Recent experiences in other fields of medicine show that more intensive treatment does not lead to better outcomes […] We may need to re-consider the value of careful monitoring and conservative treatment as a valid and independent option in the treatment of AKI.

The purpose of the study was to compare the long-term catheter-related complications associated with temporary untunneled hemodialysis catheters, locked with citrate in the interdialysis period, inserted in critically ill patients with acute kidney injury, between different catheter insertion sites (femoral vs. jugular and subclavian) and catheter types (single-lumen [SL] vs. double-lumen [DL]). In a retrospective clinical study, the long-term catheter-related complications in 290 critically ill patients treated with intermittent high-volume online hemofiltration or hemodialysis between December 2004 and January 2008 were analyzed. Among 534 inserted catheters, 493 (92.3%) were femoral, 29 (5.4%) jugular, and 12 (2.3%) subclavian; 304 (56.9%) were SL and 230 (43.1%) were DL. There were 125 (20.3/1000 catheter days [c.d.]) thrombotic complications, while infectious complications were exceptionally rare, that is, only 13 (2.1/1000 c.d.), of which 10 (1.6/1000 c.d.) were possible catheter-related bloodstream infections and 3 (0.5/1000 c.d.) exit-site infections. The incidence rate of all thrombotic complications was significantly lower in all jugular and subclavian vs. all femoral catheters (7.7/1000 c.d. vs. 21.8/1000 c.d., P = 0.01), and in all SL vs. DL catheters (11.4/1000 c.d. vs. 32.2/1000 c.d., P < 0.001). The incidence rate of any possible catheter-related bloodstream and exit-site infections was not significantly different in all jugular and subclavian vs. all femoral catheters, neither in femoral SL vs. DL catheters. The major long-term catheter-related complications were thrombotic, and significantly more frequent in DL vs. SL catheters. Infectious complications were exceptionally rare, most probably due to the strict catheter care protocol, as well as the routine use of a citrate catheter lock and antibiotic ointment at the catheter exit-site.

There is no consensus on the optimal renal replacement treatment in intensive care units. Among intermittent dialysis methods, hemofiltration (HF) is preferred by some because of better hemodynamic stability and cytokine removal. We report our experience with regional citrate anticoagulation for intermittent predilution online HF. Forty-one patients (age 69 +/- 10 years, 73% male) with acute renal failure and an increased bleeding risk in intensive care units were included in this retrospective analysis. Citrate anticoagulation was performed with 4% citrate (starting at 400 mL/h) and 1 mol/L calcium chloride (starting at 7 mL/h). Calcium-containing (1.25 mmol/L) infusate, prepared online, was used. Anticoagulation was assessed visually after HF in a subgroup of 36 procedures using a score of 5 (no clotting) to 1 (total occlusion). The duration of the 94 HF sessions performed was 4 h 50 min +/- 47 min, and the infusate volume reached was 77 +/- 9 L. During HF, ionized calcium increased (1.01 +/- 0.14 to 1.13 +/- 0.09 mmol/L, P < 0.001), and the increases in sodium (141 +/- 5 to 143 +/- 3 mmol/L, P < 0.001) and bicarbonate (23 +/- 6 to 25 +/- 4 mmol/L, P < 0.01) were significant, but small. There were two cases of metabolic alkalosis (pH > 7.5) not requiring any intervention. None of the circuits clotted. The mean anticoagulation assessment scores were 4.6 +/- 0.6 at the arterial bubble trap, 4.2 +/- 1.0 at the dialyzer, and 4.2 +/- 0.9 at the venous bubble trap. To conclude, regional citrate anticoagulation for predilution online hemofiltration with calcium-containing infusate provides a good anti-thrombotic effect and has rare metabolic side effects.

