Improvements in Pneumatosis Cystoides Intestinalis and Hepatic Portal Venous Gas with Conservative Therapy in a Patient on Maintenance Dialysis.

A 77-year-old man on maintenance dialysis developed hypotension, nausea and abdominal pain one hour after beginning to undergo hemodialysis. Abdominal computed tomography (CT) showed gas shadows in the intrahepatic portal vein and the small intestinal wall, but no signs indicating intestinal necrosis. Three days later, the gas shadows on abdominal CT disappeared by conservative therapy. In cases with both pneumatosis cystoides intestinalis and hepatic portal venous gas, intestinal necrosis should therefore be suspected and surgical therapy should also be considered, particularly in hemodialysis patients with a risk of intestinal ischemia. However, conservative therapy may be an option in cases with no intestinal necrosis.

A case of membranoproliferative glomerulonephritis and AA amyloidosis complicated with pulmonary nontuberculous mycobacterial infection.

A 75-year-old man was diagnosed with pulmonary nontuberculous mycobacterial (NTM) infection in February 2005 and was treated with rifampicin, ethambutol, and clarithromycin. However, the infection was resistant to treatment, and his chest radiograph showed an abnormality that gradually seemed to aggravate. The patient's sputum was positive for Mycobacteria. Moreover, the patient had dyspnea and an underlying chronic inflammation in the lungs. He visited our hospital because of dyspnea and leg edema in June 2011. Laboratory evaluation on admission revealed proteinuria (6 g/day) and decreased serum total protein (5.8 g/dL) and albumin (1.6 g/dL) levels, indicating nephrotic syndrome. Percutaneous renal biopsy revealed membranoproliferative glomerulonephritis (MPGN) in the acute stage and AA amyloidosis of mild degree. AA amyloidosis was also diagnosed histologically on gastric and colonic biopsy, in addition to renal biopsy. His renal function decreased gradually, and therefore, he underwent hemodialysis therapy in January 2012. However, his gastrointestinal-related symptoms persisted, and his appetite diminished, because of which he had become severely malnourished; he died 8 months later. This is a rare case of a patient with two different renal lesions (MPGN and AA amyloidosis) complicated with NTM. Our case suggests that MPGN and amyloidosis should be considered in elderly patients with nephrotic syndrome onset and chronic inflammation.

Tuberculous osteomyelitis in the ulna of a patient undergoing hemodialysis.

A 76-year-old woman on hemodialysis (HD) presented with pain and swelling in the left wrist and forearm. The osteomyelitis occurred in the part of the ulna adjacent to the arteriovenous fistula. Mycobacterium tuberculosis was identified in pus obtained from the left forearm, leading to a diagnosis of tuberculous osteomyelitis. The patient was treated with anti-tuberculous drugs and her symptoms improved. In this study, we report a case of tuberculous osteomyelitis occurring in the ulna, which is not the usual site of predilection for tuberculosis infection. As HD patients exhibit a high frequency of extrapulmonary tuberculosis, tuberculous osteomyelitis should be considered in the differential diagnosis of infectious osteomyelitis. In addition, it may be useful to perform stab cultures at an early stage in order to diagnose tuberculous osteomyelitis.

Clinical and Immunological Evaluation of Infection in Patients on Hemodialysis.

Infection is a major complication associated with increased morbidity and mortality in patients on hemodialysis. We analyzed the incidence and type of infection occurring in 4841 patients on hemodialysis between 1986 and 1993 in our hospital and 11 other hemodialysis centers. Infection was noted in 193 patients (4.98 infections/1000 patients/year). Pneumonia (n=71) and bacteremia (n=24) were the 2 most common infections, followed by tuberculosis (n=14), herpes zoster infections (n=12) and infections at the vascular access site (n=12). The most commonly isolated organism in pneumonia, bacteremia and vascular access site infections wasStaphylococcus aureus. Analysis of the prognosis of patients with pneumonia showed a mortality rate of 50% in patients greater than 60 years old, which was significantly higher than that of younger patients (6.7%,P<0.01), whereas the mortality rate in patients with bacteremia was not different between the 2 age groups (60.0% vs. 57.9%, respectively). We also analyzed changes in immunological function and nutritional status in 16 patients on hemodialysis and 21 healthy control subjects. Although the phagocytic and bactericidal activities of neutrophils and monocytes were not different between the groups, superoxide production, the percentage of natural killer cells and the degree of blastoid transformation with phytohemagglutinin stimulation were significantly lower in hemodialysis patients. Low levels of Niderman's index and serum albumin and transferrin indicated poor nutritional status in these patients. Furthermore, the degree of Niderman's index and serum albumin significantly correlated with impairment of immunological function, such as reduced blastoid transformation and the number of lymphocytes. Our results suggest that analysis of the patterns of infection in patients on hemodialysis should provide better management and that improvement of malnutrition may ameliorate impaired immunity in hemodialysis patients.