When the source of inflammation is hiding in plain sight: Failed kidney transplants, clotted arteriovenous grafts, and central venous catheters

Cardiovascular mortality accounts for most deaths among hemodialysis patients and far exceeds the cardiovascular mortality rate of the general population. One important aspect of cardiovascular risk among dialysis patients is chronic inflammation. Iatrogenic sources of chronic inflammation in the form of failed renal allografts, old clotted arteriovenous grafts, and hemodialysis catheters play important, sometimes, unrecognized roles in this inflammatory state. There is ample observational evidence that these sources of inflammation are associated with hypoalbuminemia, erythropoetin-resistant anemia, and increased markers of chronic inflammation. In dialysis patients with chronic inflammation from potentially modifiable sources, causes should be sought and correction undertaken if possible. Allograft nephrectomy should be offered to patients with a chronic inflammatory state and a failed renal transplant. Unused, clotted AV grafts should be considered a likely source of chronic inflammation as well as infection and should be removed when evidence of infection is present on indium scanning. Catheter rates ought to be kept to a minimum for the many well-recognized reasons for their undesirability as well as for their potential to produce chronic inflammation with all of its ill effects.