Laparoscopic Continuous Ambulatory Peritoneal Dialysis (CAPD) Catheter Placement Using a Two-Port Method in Adult End-stage Renal Disease (ESRD) Patients: Early Experience

PURPOSE: Laparoscopy is being widely utilized beyond the field of surgery. We report on the early experience of laparoscopic CAPD catheter placement in adult ESRD patients. In addition, we investigate the question of whether laparoscopic CAPD catheter insertion can be used as a feasible long-term procedure. METHODS: Laparoscopic CAPD catheter placement was performed in 28 patients by one surgeon, between June, 2010 and October, 2013, and observed. A retrospective outcome study was conducted based on review of medical records. RESULTS: A total of 28 laparoscopic procedures were performed. The mean age of patients who underwent laparoscopic placement of a catheter was 60.3 years old. The most common cause of ESRD was uncontrolled hypertension combined with diabetes. The procedure took 45.7 minutes. Peritoneal dialysis was introduced on postoperative day eight, after one week of daily washing and no dialysate leaks were observed. Two incidences of catheter-related complications were observed: one incidence of catheter obstruction (due to its m igration and omental w rapping, w hich was m anaged with surgical removal) and one incidence of peritonitis (which was controlled with antibiotics). CONCLUSION: Laparoscopic CAPD catheter placement using tw o ports is a simple procedure with minimal complication. Laparoscopic CAPD catheter placement will gain greater acceptance as an alternative to the traditional method of CAPD catheter placement.

A Case Report of CAPD Drainage Failure due to Fracture of Tenckhoff Catheter / 대한신장학회잡지

The most frequent cause of continuous ambulatory peritoneal dialysis (CAPD) drainage failure is catheter migration. We experienced a rare case of CAPD drainage failure due to fracture of Tenckhoff catheter. A 56-year-old man presented for evaluation of CAPD drainage failure. KUB showed broken radio opaque line of the Tenckhoff catheter proximal to the internal cuff. It was thought that CAPD drainage failure was due to catheter fracture. CAPD drainage failure had been treated successfully with surgical catheter reinsertion. Our case demonstrated that catheter fracture should be considered in the differential of CAPD drainage failure.

Two Cases of Central Venous Catheter Removal Distress Syndrome / 대한신장학회잡지

Much attention has been paid to the insertion of central venous catheter(CVC) but their removal is a subject discussed rarely. After removal of a central venous catheter, rare but potentially life-threatening, transient cardiopulmonary collapse or neurological dysfunction had developed. The failure to appreciate these complications may be a significant factor in their high mortality. Early recognition and treatment may be made possible by a high index of suspicion. In this report, the clinical courses of two patients with central venous catheter removal distress syndrome are reviewed. Also guidelines for safe removal of CVC are formulated. An awareness of potential CVC removal complications is most important for their prevention and timely treatment. CVCs should be removed with the same degree of meticulous attention to detail that accompanies their insertion. Medical personnel should be reminded that removal of the catheter is an integral component of CVC management.

Bromate Intoxication Associated with Acute Renal Failure / 대한신장학회잡지

Bromate salt is very toxic oxidant. The clinical manifestations of bromate intoxications are vomiting, diarrhea, depression of central nervous system, oliguric or non-oliguric renal failure, hemolytic anemia and deafness. Most of the toxic manifestations are reversible with the exception of renal failure and deafness. Since bromate is a small hydrophilic molecule, its removal by dialysis, especially hemodialysis, can reasonably be expected. Since the serious complications such as deafness, acute renal failure usually occur concurrently within 4-16 hours after ingestion, dialysis should therefore be considered in every patient presenting within a few hours of a significant amount of bromate. Recently, we encountered a 40-year-old female, past hairdresser, who was admitted to Asan Kangnung Hospital due to frequent diarrhea, vomiting and anuria after ingestion of sodium bromate. The patient required regular hemodialysis therapy and has not any evidence of complication such as hearing loss, blindness and irreversible renal failure. The clinician must assess the potential for preventing irreversible ototoxicity and nephrotoxicity and weigh the importance of early intervention against the possible risks of aggressive treatment in bromate intoxication.

