In general, nonrheumatic atrial fibrillation is associated with a high risk of stroke. However, its impact on stroke in the setting of chronic hemodialysis treatment is insufficiently addressed in the literature. We assessed the incidence of stroke among 430 chronic hemodialysis patients and the impact of atrial fibrillation and various other potential risk factors on stroke in a retrospective study covering 1,111.16 patient-years. The overall incidence of stroke was 3.78/100 patient-years. Among patients with chronic atrial fibrillation without any antithrombotic therapy besides regular dialysis anticoagulation, the stroke incidence was 1.0/100 patient-years and did not differ statistically significantly from the rate among patients without this arrhythmia, in whom the incidence was 2.8/100 patient-years (p = 0.220). Conversely, the overall rate of stroke incidence per 100 patient-years was statistically significantly higher in patients with diabetic nephropathy (6.46, p = 0.0036), age >65 years (5.90, p = 0.0001), moderate to severe hypertension (6.8, p = 0.0017), weight gain of >2 kg between dialyses as a marker of poor patient compliance (6.47, p = 0.0433), and antithrombotic therapy with salicylates or warfarin (8.33, p = 0.0002), as compared with corresponding groups without these risk factors. Our data suggest that in contrast to other risk factors nonrheumatic atrial fibrillation in itself is not associated with an increased risk of stroke in patients on maintenance hemodialysis treatment.

1. Blood leptin levels are increased in obese subjects and seem to play a major role in the hypothalamic regulation of appetite and energy expenditure. 2. We measured plasma leptin levels in a cohort of 46 patients on maintenance haemodialysis treatment and 26 control subjects. 3. Higher body mass indices were associated with higher plasma leptin levels in both groups. 4. The increase was more pronounced in the dialysis group than in the control group (P = 0.001), leading to inappropriately high plasma levels. 5. Haemodialysis with low flux cellulosic dialysers did not result in a decrease in plasma levels, while dialysis with high flux dialysers and haemodiafiltration led to a substantial reduction of the initial value to 76.95 +/- 14.89% (P = 0.013) and 62.90 +/- 24.94% (P = 0.001) respectively. 6. Our data suggest that high flux dialysis membranes can decrease plasma leptin levels and that inappropriately high plasma leptin levels may play a role in the nutrition of haemodialysis patients.

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Disseminated infection with the coelomycetous fungus Nattrassia mangiferae is a very rare disease affecting only the immunocompromised host. We report the first case of a disseminated infection with spondylodiscitis and granular skin lesions due to N. mangiferae in a renal transplant patient. CASE REPORTA 62-year-old male of Turkish origin, who had been living in Austria for more than 15 years, underwent cadaveric kidney transplantation because of vascular nephropathy in September 2001. Initial immunosuppressive therapy consisted of cyclosporin A, mycophenolate mofetil, and steroids.In August 2002, the patient stayed in Izmir, Turkey, for 4 weeks. During his stay, he developed fever. Moreover, coinshaped lesions on the back of both hands and feet were described. The patient returned to Austria and was admitted with suspected pneumonia. In addition, the patient complained about lumbosacral pain, and black granulomatous lesions were now seen all over the body. Subsequent magnetic resonance imaging of the lumbosacral spine detected an L2/L3 spondylodiscitis (Fig. 1). Massive compression of the vertebral bodies together with the osteolytic process between the vertebral bodies and moderate swelling of the paraspinal soft tissues were described. Computed tomography (CT) showed pulmonary infiltrates and inflammatory destruction of ribs 8 and 10. An elevated C-reactive protein level of 13.1 mg/dl (usually Ͻ1 mg/dl) and leukocyte count of 15.8 per liter with 89% neutrophils and 5% lymphocytes were indicative of an inflammatory process. A CT-guided aspiration obtained from L2/L3, cerebrospinal fluid (CSF), and a skin biopsy of the coin-shaped lesions were cultured and histologically investigated. A black granulomatous lesion localized to the big toe was especially prominent and was recognized as one of the first skin lesions (Fig. 2). Histologically, the L2/L3 aspirate showed a chronic inflammatory process; the presence of tuberculosis could be excluded. Also, PCR performed repeatedly to detect Mycobacterium tuberculosis and Mycobacterium avium from CSF and urine showed only negative results. In the CSF, pleocytosis was observed (667 cells/l with 95% neutrophils), but neither bacteria nor fungal elements could be detected. The aspirate and the skin biopsy showed growth of a fungus. The cultures from CSF and blood remained negative.The aspirate and the skin biopsy were inoculated on blood agar (bioMérieux, L'Etoile, France), Sabouraud dextrose agar (Oxoid, Basingstoke, United Kingdom), and brain heart infusion agar (Oxoid) and incubated at both 30 and 35°C. After 24 h, cultures were positive with a rapidly expanding filamentous hyaline fungus. After 3 to 4 days, a hairy black growth that consisted of large brown arthroconidia identical to the Scytalidium synanamorph of Nattrassia mangiferae could be observed. Growth was observed on all media inoculated.The fungus was identified as N. mangiferae by its colonial and microscopic features. Identification was confirmed by the national reference laboratory, the Centraalbureau vo...

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