Diabetes is challenging to manage in patients who have end-stage renal disease (ESRD), as both uremia and dialysis can complicate glycemic control by affecting the secretion, clearance, and peripheral tissue sensitivity of insulin. The authors summarize the available evidence and make practical recommendations.

Bloodstream infections (BSIs) are common in hemodialysis, especially when the access is a catheter. These infections are more commonly gram-positive bacteria or gram-negative bacilli and on some occasions, fungi. Ochrobactrum anthropi and Shewanella putrefaciens are ubiquitous hydrophilic gram-negative bacilli. There have been three cases of O. anthropi BSI reported in hemodialysis patients (one from the United States and two from Vienna) and two cases of S. putrefaciens BSI in hemodialysis patients (one from the United States and the other from Japan). There have been few more cases reported of infections with these bacteria in peritoneal dialysis, especially outside the United States. We present a novel case of a patient with both recurrent O. anthropi and S. putrefaciens BSI complicating hemodialysis. There have been no reports in the literature of such a case. We also discuss the microbiology, clinical features, and the challenging aspects of treatment of such infections.

We report a patient who presented with acute kidney injury after treatment with linezolid and Bactrim DS, 2 tablets twice a day, for a leg wound. The patient also was receiving furosemide for leg edema. Fractional excretion of sodium was 46%, and kidney ultrasound showed normal-sized kidneys with no hydronephrosis. Urinalysis showed pH of 5.5 and no protein, blood, leukocyte esterase, or nitrite. Polarized urine microscopy showed birefringent pleomorphic crystalluria (Fig 1A). Some crystals had the characteristic "coffin lid" appearance suggesting struvite (triple phosphate) crystals. Others had notched edges suggestive of uric acid crystals. Still other crystals formed a rosette.