Background Patients receiving maintenance hemodialysis experience a high burden of infectious morbidity, and vaccination is a key preventive strategy in this population. Despite international guideline recommendations, vaccination uptake and immune response in this population remain suboptimal. Aims The study aimed to evaluate hepatitis B virus (HBV) vaccination completion and seroprotection, pneumococcal vaccination coverage, and pneumonia-related hospitalizations among incident hemodialysis patients managed under a pharmacist-led vaccination program. Design This retrospective cohort study was conducted between 2019 and 2022 at a tertiary hospital dialysis program in Singapore, where vaccination delivery was integrated into routine hemodialysis care by clinical pharmacists. Methods All consecutive incident adult hemodialysis patients managed between January 2019 and December 2022 under a pharmacist-led vaccination model were included. They were evaluated for vaccination uptake, immune response to HBV vaccination, and pneumonia-related hospitalizations within the first year of dialysis initiation. Data were extracted from the hospital's electronic medical record (EMR) system. As this was a service evaluation of the entire eligible population during the study period, no formal sample size calculation was performed. Statistical analysis Categorical variables were analyzed using chi-square testing, with statistical significance defined as a two-sided p-value < 0.05. Results are reported with corresponding chi-square statistics and p-values where applicable. Results Among HBV-susceptible patients, just over one-third completed the recommended three-dose vaccination schedule, and approximately half of those achieved seroprotection. Pneumococcal vaccination coverage within the first year of hemodialysis initiation was below 50%. Pneumonia-related hospitalizations were lower among vaccinated patients (2.2%) compared with unvaccinated patients (7.5%) and were statistically significant (p = 0.032). Conclusions A pharmacist-led vaccination program was associated with moderate vaccine uptake and reduced pneumonia-related hospitalizations; however, substantial gaps in vaccination completion and immune response persisted. Multicomponent, system-level strategies may be required to enhance vaccine uptake and effectiveness in hemodialysis populations.

A man in his 60s presented with Escherichia coli peritoneal dialysis (PD)-associated peritonitis. Despite appropriate therapy, his effluent leucocyte count, though downward trending, remained >2000/µL on day 5, meeting criteria for refractory peritonitis and prompting recommendation for PD catheter removal. This option was declined by the patient because of his poor premorbid condition and high procedural risk. As treatment continued, a steady further downward trend in effluent leucocytes emerged, and catheter preservation was pursued. Intraperitoneal amikacin was added to intravenous ceftriaxone, providing dual-route, dual-class antimicrobial therapy. Unexpectedly, his peritonitis resolved by day 15 without catheter removal. He was discharged eventually. This case illustrates that PD catheter removal may not always be practical in frail patients. Trends in effluent leucocyte counts may offer more clinical insight than a strict absolute threshold for catheter removal. It raises the hypothesis that combined intravenous and intraperitoneal antibiotics may be beneficial in selected gram-negative infections.

Objectives:Diabetes mellitus (DM) and chronic kidney disease (CKD) are prevalent conditions in the elderly population, increasing the risk of bone fractures due to their adverse effects on bone quality. This study aimed to assess their impact on bone health and propose interventions to mitigate fracture risk in this demographic. Methods:A cross-sectional study involving 571 elderly patients (aged ≥ 65 years) with fragility hip fractures was conducted at a tertiary care hospital between June 2014 and June 2016. Patients were categorized into four groups based on DM and CKD presence. Bone mineral density (BMD) at the femoral neck was measured using dual-energy X-ray absorptiometry (DXA) scan. Statistical analysis included ANOVA with Bonferroni correction. Results:The mean age was 79.5 ± 7.3 years, with females comprising 70.6%. Group 2 (No CKD with diabetes) exhibited higher T-scores than Group 1 (No CKD or Diabetes). Patients with DM had higher T-scores, with an increase of 0.2 compared to those without DM and CKD. Surprisingly, CKD and DM coexistence (Group 4) did not worsen T-scores. Higher HbA1c levels were positively associated with a higher T-score, but this was lost in concurrent CKD. Conclusions:Patients with DM had higher T-scores; the combination of CKD and DM did not worsen T-scores. However, the positive association between higher HbA1c and higher T-score was nullified in concurrent CKD. These findings emphasize the need for tailored interventions to mitigate fracture risk in elderly populations with DM and CKD.

