Objective Arteriovenous fistulas (AVF) are considered superior to arteriovenous grafts (AVG) because of longer secondary patency after successful cannulation for dialysis. We evaluated whether access interventions before successful cannulation impact the relative longevity of AVF and AVG after successful use. Methods This retrospective study of a prospective database identified patients who initiated dialysis with a catheter, and subsequently had a permanent access (289 AVF and 310 AVG) placed between 1/1/06-12/31/11 and successfully cannulated for dialysis at a large medical center. Patients were followed until 6/30/14, and we evaluated the clinical outcomes (secondary patency and frequency of interventions) of the vascular accesses. Results An intervention before successful cannulation was required more frequently with AVF than with AVG (50.5 vs 17.7%; OR 4.74; 95% CI 3.26 to 6.86, P < .0001). As compared to AVF that matured without interventions, those that required intervention had shorter secondary patency after successful cannulation (HR 1.84; 95% CI 1.30–2.60, P < .0001) and required more interventions per year after successful use (RR 1.81; 95% CI 1.49–2.20, P < .0001). Similarly, AVG that required intervention before successful cannulation had shorter secondary patency than those without prior intervention (OR 1.98, 95% CI 1.52 to 4.02, P < .0001) and required more interventions per year after successful use (RR 1.49; 95% CI 1.27–1.74, P < .0001). AVF requiring intervention before maturation had inferior secondary patency as compared to AVG that were cannulated without prior intervention (HR 1.45, 95% CI 1.08 to 2.01, P = 0.01), but required fewer annual interventions after successful use (RR 0.57; 95% CI 0.49–0.66, P < .0001). Conclusions The patency advantage of AVF over AVG is no longer evident in patients requiring an AVF intervention prior to successful cannulation, but the AVF require fewer interventions after successful use.

Objectives:This case report describes two cases of high-dose methotrexate–induced nephrotoxicity: death in the case of conventional supportive care and successful renal function recovery in a patient treated with glucarpidase and continuous dialysis.Methods:High dose methotrexate is widely used for management of adult and pediatric malignancies. However, high-dose methotrexate–induced renal nephrotoxicity may cause severe, even lethal complications. Here we present examples of such outcomes.Results:We present one case of lethal high-dose methotrexate nephrotoxicity in a patient treated with conventional rescue therapy. We contrast this outcome with another patient with high-dose methotrexate–induced anuric acute kidney injury, who has recovered renal function following therapy with glucarpidase and continuous dialysis.Conclusions:This is only the second reported case of high-dose methotrexate–induced anuric acute kidney injury, and the only one with a reported clinical outcome. This first report of recovery from high-dose methotrexate–induced anuric acute kidney injury after glucarpidase administration supports available evidence pointing to the effectiveness of this therapy.

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Background Diagnosing pneumonia in hemodialysis patients is challenging. We hypothesized that pulmonary edema, which occurs commonly in hemodialysis patients, may frequently be misdiagnosed as pneumonia. Methods We retrospectively reviewed the records of 105 hemodialysis patients admitted with the diagnosis of pneumonia. Two experienced radiologists masked to the clinical course and subsequent imaging, independently interpreted the admission chest radiographs. In 68 of the patients, 2 internists independently reviewed the hospitalization records to diagnose pneumonia and pulmonary edema. The level of agreement among the radiologists was assessed using the kappa test. Using the clinical diagnoses, chest radiograph attributes were calculated. Logistic regression was performed to identify clinical and laboratory markers associated with pneumonia and pulmonary edema. Results The radiologist showed slight agreement on pneumonia (κ = 0.32) and pulmonary edema (κ = 0.28). Using clinical consensus, pneumonia was diagnosed in only 21% (14/68) of patients. Chest radiograph attributes for diagnosing pneumonia included: sensitivity 50%, specificity 58%, positive predictive value 25% and negative predictive value 81%. Pneumonia was associated with presenting temperature (odds ratio [OR] = 2.01; 95% CI, 1.03–3.93). Pulmonary edema was associated with shortness of breath (SOB) at admission (OR = 4.83; 95% CI, 1.25–18.6), presenting temperature (OR = 0.44; 95% CI, 0.21–0.92) and volume removed during hemodialysis (OR = 1.96; 95% CI, 1.16–3.31). Conclusions The admission chest radiograph has significant limitations when used to diagnose pneumonia in hemodialysis patients. A high presenting temperature supports the diagnosis of pneumonia, while a low presenting temperature, SOB and large volume ultra-filtration favor the diagnosis of pulmonary edema.