Hemodialysis International 2015; 19:132–145
19 Zhang L, Kang Y, Fu P, et al. Myoglobin clearance by continuous venous-venous haemofiltration in rhabdomyolysis with acute kidney injury: A case series. Injury. 2012; 43:619–623. 20 Guzman N, Podoll AS, Bell CS, Finkel KW. Myoglobin removal using high-volume high-flux hemofiltration in patients with oliguric acute kidney injury. Blood Purif. 2013; 36:107–111. 21 Timokhov VS, Ipat’eva EI, Iakovleva II, et al. Plasma myoglobin and continuous hemofiltration in patients with rhabdomyolysis and acute kidney failure. Ter Arkh. 1997; 69:40–44. 22 Ronco C. Extracorporeal therapies in acute rhabdomyolysis and myoglobin clearance. Crit Care. 2005; 9:141– 142.
23 Keir R, Evans ND, Hutchison CA, et al. Kinetic modelling of haemodialysis removal of myoglobin in rhabdomyolysis patients. Comput Methods Programs Biomed. 2013; doi: 10.1016/j.cmpb.2013.07.017. [Epub ahead of print]. 24 Prowle JR, Bellomo R. Continuous renal replacement therapy: Recent advances and future research. Nat Rev Nephrol. 2010; 6:521–529. 25 GmbH GD Myoglobin Removal by High Cut-off CVVHD (HicoRhabdo). Clinical Trial Register, 2011. Available from: http://clinicaltrials.gov/ct2/show/NCT01467180 ?term=Rhabdomyolysis&rank=5 (accessed date: September 23, 2013).
Iatrogenic or congenital arteriovenous fistula of left upper arm used for hemodialysis after venous superficialization Mariusz KUSZTAL,1 Krzysztof LETACHOWICZ,1 Tomasz GOŁE˛BIOWSKI,1 Ewa WA˛TOREK,1 Przemysław SZYBER,2 Jerzy GARCAREK,3 Wacław WEYDE,1,4 Marian KLINGER1 1
Nephrology and Transplantation Medicine, 2General and Vascular Surgery, 3Radiology, 4Faculty of Dentistry, Wroclaw Medical University, Wroclaw, Poland
Abstract The authors report a case of iatrogenic brachial arteriovenous fistula (AVF) on the left arm in a 20-year-old man with a history of autosomal dominant polycystic kidney and failing kidney transplant. An attempt to create vascular access for hemodialysis by utilization of an existing iatrogenic brachial AVF was undertaken. The patient underwent surgical superficialization of a concomitant enlarged and deeply located vein. Four weeks after the procedure, the AVF was successfully cannulated for hemodialysis. In this case, iatrogenic/congenital AVF was successfully converted to vascular access for hemodialysis. Key words: Iatrogenic, congenital, fistula, brachial, superficialization, hemodialysis
Correspondence to: M. Kusztal, MD, PhD, Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, Wroclaw 50-556, Poland. E-mail: [email protected] Support and Financial Disclosure Declaration The sources of support: Wroclaw Medical University; Polish Government. Financial disclosure: All authors have no competing interests to report. Conflict of interest: The authors have not transmitted any conflicts of interest.
