Hemender S. Vats

Complications of Catheters: Tunneled and Nontunneled

Central venous catheters for hemodialysis remain an indispensable modality of vascular access in the United States. Despite strong recommendations by the NKF-KDOQI guidelines to reduce the dependence on catheters, > 80% of all patients initiate hemodialysis using a central venous catheter. Although the tunneled dialysis catheters have some advantages, their disadvantages are many and often dwarf the miniscule advantages. This review is intended to discuss the complications--both acute and chronic--related to the use of tunneled dialysis catheters for hemodialysis access.

Infected vertebroplasty: case report and review of literature.

Study Design. Case report. Objectives. To describe a case of infected vertebroplasty and to demonstrate the importance of polymerase chain reaction (PCR) in the diagnosis of such infections. Summary of Background Data. Infection of the vertebroplasty site is an uncommon complication of vertebroplasty. Only 4 cases have been reported in the literature so far, and an organism could be identified in only 2 of those cases. To our knowledge, the use of PCR to diagnose infection in these cases has not been reported before. Methods. Vertebroplasty, laminectomy, radiology, fluid aspiration, microbial culture, and 16S RNA PCR. Results. A 73-year-old diabetic woman underwent vertebroplasty for L2 and L3 vertebral compression fractures followed by L4–L5 laminectomy for spinal stenosis. Three months later, she had an L1 fracture that was augmented with vertebroplasty. Six months later, she presented with incapacitating low back pain. There was a fluid-filled cavity surrounding the polymethylmethacrylate in the L1 and L2 vertebral bodies. The fluid had 95,000 white blood cells with 96% neutrophils, grew nothing on culture, but had 100% homology with Streptococcus agalactiae on 16S ribosomal nucleic acid analysis. Conclusions. We report a case of infected vertebroplasty with atypical radiologic findings of vertebral infection. To our knowledge, this is the third reported case where an organism could be isolated for these infections and the first time PCR has been used to diagnose such an infection.

Early postnephrectomy donor renal function

Laparoscopic donor nephrectomy (LDN) is becoming the method of choice to procure kidneys from living donors. Despite the benefits to the donor, there have been concerns over the transient deterioration of renal function in the recipient of LDN compared with standard nephrectomy. We carried out a retrospective review of all living donors at our institution between January 2000 and December 2002. On the first postoperative day, the fall in renal function in laparoscopic donors is significantly greater than the fall seen in open donors. This difference could not be explained by relative hypotension, excessive blood loss, or inadequate fluid replacement in the laparoscopic group. Importantly, this difference is no longer evident by the third postoperative day. We speculate that this may be secondary to the pneumoperitoneum or the prolonged anesthesia on glomerular filtration rate. Furthermore, this finding could explain the slower recovery of graft function in recipients of laparoscopically procured kidney transplants.

Rapid reduction of severely elevated serum triglycerides with insulin infusion, gemfibrozil and niacin.

The conventional methods of treatment of severe hypertriglyceridemia are dietary restriction and lipid lowering medications, mainly fibric acid derivatives. In the medical literature, use of insulin infusion to treat hypertriglyceridemia has not been highlighted sufficiently. We report a 53-year-old male who presented with a four-day history of epigastric pain. The patient’s clinical history was significant for hypertriglyceridemia, type-2 diabetes mellitus with medication noncompliance, obesity, status post-gastric bypass surgery, and alcohol abuse with prior admissions for detoxification. Physical examination revealed mild epigastric tenderness. Laboratory studies revealed severely elevated serum triglyceride (TG) level (8116 mg/dL). Computed tomography (CT) scan of the abdomen exhibited no evidence of pancreatitis. Regular insulin infusion was started at 3 U/h and gradually increased to 7–10 U/h. Dextrose infusion was titrated to avoid hypoglycemia and maintain blood glucose levels below 150 mg/dL. Gemfibrozil and niacin were also started. After 24 hours, his TG levels were decreased to 2501 mg/dL. Insulin infusion was continued for about 48 hours. A low carbohydrate diet excluding simple carbohydrates was given. The patient’s serum TG levels normalized over a period of one month. Thus insulin infusion can be considered a safe modality of treatment for rapid reduction of serum TG in addition to fibrates and niacin.

