The use of tunneled catheters (TDC) for chronic hemodialysis is frequent and often fails due to fibrin or thrombus and infection. We hypothesized that the presence of fibrin sheath in TDC increases the risk for subsequent catheter malfunction and infection. We did a retrospective review of TDC exchanges and de novo placements from January 2005 to September 2011. Demographic data, information about the catheter procedure, and radiological data were collected. Final outcome analysis included 168 procedure events. Three groups of catheter procedures were identified: catheter exchange without a fibrin sheath (CE), catheter exchange with a treated fibrin sheath (CEF), and de novo catheter placements (DCP). Fibrin sheath incidence was 47%. In the CEF group, there was no statistical difference in the incidence of subsequent infections or dysfunctions (7% and 60%, respectively), when compared with the CE group (9% and 43%, respectively), (p=0.3). Mean time to subsequent dysfunction or infection was similar for CEF and CE (135 vs. 136 days, p-value, 0.98). Fibrin sheaths are common and should be evaluated when performing TDC exchange. If the fibrin sheath is treated, there is no increased incidence in subsequent catheter dysfunction or infection compared with patients without a fibrin sheath.

Hemodialysis using a bath with less-than-normal calcium level can cause hypocalcemia. The development of symptomatic hypocalcemia with resultant hypotension after the inadvertent use of a calcium-free dialysate in a maintenance hemodialysis patient is described. It is suggested that the occurrence of similar mishaps in the future can be reduced by close checking of dialysate concentrate labels.

We describe a diabetic patient who presented with acute renal failure as a result of acute bilateral emphysematous pyelonephritis. Initially, both an abdominal X-ray examination and a renal sonogram were unremarkable. Two days later, however, the previously visualized right kidney could not be demonstrated again by a repeat renal sonogram. A computed tomogram and a repeat abdominal X-ray study confirmed the diagnosis of emphysematous pyelonephritis. To our knowledge this is one of the few described cases of emphysematous pyelonephritis distinguished by a sonogram's inability to visualize a kidney because of interference with imaging by the gas produced by the bacteria that are responsible for the pyelonephritic infection.

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