© 2014 International Society for Hemodialysis DOI:10.1111/hdi.12191
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Case Reports
INTRODUCTION Arteriovenous fistula (AVF) is defined as communication between the arterial and venous systems and is widely created as vascular access for hemodialysis. It is rarely found as congenital or acquired.1 Iatrogenic injuries are responsible for 0.02% to 13% of AVFs observed in the normal population.2,3 These are usually secondary to invasive diagnostic or therapeutic procedures, such as percutaneous cardiac catheterization (e.g., transradial, transfemoral arteriography), but there is little information regarding this complication by puncture, which is routinely performed, possibly due to hesitation in reporting it.1,2,4 Congenital vascular abnormalities, which are more frequent in autosomal dominant polycystic kidney disease (ADPKD), may additionally contribute to difficulties in vascular access creation.5
CASE REPORT We report on a 20-year-old man with a history of ADPKD and renal replacement therapy for 7 years. He was admitted to the nephrology ward due to a failing 5-year kidney transplant, probably because of immunosuppressive regimen noncompliance. The biopsy proven graft rejection was resistant to antirejection treatment. Medical anamnesis revealed no trauma in the past, but some vascular anomaly on the left upper arm was found at the age of 6 years. Finally, we decided to prepare him for hemodialysis, so vascular access was required. Peritoneal dialysis was not considered because that modality was ineffective in the past (at the age of 15 years), when dialysis-related peritonitis developed and he was switched at that time to a hemodialysis program. Due to the lack of suitable veins on both upper extremities for AVF creation and an asymptomatic “vascular anomaly” on the left arm, the cuffed catheter inserted into the right jugular vein served as vascular access for hemodialysis until kidney transplantation in 2007. Physical examination focused on vasculature revealed a pronounced pulse (70 beats per minute) on both radial and ulnar arteries bilaterally, and lack of a patent cephalic vein in the forearm. Palpation of the left arm revealed generalized pulsation. Moreover, a trill above the cubital fossa was found. There were no clinical or ultrasound features of low cardiac output. Further imaging diagnostics were employed. Duplex scan (Doppler ultrasonography), venogram, and computed tomography (CT) angiography allowed for the diagnosis of a brachial artery-to-brachial vein fistula. A
Hemodialysis International 2015; 19:132–145
Figure 1 Iatrogenic or congenital brachial arteriovenous fistula (AVF) in selective angio-computed tomography scan after volume rendering.
selective angiogram (Figure 1) illustrated the actual fistula. The oblique communicating channel between the brachial artery and the brachial vein was mapped near the cubital fossa, 5 cm proximal to the bifurcation of the brachial artery. On color Doppler examination, the vena comitans was found as a characteristic “mosaic” pattern (turbulent flow; Supporting Information Figure S1). A lower resistance waveform was found in the communicating artery and arterialized flow through the markedly enlarged communicating vein respectively. The blood outflow was observed by enlarged deep veins as well as by the basilic vein and further wide subclavian and patent superior vena cava. The left cephalic vein was narrowed but patent. With cardiology evaluation and an echocardiogram, no compromise of the cardiovascular system as a consequence of the fistula was observed. The patient underwent surgical superficialization of the concomitant enlarged vein as described by Weyde et al.,6,7 used for deeply located arterialized vein. The procedure was undertaken by a vascular surgeon in general anesthesia. Four weeks after the procedure, the AVF was successfully cannulated for hemodialysis with a single needle. Doppler ultrasonography showed AVF blood flow of 1292 mL/min, and brachial artery diameter of 6.1 mm and 4 mm at the precommunicating and postcommunicating channel sections respectively. The vein transposed
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Case Reports
Figure 2 Two dialysis needles inserted into the superficialized venous part of fistula.
underneath the skin was 7 mm in diameter during ultrasound measurement (Supporting Information Figure S2). Air plethysmography as well as photoplethysmography on the fingers (PVL, Biomedix, MN, USA) performed preoperatively and postoperatively showed no ischemia up to the level of the fingers on both extremities. The follow-up since fistula superficialization has reached 18 months, without any complications related to AVF. Hemodialysis is performed three times a week for 4 hours, with two needles inserted into the elevated vessel resulting in effective blood flow of 340 mL/min–360 mL/ min in the machine (Figure 2). Hemodialysis program without any complication is fully acceptable by the patient.