The Effect of Buttonhole Cannulation vs. Rope‐ladder Technique on Hemodialysis Access Patency

The rope‐ladder (RL) technique is the most common technique used for cannulation of arteriovenous fistulae (AVF). Buttonhole cannulation (BHC), or constant‐site technique, is recommended by the National Kidney Foundations Kidney Disease Outcome Quality Initiative (NKF/KDOQI) vascular access guidelines. We compared outcomes of primary patency, episodes of bacteremia, access blood flow (Qa), and quality of life (QoL) scores between RL and BHC patients. Using a prospectively collected, vascular access database, a total of 45 prevalent dialysis patients using BHC were compared with 38 patients using the RL technique over a median of 12 months (inter‐quartile range: 4–27 months). The two groups did not differ significantly in demographics except that diabetes was more common in those using BHC as compared to rope‐ladder (69% vs. 34%; p = 0.002). Risk factors associated with lack of primary patency were age (hazards ratio [HR] = 1.02 per decade; 95% CI: 1.00–1.03; p = 0.04) and female gender (HR = 1.92; 95% CI: 1.08–3.40; p = 0.03). Use of the buttonhole technique was not associated with improved primary patency (HR = 1.22, 95% CI: 0.65–2.28; p = 0.53). Episodes of bacteremia and mean scores from KDQOL‐36 did not differ significantly between the groups. This study demonstrates for the first time that BHC use is not associated with improved access patency.

Does Early Initiation of Continuous Renal Replacement Therapy Affect Outcome: Experience in a Tertiary Care Center

Abstract Background: Acute kidney injury (AKI) requiring dialysis commonly occurs in critically ill patients and is associated with high mortality. Factors impacting outcomes of individuals with AKI who underwent continuous renal replacement therapy (CRRT), including early versus late initiation and duration of CRRT, were examined. Methods: Survival and recovery of renal function for patients with AKI in the intensive care unit were retrospectively examined over a 7-year period. Factors associated with mortality and renal recovery were analyzed based on severity of illness as defined by Cleveland Clinic Foundation (CCF) score. Univariate and multivariate logistic regression analysis with backward elimination was performed to determine the most significant risk factors. Results: Of patients who underwent CRRT, 230/330 met inclusion criteria. During index admission 112/230 (48.7%) patients died. Median survival was 15.5 days [95% confidence interval (12.0, 18.0)]. Among survivors, renal recovery occurred in 84/118 (71.2%). Renal recovery overall was observed in 90/230 subjects (39.13%). A higher baseline CCF score correlated with higher mortality and lower probability of renal recovery. Patients initiated on CRRT > 6 days after AKI diagnosis had significantly higher mortality compared with those initiated earlier (odds ratio = 11.66, p = 0.0305). Patients receiving CRRT >10 days had a higher mortality rate compared with those with shorter exposure (71.3% vs. 45.5%, respectively, p = 0.012). Conclusions: CRRT remains an important dialysis modality in hemodynamically unstable patients with AKI. Mortality in these patients continues to be high. Renal recovery is high in survivors. Delay in initiation and length of CRRT exposure may portend poorer prognosis.

Chronic Total Occlusion and Successful Drug-Eluting Stent Placement in Takayasu Arteritis–Induced Renal Artery Stenosis

Takayasu arteritis-induced renal artery stenosis (TARAS) is a condition rarely described in the literature. Although percutaneous transluminal angioplasty and stenting has been well-described in the treatment of atherosclerotic renal artery stenosis, its role has not been established in non-atherosclerotic TARAS. We report a case of a female, age 17 years, with Takayasu arteritis who presented to the hospital with seizures and hypertensive crisis. A renal angiogram showed chronic total occlusion (CTO) of the left renal artery. Renal angioplasty and stenting was successfully performed after multiple attempts to deliver a wire distal to the CTO. After sequential balloon predilation, a drug-eluting stent was deployed, resulting in full reperfusion of the kidney. The patient’s blood pressure improved dramatically, and patency of the stent was demonstrated with magnetic resonance angiography over 9 months after the procedure.

