A stethoscope can be to evaluate arteriovenous access (AVA) to determine flow and the presence of stenosis. However, the usefulness and limitation of this approach have not been fully investigated. We used a simple method of auscultation to examine AVA. The chest-piece of the stethoscope was removed, and we listened to an AVA using the tip of the tube placed perpendicularly on the skin. We called this maneuver, the “tube auscultation method”, and compared the bruit of AVA obtained by this new method with that by the conventional method using an ordinary stethoscope. A fast Fournier transform was used to evaluate differences of the bruit. In an AVA with mild upstream stenosis, a low-pitched bruit was audible throughout the entire length of the vein, but it was difficult to detect the stenotic site by the conventional auscultation method. In contrast, using the tube auscultation method, a remarkable change in the pitch of the bruit was detected. The pitch of the bruit rose at the stenotic site, and gradually decreased beyond the stenosis. In a pulsating AVA with severe downstream stenosis, low-pitched bruit was heard along the entire length of the vein by the conventional method. Using the tube method, localized bruit was heard at the point of venous stenosis. The retrograde spread of bruit from the downstream stenotic site was the origin of the bruit heard with the conventional auscultation method. This retrograde spread of bruit could be eliminated with the tube method. We could localize stenosis exactly with the tube auscultation, but sometimes not with the conventional stethoscope. The tube auscultation method is a simple, inexpensive and very useful method for the examination of AVA.

View full abstract

One of the main problems during hemodialysis treatment with a double-lumen catheter (DLC) is dysfunction due to malpositioning of the tip against the vessel wall so that the DLC tip sucks the vessel wall. In this study, possible factors causing the sucking phenomenon were investigated using ten types of DLCs. The sucking phenomenon was evaluated in a simulated vessel of cellulose tube in which DLC was inserted. Catheter tips tended to suck the tube in eight types of DLC with arterial holes that converge on one side of the circumferences of their trunks. Five of those eight types DLC, in which the arterial holes converge in less than one third of the circumferences, tended to suck the vessel wall more frequently. In contrast, the tips did not suck the tube in two types DLC that have arterial holes around the entire circumferences. Then the arterial holes of the latter types of DLCs were artificially occluded one-by-one and the relation between sucking and arrangement of the open holes was examined. In the DLC with six arterial holes, it was not until the number of open holes decreased to three that sucking took place. In the cases of two open holes, the sucking frequency increased with decreases in the distance between the two open holes, and the frequency was highest when the two open holes were aligned longitudinally. When one of the two longitudinally aligned open holes was occluded, the sucking frequency increased further and the open hole flow resistance increased profoundly. In eight types of DLCs in which sucking were observed, the frequency increased with increased flow inside DLCs and decreased flow in the cellulose tube. These results indicate that arterial hole convergence, high open hole flow resistance, an increase in DLC flow, and a decrease in vessel flow cause the catheter tip to suck the vessel wall easily.

View full abstract

Acute hyperammonemia caused by disorder of the urea cycle is a medical emergency requiring immediate management to minimize permanent brain damage. We report two successful uses of hemodiafiltration for acute treatment of hyperammonemia in a patient with ornithine transcarbamylase deficiency and the other one with in a case of adult-onset type II citrullinemia. A 29-year-old female patient who had been diagnosed as having ornithine transcarbamylase deficiency at the age of one year five months was hospitalized for coma with hyperammonemia (serum ammonia, 536 μg/dL), and intravenous arginine was initiated to activate the alternative nitrogen waste pathway. Despite receiving appropriate doses of arginine, however, the severity of hyperammonemia increased. A 28-year-old female was hospitalized for severe coma with hyperammonemia (serum ammonia, 717 μg/dL) and was diagnosed as having adult-onset type II citrullinemia. We performed hemodiafiltration for both cases, and rapid improvement of hyperammonemia was achieved in each case. Severe hyperammonemia is usually associated with irreversible neurological damage. Therefore treatment should be aimed at lowering the serum ammonia concentrations as rapidly as possible. Hemodialysis is the most effective treatment for rapid reduction of the blood ammonia levels. We strongly recommend that hemodialysis or hemodiafiltration should be instituted in cases of serum ammonia concentrations >500 mg/dL and those in which the serum ammonia levels do not fall promptly with sodium benzoate and arginine infusion.

