LETTER TO THE EDITOR
Year : 2009 | Volume
: 20 | Issue : 1 | Page : 130--131
Continuous ambulatory peritoneal dialysis in a patient with scleroderma
Ambar Khaira, Om P Rathi, Sanjay Gupta, Sanjay K Agarwal
Department of Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
Department of Nephrology, All India Institute of Medical Sciences Ansari Nagar, New Delhi 110029
|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;20:130-131
|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 2021 Jan 19 ];20:130-131
Available from: https://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.  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.  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.  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. 
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.  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.
|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.|
|2||Robson M, Oreopoulos DG. Dialysis in scleroderma. Ann Intern Med 1978;88(6):843.|
|3||Copley JB, Smith BJ. Continuous ambulatory peritoneal dialysis and scleroderma. Nephron 1985;40(3):353-6.|