In conclusion, a significant acceleration of eGFR decline is observed over the 12 months following the closure of a functioning AVF in KTRs.

Arteriovenous fistula (AVF) is regarded as the best vascular access for chronic haemodialysis (HD). Still, AVF inherently causes significant haemodynamic changes. Although the necessity for vascular access despite its putative cardiovascular complications favours AVF creation in patients under chronic HD, one may question whether sustaining a functional AVF after successful kidney transplantation extends the haemodynamic threat. Small prospective series suggest that AVF ligation causes rapid and sustained reduction in left ventricular hypertrophy. Still, the benefits of such a cardiac remodelling in long-terms of cardiovascular morbi-mortality still need to be proven. Furthermore, the elevation of diastolic blood pressure and arterial stiffness caused by AVF ligation may blunt the expected cardio-protection. Finally, the closure of a functioning AVF may accelerate the decline of kidney graft function. As a whole, the current management of a functioning AVF in kidney transplant recipients remains controversial and does not rely on strong evidence-based data. The individual risk of graft dysfunction and a return to chronic HD also needs to be balanced. Careful pre-operative functional assessments, including cardio-pulmonary testing and estimated glomerular filtration rate slope estimation, may help better selection of who might benefit the most from AVF closure. Large-scale prospective, ideally multi-centric, trials are essentially needed.

Objective: Blood pressure (BP) control in haemodialysis (HD) patients is crucial given their very high cardiovascular risk. Per-dialytic BP levels do not accurately predict the cardiovascular mortality. Here, we compare the prognostic yield of 2 ambulatory BP measurement techniques in prevalent HD patients. Design and method: We recruited adult patients who had been on chronic HD for more than 3 months. Seven-day home BP monitoring (HBPM) (values of Day 1 discarded) and 44-h interdialytic ambulatory BP monitoring (iABPM) were performed. Pre- and post-dialysis BP levels were measured during the 6 dialysis sessions prior to iABPM. A 5-year follow-up was carried out to assess all-cause and cardio-vascular mortality. Results: We recruited 43 patients including 15 women. Mean age was 68.3±13 years, mean body mass index was 24.1±3.8 kg/m2, median dialysis vintage was 2.4 years [0.25;11], and 67% of patients were under anti-hypertensive medications. In patients considered as normotensive in pre-dialysis (n = 17), masked hypertension was found in 24% (11.6% of the entire cohort) and 29%, based on iABPM and HBPM, respectively. Conversely, among hypertensive patients in pre-dialysis (n = 26), “white-coat” hypertension was noted in 23% (14% of the entire cohort), either by iABPM or HBPM. In treated hypertensive patients, ambulatory techniques detected a higher proportion of uncontrolled hypertension (76% of cases in iABPM and HBPM) compared to pre-dialysis measurements (65% of cases). Focusing on the first 24 hours of iABPM underestimated the proportion of hypertensive patients (49% of the entire cohort) compared to the 44-h coverage (58% of the entire cohort). Restricting HBPM for only 3 days decreased the concordance with iABPM from 86% (k = 0.79) to 76.7% of cases (k = 0.67). After a 5-year follow-up, 25 patients were deceased including 6 patients from cardiovascular causes. All-cause mortality was associated in an adjusted model for age and gender with day-time systolic BP measured by iABPM (p = 0.045). Conclusions: In chronic HD patients, 44-h iABPM and 7-day HBPM show a reliable concordance and help to re-classify ∼25% of cases miscategorised on the basis of pre-dialysis measurements. Day-time systolic BP levels using iABPM were significantly associated with 5-year all-cause mortality.

An 81-year-old man was hospitalized for a long time in geriatric unit for a meningeal hemorrhage with secondary hydrocephalus. He underwent a ventriculoperitoneal shunt but had limited mobility with confusion and needed chronic urinary tract catheter. He has mainly cardiovascular history (coronary bypass, ventricular arrhythmia, hypertension, atril fibrillation and pace make). During hospitalization, his chronic kidney disease has increased (eGFR 30 mL/min) and he has presented constipation requiring laxative medication. One day, the health care team noticed the purple coloration of the urine bag (Figure 1). A urinalysis showed pyuria, and an alkaline pH (pH 8). The urine culture yielded E. Coli and K. Pneumoniae (growth was greater than 10 6 CFU/mL for both). The purple urine bag syndrome was diagnosed.