Atheroembolic renal disease (AERD) is a rare and often underdiagnosed cause of acute kidney injury (AKI), particularly in patients with atherosclerotic disease. We present the case of a 66-year-old man with hypertension, hyperlipidemia, and stage 3 chronic kidney disease (CKD) (baseline creatinine 100-120 μmol/L) who developed AKI after coronary artery bypass graft (CABG) for non-ST-elevation myocardial infarction (NSTEMI), followed by recurrent episodes and progressive renal decline despite no further invasive procedures. Fundoscopic examination revealed Hollenhorst plaques, leading to a clinical diagnosis of AERD. This case underscores the diagnostic value of noninvasive ophthalmologic evaluation in patients at high risk for cholesterol embolism. The patient was managed with supportive measures, including hydration and blood pressure control, which helped stabilize renal function (creatinine improved from 591 to 410 μmol/L). Our objective is to highlight the diagnostic utility of fundoscopy in evaluating unexplained renal deterioration and systemic ischemic symptoms in frail patients where biopsy is contraindicated.

Introduction: Long-term proton pump inhibitor (PPI) use has been associated with hypomagnesemia. It is unknown how frequently PPI use is implicated in patients with severe hypomagnesemia, and its clinical course or risk factors. Methods: All patients with severe hypomagnesemia from 2013 to 2016 in a tertiary center were assessed for likelihood of PPI-related hypomagnesemia using Naranjo algorithm, and we described the clinical course. The clinical characteristics of each case of PPI-related severe hypomagnesemia was compared with three controls on long-term PPI without hypomagnesemia, to assess for risk factors of developing severe hypomagnesemia. Results: Amongst 53,149 patients with serum magnesium measurements, 360 patients had severe hypomagnesemia (<0.4 mmol/L). 189 of 360 (52.5%) patients had at least possible PPI-related hypomagnesemia (128 possible, 59 probable, two definite). 49 of 189 (24.7%) patients had no other etiology for hypomagnesemia. PPI was stopped in 43 (22.8%) patients. Seventy (37.0%) patients had no indication for long-term PPI use. Hypomagnesemia resolved in most patients after supplementation, but recurrence was higher in patients who continued PPI, 69.7% versus 35.7%, p = 0.009. On multivariate analysis, risk factors for hypomagnesemia were female gender (OR 1.73; 95% CI: 1.17–2.57), diabetes mellitus (OR, 4.62; 95% CI: 3.05–7.00), low BMI (OR, 0.90; 95% CI: 0.86–0.94), high-dose PPI (OR, 1.96; 95% CI: 1.29–2.98), renal impairment (OR, 3.85; 95% CI: 2.58–5.75), and diuretic use (OR, 1.68; 95% CI: 1.09–2.61). Conclusion: In patients with severe hypomagnesemia, clinicians should consider the possibility of PPI-related hypomagnesemia and re-examine the indication for continued PPI use, or consider a lower dose.

A 62-year-old male on maintenance hemodialysis, who was bedbound after a cerebrovascular accident, developed progressive hypercalcemia during a prolonged hospital stay. The etiology of hypercalcemia was attributed to immobility after extensive workup including imaging for malignancy or granulomatous disease, parathyroid hormone levels, parathyroid hormone related peptide, and vitamin D levels were unyielding. Low calcium dialysate would transiently reduce serum calcium levels, but levels would rebound in the interdialytic period. In view of recalcitrant hypercalcemia presenting with crisis, denosumab was successfully used to lower serum calcium. We review the literature and propose a management algorithm for severe hypercalcemia in a patient on dialysis.

