Summary Background and objectives Poor physical performance is common in patients with kidney failure on dialysis (CKD-5D). Whether lung congestion, a predictable consequence of cardiomyopathy and fluid overload, may contribute to the low physical performance of CKD-5D patients has not been investigated in hemodialysis patients. Design, setting, participants, & measurements This study investigated the relationship between the physical functioning scale of the Kidney Disease Quality of Life Short Form and a validated ultrasonographic measure of lung water in a multicenter survey of 270 hemodialysis patients studied between 2009 and 2010. Results Moderate to severe lung congestion by lung ultrasonography was observed in 156 (58%) patients; among these, 60 (38%) were asymptomatic (New York Heart Association [NYHA] class I). On univariate analysis, physical functioning was inversely associated with lung water in the whole group (r=−0.22; P<0.001) and in the subgroup of asymptomatic patients (r=−0.40; P=0.002). Age (r=−0.45; P<0.001) and past cardiovascular events (r=−0.22; P=0.002) were also inversely associated with physical functioning, whereas albumin (r=0.23; P<0.001) was directly associated with the same parameter. NYHA class correlated strongly with physical functioning (r=−0.52; P<0.001). In a multiple regression analysis, both NYHA class and lung water maintained an independent association with physical functioning, whereas albumin and background cardiovascular events failed to independently relate with the same outcome. Conclusions Symptomatic and asymptomatic lung congestion is associated with poor physical functioning in hemodialysis patients. This association is independent of NYHA, suggesting that this measurement and NYHA may have complementary value to explain the variability in physical performance in hemodialysis patients.

Background: Lung congestion is emerging as a pervasive, insidious problem in end-stage renal disease (ESRD) patients on dialysis. Summary: Chest ultrasound (US), a novel, easy-to-perform, cheap technique, which is currently applied for objective monitoring of pulmonary congestion in patients with heart failure in Europe, allows reliable quantification of lung water in clinical practice. Before hemodialysis (HD), about 60% of ESRD patients displayed moderate-severe lung congestion and this alteration is frequently asymptomatic. Lung congestion is reduced but not abolished by ultrafiltration dialysis, and about one third to one fourth of patients still have excessive lung water after dialysis. Lung congestion is also prevalent in patients on peritoneal dialysis (PD), and in apparently asymptomatic HD and PD patients this alteration is strongly associated with poor physical performance. Lung water in HD patients correlates in an inverse fashion with echocardiographic parameters of systolic and diastolic function, but it is only weakly related with hydration status measured by bioimpedance analysis. Moderate-severe lung congestion is a strong predictor of death and cardiovascular events and provides prognostic information independent of NYHA class, and traditional and nontraditional risk factors in ESRD patients on HD. Key Messages: Systematic application of chest US in ESRD patients shows that hidden or clinically manifest lung congestion is exceedingly frequent in this population. This alteration largely reflects left ventricular disorders superimposed on volume overload. The clinical usefulness of systematic application of chest US in ESRD remains to be tested in a formal clinical trial.

An updated review of cases of reactivated visceral leishmaniasis (VL) in transplant patients is presented, with a new report of a kidney transplant patient who had VL caused by reactivation of a dormant infection contracted 21 years previously. Close to the time of disease reactivation, the patient had a primary varicella-zoster infection.

In patients with nephrotic syndrome (NS), the lung is considered an organ protected from the risk of edema. However, data on objectively measured lung water in NS patients is lacking. Here we measured lung water by an ultrasound (US) technique as well as by transthoracic impedance in 42 asymptomatic patients with active NS, in 14 stage G5D CKD patients on chronic hemodialysis, and in 21 healthy individuals. In patients with active NS, the median number of US-B lines (a metric of lung water) after 5 min in a supine position was significantly higher (12; interquartile range: 7-25) compared with that in healthy individuals (4; 2-9) but similar to that in hemodialysis patients (23; 10-39). The difference between NS patients and healthy individuals was significantly amplified (16; 10-35 vs. 4; 2-9) after 60 min of supine resting and significantly attenuated after 5 min of standing (10; 7-25 vs. 3; 1-6). Posture-dependent changes in lung water in patients with active NS were significantly accentuated compared with both hemodialysis patients and healthy individuals. After NS remission, the number of US-B lines was significantly reduced to 5 (4-18) at 5 min and to 6 (5-22) at 60 min approaching the normal range. Lung congestion in patients with active NS was confirmed by transthoracic impedance. Thus, asymptomatic pulmonary congestion is pervasive in patients with NS. A clinical trial is needed to assess the utility of lung US for the management of patients with NS.