DISCUSSION Congenital or acquired AVFs often remain asymptomatic for many years, as in the present case. The congenital communication between the brachial vein and the brachial artery is an extremely rare vascular malformation. In one of the reports, such fistulas on both sides of a 54-yearold male cadaver who died of road traffic accident were described. There was a communication (1.5 cm in length) between the brachial artery and the brachial vein, 11.5 cm above the medial epicondyle.8 Iatrogenic origin of AVF is most probable in our case, but a congenital origin in ADPKD cannot be excluded. Patients with ADPKD present a number of vascular abnormalities, including cerebral aneurysms, heart valve lesions, coarctations of the aorta, and abdominal aortic aneurysms.5 Incidence of AVF secondary to venipuncture may be less than 0.03%. The brachial artery and the median cubital vein are anatomically very near each other and can thus easily communicate even with a simple puncture.4 It
142
is important that physicians be aware of this rare complication of venipuncture and avoid deep probing and running through with the needle. The natural history of AVF can be benign with spontaneous closure or persist and be symptomatic.9 Indications for repair of AVF include arterial or venous enlargement, symptoms secondary to venous engorgement, congestive heart failure, and worsening of symptomatic claudication.10 There are three treatment options: surgical repair, exclusion with a covered stent, and transcatheter embolization.11 In the patient reported here, his heart function was not impaired by the shunt, and finally its presence was utilized to construct sufficient vascular access for hemodialysis. In summary, this is a straightforward albeit unique case report of iatrogenic and/or congenital (patient with polycystic kidney disease) AVF that was superficialized and successfully used for hemodialysis. If any vascular anatomic variations are suspected, this should be verified by imaging studies since this may influence proper angioaccess planning for dialysis.
Manuscript received December 2013; revised May 2014.
REFERENCES 1 Norcross WA, Shackford SR. Arteriovenous fistula. A potential complication of venipuncture. Arch Int Med. 1988; 148:1815–1816. 2 Spies JB. Complications of diagnostic arteriography. Semin Intervent Radiol. 1994; 11:93–101. 3 Kollmeyer KR, Hunt JL, Ellman BA, et al. Acute and chronic traumatic arteriovenous fistulae in civilians. Arch Surg. 1981; 116:697–702. 4 Ino T, Yazawa K, Kawamura S, Takeoka M, Yashiro N. Secondary arteriovenous fistula after a single arterial puncture. Pediatr Int. 2001; 43:179–180. 5 Ecder T, Schrier RW. Cardiovascular abnormalities in autosomal-dominant polycystic kidney disease. Nat Rev Nephrol. 2009; 5:221–228. 6 Weyde W, Krajewska M, Letachowicz W, Klinger M. Superficialization of the wrist native arteriovenous fistula for effective hemodialysis vascular access construction. Kidney Int. 2002; 61:1170–1173. 7 Weyde W, Krajewska M, Letachowicz W, Kusztal M, Penar J, Klinger M. A new technique for autogenous brachiobasilic upper arm transposition for vascular access for hemodialysis. J Vasc Access. 2006; 7:74–76. 8 Das S, Othman F, Suhaimi FH, Latiff AA. Congenital arteriovenous communication in the arm: A cadaveric study. Rom J Morphol Embryol. 2008; 49:421–423.
Hemodialysis International 2015; 19:132–145
Hemodialysis International 2015; 19:132–145
9 Hoffer EK, Sclafani SJ, Herskowitz MM, Scalea TM. Natural history of arterial injuries diagnosed with arteriography. J Vasc Interv Radiol. 1997; 8:43–53. 10 Marin ML, Veith FJ, Panetta TF, et al. Percutaneous transfemoral insertion of a stented graft to repair a traumatic femoral arteriovenous fistula. J Vasc Surg. 1993; 18:299– 302. 11 Hilfiker PR, Mahmood KR, Kee ST, et al. Stent graft therapy for subclavian artery aneurysms and fistulas: Single-center midterm results. J Vasc Interv Radiol. 2000; 11:578–584.
SUPPORTING INFORMATION Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Figure S1. Transverse color Doppler sonogram shows the position of the shunt by the characteristic mosaic pattern. Figure S2. Transverse ultrasonography image of arteriovenous fistula (AVF) after superficialization (3 mm distance to skin and 7 mm in diameter).
