Psoas abscess with osteomyelitis in a patient undergoing long-term hemodialysis.

We describe a 69-year-old male patient on maintenance hemodialysis for 24 years who developed a fatal left psoas abscess with osteomyelitis at the hip joint following acute enterocolitis. He had systemic beta(2)-microglobulin amyloid deposition in colon epithelium and psoas muscle. Cultures from abscess fluid and femoral bone marrow yielded Bacteroides fragilis. To our knowledge, this is the first case on hemodialysis having a psoas abscess following acute gastrointestinal infection. This rare case suggested that a secondary psoas abscess could be one of the occult infections in patients undergoing long-term maintenance hemodialysis.     

Renal oncocytoma developed in a long-term hemodialysis patient

A case of renal oncocytoma which developed in a 38-year-old Japanese woman after 7 years of maintenance hemodialysis is reported. An encapsulated round tumor with a diameter of about 5 cm was incidentally discovered by abdominal echography. This is the first case of renal oncocytoma found in a long-term hemodialysis patient. Identification and differentiation of this subgroup from renal carcinomas are very important because of its benign nature. Careful clinicopathological investigation of renal tumors should therefore be required in hemodialysis patients.     

Giant serpentine aneurysm in a long-term hemodialysis patient

A long-term hemodialysis patient with a giant intracranial vascular channel, which has been called a giant serpentine aneurysm, is presented. A 50-year-old man with an eight-year history of hemodialysis treatment was admitted because of headache, nausea and double vision. Computed tomographic scans and nuclear magnetic resonance revealed intracranial abnormal shadow. The left vertebral arteriography showed that the distal portion of the left vertebral artery was dilated to 17 mm in diameter. The basilar artery showed a large tortuous vascular channel and globular aneurysms over 25 mm in diameter. This giant serpentine aneurysm is a rather rare disease. To our knowledge, it has not been reported as a complication in a hemodialysis patient, although fourteen cases have been reported in the literature. In our case, several conditions such as long-term hypertension, hyperlipidemia, hypercalcemia, atherosclerosis and abnormal blood flow due to arteriovenous fistula for hemodialysis treatment might be considered to play a role in the formation of the giant serpentine aneurysms.     

Renal oncocytomatosis in a long-term hemodialysis patient treated by laparoscopic surgery

A 50-year-old female, who had been on maintenance hemodialysis for 22 years, consulted our clinic because of a left renal mass detected incidentally by ultrasonography. Computed tomography (CT) demonstrated a solid hypervascular mass, suggesting a renal cell carcinoma (RCC), in the left atrophic kidney. Left hand-assisted laparoscopic nephrectomy (HALN) was performed. The histopathological diagnosis was renal oncocytomatosis. Renal oncocytomatosis in a long-term hemodialysis patient is extremely rare. We report the first case of renal oncocytomatosis in a long-term hemodialysis patient treated with hand-assisted laparoscopic nephrectomy.     

Subcutaneous amyloid-tumor of beta-2-microglobulin origin in a long-term hemodialysis patient

beta 2-Microglobulin (beta 2M)-derived amyloidosis has become a major concern in long-term hemodialysis patients. Clinical symptomatology is largely restricted to the articular and periarticular sites and in rare cases systemic manifestations have been described. We present a long-term hemodialysis patient, who after 16 years of hemodialysis with regenerated cellulosic membranes not only had a bilateral carpal tunnel syndrome, cystic bone translucencies and humeroscapular periarthritis but also developed two subcutaneous tumors in both gluteal regions, causing discomfort when sitting. Histology, immunohistology and electron microscopy of the tumor from the right side showed that it consisted of beta 2M-derived amyloid with concurrent scattered amyloid infiltration of the overlying skin. This report therefore adds a new clinical manifestation to the symptomatology of this type of amyloid.     

Primary hypothyroidism and multiple endocrine failure in association with hemochromatosis in a long-term hemodialysis patient.

A 56-year-old male patient on chronic hemodialysis developed liver cirrhosis. He received a total of 20 liters of blood transfusion. Bronze pigmentation of the skin and iron deposition to the liver, spleen, pancreas and thyroid gland, which was demonstrated by computed tomography and magnetic resonance imaging studies, and histological demonstration of iron deposition to the thyroid gland, bone marrow and gastric mucosa established a diagnosis of secondary hemochromatosis. Endocrine work-up revealed the presence of diabetes mellitus with minimum insulin secretory response, primary (or thyroprivic) hypothyroidism, hypoparathyroidism and hypogonadotropic hypogonadism. A wide-spread endocrine involvement as seen in this patient is a rare clinical feature of hemochromatosis secondary to massive blood transfusion in hemodialysis patients. Particularly, primary hypothyroidism due to iron deposition to the thyroid gland was quite a rare feature of hemochromatosis.     

Brown tumor of the thoracic spine in a patient on long-term hemodialysis

A 39-year-old woman on long-term hemodialysis presented with a history of rapidly progressive paraplegia. Radiological examination showed a compression fracture of seventh thoracic vertebra and expansive mass lesion in the posterior elements of the fourth thoracic vertebra. Laboratory tests on admission showed serum calcium of 11.9 mg/dl, phosphate 6.0 mg/dl, and the high-sensitive parathyroid hormone level of 139,191 pg/ml measured by radioimmunoassay. Percutaneous biopsy of the expansive mass showed a large number of multinucleated giant cells in a fibroblastic stroma containing abundant hemosiderin. Tumor resection and anterior interbody fusion with artificial bone graft was performed on 14th hospital day. Paraplegia gradually improved postoperatively. Total parathyroidectomy and autotransplantation of parathyroid gland were subsequently performed. Nodular hyperplasia was evident in the parathyroid glands by light microscopy. Brown tumor is rarely found in vertebral bone and this is the sixth case of such tumor in secondary hyperparathyroidism.     