BACKGROUND:The anion gap (AG) is often used to evaluate acid-base disorders. The reference interval for normal AG is used to differentiate between raised (gap) or normal AG (non-gap) acidosis. Historically accepted AG values may not be valid with the evolution of modern analytical techniques and the reference interval requires revalidation.AIMS:To determine the reference interval for AG based on current laboratory techniques.METHODS:During a health-screening exercise, 284 participants with no major illnesses volunteered surplus blood for analysis. The samples were tested in an internationally accredited clinical laboratory. AG was calculated by [Na+ ] - [Cl- ] - [HCO3 - ] and AGK by [Na+ ] + [K+ ] - [Cl- ] - [HCO3 - ]. The reference interval was determined at 2.5th-97.5th percentiles. Analysis was further undertaken for a subcohort of 156 individuals with no suboptimal health indicators.RESULTS:Median age was 35 years, body mass index 23.4 kg/m2 and the glomerular filtration rate was 106 mL/min/1.73 m2 . Median AG was 13 mmol/L and the reference interval for normal AG is 10-18 mmol/L with a 99% level of confidence. Statistically significant differences in AG were detected for sex, race, obesity and serum albumin, but the difference was 1 mmol/L between subgroups. The reference interval was the same for the sub-cohort of 156 individuals. Median AGK was 17.7 mmol/L and reference interval was 14.6-22.5 mmol/L.CONCLUSIONS:The AG reference interval of 10-18 mmol/L is valid for laboratories with similar reference intervals for electrolytes. Lower values expected with current laboratory techniques were not observed. The median AG of 13 mmol/L may be used to differentiate gap acidosis, non-gap acidosis or mixed acid-base disorders.

Introduction: Vitamin D deficiency is common in chronic kidney disease (CKD) and is associated with lower bone mineral density (BMD), decreased muscle strength, and increased hip fracture risk. Guidelines have suggested targeting 25-OH vitamin D (25(OH)D) levels between 20 and 30 ng/ml. However, vitamin D metabolism is altered in CKD, and threshold levels for optimal BMD are unknown.Methods: We included 1097 patients with hip fractures. CKD was defined as estimated glomerular filtration rate <60 ml/min/1.73 m (Mucsi et al., Clin. Nephrol., 2005, 64(4), 288–294) and low BMD defined as T score ≤ −2.5 at femoral neck. We assessed the association of 25(OH)D with low BMD in patients with and without CKD: using the conventional threshold 25(OH)D < 30 ng/dl, as well as a new threshold.Results: CKD was present in 479 (44%) patients. Using a threshold of 25(OH)D < 30 ng/ml, there were no significant differences in patients with CKD and low BMD when compared to the other groups. We identified 27 ng/ml as a better threshold with the Youden index. Using 25(OH)D < 27 ng/ml as a threshold, 360 of 482 patients (74.7%) with low 25(OH)D had low BMD, compared to only 185/276 (67%) of patients with adequate vitamin D, p = 0.02, which was irrespective of the presence or absence of CKD. Furthermore, patients with CKD and 25(OH)D < 27 ng/ml had a higher odds ratio of mortality upon follow-up, 1.61, 95% CI: 1.08–2.39, compared to those with CKD and 25(OH)D ≥ 27 ng/ml.Conclusion: We find that 25(OH)D < 27 ng/ml is associated with low BMD in patients with and without CKD. Further prospective studies targeting vitamin D repletion to at least 27 ng/ml and the outcome of hip fractures will be useful to validate these findings.

Secondary hypertension, where a treatable underlying cause can be identified, is reported to be about 10% of all diagnosed hypertension. Treating the underlying condition can improve or cure hypertension. An increased prevalence is seen in patients with resistant hypertension, hypokalemia, and younger patients. Common causes of secondary hypertension also include renovascular and renal parenchymal disease, and primary aldosteronism. Other conditions including pheochromocytoma, Cushing’s Syndrome, and coarctation of the aorta are less frequent causes of secondary hypertension. Obstructive sleep apnea is common and is associated with hypertension. Increased awareness and early diagnosis with targeted treatment significantly improves outcomes for patients diagnosed with secondary hypertension.

