Siu-Ka Mak

Long-term follow-up of thoracoscopic pleurodesis for hydrothorax complicating peritoneal dialysis

BACKGROUND Massive hydrothorax is a significant complication of continuous ambulatory peritoneal dialysis (CAPD) and its ideal management remains undefined. Conservative management in the form of intermittent peritoneal dialysis had limited success. The use of conventional pleurodesis and open thoracotomy were associated with morbidities and limitations. We retrospectively reviewed the long-term outcome of 8 patients with massive hydrothorax complicating CAPD, 6 of whom received thoracoscopic pleurodesis. METHODS Among 397 patients undergoing continuous ambulatory peritoneal dialysis during the period from 1994 to 1998, hydrothorax developed in 8 patients. Four patients were first treated with temporary intermittent peritoneal dialysis using 1-L exchange cycles. Three of them had a recurrence of the hydrothorax whereas only one could resume continuous ambulatory peritoneal dialysis successfully. Two patients then underwent conventional pleurodesis but failed. One of them was switched to hemodialysis. Thoracoscopic pleurodesis was performed for the remaining 2 patients together with 4 other patients with hydrothorax once this complication developed. There were no gross abnormalities including pleuroperitoneal communication sites identified. Talc poudrage was performed in 2 patients and mechanical rub pleurodesis in the other 4 patients. All had uncomplicated procedure and uneventful recovery. RESULTS One patient after thoracoscopic pleurodesis was soon switched to hemodialysis for an unrelated reason. The other 5 patients resumed continuous ambulatory peritoneal dialysis with no recurrence of hydrothorax for a mean period of 50 months (range 19 to 84). CONCLUSIONS With thoracoscopic pleurodesis, patients resumed continuous ambulatory peritoneal dialysis without recurrence of hydrothorax on long-term follow-up.

Efficacy of enteric‐coated mycophenolate sodium in patients with active lupus nephritis

Background:  The ideal treatment of lupus nephritis has yet to be defined. Both cyclophosphamide and mycophenolate mofetil have been used with encouraging results, but adverse events are frequently seen. There are no data on the use of enteric‐coated mycophenolate sodium.

Clinical presentation and outcome of severe acute respiratory syndrome in dialysis patients

Abstract There was a major outbreak of severe acute respiratory syndrome (SARS) affecting more than 300 patients occurring in a private housing estate in Hong Kong, in which an infected renal patient was suspected to be the primary source. It is unknown whether renal patients would represent a distinct group of patients who share some characteristics that could predispose them to have higher infectivity. In this context, we have encountered 4 dialysis patients contracting SARS in a minor outbreak, which involved 11 patients and 4 health care workers, in a medical ward of a regional hospital. Of these 4 dialysis patients, 1 patient was receiving hemodialysis while the other 3 patients were on continuous ambulatory peritoneal dialysis. Fever and radiological changes were their dominant presenting features. All were having positive results for SARS-associated coronavirus ribonucleic acid by reverse transcriptase-polymerase chain reaction performed on their nasopharyngeal aspirates or stool samples. It appeared that treatment with high-dose intravenous ribavirin and corticosteroids could only resolve the fever, but it could not stop the disease progression. All 4 patients developed respiratory failure requiring mechanical ventilation on days 9 through 12. At the end, all of the patients died from sudden cardiac arrest, which was associated with acute myocardial infarction in 2 cases. From this small case series, it appeared that dialysis patients might have an aggressive clinical course and poor outcome after contracting SARS. However, a large-scale study is required to further examine this issue, and further investigation into the immunologic abnormalities associated with the uremic state in this group of patients is also warranted.

Treatment with Cyclophosphamide in Elderly-Onset Nephrotic Syndrome

Background:The best treatment of elderly-onset nephrotic syndrome has not been well defined. The use of corticosteroids or combination immunosuppressants may be associated with a significant incidence of side effects in the elderly. There is little data on the use of cyclophosphamide alone. Methods:We retrospectively reviewed 30 patients with idiopathic elderly-onset nephrotic syndrome treated with cyclophosphamide. Results:Male to female ratio was 2:1, mean age at diagnosis was 72.7 ± 5.9 years and average length of follow-up was 41.4 ± 21.3 months. Significant co-morbidities, including hypertension, were present in 57%. A raised serum creatinine level was found in 57%. Biopsy revealed 15 membranous nephropathy, 4 mesangial proliferative Gn, 5 IgA nephropathy, 3 minimal change nephropathy, 2 focal segmental glomerulosclerosis and 1 C1q nephropathy. Cyclophosphamide was given for 32.0 ± 16.2 weeks with an averaged cumulative dose per patient 177 ± 84 mg/kg BW. Remission (complete or partial) was attained by 40, 63, 80 and 87% of patients within 12, 24, 36 and 48 weeks of treatment, respectively. Eighteen patients attained complete remission and 9 partial remission after treatment. The mean interval to attain first remission (complete or partial) was 18.9 ± 14.6 weeks. This was not affected by age (p = NS) or initial albumin level (p = NS). At the time of last follow-up, all but 2 patients were in complete or partial remission with raised serum creatinine levels in 40%. Conclusions:Cyclophosphamide was effective and well tolerated in the treatment of elderly-onset nephrotic syndrome, with sustained remission and preserved renal function.

