Improvement of peritoneal calcification after parathyroidectomy in a peritoneal dialysis patient.

Peritoneal calcification is one of the complications of peritoneal dialysis (PD). It can become serious, leading to severe abdominal pain and even death. Possible mediators of peritoneal calcification in PD patients are assumed to include acetate buffer, overdosage of vitamin D, repeated peritonitis, hypertonic dialysate, calciphylaxis and secondary hyperparathyroidism (SHPT). However, the mechanism and treatment of peritoneal calcification are controversial. Few reports have appeared on improvement of peritoneal calcification after parathyroidectomy (PTX) for SHPT of long duration. We report herein the case of a 48-year-old man on dialysis for 17 years including PD for 14 years. In 1989, he was admitted to hospital because of end-stage renal disease (ESRD), and started treatment with PD. Abdominal computed tomography (CT) first showed peritoneal calcification in August 2002. Peritoneal calcification did not improve despite conventional treatment including discontinuation of PD, control of calcium phosphate product to less than 55 mg2/dl2, removal of the peritoneal catheter and empirical prednisolone (PSL) usage. The intact parathyroid hormone (i-PTH) level was increased over 1,000 pg/ml and extra-osseous calcification occurred. Total PTX was performed in November 2004. Postoperatively, the i-PTH level decreased immediately and calcium phosphate product was maintained in the reference range. Abdominal CT after PTX showed improvement of peritoneal calcification in September 2005. It appeared that PTX could be used to treat patients with persistent peritoneal calcification not responding to conventional treatment. It was postulated that SHPT might play a crucial role in accelerating peritoneal calcification in PD patients.

Implantation of presternal catheter using Moncrief technique: aiming for fewer catheter-related complications.

OBJECTIVES: To reduce catheter-related complications, we developed a new technique of catheter implantation, combining a presternal catheter with the Moncrief technique. METHODS: The presternal catheter, consisting of 2 catheters joined by a titanium extender, was surgically implanted. Its end was left embedded in the presternal wall. A few weeks after implantation, the embedded subcutaneous catheter was exteriorized, exiting in the 4th intercostal space, and peritoneal dialysis (PD) was commenced. RESULTS: Using the new technique, 9 catheters were implanted (3 in women and 6 in men). Exteriorization was performed 30.6 +/- 14.3 days after implantation of the catheter. Total observation period was 70 patient-months. Average hospitalization was 4.4 +/- 1.3 days for catheter implantation, and 2.6 +/- 2.6 days for exteriorization. Peritoneal dialysis commenced on the day of exteriorization with an exchange volume of 1.8 +/- 0.3 L, using 4 exchanges daily. During the observation period, none of the patients experienced a catheter infection or dialysate leak. One non infectious complication was observed (a catheter wrapped in omentum). CONCLUSIONS: Our approach of combining a presternal catheter and the Moncrief technique had some advantages not only in regard to catheter infection and dialysate leakage, but also in regard to quality of life and hospitalization for the patient.

[A case of gastric antral vascular ectasia (GAVE) with chronic renal failure].

A 76-year-old woman was admitted to our hospital complaining of tarry stool, general fatigue and marked anemia(Hb 5.2 g/dl). Gastric endoscopic findings showed longitudinal red stripes and diffuse erythematous spots, indicating dilated vascular vessels. They resembled the stripes of a watermelon at the gastric antrum. The marked anemia was caused by chronic blood loss from the abnormally dilated mucosal and submucosal capillary veins in the gastric antrum. She was diagnosed as having gastric antral vascular ectasia(GAVE) with chronic renal failure(CRF). The association of GAVE and CRF is considered to be rare according to previous reports in Japan. Endoscopic argon plasma coagulation therapy was performed three times. After therapy, capillary dilatation disappeared, and the marked anemia was greatly improved. Argon plasma coagulation therapy was found to be a safe and effective procedure for this disease. Although GAVE is essentially a benign gastric disease, endoscopic therapy should be the treatment of first choice for this disease.