Piperacillin/tazobactam-induced neurotoxicity in a hemodialysis patient: A case report Precil Diego M. M. NEVES1, Fernanda M. FREITAS1, Christiane A. KOJIMA2, Beatriz L. CARMELLO2, Rodrigo BAZAN3, Pasqual BARRETTI2, Luis C. MARTIN2 1
Internal Medicine Department 2Nephrology Department 3Neurology Department, University of São Paulo State, São Paulo, Brazil
Abstract Antibiotics are potentially a cause of neurotoxicity in dialysis patients, the most common are the beta-lactams as ceftazidime and cefepime, and few cases have been reported after piperacillin/ tazobactam use. This report presents a case of a hypertensive and diabetic 67-year-old woman in regular hemodialysis, which previously had a stroke. She was hospitalized presenting pneumonia, which was initially treated with cefepime. Two days after treatment, she presented dysarthria, left hemiparesis, ataxia, and IX and X cranial nerves paresis. Computed tomography showed no acute lesions and cefepime neurotoxicity was hypothesized, and the antibiotic was replaced by piperacillin/tazobactam. The neurologic signs disappeared; however, 4 days after with piperacillin/ tazobactam treatment, the neurological manifestations returned. A new computed tomography showed no new lesions, and the second antibiotic regimen withdrawn. After two hemodialysis sessions, the patient completely recovered from neurological manifestations. The patient presented sequentially neurotoxicity caused by two beta-lactams antibiotics. This report meant to alert clinicians that these antibiotics have dangerous neurological effects in chronic kidney disease patients. Key words: Chronic kidney disease, hemodialysis, neurotoxicity, piperacillin/tazobactam
Correspondence to: Precil Diego Miranda de Menezes Neves, MD, University of São Paulo State, Distrito de Rubião Júnior, without number, Botucatu, SP 18618-970, Brazil. E-mail: [email protected] Conflict of interest: The authors report no conflicts of interest. The authors are responsible for the content and writing of the paper.
© 2014 International Society for Hemodialysis DOI:10.1111/hdi.12194
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Copyright of Hemodialysis International is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
19 Zhang L, Kang Y, Fu P, et al. Myoglobin clearance by continuous venous-venous haemofiltration in rhabdomyolysis with acute kidney injury: A case series. Injury. 2012; 43:619–623. 20 Guzman N, Podoll AS, Bell CS, Finkel KW. Myoglobin removal using high-volume high-flux hemofiltration in patients with oliguric acute kidney injury. Blood Purif. 2013; 36:107–111. 21 Timokhov VS, Ipat’eva EI, Iakovleva II, et al. Plasma myoglobin and continuous hemofiltration in patients with rhabdomyolysis and acute kidney failure. Ter Arkh. 1997; 69:40–44. 22 Ronco C. Extracorporeal therapies in acute rhabdomyolysis and myoglobin clearance. Crit Care. 2005; 9:141– 142.
23 Keir R, Evans ND, Hutchison CA, et al. Kinetic modelling of haemodialysis removal of myoglobin in rhabdomyolysis patients. Comput Methods Programs Biomed. 2013; doi: 10.1016/j.cmpb.2013.07.017. [Epub ahead of print]. 24 Prowle JR, Bellomo R. Continuous renal replacement therapy: Recent advances and future research. Nat Rev Nephrol. 2010; 6:521–529. 25 GmbH GD Myoglobin Removal by High Cut-off CVVHD (HicoRhabdo). Clinical Trial Register, 2011. Available from: http://clinicaltrials.gov/ct2/show/NCT01467180 ?term=Rhabdomyolysis&rank=5 (accessed date: September 23, 2013).
