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;() | Doi. 10.3265/Nefrologia.2009.29.5.5418.en.full
Genital oedema in peritoneal dialysis
Edema genital en diálisis peritoneal

Enviado a Revisar: 29 Oct. 2009 | Aceptado el: 29 Oct. 2009
Juan Santos Nores , Maria Paz Borrajo Prol , Olaia Conde Rivera , Cristina Pérez Melón
Servicio Nefrología. Complexo Hospitalario de Ourense . Ourense , Ourense (España)
Abstract
Dear Editor, Genital oedema is a relatively common complication in peritoneal haemodialysis. Different tests are used to diagnose the possible causes. We would like to present the case of an 80-year-old male patient with a history of colon cancer in 1995, monoclonal gammopathy of undetermined significance and chronic kidney disease of unknown origin, who began haemodialysis in 1999.
Resumen
Sr. Director: El edema genital es una complicación relativamente frecuente de la diálisis peritoneal, para el diagnóstico de las distintas posibles etiologías se han usado diferentes pruebas. Presentamos el caso de un varón de 80 años de edad con antecedentes personales de carcinoma de sigma in situ en 1995, gammapatía monoclonal de significado incierto e insuficiencia renal crónica de etiología desconocida que inicia programa de hemodiálisis en 1999.

Dear Editor,

Genital oedema is a relatively common complication in peritoneal haemodialysis. Different tests are used to diagnose the possible causes. We would like to present the case of an 80-year-old male patient with a history of colon cancer in 1995, monoclonal gammopathy of undetermined significance and chronic kidney disease of unknown origin, who began haemodialysis in 1999. After failing with several AV fistulas and being unable to create a new vascular access point, a permanent catheter was implanted in the right internal jugular vein in July 2004. In April 2009, an attempt was made to replace the permanent catheter but it was unsuccessful. Angiography of the vena cava revealed occlusion of the superior vena cava adjacent to the right auricle, with collateral circulation developing in the azygos vein.

Since vascular access for haemodialysis was impossible, a peritoneal catheter was implanted and the ventral hernia was repaired with mesh. This procedure was carried out by the Department of General Surgery and the removal of
some loose adhesions was performed at the same time.

Seven days after the insertion of the peritoneal catheter, dialysis was started with a cycler and low infusion volumes. Forty-eight hours after starting the technique a very significant bilateral oedema affecting the scrotum
and penis was observed.

Peritoneal dialysis was suspended for one week and the patient’s condition progressively improved until the oedema disappeared. During this period haemodialysis was carried out using a femoral catheter with no complications.

Peritoneal dialysis was attempted once more using a cycler and low volumes but the scrotal oedema reappeared after the first session.

In order to establish the cause of the oedema, iodinated contrast was administered through the peritoneal catheter (iobitridol 300mg/l), regular abdominal control x-rays were carried out afterwards. At first 25ml of contrast was administered and the presence of the contrast was observed in the abdominal cavity (figure 1). Another 25ml was administered five minutes later and an x-ray in with the patient in the standing position was carried out, which showed the flow of the contrast from the peritoneal cavity to the scrotum in relation to the persisting peritoneo-vaginal canal (figure 2).

Genital oedema is well documented in peritoneal dialysis patients.1 This phenomenon is associated with the flow of dialysis liquid from the abdominal cavity though inguinal hernias, a persisting peritoneo-vaginal canal, abdominal wall defects, etc.

The most commonly used method for diagnosis is a CT scan carried out after the infusion of two litres of dialysis
liquid that contains contrast.2,3 Another technique used is gammagraphy with Tc-99m.4,5

In the case of this patient, we have shown how a simple and easily accessible diagnostic procedure can help to identify the cause of genital oedema and establish the need for surgery.

Referencias Bibliográficas

BIBLIOGRAFIA

1.Davidson PG, Usal H, Fiorillo MA, Maniscalco A. The importance of peritoneal imaging in the workup of genital edema in patients on continuos ambulatory peritoneal dialysis. Mt Sinai J Med. 1999 Mar; 66(2):125-7.

2. Leblanc M, Ouimet D, Pichette V. Dialysate leaks in peritoneal dialysis. Semin Dial. 2001 Jan-Feb;14(1):50-4.

3.J. Litherland, E.W. Lupton, P.A. Ackrill, M.Venning and P. Sambrook. Computed tomographic peritoneography: CT manifestations in the investigation of leaks and abnormal collections in patients on CAPD. Nephrol Dial. Transplant (1994) 9: 1449-1452.

4.Bhattacharya A, Mittal BR. Peritoneo-scrotal communication: demonstration by 99mtechnetium sulphur colloid scintigraphy. Australas Radiol. 2005 Aug;49(4):335-7.

5. Tokmak H, Mudun A, Türkmen C, Sanli Y, Cantez S, Bozfakioglu S. The role of peritoneal scintigraphy in the detection of continuous ambulatory peritoneal dialysis complications. Ren Fail.2006;28(8):709-13.



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