What is the best course of action for a patient with end-stage renal disease (ESRD) on hemodialysis, presenting with bilateral massive lower limb swelling and fever for 2 days, after deep vein thrombosis (DVT) has been ruled out by ultrasound?

Management of Bilateral Lower Limb Swelling with Fever in Hemodialysis Patient (DVT Excluded)

In a hemodialysis patient with bilateral massive lower limb swelling and fever after DVT exclusion, immediately evaluate for central venous stenosis/thrombosis (especially if using or previously used a central venous catheter), volume overload from inadequate dialysis, and catheter-related bloodstream infection as the most likely culprits.

Immediate Diagnostic Workup

Assess for Central Venous Obstruction

• Obtain CT venography or MR venography with contrast to evaluate central veins (superior vena cava, brachiocephalic veins, subclavian veins) for stenosis or thrombosis, particularly if the patient has current or previous central venous catheter use 1, 2
• Bilateral lower extremity swelling strongly suggests central venous obstruction rather than unilateral DVT 2
• Central venous stenosis can occur even without history of ipsilateral catheter insertion due to collateral flow patterns 2

Evaluate for Catheter-Related Bloodstream Infection (CRBSI)

• Draw blood cultures from both the catheter (if present) and peripheral vein before initiating antibiotics 1
• Fever in a dialysis patient with central venous catheter mandates evaluation for CRBSI 1
• If blood cultures confirm infection, remove the catheter if positive for Staphylococcus aureus, Candida species, or gram-negative bacilli 1
• For S. aureus bacteremia, catheter removal is mandatory even in patients with limited venous access 1

Assess Volume Status and Dialysis Adequacy

• Evaluate for volume overload: check weight gain since last dialysis, jugular venous pressure, pulmonary edema 3
• Review recent dialysis sessions for adequacy of ultrafiltration 3
• Bilateral edema with fever may indicate inadequate fluid removal combined with systemic inflammation 3

Immediate Management Algorithm

If Central Venous Stenosis/Thrombosis Identified

• Perform balloon angioplasty across stenotic segments as first-line intervention 2
• Consider anticoagulation if acute thrombosis present, though data in ESRD patients are limited 4
• If using enoxaparin in dialysis patients (generally not recommended), administer only after dialysis on dialysis days with anti-factor Xa monitoring (target 0.7-1.2 IU/mL measured 4 hours post-dose) 4

If CRBSI Confirmed

• For gram-negative bacilli: Remove catheter due to high treatment failure rates if retained 1
• For S. aureus: Remove catheter and treat with appropriate antibiotics 1
• For Candida: Remove catheter within 72 hours and initiate fluconazole or echinocandin for 2 weeks after last positive culture 1
• Empiric broad-spectrum antibiotics should cover multidrug-resistant organisms in critically ill dialysis patients 1
• Adjust antibiotic dosing for ESRD: cefepime 1g on day 1, then 500mg every 24 hours after hemodialysis 5

If Volume Overload Predominates

• Intensify dialysis prescription: increase ultrafiltration goals and consider additional dialysis session 3
• Implement strict sodium and fluid restriction 3
• Optimize blood pressure control through volume management rather than additional antihypertensives 3

Vascular Access Considerations

Current Access Evaluation

• If using tunneled catheter, evaluate for catheter dysfunction and consider contrast study 1
• Presence of fever alone is not indication for catheter removal, but confirmed bacteremia requires removal 1

Future Access Planning

• Transition from catheter to arteriovenous access (fistula or graft) as soon as feasible to reduce infection and mortality risk 6, 3
• For temporary access while planning permanent solution, use right internal jugular vein as preferred site 1, 6
• Avoid subclavian vein catheterization when possible to preserve future access options 1, 6

Common Pitfalls to Avoid

• Do not assume bilateral swelling excludes venous thrombosis—central venous obstruction causes bilateral symptoms 2
• Do not delay imaging if catheter is present—even without ipsilateral catheter history, central stenosis can develop 2
• Do not retain catheter with S. aureus or gram-negative bacteremia—high failure rates mandate removal 1
• Do not use standard enoxaparin dosing in dialysis patients—requires specialized protocol with anti-Xa monitoring if used at all 4
• Do not overlook inadequate dialysis—volume overload can present with fever due to inflammatory state 3

Monitoring and Follow-up

• Serial physical examinations to assess edema resolution 3
• Daily weights and strict intake/output monitoring 3
• If antibiotics initiated, monitor for response with repeat cultures at 48-72 hours 1
• If angioplasty performed, monitor access function and clinical improvement 2
• Consider nephrology consultation if not already involved for dialysis prescription optimization 3