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Kidney international / Reports 5(8), 1327-1332 (2020). doi:10.1016/j.ekir.2020.05.030, Published by Elsevier, Amsterdam

Interdialytic hemodialysis catheter-locking solutions could contribute to a reduction of catheter-related complications, especially infections. However, they can cause side effects because of leakage from the tip of the catheter. Recently, trisodium citrate (TSC) has been advocated because of its antimicrobial properties and local anticoagulation. In a multicenter, double-blind, randomized, controlled trial, TSC 30% was compared with unfractionated heparin 5000 U/ml for prevention of catheter-related infections, thrombosis, and bleeding complications. The study was stopped prematurely because of a difference in catheter-related bacteremia (CRB; P < 0.01). Of 363 eligible patients, 291 could be randomized. The study included 98 tunneled cuffed catheters and 193 untunneled. There were no significant differences in patient and catheter characteristics on inclusion. In the heparin group, 46% of catheters had to be removed because of any complication compared with 28% in the TSC group (P = 0.005). CRB rates were 1.1 per 1000 catheter-days for TSC versus 4.1 in the heparin group (P < 0.001). For tunneled cuffed catheters, the risk reduction for CRB was 87% (P < 0.001) and for untunneled catheters was 64% (P = 0.05). Fewer patients died from CRB in the TSC group (0 versus 5; P = 0.028). There were no differences in catheter flow problems and thrombosis (P = 0.75). No serious adverse events were encountered. Major bleeding episodes were significantly lower in the TSC group (P = 0.010). TSC 30% improves overall patency rates and reduces catheter-related infections and major bleeding episodes for both tunneled and untunneled hemodialysis catheters. Flow problems are not reduced.

A 63-year-old HIV-negative homosexual man was treated for 16 weeks with mycophenolate mofetil for biopsyproven membranous glomerulopathy with nephrotic proteinuria. An extensive search for a viral or malignant cause for the membranous glomerulopathy had not shown any possibilities other than immunity against hepatitis B virus (negative for hepatitis B surface antigen [Hbs-Ag] and for antibodies against hepatitis B e antigen [anti-Hbe], positive for antibodies against hepatitis B core and surface antigens [anti-Hbc and anti-Hbs, respectively]). Antibodies against HIV types 1 or 2 were absent (microparticle enzyme immunoassay HIV1/2, Abbot Diagnostic Division, Hoofddorp, Netherlands). Mycophenolate mofetil was discontinued in November, 2004, because of noncompliance. Earlier in the course of his disease, the patient was given corticosteroids, which were stopped because the patient did not show a clinical response and had psychiatric adverse eff ects. Several months after mycophenolate mofetil was stopped, he developed a few skin lesions on both wrists. Excisional biopsy of a skin lesion showed spindle cells compatible with Kaposi’s sarcoma. Immunohistochemical staining showed expression of human herpesvirus 8 (HHV8). Immunohistochemical staining for HHV8 of the former renal biopsy was negative. Treatment did not yet seem warranted. In March, 2005, he underwent an axillobifemoral bypass after occlusion of an aorta-bifemoral bypass. Because of an infectious complication, the wound in his left groin was re-explored. Soon after, he developed rapidly progressive Kaposi’s sarcoma on both legs. The largest lesions appeared near to the surgical wound (fi gure A). HHV8 PCR showed 10 000 copies/mL but repeated tests for HIV infection remained negative. Immunoglobin concentrations and the ratio of CD4 to CD8 cells were normal. Subsequently, severe lymphoedema developed in his left leg (fi gure B), which was complicated by recurrent episodes of erysipelas. Repeated courses with amoxicillin and clavulanic acid, or fl ucloxacillin, were given successfully. Blood, urine, and wound cultures remained negative. Deep venous thrombosis or occlusion of the arterial bypass was excluded with repeated ultrasonography and magnetic resonance angiography. Because the Kaposi’s lesions were extensive and located around a surgical wound covering an arterial bypass, systemic treatment seemed warranted. Radiotherapy was not an option. Chemotherapy was contraindicated because of his poor performance status, renal failure, and the infected wound. Inspired by a report in kidney transplant recipients, we started the patient on a course of low-dose sirolimus (target blood concentration 5 μg/L). After 6 weeks, lymphoedema and skin lesions clearly regressed and some lesions spontaneously ruptured. HHV8 viral load was not signifi cantly altered (from 1×10 to 0·6×10 copies/mL). During the following months, the lesions continued to regress (fi gure), and kidney function decreased from a calculated creatinine clearance of 12 mL/min to 9 mL/min (