The aim of our report is to present our 11-year experience with therapeutic membrane plasma exchange therapy for the treatment of idiopathic thrombotic thrombocytopenic purpura syndrome (TTP). In 56 patients, membrane plasma exchange therapy was initiated immediately and performed once or twice daily until the platelet count normalized. During each plasma exchange procedure, 1-1.5 plasma volumes (3606 +/- 991 mL) were replaced with fresh frozen plasma. In 37 females and 19 males (44 +/- 21 years), 1066 plasma exchange procedures were performed. The average duration of treatment was 23 +/- 17 days. The average number of plasma exchanges was 19 +/- 17 per patient. Renal impairment was detected in 36% of patients. At the initiation of plasma exchange treatment, the average platelet count was 31 +/- 30 x 10(9)/L and reached 199 +/- 95 x 10(9)/L thereafter. Fifty-two of 56 (93%) patients demonstrated an excellent response to plasma exchange therapy, of whom 48 patients (86%) attained complete remission with a platelet count of more than 100 x 10(9)/L. Four patients died soon after the initiation of plasma exchange therapy, when only 1-3 procedures had been performed. During the follow-up period, six patients with complete remission had 1-5 subsequent relapses each year. One of them died of acute hemolytic reaction during the tapering of plasma exchange procedures. Three patients underwent additional splenectomy. Our experience with primary TTP supports the plasma exchange treatment with fresh frozen plasma as a mandatory, up-to-date therapy. Close monitoring during all 1066 procedures showed no serious side-effects.

INTRODUCTION Catheter-related right atrial thrombosis (CRAT) is potentially life-threatening complication of long-term indwelling central venous catheters (CVC), which are used extensively in various patients. Reported incidence of CRAT is variable (2-62%) and probably underestimated due to predominantly asymptomatic course and lack of routine screening. Main pathogenic mechanisms that promote CRAT include mechanical and chemical injury of atrial endocardium by the catheter and infused drugs, stasis of blood and hypercoaguability. Differential diagnosis between thrombus and other intracardiac masses, especially myxoma, is sometimes very difficult and requires multimodality imaging studies. CASE PRESENTATION 62-years old patient after chemotherapy of lymphoma, in remission, with subcutaneous CVC inserted in right subclavian vein, which was used as chemotherapy port several years ago, was sent to emergency department because right atrial mass was found on elective outpatient transthoracic echocardiography (TTE). Urgent computed tomography (CT) was performed and showed well defined, 1.8 x 2.0 cm large, low attenuating mass with some calcifications. Several features were primarily suggestive of myxoma, however differentiation from thrombus was not possible. Patient was admitted to hospital, where transesophageal echocardiography (TEE) confirmed the presence of heterogenous mass attached to right atrial free wall with tumor-like movement. Mobile catheter tip was nearby and touching the mass irregularly. Although in addition to CT also some echocardiographic characteristics were more consistent with myxoma, there was still high clinical suspicion of CRAT due to multiple risk factors for thrombosis. Cardiac magnetic resonance imaging (MRI) using cine sequence was performed for further evaluation and revealed mobile, homogeneously low-signal intensity mass that remained hypointense on contrast-enhanced sequences (first pass perfusion and late gadolinium enhancement), which led to final diagnosis of thrombus. CONCLUSION CRAT should be suspected and anticipated in all, also asymptomatic patients with long-term indwelling CVC (e.g. for chemotherapy, parenteral nutrition, hemodialysis..), majority of whom have additional multiple risk factors for thrombosis. Routine screening for CRAT can provide early diagnosis and treatment and should be considered especially in high-risk patients in order to prevent potentially severe complications. Although echocardiography is the modality of choice for screening, further imaging modalities, e.g. CT and MRI are often required to differentiate thrombus from myxoma or other cardiac masses. Our case demonstrates difficult differential diagnosis of right atrial mass in an asymptomatic patient with a long-term indwelling chemotherapy port, in whom multimodality imaging studies were performed, but only MRI with contrast-enhanced sequences providing superior tissue characterization, could differentiate between CRAT and myxoma. Abstract P708 Figure. Multimodality imaging of atrial thrombus