug administration indications, and the patients hepatic and renal function. Many of these drugs do not have antidotes in case of bleeding. Lidocaine hypersensitivity is usually a delayed type reaction, although adverse reactions, which are much more common, are wrongly labeled as an allergy. 1% diphenhydramine and benzyl alcohol may be used as alternatives.

Telescoping of Sheaths—An Easy Technique To Facilitate the Removal of a Stuck Ruptured Transluminal Angioplasty Balloon

Balloon rupture during angioplasty is an uncommon event. The ruptured balloon usually is removed through its introducer sheath without any problems. However, there may be occasions when a ruptured balloon cannot be withdrawn from an access. We describe a simple technique that can be used to extricate a stuck ruptured angioplasty balloon.

LEARNING FROM IMAGES

lower extremity edema. He was on 7 anti-hypertensive medications. His serum creatinine had gradually increased from 2.5mg/dl to 3.1mg/dl over the last year. The initial renal Doppler ultrasound followed later by an angiogram demonstrated the presence of a hemodynamically significant renal artery stenotic lesion (Fig. 1A). Following angioplasty and stent placement (Fig. 1B, C), his serum creatinine stabilized at 2.8mg/dl and his blood pressure was well controlled on 5 antihypertensives.