Hyperammonemia, post-orthotopic lung transplantation, is a rare but mostly fatal complication. Various therapies, including those to decrease ammonia generation, increase nitrogen excretion, and several dialytic methods for removing ammonia have been tried. We describe three lung transplant recipients who developed acute hyperammonemia early after transplantation. Two of the three patients survived after a multidisciplinary approach including discontinuation of drugs, which impair urea cycle, aggressive ammonia reduction with prolonged daily intermittent hemodialysis (HD), and overnight slow low-efficiency dialysis in conjunction with early weaning of steroids and other therapeutic measures. Our experience suggests that early initiation of dialysis, high dialysis dose, increased frequency, and HD preferably to less efficient modalities increases survival in these patients.

Anemia is a very common complication of chronic kidney disease (CKD). Anemia confers significant risk of cardiovascular disease and contributes to decreased quality of life. Anemia in CKD patients can be multi-factorial, including but not invariably due to the underlying renal insufficiency. Identifying the type of anemia is important in this group of patients and can often be challenging. Diagnosing anemia of renal disease due to erythropoietin (EPO) deficiency is a diagnosis of exclusion. Erythropoiesis stimulating agents (ESA) are the mainstay for the treatment of anemia secondary to CKD. However, over the last four years the use of ESA in the treatment of anemia in CKD patients has undergone a severe interrogation as several trials have reported adverse outcomes with targeting higher hemoglobin (Hb) levels with these agents. Thereby, this review describes the pathophysiology of anemia in CKD patients, diagnosis and the current role of ESA's as it relates to anemia of CKD as well as safety and efficacy of ESA's.

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Multiple myeloma complicated by acute renal failure is a diagnosis often encountered by the practicing nephrologist. The role of plasmapheresis in such patients has been of interest for decades. Three randomized controlled trials (RCTs) and multiple observational trials have evaluated the potential role of plasmapheresis in the management of this condition. This systematic review presents the results of these trials regarding survival benefits, recovery from dialysis, and improvement in renal function. A comprehensive search revealed 56 articles. Of these, only 8 articles met our inclusion criteria (3 RCTs, 1 correction of results, and 4 observational trials). Two of the 3 RCTs showed no difference in survival benefit. Two of the 3 RCTs showed a greater percentage of patients stopping dialysis in the intervention group; however, these results were not reproduced in the largest trial. All the studies showed an improvement in renal function for patients receiving plasmapheresis; however, only 2 RCTs and 1 retrospective study showed a statistically significant improvement in renal function among patients who received plasmapheresis in comparison with a control group. Our systematic review does not suggest a benefit of plasmapheresis independent of chemotherapy for multiple myeloma patients with acute renal failure in terms of overall survival, recovery from dialysis, or improvement in renal function.

Background: Iron deficiency anemia is common in patients with chronic kidney disease, and intravenous iron is the preferred treatment for those on dialysis. We investigated the pharmacokinetics, pharmacodynamics, and safety of three doses (100 mg, 200 mg, and 500 mg) of iron isomaltoside 1000administered as bolus injections in patients with stage 5 chronic kidney disease on dialysis therapy.Methods: This prospective, randomized, open-label pharmacokinetic study was conducted in 18 patients at one center. Patients were randomly assigned in a 1:1:1 ratio to receive a single dose of 100 mg, 200 mg, or 500 mg intravenous bolus injection (6 patients each) of iron isomaltoside 1000 at baseline visit. The pharmacokinetic, pharmacodynamics, and safety parameters were assessed over seven days and increases in serum-iron was used as a surrogate for iron isomaltoside 1000. Results:There was a dose-dependent increase in the geometric mean values of area under serum concentration-time curve (AUC) from injection to last measurable data point, area under serum concentration-time curve from injection to infinity (AUC 0-t ), and maximum serum concentration (C max ), whereas time to reach maximum concentration (T max ) decreased with increasing doses of iron isomaltoside 1000. Thegeometric mean of half-life (T ½ ) was approximately 30 h and the elimination rate constant (K e ) remained similar across the three doses. Serum-iron, transferrin saturation, and serum-ferritin increased significantly, and the increases were related to iron dose. No major change was observed in the mean hemoglobin, reticulocyte count, reticulocyte hemoglobin content, ortotal iron binding capacity across the three doses. Three adverse events occurred of which one, asthma exacerbation, was considered probably related to the treatment. Conclusions:The pharmacokinetic characteristics and simplicity of administration of iron isomaltoside 1000 suggest it to be a convenient iron replacement therapy over this dosage range.