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The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research., (Copyright © 2019. Published by Elsevier Inc.)

Interventional nephrologists and radiologists place peritoneal dialysis catheters using the percutaneous fluoroscopic technique in both the inpatient and outpatient setting. Nephrologists caring for such patients may have to diagnose and manage the complications resulting from these procedures. Abdominal pain can occur following peritoneal dialysis catheter placement when the local and systemic analgesia wears off. However, abdominal pain with hypotension is suggestive of a serious complication. Bleeding into the abdomen and perforation of the colon or bladder should be considered in the differential diagnosis. In the case reported here, the peritoneogram showed contrast in the bowel, and correct interpretation by the interventionist would have prevented this complication. The characteristic pattern of peritoneogram images in this case will guide interventionists to avoid this complication, and the discussion of the differential diagnosis and management will assist nephrologists in taking care of such patients., (Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Many of the tools used in interventional nephrology, such as glidewires and sheaths, are coated with a hydrophilic polymer to increase their lubricity; however, this polymer can shear off, which causes polymer embolization. We describe 3 cases in which polymer emboli were found on histopathologic examination in an arteriovenous graft, a transplanted kidney, and the myocardium. A review of the literature shows that although most of these phenomena are benign, in some patients, it may present with significant morbidity., (Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: During clinical application of flow surveillance of hemodialysis grafts, the risk of thrombosis is assessed month after month, rather than after one or several measurements, as has been done in published studies. Adequate assessment of risk should consider the many measurements obtained over time., Study Design: Prospective cohort diagnostic test study., Setting & Participants: 176 patients with hemodialysis grafts from 2 university-affiliated dialysis units during a 6-year period., Index Tests: Monthly measurement of graft blood flow or change in flow., Outcome: Graft thrombosis., Results: We used logistic regression analysis to compute the risk of thrombosis and used receiver operating characteristic (ROC) curves to assess the accuracy in predicting thrombosis within 1 month. Newer grafts were most likely to thrombose, whereas older grafts were unlikely to thrombose even at low flows or large decreases in flow. Areas under the ROC curves were 0.698 for flow and 0.713 for change in flow measured over 2 months. Flow predicted thrombosis with a sensitivity of 53% at a specificity of 79%, and change in flow had a sensitivity of 58% at a specificity of 75%. More than half the thromboses lacked a change in flow measurement, usually because thrombosis occurred before a change could be measured. Thus, the effective predictive accuracy of change in flow was much less than the ROC curves indicated because the curves do not consider missing measurements., Limitations: Performance characteristics of index tests may vary across patient populations., Conclusion: Flow and change in flow are inaccurate predictors of thrombosis. Many thromboses are not predicted, and intervention based on surveillance likely yields many unnecessary procedures. Thus, this study does not support routine application of surveillance to prevent thrombosis.

Isopropyl alcohol (IPA) is an ingredient of commonly used household solutions. Accidental and suicidal ingestion of IPA sometimes can be fatal if it goes unrecognized and untreated. There are few published reports on IPA intoxication. We describe a case of repeated IPA ingestion in a single individual, followed by a review of the literature on the subject. The differential diagnosis, diagnostic pitfalls, and therapeutic interventions in patients with IPA intoxications are discussed., (Copyright 2002 by the National Kidney Foundation, Inc.)

Many arteriovenous (AV) fistulae fail to achieve an adequate blood flow or size for successful cannulation because of accessory veins. We describe a simple technique to ligate accessory veins that does not require a surgical incision. In this retrospective study, 17 end-stage renal disease patients underwent ligation of accessory veins of poorly developed AV fistulae. There were 14 men and 3 women, and their average age was 50 +/- 13 years. There were 14 radiocephalic and 3 brachiocephalic fistulae. After identifying accessory veins with a fistulogram, two nonabsorbable 2-0 polypropylene (Prolene) sutures were placed percutaneously around each accessory vein in proximity to the AV fistula. Successful ligation was confirmed with a repeat fistulogram. This procedure was undertaken after 4 +/- 3 months following surgical placement. Successful maturation was defined as adequate blood flow to support effective hemodialysis and adequate caliber to allow for repeated cannulation with a 15G or 16G needle. Of 17 AV fistulae, 15 (88%) successfully matured 1.7 +/- 1 month (range, 0.3 to 6 months) after the procedure. The average number of accessory veins ligated was 1.7 +/- 0.8 (range, 1 to 3). All AV fistulae that matured after ligation of accessory veins were functioning at 44.5 +/- 12 weeks after first use. A technique for salvaging nonmaturing AV fistulae not requiring surgical cutdown for ligation of accessory veins is described. AV fistulae mature quickly after ligation of accessory veins. This is a rapid and safe procedure that can increase the prevalence of AV fistulae., (Copyright 2002 by the National Kidney Foundation, Inc.)

