Nephrol Dial Transplant Vol. 20 No. 1 © ERA-EDTA 2005; all rights reserved
Images in Nephrology
(Section Editor: G. H. Neild)
The early vascular ageing of long-term RRT patients: endoprosthetic repair of an aortic aneurysm in a young patient on RRT for over 20 years
1 Chair of Nephrology, Department of Internal Medicine, University of Torino, 2 Interventional Radiology, 3 Division of Vascular Surgery, Molinette Hospital and 4 II Department of Radiology, ASO ‘S. Giovanni Battista’ di Torino, Italy
Correspondence and offprint requests to: Giorgina Barbara Piccoli, Chair of Nephrology of the University of Torino, SCDU Nefrologia, Dialisi e Trapianto, Corso Bramante 88, 10126 Torino, Italy. Email: giorgina.piccoli{at}unito.it
Keywords: aortic aneurism; atherosclerosis; endoprothesis; daily haemodialysis; long-term RRT
The impressive calcifications seen in the computed tomography (CT) reconstruction of an aortic aneurysm of the abdominal aorta in Figure 1 belong to a 48-year-old male, on renal replacement therapy (RRT) from the age of 22. His end-stage renal disease was membrano-proliferative glomerulonephritis with severe and prolonged nephrotic syndrome. In 1981, 3 years after diagnosis, he started RRT on peritoneal dialysis; he was switched to haemodialysis in 1985 due to functional exhaustion of the peritoneum, and a cadaveric graft was performed in 1993. Haemodialysis was resumed in 1996 after graft failure due to recurrent membranous and proliferative glomerulonephritis, again with severe nephrotic syndrome. He had hypertension, usually well controlled by multiple drug therapy, parathyroidectomy because of severe hyperparathyroidism unresponsive to conservative treatment (1993) and a coronary by-pass (1997). The aortic aneurysm shown in Figure 1 was first diagnosed in 1991: at that time, the maximum diameter was 4.2 cm. The diameter was stable until March 2000, when it increased to 4.6 cm and further to 4.8 cm in November 2000, despite a daily haemodialysis schedule (started in 1999), minimizing weight loss per dialysis and with a good blood pressure control without need for drug therapy.
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Balancing the young age of the patient and the surgical risks due to the diffuse arterial calcifications typical of uraemic patients (Figure 2), a percutaneous endoluminal approach was chosen and successfully performed in January 2001, employing a modular bifurcated graft (an endoprosthetic graft composed of an aortic section and the iliac bifucation, with the first portion of the iliac vessels) (Figure 3).
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This case is emblematic of the precocious and severe vascular disease representing a major problem on long-term RRT and summarizes the multiple risk factors for subintimal calcifications (hyperparathyroidism, nephrotic syndrome, long RRT duration) [1–3]. The interest of this case is enhanced by the fact that it represents so far, according to a Medline and Embase search combining the terms of RRT and aortic aneurysm, the first long-term RRT patient described in the medical literature with an aortic aneurism treated by an endoprosthetic approach.
The patient is presently asymptomatic, normotensive, on daily haemodialysis in a Limited Care Dialysis Unit.
Conflict of interest statement. None declared.
References
- Lindner A, Charra B, Sherrard DJ, Scribner BH. Accelerated atherosclerosis in prolonged maintenance hemodialysis. N Engl J Med 1974; 29: 897
- Piccoli GB, Mezza E, Anania P et al. Patients on renal replacement therapy for 20 or more years: a clinical profile. Nephrol Dial Transplant 2002; 17: 1440–1449
[Abstract/Free Full Text] - Seelig MH, Oldenburg WA, Hakaim AG et al. Endovascular repair of abdominal aortic aneurysms: where do we stand? Mayo Clin Proc 1999; 74: 999–1010[Abstract]
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