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: Due to increased risk for infection, fluid leak, metabolic complications and poor uremic solute clearance, concerns have been raised in using peritoneal dialysis in obese patients. However, due to unprecedented need for renal replacement therapy (RRT) in New York City during the COVID-19 pandemic, acute peritoneal dialysis (APD) was initiated in patients regardless of body mass index (BMI).
Method(s): 36 patients who received PD between April 8, 2020 and May 8,2020 were categorized into 3 groups based on BMI calculated using admission height and weight. Group 1 with BMI < 30, Group 2 with BMI 30-40 and Group 3 with BMI > 40 kg/ m². Treatment goals included correction of hyperkalemia, hyperphosphatemia, acid-base abnormalities, reduction in blood urea nitrogen (BUN), creatinine and maintaining euvolemia. All patients were initially started on manual exchanges every 1-2 hours (Total volume 10-13L/24 hours) and eventually most were changed to automated PD (Total volume 18-20L/24 hours). We compared the frequency of treatment-related complications among the groups.
Result(s): Of the 36 patients, 13 had BMI < 30, 18 patients had BMI 30-40, and 5 had BMI > 40, one of whom had BMI > 50 kg/ m². Patients showed improvement in serum creatinine, BUN, phosphorus, potassium, and bicarbonate. All had adequate ultrafiltration and improved volume status after optimization of PD prescription. No differences were observed between groups in achievement of treatment goals. No patients in any group required discontinuation of PD because of treatment-related complications or insufficient dialysis.
Conclusion(s): Acute PD was successfully performed in obese, and morbidly obese patients during the COVID-19 pandemic. Treatment goals were achieved based on relevant parameters and there were no increases of treatment related complications compared to non-obese patients. Acute PD should not be restricted based on elevated BMI

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.