Blacks are less likely than whites to use peritoneal dialysis (PD) as the initial renal replacement therapy. The reason for the underusage of PD by blacks is unknown. In a cross-sectional multicenter trial, we studied peritoneal transport character, small-molecular-weight solute clearances, and nutritional status in 475 patients undergoing PD (168 whites, 192 blacks, and 115 Asians). The mean age of blacks undergoing PD was significantly younger than that of whites (47.6 +/- 14.7 v 58.2 +/- 16.7 years; P < 0.0001). Target Kt/V and weekly creatinine clearance (WCC) as defined by the Dialysis Outcome Quality Initiative Work Group was achieved by 62.5% of whites, 67.2% of blacks, and 54.8% of Asians (P = 0.05). Total protein (7.25 +/- 0.88 v 6.55 +/- 0.73 g/dL), albumin (3.72 +/- 0.57 v 3.55 +/- 0.53 g/dL), and lean body mass (LBM; 41.7 +/- 15.6 v 33.0 +/- 11.8 kg) were lower in whites compared with blacks (P < 0.001). Although the normalized protein catabolic rate (nPCR) was greater (0.82 +/- 0.24 v 0.90 +/- 0.32 g/kg/d; P = 0.04), total protein (6.24 +/- 0.85 g/dL) and serum albumin levels (3.36 +/- 0.52 g/dL) and LBM (30.1 +/- 8.0 kg) were significantly lower in Asians than blacks (P < 0.0001). The favorable anabolic response in blacks may partially be explained by a higher calorie intake in this group of patients (29.6 +/- 10.7 Cal/kg/d) compared with whites (22.4 +/- 6.8 Cal/kg/d) and Asians (23.9 +/- 9.8 Cal/kg/d; P = 0.03). Multiple regression analysis identified that black race and weight were positively associated, whereas dialysate/plasma creatinine ratio (D/P(Creat)) and age had a negative effect on serum albumin level. Follow-up data indicated that the Kt/V (2.09 +/- 0.50 v 2.39 +/- 0.56; P = 0.02) and WCC (60.8 +/- 4.3 v 70.2 +/- 7.3 L/1.73 m2; P = 0.02) increased significantly from baseline only in blacks. We conclude that PD is an ideal renal replacement therapy in at least a subset of blacks with end-stage renal disease.

Liddle's syndrome, a rare cause of hypokalemic hypertension, is characterized by a renal tubular sodium channel defect resulting in excessive sodium absorption and concomitant potassium wasting. In this disorder, although the clinical manifestations resemble primary aldosteronism, serum and urine aldosterone are suppressed. The syndrome is transmitted in an autosomal dominant pattern. It has been reported previously in white and oriental populations but not in the black individuals. We identified four patients (two of whom are black) in our nephrology clinic, with severe hypokalemic hypertension not correctly diagnosed for several years. All patients underwent an extensive work-up for secondary hypertension because of persistent severe hypertension (average blood pressure, 210/130 mm Hg) despite high-dose multi-drug therapy. Primary aldosteronism was excluded because of low serum aldosterone. Cushing's syndrome, pheochromocytoma, renal artery stenosis, and enzymatic deficiencies of cortisol synthesis (11 beta-hydroxylase, 17 alpha-hydroxylase, 5 beta-reductase, and 11 beta-hydroxysteroid dehydrogenase) were ruled out with extensive endocrine and radiologic studies. Once the diagnosis of Liddle's syndrome was suspected, all patients were treated with either triamterene or ameloride, with resolution of hypokalemia and correction of hypertension occurring within 5 to 7 days. Our findings suggest that Liddle's syndrome can occur in the black population. Although the actual incidence of this syndrome remains unknown, it may be significantly more common than we are led to believe since it is inherited in a Mendelian pattern. Whether there is a subset of low-renin, salt-sensitive black hypertensive patients who have the same or similar sodium channel defect remains to be elucidated.