Renal cell carcinoma with a long-term hemodialysis patient: a case report

A 59-year-old man was found to have a renal cell carcinoma during about one hundred months of hemodialysis by means of an ultrasound tomography. Nephrectomy was done and renal cell carcinoma, clear cell type, with acquired renal cysts were observed, histologically. The usefulness and routine application of ultrasound tomogram are stressed for examination of the renal appearance during the management of hemodialysis.     

Exacerbation of latent heart failure by mild hypocalcemia after parathyroidectomy in a long-term hemodialysis patient.

A 60-year-old uremic patient treated with hemodialysis for 13 years developed acute hypotension during hemodialysis and overt heart failure subsequently in a period of relatively mild hypocalcemia after parathyroidectomy. Blood pressure during hemodialysis was maintained by continuous calcium infusion alone. Cardiomegaly was improved by normalization of serum calcium. The cardiac complication is considered to be exacerbation of the underlying myocardial dysfunction by the acute decline of serum calcium which might be a feature of the 'hungry bone' syndrome. Latent myocardial dysfunction might be exacerbated by only mild hypocalcemia after parathyroidectomy in long-term hemodialysis patients.     

Acquired renal cystic disease mimicking adult polycystic kidney disease in a patient undergoing long-term hemodialysis.

Acquired renal cystic disease (ARCD) is defined as the development of multiple cysts in the renal cortex and medulla in patients with chronic renal failure who are free from congenital polycystic kidney disease. ARCD develops generally in contracted kidneys. We report a case of grotesque enlargement of a single kidney in a patient who had been receiving hemodialysis for 18 years. Although the exact causes of ARCD are not known, 3 factors may contribute to the development of nephromegaly; the sex, the duration of hemodialysis and previous unilateral nephrectomy. As in polycystic disease, when the involved kidney reaches considerable size, ARCD may have a favorable effect on anemia caused by chronic renal failure.     

Isolated adrenocorticotropic hormone deficiency presenting with hypercalcemia in a patient on long-term hemodialysis

The authors report on a 44-year-old female hemodialysis (HD) patient who presented with hypercalcemia secondary to isolated adrenocorticotropic hormone (ACTH) deficiency. She had been suffering from nausea and abdominal pain caused by recurrent esophageal ulcer. Blood calcium (Ca) adjusted for serum albumin concentration was increased to 14.9 mg/dL (3.72 mmol/L) concurrently with fever and hypotension. Serum intact parathyroid hormone (PTH)-related peptide was not elevated, but serum intact PTH and 1,25-(OH)₂ vitamin D₃ were decreased to 31 pg/mL (ng/L) and 8.1 pg/mL (2.6 pmol/L), respectively. Endocrinologic examination found that plasma ACTH was reduced below 5.0 pg/mL (0.22 pmol/L). A single ACTH stimulation normally increased blood cortisol, whereas a single corticotropin-releasing hormone injection failed to increase plasma ACTH and cortisol. Pituitary magnetic resonance imaging disclosed no enlargement of pituitary gland. Circulating bone formation and absorption markers were not elevated. Blood Ca was normalized shortly after pamidronate disodium administration without glucocorticoid supplementation. This case suggested that secondary adrenal insufficiency caused by isolated ACTH deficiency could be an occult cause of severe hypercalcemia in HD subjects.     

Remission of a recurrent carpal tunnel syndrome by a new device of the hemodialysis method in a long-term hemodialysis patient

This report concerns a case in which remission was achieved from the recurrent carpal tunnel syndrome employing new methods of hemodialysis. These being the maintenance of low endotoxin in dialysate, a highly permeable membrane and a 32-microglobulin-adsorbent column. A 78-year-old female patient with a 19-year history of hemodialysis was diagnosed as being a suitable recipient of a third operation. The concentration of endotoxin was maintained at under 10 EU/l and the highly permeable dialyzer with a larger sieving coefficient of beta2-microglobulin was introduced. A Lixelle adsorption column for beta2-microglobulin removal was also introduced and the serum concentration of the beta-microglobulin was maintained at under 20 mg/dl. Consequently, within 6 months the symptoms in the right hand had completely disappeared, the motor nerve latency had almost normalized at 5.0 msec and no recurrence was observed.     

A case of iron and aluminum related osteomalacia in a long-term hemodialysis patient

A 32-year-old woman undergoing hemodialysis for 12 years was referred because of systemic bone pain and pathological fracture of ribs and right tibia. Her serum ferritin was 4800 ng/ml, liver CT level was extremely high and skeletal scintigram by 99 m-Tc-MDP revealed high activity of soft tissue. Her serum aluminum was elevated more than 20 micrograms/dl by deferoxamine infusion test. Osteomalacia and positive staining of both aluminum and iron was observed by bone biopsy examination. After treatment with deferoxamine as a chelating agent of iron and aluminum, bone pain was relieved and second bone biopsy specimen revealed improvement of osteomalacia. But serum aluminum was slightly reduced and serum ferritin level and liver CT level were unchanged.