No abstract

A 43-year-old woman with end-stage renal disease on hemodialysis for 4 years presented complaining of recurrent edema of her left arm, neck and face during the last 12 months. She dialyzes via a left brachial artery to cephalic vein arteriovenous fistula. Due to difficulties in vascular access, she had three temporary left subclavian catheters placed previously. On examination, the left neck veins were dilated with large collateral veins on the chest wall. A computed tomography (CT) angiogram ( Fig. 1a,b) followed by a fistulogram (Fig. 2) was performed.What does the CT angiogram show (Fig. 1a,b)? What does the fistulogram show ( Fig. 2)? How should the patient be managed? AnswersThe CT angiogram showed an extensive collateral vein network involving the chest wall and suprascapular veins (Fig. 1a,b). The fistula is evident in the left upper arm on digital reconstruction images (Fig. 1b). A fistulogram was performed and revealed severe stenosis (>95%) of the left branciocephalic vein and a large collateral network of veins (Fig. 2). She underwent balloon angioplasty with successful vein dilatation with 8 and 10 mm balloons. There was no immediate angiographic improvement of collateral veins, but the edema on the face, arm and neck moderately subsided.Swelling of the face and neck in hemodialysis patients should prompt clinicians to consider impaired venous return due to central venous stenosis. The literature suggests that cannulation of central veins with catheters is associated with up to 50% stenosis rates. The number of catheters inserted and the increased duration of catheter days is also associated with the development of central venous stenosis (1). Such a stenosis is more common with subclavian catheters; they should be avoided even temporarily.

Background: The aim of this study was to evaluate the prognostic value of automated office blood pressure (AOBP) measurement in patients with hypertension and chronic kidney disease (CKD) stage 3–5 not on dialysis. Methods: At baseline, 140 patients were recruited, and blood pressure (BP) measurements with 3 different methods, namely, office blood pressure (OBP), AOBP, and ambulatory blood pressure measurement (ABPM), were recorded. All patients were prospectively followed for a median period of 3.4 years. The primary outcome of this study was a composite outcome of cardiovascular (CV) events (both fatal and nonfatal) or a doubling of serum creatine or progression to end-stage kidney disease (ESKD), whichever occurred first. Results: At baseline, the median age of patients was 65.2 years; 36.4% had diabetes; 21.4% had a history of CV disease; the mean of estimated glomerular filtration rate (eGFR) was 33 mL/min/1.73 m2; and the means of OBP, AOBP, and daytime ABPM were 151/84 mm Hg, 134/77 mm Hg, and 132/77 mm Hg, respectively. During the follow-up, 18 patients had a CV event, and 37 patients had a renal event. In the univariate cox regression analysis, systolic AOBP was found to be predictive of the primary outcome (HR per 1 mm Hg increase in BP, 1.019, 95% CI 1.003–1.035), and after adjustment for eGFR, smoking status, diabetes, and a history of CV disease and systolic and diastolic AOBP were also found to be predictive of the primary outcome (HR per 1 mm Hg increase in BP, 1.017, 95% CI 1.002–1.032 and 1.033, 95% CI 1.009–1.058, respectively). Conclusions: In patients with CKD, AOBP appears to be prognostic of CV risk or risk for kidney disease progression and could, therefore, be considered a reliable means for recording BP in the office setting.

Sarcoidosis is a multisystem disorder of unknown origin characterized by the presence of non-caseating granulomas in multiple organs. [1] Although it most commonly affects the respiratory system, with bilateral hilar adenopathy and pulmonary infiltrates being the most common findings, any organ can be involved. Renal involvement is rare and, if present, is due either to hypercalcaemia or granulomatous interstitial infiltration and, less frequently, to glomerulopathies or granulomatous involvement of the renal vasculature and retroperitoneum. [1] This report focuses on the case of a 32-year-old man who presented complaining of nausea, vomiting, fatigue, and a 5 kg weight loss over the past three months. His medical history was unremarkable. Physical examination revealed the presence of generalized lymphadenopathy. Laboratory evaluation showed severely impaired renal function (urea 150 mg/dL, creatinine 4 mg/dL), severe hypercalcemia (13.5 mg/dL) with hypercalciuria (416 mg in a 24-hour collection), and normal PTH levels (5 pg/mL). Hematocrit and hemoglobin values stood at 34% and 11.5 gr/dL, respectively. Renal ultrasound indicated normal-sized kidneys with the presence of a 4 mm stone on the upper calyceal group of the right kidney without urinary obstruction. Chest X-ray showed bilateral hilar adenopathy and reticulo-nodular pattern. A chest and abdominal CT-scan revealed the presence of diffuse mediastinal and abdominal lymphadenopathy less than 1 cm in size. Serum angiotensin converting enzyme was significantly raised (128IU/L). Serology for HIV, CMV, EBV, Toxoplasma, and autoimmune diseases as well as PPD was negative.As sarcoidosis rarely invades with symptomatic hypercalcaemia [2] and renal involvement, [3] a diagnostic dilemma concerning lymphoproliferative disorders emerged. Mediastinoscopy was performed, and the presence of non-caseating granulomas in the resected lymph nodes established the diagnosis of sarcoidosis. As expected, 1,25-dihydroxy vitamin D3 serum concentration was increased (202 nmol/Lt, r.r. 25-120 nmol/Lt), thus justifying hypercalcaemia. [4] Upon admission, the patient was treated with normal saline and diuretics IV (furosemide, 80 mg/daily) aiming to normalize serum calcium. Renal insufficiency was attributed to hypercalcaemia as it subsided gradually by the correction of calcium serum concentration. Therefore, although renal biopsy was not performed (due to the rapid improvement of the renal function), the direct renal insult by sarcoidosis seems unlike. Following the pathological diagnosis of sarcoidosis, the patient was started on corticosteroids (methylprednizolone at a daily dose of 2 mg/kg) and ketoconazole (600 mg/day), resulting in a significant reduction in 1,25-dihydroxy vitamin D3 concentration (85 nmol/Lt). Ketoconazole has been reported to inhibit 1B-hydroxylation of vitamin D by acting directly on 1B-hydroxylase, thus lowering 1,25-dihydroxy vitamin D3 production in pulmonary macrophages and sarcoid granulomas. [5] After six months on corticosteroids, the patient's renal ...