"Pseudo-empty pelvis" in a pre-dialysis patient.

Abstract

While peritoneal integrity is crucially important for peritoneal dialysis (PD) patients, there are various pathological conditions which induce peritoneal dysfunction. Here we present a case of a non-dialysis chronic kidney disease patient with asymptomatic peritoneal sclerosis which was diagnosed during laparoscopic screening at the placement of a PD catheter. A 57-year-old woman with end-stage kidney disease was admitted for the placement of a PD catheter. Fifteen years prior to admission, she was diagnosed with acute lymphocytic leukemia (ALL) for which she had been treated with chemotherapy and an unrelated bone marrow transplant. Although ALL had been in remission, she developed enterocolitis with slight ascites as a consequence of chronic graft-versus-host disease (GVHD); subsequently, her renal function gradually deteriorated. Three years after the transplantation, she experienced acute appendicitis with a local abscess, which was treated nonsurgically by antibiotics. She had no history of diabetes mellitus, autoimmune diseases, intraperitoneal malignancies, abdominal surgery, or tuberculosis. She had been prescribed carvedilol for heart failure for the previous 10 years. At admission, she was afebrile and had no complaints of nausea, hypophagia, or abdominal pain. Her physical examination was unremarkable. Her serum C-reactive protein level was within the normal range. Ultrasonography and computed tomography (CT) scans showed no evidence of ascites, peritoneal calcification, air-fluid levels, or intestinal wall thickening (Figure 1(a)). However, intraoperative laparoscopy revealed collagenous connective tissues bridged between the liver and the parietal peritoneum (Figure 1(b)). Furthermore, a diffuse cocoon-like thickening of the peritoneum completely covered up the small bowel loops, ovary, uterus, and rectum. As a consequence, the pelvic cavity appeared to be empty (“pseudo-empty pelvis”) (Figure 1(c)). We diagnosed this patient with simple peritoneal sclerosis, but not encapsulating peritoneal sclerosis (EPS), given that the diagnosis of EPS requires a constellation of clinical symptoms with some evidence of inflammation. Based on the laparoscopic Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan Department of Inter-Organ Communication Research in Kidney Disease, Osaka University Graduate School of Medicine, Suita, Osaka, Japan Department of Internal Medicine, Kisei Hospital, Osaka, Japan