The Effect of rhEPO on Anemia in 5/6 Nephrectomized Rats / 대한신장학회잡지

Anemia is a common clinical feature in chronic renal failure(CRF) patients. The primary cause of anemia in CRF is a deficiency of erythropoietin which is normally produced in the kidney. Erythropoietin therapy for correcting anemia has greatly increased the well-being of CRF patients and decreased cardiac morbidity. In Korea approximately 40% of CRF population on maintenance dialysis are using recombinant human erythropoietin(rhEPO). Commercially available rhEPO used in Korea is imported from abroad. Recently LG Chemical Co., produced rhEPO. In this study we evaluated the effect of LG-rhEPO on anemia in 5/6 nephrectomized rats. A total of 23 normal male Sprague-Dawley rats were used. A two-stage 5/6 nephrectomy was performed under ether anesthesia in 15 rats(group 1), additional 4 rats underwent sham operation(group 2). 4 normal rats served as normal control(group 3). rhEPO was injected subcutaneously 8 weeks after surgery. To evaluate the dose effect of rhEPO 250 IU/kg/day was injected in 2 rats, 500IU/kg/day in 4 rats, and 1000 IU/kg/day in 4 rats in group 1. To exclude the effect of LG-rhEPO vehicle, PBS, the same amount of PBS was injected in 4 rats in group 1. One rat each in groups 2 and 3 received rhEPO 250 IU/kg/day, 500 IU/kg/day, 1000 IU/kg /day, and PBS. rhEPO or PBS were injected daily in the first week, every other day in the second week and twice a week in the third week. Body weight and hematocrit level were observed weekly for the initial 8 weeks of observation period and then every other day for 3 weeks of injection and 1 week after discontinuation of injection, and BUN level every week during the study period. Body weight progressively increased in 3 groups. BUN level increased 1 week after 5/6 nephrectomy in group 1 and was stable in group 2 and 3. Hct level was significantly lower after 2 weeks of nephrectomy in group 1. Hct decreased transiently for the first week after sham operation and then returned to the baseline value in group 2. No significant change in Hct level was observed in group 3. After injection of rhEPO, Hct level increased significantly at 2 days in all 3 groups. Hct level increased significanly at 2 days in all 3 groups. Hct did not change in 3 groups with PBS injecion. In conclusion LG-rhEPO is effective in correcting anemia in animal model of CRF. A further study to evaluate the effect rhEPO on anemia in CRF patients and longterm consequences are required.

Incidence of Hypercalcemia in Dialysis Patients: HD vs. CAPD / 대한신장학회잡지

Oral phosphate binders and high calcium dialysate have been used as standard therapies for dialysis patients to prevent renal osteodystrophy. Calcium containing phosphate binders are used to prevent intestinal absorption of dietary phosphate and to avoid aluminum loading by using aluminum containing phosphate binders. The use of calcium products resulted in hypercalcemia in a substantial portion of dialysis population. Calcium carbonate as a phophate binder is widely used in Korea. However, the incidence of hypercalcemia in Korean dialysis patients has not been reported to date. In this study we evaluated the incidence of hypercalcemia in dialysis patients. Patients with associated diseases that may influence serum calcium level were excluded from the study. A total of 180dialysis patients (116 HD patients and 64 CAPD patients) maintained at Soon Chun Hyang University Hospital were included. Three consecutive 2 monthly measurements of serum calcium, phosphate, albumin, alkaline phosphatase, bicarbonate in HD and two consecutive measurements in 3 month interval in CAPD patients were retrospectively evaluated. Ionized calcium and intact parathyroid hormone (N-terminal) were measured every 6 months. Serum total calcium level was corrected by serum albumin level. Three HD patients(2.5%) were hypercalcemic pre-HD while 50(43.1%) hypercalcemic postdialysis. 5 CAPD patients(7.8%) were hypercalcemic. Pre-HD calcium level did not differ from the value in CAPD patients. An average value of pre-and post-HD calcium, and serum albumin levels were significantly higher in HD patients than those values in CAPD patients(p<0.01). Ionized calcium (p<0.01) and serum PTH(p<0.05) levels were significantly higher, while serum bicarbonate level (p<0.01) was significantly lower in HD patients than in CAPD patients. The amount of calcium carbonate used were 2.2g in HD and 2.8g in CAPD. In conclusion, the incidence of hypercalcemia is low in pre-HD (2.5%) and in CAPD patients(7.8%). However, the high incidence of post-HD hypercalcemia observed in this study advocates a future study to evaluate the effect of low calcium dialyste on calcium-phosphate metabolism.

A Case of Primary Aldosteronism, Nephrotic Syndrome and Chronic Renal Failure: A Diagnostic Dilemma / 대한신장학회잡지

Primary aldosteronism is characterized by hypertension, hypokalemia, low plasma renin activity (PRA) and elevated plama aldosterone (PA) level. Primary aldosteronism is suspected in patients with hypertension and unexplained hypokalemia. In chronic renal failure(CRF), however, renin-angiotensin-aldosterone axis is altered by renal disease per se, antihyppertensive drugs used and volume status. Therefore, it is difficult to diagnose primary aldosteronism in CRF on the basis of serum potassium, PRA and PA level. Recently, we experienced a case of primary aldosteronism associated with nephrotic syndrome and CRF. The patient was a 49 years old woman who presented with 10 year old history of high blood pressure and general weakness of one year's duration. Her initial serum creatinine was 7.3mg/dL and serum potassium 2.6mEq/L. PRA was decreased and PA was markedly increased. Persistent hypokalemia urged to evaluate adrenal gland in this case. The round mass was found in left adrenal gland and it was surgically removed. CRF and nephrotic syndrome can alter serum potassium and PRA and there lies the diagnostic dilemma for primary aldosteronsim. It will be well to consider associated primary alodsteronism in a patient with CRF and persistent hypokalemia.