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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 1  |  Page : 130-131
Continuous ambulatory peritoneal dialysis in a patient with scleroderma


Department of Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India

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How to cite this article:
Khaira A, Rathi OP, Gupta S, Agarwal SK. Continuous ambulatory peritoneal dialysis in a patient with scleroderma. Saudi J Kidney Dis Transpl 2009;20:130-1

How to cite this URL:
Khaira A, Rathi OP, Gupta S, Agarwal SK. Continuous ambulatory peritoneal dialysis in a patient with scleroderma. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2014 Jul 22];20:130-1. Available from: http://www.sjkdt.org/text.asp?2009/20/1/130/44721
To the Editor ,

The ideal form of renal replacement therapy in a case of scleroderma-related end-stage renal disease (ESRD) is a subject of debate. Diffi­culty in creating a vascular access makes hemodialysis (HD) a difficult proposition and despite suboptimal graft survival, kidney trans­plant has been advocated as the best form of renal replacement therapy. [1] We report a case of scleroderma-related ESRD with good out­come on continuous ambulatory peritoneal dialysis (CAPD) at 15-months of follow-up.

We herewith report on a 21 year old male patient, a known case of scleroderma-related ESRD on CAPD, who was admitted for follow-up evaluation. The patient had earlier presented in renal crisis (SRC) with advanced azotemia (serum creatinine, 13.5 mg/dL and blood urea, 198 mg/dL), and accelerated hyper­tension (BP, 190/110 mmHg). He was anuric and had fluid overload at admission. The pa­tient was initiated on regular thrice weekly HD via a double lumen jugular catheter. Along with other medicines, he was also prescribed tab ramipril 10 mg daily and tab telmisartan 80 mg daily to control his blood pressure. Over the next four weeks he remained anuric and dialysis dependant; he was then subjected to renal biopsy. Biopsy showed two cores with 10 glomeruli of which eight were sclerosed and two showed mesangiolysis, along with ischemic necrosis of the tubules. There was evidence of patchy interstitial fibrosis. The interlobular artery showed tiny and occluded lumen with surrounding fibrous intimal thicke­ning. The overall histology was compatible with SRC with significant degree of chronicity [Figure 1]. Two attempts at creating an arterio­venous (AV) fistula were unsuccessful and the patient was initiated on peritoneal dialysis (PD) after four weeks of HD, 15 months ear­lier. The initial PD prescription consisted of three day-time exchanges, (2 liters of 1.5% solution) and one overnight dwell of two liters of 2.5% solution. A modified peritoneal equili­bration test performed at three months showed an average transporter status. Over the next six months, his requirement for antihypertensive medications came down and for the last six months we have been able to withdraw all his antihypertensive drugs. At last follow-up his subjective skin symptoms have not progressed. The PD prescription has remained same and he gets an ultra filtration of 1.5 liters daily. There have not been any episodes of peritonitis.

Similar to our observation, Robson et al have reported good outcome on intermittent PD in two patients followed-up for nine and 10 months respectively. [2] Survival as long as 18 months has been reported previously in one patient, wherein the authors have reported good quality of life and adequate peritoneal clearances along with good control of uremia. [3] Like our case, this patient too became free of antihypertensives and did not have disease progression. Such good control of blood pre­ssure has not been reported with HD or after transplantation and literature is replete of reports of bilateral nephrectomy to control blood pressure. [3]

On the contrary, Gibney et al, have reported a graft survival of only 68% at one-year post­transplant in a retrospective analysis of the UNOS data. Although the patient survival was reported to be better than those on dialysis, the modality of dialysis has not been specified. [1] Thus, the apprehension that patients with scleroderma have reduced peritoneal clearan­ces secondary to vasoconstriction may not be true and CAPD is perhaps an indicated moda­lity for this disease. However, since a rando­mized trial to compare various modalities appears non-feasible, the ideal form of renal replacement in such cases remains a subject of debate.

 
   References Top

1.Gibney EM, Parikh CR, Jani A, Fischer MJ, Collier D, Wiseman AC. Kidney transplantation for systemic sclerosis improves survival and may modulate disease activity. Am J Transplant 2004;4(12):2027-31.  Back to cited text no. 1    
2.Robson M, Oreopoulos DG. Dialysis in sclero­derma. Ann Intern Med 1978;88(6):843.  Back to cited text no. 2    
3.Copley JB, Smith BJ. Continuous ambulatory peritoneal dialysis and scleroderma. Nephron 1985;40(3):353-6.  Back to cited text no. 3    

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Correspondence Address:
Ambar Khaira
Department of Nephrology, All India Institute of Medical Sciences Ansari Nagar, New Delhi 110029
India
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PMID: 19112233

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