A comparison between blood flow outcomes of tunneled external jugular and internal jugular hemodialysis catheters

Purpose The right internal jugular (RIJ) vein is preferred for placement of long-term venous catheters (CVC) for hemodialysis (HD). Use of left IJ vein potentially depletes the access site for arteriovenous fistula (AVF) or arteriovenous graft (AVF) placement because of the high rates of central venous stenosis. The right external jugular (EJ) vein is a viable alternative to the LIJ. The purpose of this study is to compare blood flow outcomes in a series of percutaneously placed external jugular (EJ), LIJ and RIJ HD catheters. Methods Using a prospectively collected database, we identified 46 hemodialysis patients who received a tunneled catheter during a 4-year period. Blood flow outcomes of RIJ, LIJ, and EJ catheters that were date-matched over the study period were compared. Using ANOVA, the blood flow outcomes of the 3 tunneled catheter techniques at 30-d and 90-d were compared. Results The 90-d blood flow outcomes of the 3 groups did not differ significantly. The 30-d blood flow was found to be 348.5± 56.62, 341± 22.42, and 365.7± 71.76 mL/min for RIJ, LIJ, and EJ respectively (P<.05). Using multiple regression analysis, no covariates (age, sex, race, diabetes) were found to be associated with blood flow outcomes at 30-d or 90-d. No identifiable factors were found to be associated with the difference in blood flow between 30-d and 90-d either. Conclusions EJ blood flow outcomes at 30-d and 90-d were comparable to both LIJ and RIJ historic data. Further prospective investigation is required to define the role of EJ CVC placement as another potential long-term access modality.

Metastatic Virilizing Adrenocortical Carcinoma: A Rare Case of Cure with Surgery and Mitotane Therapy

A 57-year-old white woman with metastases to lungs and liver from virilizing adrenocortical carcinoma (ACC) was treated with radical nephroadrenalectomy followed by oral mitotane 3 to 6 g/day for 5 months. She developed complete response and remained free of disease for more than 25 years. Here we present the case and review the literature. ACC is a rare tumor and may occur at any age. About 60% are functional tumors with hormonal secretions and clinical manifestations due to specific hormone secretions: Cushing’s syndrome due to cortisone, virilizing tumor due to androgens, feminizing tumor due to estrogens, or hypertension due to aldosterone. Stage I and II disease is curable with surgery. Stage III and IV disease may benefit from mitotane orally with gradual adjustment of the dosage to a tolerable level. Plasma mitotane level at 14 to 20 g/L results in optimal response both in hormonal secretion and symptom control, as well as tumor regression. Addition of chemotherapy (streptozotocin or a combination of etoposide, cisplatin and doxorubicin) to mitotane also produced responses along with increased survival among responders. An international study has been started by randomizing between two of the above combinations by the Collaborative Group for Adrenocortical Carcinoma Treatment.

Palliative medicine referral in patients undergoing continuous renal replacement therapy for acute kidney injury.

Abstract Background: Referral patterns for palliative medicine consultation (PMC) by intensivists for patients requiring continuous renal replacement therapy (CRRT) have not been studied. Methods: We retrospectively analyzed clinical data on patients who received CRRT in a tertiary referral center between 1999 and 2006 to determine timeliness and effectiveness of PMC referrals and mortality rate as a surrogate for safety among patients receiving CRRT for acute kidney injury. Results: Over one-fifth (21.1%) of the 230 CRRT patients studied were referred for PMC (n = 55). PMC was requested on average after median of 15 hospital and 13 intensive care unit (ICU) days. Multivariate regression analysis revealed no association between mortality risk and PMC. Total hospital length of stay for patients who died after PMC referral was 18.5 (95% CI = 15–25) days compared with 12.5 days (95% CI = 9–17) for patients who died without PMC referral. ICU care for patients who died and received PMC was longer than for patients with no PMC [11.5 (95% CI = 9–15) days vs. 7.0 (95% CI = 6–9) days, p < 0.01]. CRRT duration was longer for patients who died and received PMC referral than for those without PMC [5.5 (95% CI = 4–8) vs. 3.0 (95% CI = 3–4) days; p < 0.01]. Conclusions: PMC was safe, but referrals were delayed and ineffective in optimizing the utilization of intensive care in patients receiving CRRT. A proactive, “triggered” referral process will likely be necessary to improve timeliness of PMC and reduce duration of non-beneficial life-sustaining therapies.