View full abstract

A 59-year-old female patient diagnosed as having adult T-cell leukemia/lymphoma (ATL) in June 2005 was admitted to our hospital on August 11 th, 2006 because of acute renal failure and hypercalcemia. Laboratory tests at admission demonstrated that the patient's corrected serum Ca level (13.1 mg/dL) and soluble IL-2 receptor level (370,500 U/mL) were high and abnormal lymphocytes (2,860/mm³) were present. Her serum levels of blood urea nitrogen (BUN) and creatinine were also high, at 80.9 mg/dL and 5.1 mg/dL, respectively. Physical examination demonstrated general edema and pleural effusion and ascites were detected using computed tomography (CT). Abdominal ultrasonography showed bilateral enlargement of the kidneys with high-intensity signals from the renal cortex and low-intensity signals from the renal pyramids. Neither pyelectasis nor caliectasis were observed. In addition, plain CT showed bilateral enlargement of the kidneys with irregular and high-density areas. We performed hemodialysis during the combination chemotherapy. After treatment, the enlarged kidneys and renal failure were improved, and the patient was weaned from hemodialysis. Despite additional chemotherapy, however, she died due to tumor progression in September 2006. Autopsy findings showed that ATL cells were bilaterally present in the renal interstitium, but not in the glomeruli or uriniferous tubules. In this case, it seems that acute renal failure was induced by stenosis and occlusion of the kidney tubules due to invasion of ATL cells into the renal interstitium. Swollen kidneys in ATL cases might indicate renal failure induced by the invasion of ATL cells, for which hemodialysis in combination with the chemotherapy may be effective.

View full abstract

We report a case of severe active ulcerative colitis in a pregnant woman receiving granulocytapheresis. The patient was a 35-year-old parous woman who had developed UC at the age of 24. She miscarried at 8 weeks during discontinuation of therapeutic agents when she was 30, and she had her first baby while receiving steroid therapy when she was 32. In July 2006, the patient was receiving oral prednisolone (PSL) 5 mg/day and mesalazine, and her UC activity was considered moderate according to the clinical activity index. However, the patient discontinued the drugs on her own judgment because of her pregnancy. At 8 weeks and 0 days pregnant, she was hospitalized because of diarrhea and hematochezia. We administered PSL 20 mg/day and treated her with bowel rest by fasting and intravenous hyperalimentation, but her symptoms did not improve. She also had rebound tenderness in the abdomen, which made us consider open abdominal surgery. We started intravenous administration of PSL 50 mg/day when she was 10 weeks and 2 days pregnant, and started to perform granulocytapheresis (GCAP) twice a week (a total of 10 sessions) when she was 11 weeks and 1 day pregnant. Her symptoms began to improve after the third GCAP session, and she developed remission by the fifth GCAP session. The dose of PSL was gradually reduced and the patient was discharged from the hospital on PSL 20 mg/day. The fetal biparietal diameter and femur length at day of discharge were both generally equivalent to those of a 16-week-old fetus. When concomitant GCAP was performed in a pregnant woman with UC that was difficult to treat, the patient showed prompt remission and could continue the pregnancy. GCAP, which has little influence on fetuses, should be used positively in pregnant women with UC in combination with conventional drug therapy.

View full abstract

Recently, the occurrence of diaphragmatic peritoneal leak has been reported during continuous ambulatory peritoneal dialysis (CAPD). A case is presented that was investigated by peritoneopleural scintigraphy. A 62-year-old female patient on CAPD developed massive left pleural effusion 14 months after beginning CAPD. She presented with cough and weight gain of 7 kg. The pleural effusion did not show high concentration of glucose. To evaluate the cause of left pleural effusion, ^99mTc-Sn-colloid was administered intraperitoneally with 1.5 liters of dialysate. At 4 hr, leakage of the dialysate into the left pleural cavity was observed, demonstrating the presence of CAPD diaphragmatic peritoneal leak. After a one-month rest from CAPD, she resumed CAPD with a decreased volume of dialysate in combination with hemodialysis.
Left diaphragmatic peritoneal leak has rarely been reported, and ^99mTc-Sn-colloid scintigraphy can be useful in diagnosing trans-diaphragmatic fluid leakage.

View full abstract