Introduction Patients who had a stroke are at increased risk of sepsis, dehydration and fluctuations in blood pressure, which may result in acute kidney injury (AKI). The impact of AKI on long-term stroke survival has not been studied well. Objective We aimed to identify incidence of AKI during acute stroke, follow-up period and its impact on long-term survival and development of chronic kidney disease (CKD). Design, setting and participants Retrospective analysis of patients who had a stroke admitted at the rehabilitation facility in Changi General Hospital, Singapore, between June 2008 and May 2017, with median follow-up of 141 (95% CI 120 to 163) months. Outcome measures and results of univariate analysis Total 681 patients, median age (63.6) years, 173 (28%) died during follow-up. Elevated blood urea (3.02, 95% CI 2.17 to 4.22; p≤0.001) and creatinine (1.96, 95% CI 1.50 to 2.57; p≤0.001) during stroke affected survival adversely. Excluding patients with CKD, we analysed the remaining 617 patients. AKI was noted in 75 (12.15%) patients during the index admission, and it affected survival adversely (2.16, 95% CI 1.49 to 3.13; p<0.001). Of the patients with AKI, 21 of 75 (28%) progressed to CKD over a median follow-up of 40.7 months. Conclusions We found AKI during stroke admission was associated with increased mortality as compared with those without AKI on univariate analysis. AKI without need of renal replacement therapy was also associated with progression to CKD in this cohort. This suggests that patients with AKI need to have their renal function monitored longitudinally for development of CKD.

Chronic kidney disease (CKD) causes bone and mineral disorders and alterations in vitamin D metabolism that contribute to greater skeletal fragility. Hip fracture in elderly is associated with significant morbidity and mortality. The aim of this study was to investigate the outcome of elderly patients with non-dialysis dependent CKD and hip fracture undergoing surgery. Retrospective study with IRB approval of patients above 65 years of age, with hip fractures admitted between June 2014 to June 2016 in a Southeast Asian cohort. Data collected included demographic variables and the haematological and biochemical parameters HBA1c, estimated glomerular filtration rate (eGFR), serum calcium, phosphorous, and 25(OH) Vitamin D. Co-morbidities investigated were ischemic heart disease, congestive heart failure, peripheral vascular disease, malignancy, chronic obstructive pulmonary disease, cerebro vascular accident, hypertension and hyperlipidaemia. All patients were followed up from index date to either death or June 1, 2018. Of the 883 patients, 725 underwent surgery and 334 had CKD. Death rates for CKD patients with hip fractures and those with normal renal function did not differ significantly [8.08% vs 6.54%, (HR= 1.33, 95% CI: 0.95, 1.86; P = .102)], whilst median hospital length of stay was significantly higher in CKD patients [10.5 vs 9.03 days (P = .003)]. Significant risk factors associated with higher risk of mortality in the elderly with hip fracture were male gender, age >= 80 years and serum albumin < 30 g/L (all, P < .0001). In summary, in elderly, non-dialysis dependent CKD patient with hip fracture we found that male gender, age >= 80 years, low serum albumin and eGFR < 30 mL/min/1.73 m(2) were associated with higher risk of death. The hospital stay in the CKD group was also longer. Additional studies are needed to validate our findings.

A 54-year-old man on maintenance hemodialysis with recurrent catheter-related bloodstream infections due to Staphylococcus aureus was admitted. Multiple prior transthoracic echocardiograms failed to reveal any vegetation. Subsequently on transesophageal echocardiography a mass consistent with fibrin sheath vegetations was identified and a follow-up diagnostic computed tomography (CT) venogram confirmed the presence of a fibrin sheath with vegetations.