Iatrogenic or congenital arteriovenous fistula of left upper arm used for hemodialysis after venous superficialization Mariusz KUSZTAL,1 Krzysztof LETACHOWICZ,1 Tomasz GOŁE˛BIOWSKI,1 Ewa WA˛TOREK,1 Przemysław SZYBER,2 Jerzy GARCAREK,3 Wacław WEYDE,1,4 Marian KLINGER1 1
Nephrology and Transplantation Medicine, 2General and Vascular Surgery, 3Radiology, 4Faculty of Dentistry, Wroclaw Medical University, Wroclaw, Poland
Abstract The authors report a case of iatrogenic brachial arteriovenous fistula (AVF) on the left arm in a 20-year-old man with a history of autosomal dominant polycystic kidney and failing kidney transplant. An attempt to create vascular access for hemodialysis by utilization of an existing iatrogenic brachial AVF was undertaken. The patient underwent surgical superficialization of a concomitant enlarged and deeply located vein. Four weeks after the procedure, the AVF was successfully cannulated for hemodialysis. In this case, iatrogenic/congenital AVF was successfully converted to vascular access for hemodialysis. Key words: Iatrogenic, congenital, fistula, brachial, superficialization, hemodialysis
Correspondence to: M. Kusztal, MD, PhD, Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, Wroclaw 50-556, Poland. E-mail: [email protected] Support and Financial Disclosure Declaration The sources of support: Wroclaw Medical University; Polish Government. Financial disclosure: All authors have no competing interests to report. Conflict of interest: The authors have not transmitted any conflicts of interest.
© 2014 International Society for Hemodialysis DOI:10.1111/hdi.12191
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Case Reports
INTRODUCTION Arteriovenous fistula (AVF) is defined as communication between the arterial and venous systems and is widely created as vascular access for hemodialysis. It is rarely found as congenital or acquired.1 Iatrogenic injuries are responsible for 0.02% to 13% of AVFs observed in the normal population.2,3 These are usually secondary to invasive diagnostic or therapeutic procedures, such as percutaneous cardiac catheterization (e.g., transradial, transfemoral arteriography), but there is little information regarding this complication by puncture, which is routinely performed, possibly due to hesitation in reporting it.1,2,4 Congenital vascular abnormalities, which are more frequent in autosomal dominant polycystic kidney disease (ADPKD), may additionally contribute to difficulties in vascular access creation.5
CASE REPORT We report on a 20-year-old man with a history of ADPKD and renal replacement therapy for 7 years. He was admitted to the nephrology ward due to a failing 5-year kidney transplant, probably because of immunosuppressive regimen noncompliance. The biopsy proven graft rejection was resistant to antirejection treatment. Medical anamnesis revealed no trauma in the past, but some vascular anomaly on the left upper arm was found at the age of 6 years. Finally, we decided to prepare him for hemodialysis, so vascular access was required. Peritoneal dialysis was not considered because that modality was ineffective in the past (at the age of 15 years), when dialysis-related peritonitis developed and he was switched at that time to a hemodialysis program. Due to the lack of suitable veins on both upper extremities for AVF creation and an asymptomatic “vascular anomaly” on the left arm, the cuffed catheter inserted into the right jugular vein served as vascular access for hemodialysis until kidney transplantation in 2007. Physical examination focused on vasculature revealed a pronounced pulse (70 beats per minute) on both radial and ulnar arteries bilaterally, and lack of a patent cephalic vein in the forearm. Palpation of the left arm revealed generalized pulsation. Moreover, a trill above the cubital fossa was found. There were no clinical or ultrasound features of low cardiac output. Further imaging diagnostics were employed. Duplex scan (Doppler ultrasonography), venogram, and computed tomography (CT) angiography allowed for the diagnosis of a brachial artery-to-brachial vein fistula. A
Hemodialysis International 2015; 19:132–145
Figure 1 Iatrogenic or congenital brachial arteriovenous fistula (AVF) in selective angio-computed tomography scan after volume rendering.