Nontuberculous mycobacterial infections are a rare but clinically important cause of infections in continuous ambulatory peritoneal dialysis (CAPD) patients. We describe seven cases of catheter-related nontuberculous mycobacterial infections associated with CAPD. Six patients had Mycobacterium fortuitum infections and one had a Mycobacterium kansasii infection. Three patients presented with peritonitis, three presented with exit site infections, and one developed an infection at the exit site after catheter removal. There were no specific clinical findings that differentiated these infections from those caused by common bacterial pathogens. Initial routine peritoneal dialysis fluid and exit site cultures were negative in two patients and grew M fortuitum in four patients and M kansasii in one patient. M fortuitum and M kansasii were sensitive to amikacin, and M fortuitum was sensitive to ciprofloxacin when tested. Sensitivities to other antibiotics were variable. All patients were treated with a combination of antibiotics from 3 weeks to 6 months. Catheter removal was necessary for cure of the infection in all patients with peritonitis and in a majority of patients with exit site infections. The majority of patients changed to hemodialysis after catheter removal. Two patients remained on CAPD, with follow-up ranging from 2 months to 4 years. One patient has received a successful renal transplant. In conclusion, M fortuitum is the most common nontuberculous mycobacterial catheter-related infection in CAPD patients. Nontuberculous mycobacterial infections should be considered in the differential diagnosis of any culture-negative infection associated with CAPD. In patients with infections secondary to M fortuitum, our findings suggest that amikacin and ciprofloxacin are the initial antibiotics of choice until antibiotic sensitivities are available.

A case of idiopathic crescentic membranous glomerulonephritis is reported. In addition to the present case, eight cases of this type of glomerulonephritis reported in the literature are reviewed. This is an uncommon form of glomerulonephritis, seen in middle age and in both sexes. Clinical presentation is similar to idiopathic membranous nephropathy. Lupus and antiglomerular-basement membrane nephritis should be excluded by serological tests. Prognosis is grave, resulting in end-stage renal failure (ESRD) within a year in most patients. There is no specific therapy known to alter the course of the disease. In this patient, short courses of high-dose corticosteroids, administered during flares of glomerulonephritis, seemed to improve renal function.

We report a case of IgA nephropathy that presented with nephrotic syndrome without hematuria. Renal biopsy revealed typical features of IgA nephropathy on light microscopy, immunofluorescence microscopy, and electron microscopy. A dramatic response occurred on corticosteroid and immunosuppressive therapy, characterized by clearance of proteinuria and a fall of serum IgA level to normal. The absence of hematuria and a response to therapy are distinctly unusual features of IgA nephropathy. This case represents a variant of IgA nephropathy associated with a nephrotic syndrome that resembles nephrotic syndrome with minimal change lesion in its responsiveness to immunosuppressive therapy.

A higher prevalence of aluminum-associated microcytic anemia was noted in hemodialysis unit A (n = 67) compared to unit B (n = 39). This finding could not be explained by differences in the aluminum content of reverse osmosis (RO) water or intake of antacids containing aluminum by patients in the two units. An intermittent source of aluminum contamination was suspected when water aluminum and total dissolved solutes (TDS) were measured at several sites in the water treatment facility of unit A. A one-way valve that maintained unidirectional flow in an RO bypass circuit was found missing. Intermittent pressure changes in this circuit altered the direction of water flow causing mixing of partially purified water with RO water. Installation of the valve stopped contamination and resulted in a decrease in plasma aluminum concentration from 183 +/- 12 micrograms/L to 76 +/- 7.3 micrograms/L, erythrocyte aluminum concentration from 210 +/- 31 micrograms/L to 61 +/- 9 micrograms/L and microcytosis from 58% to 8% in patients (n = 48) when measured 6 months later. Because contamination was missed in spite of water testing at the RO site, these findings underscore the importance of measuring water aluminum and TDS content at the dialysis stations. Frequent water testing at dialysis stations, familiarity with the design of water treatment facilities, and recognition of aluminum overload can lead to early detection and correction if similar types of aluminum contamination should occur.