Persistent hiccup in a continuous ambulatory peritoneal dialysis patient following ingestion of star fruit

Abstract Animal studies have suggested that ingestion of star fruit, which belongs to the Oxalidaceae family, may cause neurotoxicity. Outbreaks of intractable hiccups have been reported following ingestion of star fruit in patients on regular hemodialysis. Other complaints have included insomnia, agitation and mental confusion. We report a patient on continuous ambulatory peritoneal dialysis (CAPD) who presented with acute confusion and persistent hiccup following ingestion of star fruit. Symptoms resolved spontaneously. Other reported cases and management strategies are discussed.

Comparison of clinical course and outcome of hypophosphatemia with and without oral phosphate supplementation in the first year after renal transplantation: a single-center retrospective study

Abstract Introduction: Phosphate retention is a hallmark of chronic renal failure. The hypophosphatemia that occurs in the early post-renal transplantation period may represent the end result of the rapid transcellular shift of phosphate between body compartments rather than phosphate depletion. The common practice of phosphate replacement after renal transplantation should be re-evaluated. Methods The changes of serum phosphate over the first 12 months after renal transplantation were analyzed retrospectively in 30 new renal transplant recipients. Group A included nine normophosphatemic patients who did not require a phosphate supplement. Group B included 13 hypophosphatemic patients who were given a titrated dose of an oral phosphate mixture. Group C included eight hypophosphatemic patients who were not given phosphate supplementation. Results There was no difference in the duration of hypophosphatemia in Groups B and C. No complications of hypophosphatemia were found in patients in Groups B and C. A high serum phosphate level before transplantation was the single factor associated with post-transplantation hypophosphatemia. No predictors of serum phosphate level after renal transplantation were found. Conclusion Phosphate supplementation did not alter the clinical course and outcome of hypophosphatemia after kidney transplantation.

Kidney allograft failure due to acute phosphate nephropathy associated with severe secondary hyperparathyroidism

Intratubular calcification is a common finding in renal allografts. However, possible harmful effect of this calcification is not well recognized, and allograft failure purely due to this condition has not been reported. We report a kidney transplant recipient who suffered from severe secondary hyperparathyroidism and unexplained early allograft failure. A diagnosis of acute phosphate nephropathy was made subsequently based on serial allograft biopsy findings. This case calls for a high index of suspicion to look for this rare cause of allograft dysfunction among high-risk patients. It also highlights the importance of good calcium–phosphate control before renal transplantation.

Outcomes of Renal Transplantation in Elderly Patients: Experience From Two Centers

Background Elderly patients are the fastest growing age group in end-stage renal failure. Data from overseas show that transplantation is a safe and reliable mode of treatment for this group of patients. However, local data about the outcome in these patients are lacking. The aim of this study was to determine and compare the outcomes of renal transplantation among elderly recipients and younger recipients. Methods Using the Organ Registry and Transplant System in Kwong Wah Hospital and Princess Margaret Hospital, adult patients who had undergone renal transplantation and who had been followed-up by the two medical units were recruited. They were divided into the control group (age Results A total of 324 episodes of transplantation were recorded (266 controls and 58 elderly). The incidence of acute rejection was higher in the control group (18% vs. 8.6%, p = 0.08). There was a trend towards higher incidence of infection and malignancy in the elderly group, though the difference did not reach statistical significance. The graft survival rate was similar in the two groups, while the 5-year patient survival rate was worse in the elderly group (92.1% vs. 79.3%, p = 0.0058). Conclusion The transplantation outcomes in elderly recipients are satisfactory, and age per se should not be considered a contraindication to transplantation.

Outcome of Sclerosing Peritonitis Complicating Peritoneal Dialysis

Background Sclerosing peritonitis (SP) is a rare but serious complication of peritoneal dialysis. Multiple causes have been implicated in its pathogenesis. Different approaches to management include conservative treatment, surgical intervention, and immunosuppressive therapy. We retrospectively reviewed the presentation and treatment outcome of seven patients with SP. Methods Overall, 552 patients underwent continuous ambulatory peritoneal dialysis (CAPD) between 1994 and 2003. Patients were included if there were suggestive clinical features and either radiologic or surgical evidence of SP. Seven patients developed SP, five men and two women, with a median age of 41 years (range, 32-64 years). The median duration of CAPD prior to development of SP was 72 months (range, 48-125 months). In six patients, SP occurred soon after an episode of CAPD-related peritonitis (range, 1-7 months). Results Patients presented with acute abdominal pain, ascites, small bowel intestinal obstruction, and failure of Tenckhoff catheter reinsertion. Abdominal X-ray, ultrasonography, and computed tomography scans were helpful in the diagnosis. Laparotomies were performed in six patients (typical cocoon appearance of peritoneum in three). No patients underwent adhesiolysis or received immunosuppressive therapy. All patients were switched to hemodialysis. Five patients required temporary total parenteral nutritional support. Four patients survived but none returned to CAPD. The other three patients died of sepsis. Conclusion SP is a serious complication of peritoneal dialysis with a mortality rate of 43%. Severe peritonitis, especially in patients on dialysis for longer than 4 years, is associated with development of SP. Prevention and optimal treatment of CAPD-related peritonitis might be important in preventing SP.