selective angiogram (Figure 1) illustrated the actual fistula. The oblique communicating channel between the brachial artery and the brachial vein was mapped near the cubital fossa, 5 cm proximal to the bifurcation of the brachial artery. On color Doppler examination, the vena comitans was found as a characteristic “mosaic” pattern (turbulent flow; Supporting Information Figure S1). A lower resistance waveform was found in the communicating artery and arterialized flow through the markedly enlarged communicating vein respectively. The blood outflow was observed by enlarged deep veins as well as by the basilic vein and further wide subclavian and patent superior vena cava. The left cephalic vein was narrowed but patent. With cardiology evaluation and an echocardiogram, no compromise of the cardiovascular system as a consequence of the fistula was observed. The patient underwent surgical superficialization of the concomitant enlarged vein as described by Weyde et al.,6,7 used for deeply located arterialized vein. The procedure was undertaken by a vascular surgeon in general anesthesia. Four weeks after the procedure, the AVF was successfully cannulated for hemodialysis with a single needle. Doppler ultrasonography showed AVF blood flow of 1292 mL/min, and brachial artery diameter of 6.1 mm and 4 mm at the precommunicating and postcommunicating channel sections respectively. The vein transposed
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Case Reports
Figure 2 Two dialysis needles inserted into the superficialized venous part of fistula.
underneath the skin was 7 mm in diameter during ultrasound measurement (Supporting Information Figure S2). Air plethysmography as well as photoplethysmography on the fingers (PVL, Biomedix, MN, USA) performed preoperatively and postoperatively showed no ischemia up to the level of the fingers on both extremities. The follow-up since fistula superficialization has reached 18 months, without any complications related to AVF. Hemodialysis is performed three times a week for 4 hours, with two needles inserted into the elevated vessel resulting in effective blood flow of 340 mL/min–360 mL/ min in the machine (Figure 2). Hemodialysis program without any complication is fully acceptable by the patient.
DISCUSSION Congenital or acquired AVFs often remain asymptomatic for many years, as in the present case. The congenital communication between the brachial vein and the brachial artery is an extremely rare vascular malformation. In one of the reports, such fistulas on both sides of a 54-yearold male cadaver who died of road traffic accident were described. There was a communication (1.5 cm in length) between the brachial artery and the brachial vein, 11.5 cm above the medial epicondyle.8 Iatrogenic origin of AVF is most probable in our case, but a congenital origin in ADPKD cannot be excluded. Patients with ADPKD present a number of vascular abnormalities, including cerebral aneurysms, heart valve lesions, coarctations of the aorta, and abdominal aortic aneurysms.5 Incidence of AVF secondary to venipuncture may be less than 0.03%. The brachial artery and the median cubital vein are anatomically very near each other and can thus easily communicate even with a simple puncture.4 It
142
is important that physicians be aware of this rare complication of venipuncture and avoid deep probing and running through with the needle. The natural history of AVF can be benign with spontaneous closure or persist and be symptomatic.9 Indications for repair of AVF include arterial or venous enlargement, symptoms secondary to venous engorgement, congestive heart failure, and worsening of symptomatic claudication.10 There are three treatment options: surgical repair, exclusion with a covered stent, and transcatheter embolization.11 In the patient reported here, his heart function was not impaired by the shunt, and finally its presence was utilized to construct sufficient vascular access for hemodialysis. In summary, this is a straightforward albeit unique case report of iatrogenic and/or congenital (patient with polycystic kidney disease) AVF that was superficialized and successfully used for hemodialysis. If any vascular anatomic variations are suspected, this should be verified by imaging studies since this may influence proper angioaccess planning for dialysis.
Manuscript received December 2013; revised May 2014.