Regional citrate anti-coagulation (RCA) is the recommended anti-coagulation for continuous renal replacement therapy (CRRT). Citrated replacement fluids provide convenience but may compromise effluent delivery when adjusted to maintain circuit ionised calcium levels (circuit-iCa). This study aims to evaluate the effect of RCA titration on the delivered CRRT effluent dose. This prospective observational study evaluated patients on RCA–CRRT in continuous veno-venous hemodiafiltration mode. Citrated replacement fluid was titrated to target circuit-iCa 0.26–0.40 mmol/L. Patients were then stratified into ‘reduced-dose’ who required citrate down-titration and ‘stable-dose’ who did not. Data from 200 RCA–CRRT sessions were collected. The reduced-dose RCA group (n = 114) had higher median initial citrate dose (3.00 vs 2.50; P < 0.001) but lower time-averaged dose (2.49 vs 2.60; P < 0.001). In addition, median prescribed effluent dose was 33.3 mL/kg/h (28.6–39.2) but median delivered effluent dose was significantly lower at 29.9 mL/kg/h (25.4–36.9; P < 0.001). Mortality was higher in the reduced-dose RCA group (39.5% vs 25.6%; P = 0.022) and in patients with delivered-to-prescribed effluent dose ratio of < 0.9 vs ≥ 0.9 (51.3% vs 29.2%; P = 0.014). RCA titration can significantly impact delivered CRRT effluent dose. Measures should be taken to address the CRRT dose deficit and prevent poor outcomes due to inadequate dialysis.

Background: Contrast induced nephropathy (CIN) following angiography is one of the leading causes of in-hospital acute kidney injury (AKI). The aim of this study was to investigate the renoprotective effect of remote ischemic preconditioning (RIPC) to prevent CIN in patients with peripheral arterial disease (PAD) undergoing lower limb angioplasty with standard preventative measures.

A 75-year-old female with end stage kidney failure had her tunneled central venous dialysis catheter (CVC) removed. A subsequent computed tomopgraphy (CT) scan of the chest reported a filling defect in the central vein that appeared to represent a fractured remnant of the CVC. The catheter had been retained for culture and was available for direct visualization, which showed it to be entirely intact. A subsequent venogram confirmed that the CT findings represented a retained calcified central venous fibrin sheath. As retained CVC fragments may require intervention, this diagnosis should be established carefully. A calcified fibrin sheath associated with a chronic CVC is a known, although rare, complication and should be considered in the differential diagnosis of an apparent CVC fracture prior to further interventions.

Post-procedural wound haemorrhage is a potentially life-threatening complication. For haemodialysis patients, bleeding is often encountered after vascular access procedures and fatal episodes have been reported. Visual monitoring for bleeding is manpower intensive and bleeding episodes may still be missed between inspections. A device, Blood WArning Technology with Continuous Haemoglobin sensor (BWATCH), was developed to detect bleeding from wounds. This a prospective, observational clinical trial on patients who have had a dialysis catheter inserted or removed. The battery-powered, disc-shaped device (43 mm diameter, 12 mm height) was placed over the dressing for at least six hours. The device detects reflected light with characteristics specific for haemoglobin and an alarm would be triggered if bleeding occurs. There were 250 participants (177 post-insertion, 73 post-removal) and 36 episodes of bleeding occurred. The device alarm was triggered in all instances but there were also 9 false alarms. Specificity was 95.8%, false positive rate was 4.2% and positive predictive value was 80.0%. Sensitivity and negative predictive value were 100% but detection failure may still occur due to improper application or device maintenance. The use of technological aids for monitoring improves patient safety and may reduce demand on manpower.

Background: Central venous catheters are extensively used in critical care units and in dialysis centres to gain access to the blood stream for the purpose of invasive monitoring, drug administration, parenteral nutrition and to perform renal replacement therapy. One of the common areas of central venous catheter insertion is right internal jugular vein due to its anatomical continuity with the superior vena cava. The complication rates of central venous catheter insertion can be more than 15%, including early and late complications. Case report: We present an unusual complication of recurrent laryngeal nerve palsy, leading to right vocal fold paralysis, following insertion of a right internal jugular tunnelled dialysis catheter. The vocal fold paralysis improved over next 8 months with conservative management alone. Conclusion: This case illustrates an unusual complication of central venous catheter insertion and the importance of recognizing the possibility of such complications, to prevent them from happening and also to manage them appropriately.