Faculty Bibliography

Introduction: The dramatic spread of COVID-19 in March 2020 threatened to overwhelm ICU capacity. At the peak we had more than 120 patients in the ICU. About 40% of the ICU patients required RRT due to AKI. Our ability to provide RRT with CVVH and IHD was severely limited by critical shortages of equipment and personnel. We rapidly established an acute PD program at Bellevue hospital for AKI patients. The acute PD program turned out to be instrumental in the BH response to COVID AKI. Case Description: Patients All patients who needed RRT in the ICU were eligible to receive PD catheters except for those with prior abdominal surgery. 36/38 patients who received catheters were Covid (+). Proning was not always planned; we did not use this as a contraindication. We were able to successfully perform adequate PD on patients who were proned with minimal complications. Surgical Support Catheters were placed using a limited cut down to the peritoneal membrane through the rectus muscle at bedside; most of the patients were intubated and sedated. Training and Initial Experience A nurse affiliated with Bellevue's outpatient dialysis unit helped make videos and trained the lead nephrologist on how to perform PD and how to use a Cycler. 25 people were on the PD team and we were able to provide exchanges 24 hours per day. Exchanges were initially performed manually every 1-2 hours. Eventually we acquired 18 cyclers which greatly eased the workload. Outcomes As of May 8, 2020 63 patients were evaluated, 38 PD catheters were placed with 35 used for exchanges. 2 patients had catheters placed but recovered renal function prior to starting PD. 1/38 was nonfunctioning and changed to IHD. 15/35 survived >30 days; 8 recovered renal function; 20 expired <30 days.
Discussion(s): Because of the shortage of our typically used dialysis modalities we were compelled to start an acute PD program. No patient on PD required additional dialytic support with IHD or CVVH. PD was well tolerated by ventilated patients with hemodynamic instability. Acute PD more than adequately filled the gap in treatment options during this unprecedented crisis

Background: Patients with respiratory failure who require prone positioning are not considered good candidates for PD due to the concerns for increased intra-abdominal pressure, impaired diaphragmatic movement, and leaking of peritoneal fluid. We addressed the COVID-related AKI (CRAKI) surge for renal replacement therapy (RRT) by initiating an acute PD program at Bellevue Hospital including prone patients.
Method(s): All patients were in the ICU with COVID related hypoxic respiratory failure and acute kidney injury (AKI). 6/35 patients who received PD were treated for 16 hours per day in the prone position to improve oxygenation. The mean age was 54.6. The average BMI was 35.5. Patients were on mechanical ventilation 12-33 days. 3/6 patients were on CVVH however, switched to PD due to clotting. Patients were on PD for an average of 9.3 days. All PD catheters were placed at the bedside using an open cut down technique. PD was started the same day using manual exchanges. Dwell volume was gradually increased to 2 L. Exchanges were performed q1h while supine and q2h while prone, a total of 4-6 exchanges/day. The PD team coordinated timing with the prone team and ICU nurses to allow the continuation of the PD treatment. Patients were monitored clinically for abdominal distention and changes in respiratory mechanics.
Result(s): All 6 patients remained on PD for the duration of the hospitalization. There were no incidences of bowel injury, hemorrhage, exit-site infections, or peritonitis. None of the patients had any catheter malfunction. Leaking was addressed with temporarily reducing the dwell volume. Patients experienced slow draining which was due to kinking of the tubing during prone positioning. All patients were able to continue receiving PD without interruptions. Either no change or improvement in ABG and ventilator settings was noted after prone positioning and PD.
Conclusion(s): Due to COVID related surge, we saw a significant number of patients in the ICU with severe acute respiratory failure requiring prone positioning who also developed AKI requiring RRT. We were able to successfully provide acute PD in ventilator-dependent prone patients suffering from CRAKI. This required a team effort and some modifications in the conventional PD prescription. (Figure Presented)

We report a 40-year-old man who was found to have profound hypocalcaemia and hypoparathyroidism when investigated for multiple, generalized, tonic/clonic seizures and a chest infection. Computed tomography scan of the brain revealed extensive symmetric bilateral calcification within the cerebellum, thalamus and basal ganglia. Molecular cytogenetic testing by fluorescent in situ hybridization using the commercial Vysis LSI DiGeorge/VCFS dual colour probe set showed a deletion of 22q11.2. The extraordinary feature of this case is the adult presentation of hypocalcaemia, hypoparathyroidism and basal ganglia calcification due to 22q11.2 deletion.

AIMS: To assess the accuracy of the Minimed continuous glucose monitoring system (CGMS) in estimating blood glucose concentration during a controlled reduction in blood glucose. RESEARCH DESIGN AND METHODS: We studied nine adolescent diabetics (age 14 +/- 1.5 years) wearing the CGMS during hyperinsulinaemic hypoglycaemic clamp studies. The glucose values obtained by the CGMS were compared with the venous blood samples taken during the studies and measured at the bedside using a glucose oxidase technique. RESULTS: Blood glucose was lowered from euglycaemia to a mean of 2.8 mmol/l over 120 min and maintained at that level for a further 40 min. A total of 429 paired glucose measurements were available for analysis. Analysis using weighted Deming regression and t-tests revealed small differences between the methods, with blood glucose levels slightly higher than interstitial fluid levels. The mean difference across all values was 0.13 mmol/l. The observed difference was greatest at blood glucose values < 3.3 mmol/l. CONCLUSIONS: This study suggests that during a fall in systemic glucose the subcutaneous glucose sensor provides an accurate reflection of blood glucose. However, a small difference is apparent at blood glucose values < 3.3 mmol/l.

BACKGROUND: Arteriovenous fistulae (AVFs) are the preferred method of vascular access for hemodialysis patients; however, the current rate of AVF placement is only 25% to 30% in the United States. This prevalence is even smaller among women and attributed to their perceived inadequate vasculature. This commonly held view that women have less adequate vasculature for AVF placement than men has not been shown objectively in the literature. METHODS: To determine a difference in vasculature between the sexes, we retrospectively analyzed data on preoperative vascular mapping in 192 patients. During a 2-year period, vascular mapping of the upper extremities was routinely performed using duplex ultrasound in all patients requiring vascular access in our institution. RESULTS: One hundred six of these 192 patients were women, and 86 were men. There was no significant difference in vein size between men and women at any of the sites measured. A total of 87 fistulae were placed in 140 patients, 49% in women and 51% in men (P = 0.16). Prevalences of AVFs were 57% and 68% (P = 0.2) in women and men, respectively. Percentages of fistulae used at the initiation of hemodialysis therapy were 72% in women and 77% in men (P = 0.57). CONCLUSION: These data support the view that women have adequate vasculature for the placement of AVFs compared with men. We cannot explain the different outcomes found in other studies; however, we suggest that the differences are caused by physician practice patterns, not anatomic differences between men and women.

A patient with scleroderma developed renal failure secondary to recurrence of scleroderma in a renal allograft from an identical twin. This report reviews the previous reports of scleroderma recurrence in renal allografts; the differential diagnosis of scleroderma renal crisis, including cyclosporine toxicity, malignant hypertension, and allograft rejection; and the pathophysiology of this disease.