REFERENCES 1 Norcross WA, Shackford SR. Arteriovenous fistula. A potential complication of venipuncture. Arch Int Med. 1988; 148:1815–1816. 2 Spies JB. Complications of diagnostic arteriography. Semin Intervent Radiol. 1994; 11:93–101. 3 Kollmeyer KR, Hunt JL, Ellman BA, et al. Acute and chronic traumatic arteriovenous fistulae in civilians. Arch Surg. 1981; 116:697–702. 4 Ino T, Yazawa K, Kawamura S, Takeoka M, Yashiro N. Secondary arteriovenous fistula after a single arterial puncture. Pediatr Int. 2001; 43:179–180. 5 Ecder T, Schrier RW. Cardiovascular abnormalities in autosomal-dominant polycystic kidney disease. Nat Rev Nephrol. 2009; 5:221–228. 6 Weyde W, Krajewska M, Letachowicz W, Klinger M. Superficialization of the wrist native arteriovenous fistula for effective hemodialysis vascular access construction. Kidney Int. 2002; 61:1170–1173. 7 Weyde W, Krajewska M, Letachowicz W, Kusztal M, Penar J, Klinger M. A new technique for autogenous brachiobasilic upper arm transposition for vascular access for hemodialysis. J Vasc Access. 2006; 7:74–76. 8 Das S, Othman F, Suhaimi FH, Latiff AA. Congenital arteriovenous communication in the arm: A cadaveric study. Rom J Morphol Embryol. 2008; 49:421–423.
Hemodialysis International 2015; 19:132–145
Hemodialysis International 2015; 19:132–145
9 Hoffer EK, Sclafani SJ, Herskowitz MM, Scalea TM. Natural history of arterial injuries diagnosed with arteriography. J Vasc Interv Radiol. 1997; 8:43–53. 10 Marin ML, Veith FJ, Panetta TF, et al. Percutaneous transfemoral insertion of a stented graft to repair a traumatic femoral arteriovenous fistula. J Vasc Surg. 1993; 18:299– 302. 11 Hilfiker PR, Mahmood KR, Kee ST, et al. Stent graft therapy for subclavian artery aneurysms and fistulas: Single-center midterm results. J Vasc Interv Radiol. 2000; 11:578–584.
SUPPORTING INFORMATION Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Figure S1. Transverse color Doppler sonogram shows the position of the shunt by the characteristic mosaic pattern. Figure S2. Transverse ultrasonography image of arteriovenous fistula (AVF) after superficialization (3 mm distance to skin and 7 mm in diameter).
Piperacillin/tazobactam-induced neurotoxicity in a hemodialysis patient: A case report Precil Diego M. M. NEVES1, Fernanda M. FREITAS1, Christiane A. KOJIMA2, Beatriz L. CARMELLO2, Rodrigo BAZAN3, Pasqual BARRETTI2, Luis C. MARTIN2 1
Internal Medicine Department 2Nephrology Department 3Neurology Department, University of São Paulo State, São Paulo, Brazil
Abstract Antibiotics are potentially a cause of neurotoxicity in dialysis patients, the most common are the beta-lactams as ceftazidime and cefepime, and few cases have been reported after piperacillin/ tazobactam use. This report presents a case of a hypertensive and diabetic 67-year-old woman in regular hemodialysis, which previously had a stroke. She was hospitalized presenting pneumonia, which was initially treated with cefepime. Two days after treatment, she presented dysarthria, left hemiparesis, ataxia, and IX and X cranial nerves paresis. Computed tomography showed no acute lesions and cefepime neurotoxicity was hypothesized, and the antibiotic was replaced by piperacillin/tazobactam. The neurologic signs disappeared; however, 4 days after with piperacillin/ tazobactam treatment, the neurological manifestations returned. A new computed tomography showed no new lesions, and the second antibiotic regimen withdrawn. After two hemodialysis sessions, the patient completely recovered from neurological manifestations. The patient presented sequentially neurotoxicity caused by two beta-lactams antibiotics. This report meant to alert clinicians that these antibiotics have dangerous neurological effects in chronic kidney disease patients. Key words: Chronic kidney disease, hemodialysis, neurotoxicity, piperacillin/tazobactam
Correspondence to: Precil Diego Miranda de Menezes Neves, MD, University of São Paulo State, Distrito de Rubião Júnior, without number, Botucatu, SP 18618-970, Brazil. E-mail: [email protected] Conflict of interest: The authors report no conflicts of interest. The authors are responsible for the content and writing of the paper.
© 2014 International Society for Hemodialysis DOI:10.1111/hdi.12194
143
Copyright of Hemodialysis International is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
