Indexation of AVF blood flow should be considered in defining high-flow fistula because the effect of Qa may differ in individuals of different sizes. A Qa value ≥ 603 ml/min/m and its association with some echocardiographic alterations could identify patients at higher risk for HOCF.

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figure 3, A-C in ref. 5 are clathrin-coated vesicles (CCVs). Indeed, in the discussion we caveat our findings, noting that plasma membrane-bound structures could mimic virus. Similar structures, presumably representing CCVs, are occasionally seen in renal tubular epithelial cells in kidney biopsies from patients without coronavirus disease 2019 (COVID-19). There are features of the structures we report that are not typical for CCVs. CCVs are not usually seen in array-like clusters, as we have observed in several COVID-19 autopsies. The structures in figure 3 in ref. 5 are uniform in size, and CCVs can show a greater heterogeneity in sizes depending on cargo and number of clathrin triskelions, with diameters of 30-200 nm. 6 There is also some heterogeneity in the reported morphology of SARS-CoV-2, and our observed structures (65-to 91-nm diameter) are closer in size to the 60-to 81-nm diameter initially reported for SARS-CoV-2 grown in Vero cells than the 80-to 140-nm diameter reported by Miller. 7,8 Nonetheless, it is possible that uniform CCVs could accumulate in epithelial cells in unusual clusters due to cytokine storm or perimortem injury. 9 Since publication, other investigators have detected SARS-CoV-2 RNA in the kidney using in situ hybridization, although ultrastructural localization was not performed. 10 To adequately address the question of direct renal infection, a comprehensive and sufficiently powered autopsy case series, using multiple modalities of detection and with adequate non-COVID-19 controls, is needed.

Stenosis and central venous obstruction are very serious and frequent complications in hemodialysis patients. The incidence of these complications is 30% and is due to an increase in the flow and venous flow that generates inflammation and proliferation of the endothelium. Causes of acute venous occlusion have rarely been described. We report the clinical case of a acute occlusion of a covered stent in a right anonymous vein treated through a Bard Covera Plus recanalization and stent delivery procedure.

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