Nuri Baris Hasbal

Air embolism following removal of hemodialysis catheter.

Introduction: Air embolism (AE) is a rare, but serious complication that can occur in the practice of hemodialysis. In contrast to careful techniques and meticulous care during insertions and manipulations of the central catheters, awareness of the risk of AE following catheter removal is less. We aimed to analyze the clinical characteristics of the all case reports with AE after catheter removal and summarize the mechanisms, clinical consequences, treatment and prevention of AE. Methods: In addition to our case, MEDLINE database was searched for all case reports with AE following catheter removal, and the clinical, diagnostic and outcome data were analyzed. Findings: A total of 10 patients (including our case) (M/F 6/4; median age 50.5 years) were found for the analysis. Procedures for prevention of AE were reported in a few patients (Trendelenburg position 2, airtight dressing 1). The time that elapsed between catheter removals and onset of AEs was ranged from seconds to 6 hours. The most common findings were dyspnea (90%), hypoxemia (70%), and cerebral dysfunction (70%). The most common sites where air could be detected were the left ventricle (40%), pulmonary artery (30%) and right ventricle (30%). Mortality was reported in 4 (40%) cases and the remaining 6 patients had complete recovery. Blocking of air portal was not reported in any of the fatal cases. Discussion: AE following catheter removal carries a major risk of mortality. Great awareness and attention to preventive procedures and appropriate care after development of AE seem mandatory.

Leukocytoclastic Vasculitis Associated with a New Anticoagulant: Rivaroxaban

A 28-year-old man who was being treated with diltiazem (60 mg/ day) and oral methylprednisolone (32 mg on alternate days) (6th month of Pozzi protocol [1]) for IgA nephropathy was admitted to our hospital with bilateral lower extremity non-blanching palpable purpura that occurred 10 days following the addition of 20 mg of rivaroxaban once daily for acute deep venous thrombosis in the right popliteal vein by another physician. There was no significant finding in the physical examination except for purpura. The complete blood count, metabolic panel, urine analysis, coagulation studies, infectious serologies, rheumatologic work-up, and serum immunoglobulin E level were all within normal limits. Rivaroxaban was replaced with subcutaneous enoxaparin sodium at 6000 IU twice a day, and the skin lesions disappeared within 1 week. Two weeks later, the patient was prescribed rivaroxaban at 10 mg a day again by the same physician who was following the patient for deep venous thrombosis because of the rarity of LCV due to rivaroxaban in the literature. Bilateral lower extremity purpura (Figure 1) reoccurred within 3 days of retreatment and a skin biopsy revealed neutrophil-predominant infiltrations within and surrounding the dermal small vessels, nuclear dust, vessel wall damage, erythrocyte extravasation, and fibrin deposition concurrent with vasculitis. Rivaroxaban was discontinued and enoxaparin was administered again, and the skin lesions resolved. The patient was in a clinically steady state for IgA nephropathy during the two episodes of vasculitis.

Serum VEGF-C levels as a candidate biomarker of hypervolemia in chronic kidney disease

Abstract Attaining and maintaining optimal “dry weight” is one of the principal goals during maintenance hemodialysis (MHD). Recent studies have shown a close relationship between Na+ load and serum vascular endothelial growth factor-C (VEGF-C) levels; thus, we aimed to investigate the role of VEGF-C as a candidate biomarker of hypervolemia. Physical examination, basic laboratory tests, N-terminal pro b-type natriuretic peptide (NT-ProBNP), echocardiography, and bioimpedance spectroscopy data of 3 groups of study subjects (euvolemic MHD patients, healthy controls, and hypervolemic chronic kidney disease [CKD] patients) were analyzed. Research data for MHD patients were obtained both before the first and after the last hemodialysis (HD) sessions of the week. Data of 10 subjects from each study groups were included in the analysis. Serum VEGF-C levels were significantly higher in hypervolemic CKD versus in MHD patients both before the first and after the last HD sessions (P = .004 and P = .000, respectively). Healthy controls had serum VEGF-C levels similar to and higher than MHD patients before the first and after the last HD sessions of the week (P = .327 and P = .021, respectively). VEGF-C levels were correlated with bioimpedance spectroscopy results (r2 0.659, P = .000) and edema (r2 0.494, P =0.006), but not with ejection fraction (EF) (r2 −0.251, P = .134), blood pressures (systolic r2 0.037, P = 0.824, diastolic r2 −0.067, P = .691), and NT-ProBNP (r2 −0.047, P = .773). These findings suggest that serum VEGF-C levels could be a potential new biomarker of hypervolemia. The lack of correlation between VEGF-C and EF may hold a promise to eliminate this common confounder. Further studies are needed to define the clinical utility of VEGF-C in volume management.

Glisemik Dalgalanma ve Hemodiyaliz

ÖZET Kronik hiperglisemi ve akut glisemik dalgalanmalar, glisemik bozukluk patogenezinde diyabet prognozunu etkileyen iki önemli unsurdur. Diyabetin neden olduğu komplikasyonlar çoğunlukla kronik hiperglisemiye bağlı olarak gelişmekte ve HbA1c düzeyi kronik hiperglisemi hakkında bilgi vermektedir. Akut glisemik dalgalanmalar, kan glukoz düzeyinin -açlık ve tokluknormal kabul edilen değerlerin altında ve üzerinde seyretmesi olarak tanımlanarak “Sürekli Glikoz Takip Sistemi (SGTS)” ile değerlendirilmektedir. Her iki hiperglisemik durum da oksidatif stresin aktivasyonu ve ileri glikasyon son ürünlerinin oluşumu nedeni ile diyabetik komplikasyonların ortaya çıkmasına neden olmaktadır. Hemodiyaliz tedavisi boyunca hem plazma glukoz konsantrasyonu ve hem de plazma insülin düzeyindeki azalma glisemik dalgalanmaya neden olmaktadır. SGTS kısa dönem glukoz dalgalanmalarını değerlendirme ve hipoglisemiyi saptamada öneme sahiptir. Diyabetik hastalarda sadece HbA1c değerinin değil, glisemik dalgalanmaların azaltılması da tedavi hedeflerinden biri olarak kabul edilebilir. Glisemik dalga boyunun azaltılması ve hipogliseminin önlenmesi morbidite ve mortalitenin azaltılmasında faydalı olabilir.