Search

Sarcoidosis presenting as a liver disease is uncommon. Hepatic sarcoidosis was diagnosed in three male patients aged 80, 64 and 69 years. They all presented with aspecific symptoms such as weight loss. Further investigation revealed liver disease, and liver biopsies demonstrated the presence of non-caseating granulomas. However, non-caseating granulomas can be associated with a great number of disorders and are therefore not specific. Other causes were excluded before the diagnosis of hepatic sarcoidosis was established with reasonable certainty. The diagnosis was finally confirmed on the basis of medical history, laboratory tests and histology. Sarcoidosis presenting as symptomatic liver disease can be treated with corticosteroids and probably with ursodeoxycholic acid as well. These three patients were treated with corticosteroids. The first patient died a year later from a cerebral infarct, the second one after a few months from a (non-sarcoidotic) cerebral haemorrhage and the third one after eight years from hepatic failure.

Morbidity and mortality of heartfailure are decreasing because of improved medical treatment. The recompensation balance can however be very fragile, which is illustrated by three patients. A woman aged 73 and a man aged 62, both known with heart failure, became seriously ill after diarrhoea; examination revealed uraemia, hyperpotassaemia and raised digitalis levels. A man aged 72, also with heart failure and diarrhoea, developed sensory disorders in both feet. He, also, was found to suffer from renal insufficiency. All patients used an angiotensin converting enzyme inhibitor or an angiotensin-II-antagonist and an aldosterone receptor blocker as well. During the (innocent) intercurrent disease by which their intravascular volume diminished they developed a severe renal insufficiency which needed clinical, intensive treatment. After haemodialysis, all three recovered well. Renal function plays an essential role in the fragile treatment balance that exists in recompensated cardiac patients. The medication that is beneficial for the cardiac functioning may at the same time compromise the renal perfusion. Good monitoring and good instructions about what to do in case of intercurrent diseases are of vital importance in these patients.

In three patients, a man aged 34 with aids, a woman aged 67 with recurrent major dyspnoea and a woman aged 73 with chronic lymphatic leukaemia, examination revealed progressive dyspnoea while the chest X-rays showed infiltrative lesions in both lungs. In view of the inadequate response to the treatment administered, an open lung biopsy was performed, following which the diagnosis could be made. Adequate treatment was then started and followed by clinical recovery. It is not clear if open lung biopsy carries higher risks of mortality and morbidity than biopsy by means of flexible bronchoscopy. Open lung biopsy more often leads to a classifying diagnosis. For collection of endobronchial or transbronchial biopsy samples in ununderstood diffuse interstitial lung diseases, flexible bronchoscopy is the method of first choice. Open lung biopsy is a justified supplementary examination, at any rate in severely ill, immunocompromised patients who require adequate therapy without delay.

Hepatitis C virus (HCV) is an important cause of chronic hepatitis in dialysis patients. With regard to epidemiology, the time on haemodialysis, the (previous) use of intravenous drugs as well as the number of blood transfusions received are important risk factors. There are strong indications suggesting nosocomial transmission of HCV. Strict application of infection prevention procedures in haemodialysis units is mandatory to restrain spread of HCV infection. Preliminary results show equal efficacy of alpha-interferon in normalisation of serum transaminases in dialysis patients and in patients with normal kidney function. However, in both groups relapses occur often, despite induction of remission. Antiviral therapy (with interferon and ribavirin) is emerging as a valid option to induce HCV eradication in dialysis patients. Thereafter, transplantation may be considered.

Objective: To determine the number of surgical complications in patients treated with continuous ambulatory peritoneal dialysis (CAPD)., Design: Retrospective (1980-1989), partially prospective (1987-1989)., Setting: Rijnstate Hospital, Arnhem, the Netherlands., Method: In 1978 CAPD was introduced in the Netherlands. Since 1980 we have used this technique in our clinic. Over the period 1980-1989 we studied the number of surgical complications of CAPD and the loss of catheter caused by these complications. With these numbers the probability of having a functioning Tenckhoff double cuff catheter was calculated with the Kaplan-Meier method., Results: 101 patients (54 men (mean age 52.5 years), 47 women (mean age 49.6 years)) with terminal renal insufficiency were treated during the study period. 123 catheters were implanted of which 33 had to be removed afterwards. The probability of having a functioning catheter after one year was 85%, after two years 64% and after three years 53%. Peritonitis was the main cause of temporary or final loss of the catheter. The number of observed cases of peritonitis was 187., Conclusion: Methods to improve the survival of the catheter are prevention of peritonitis by using an appropriate system for the fluid exchanges, screening patients for the existence of diverticulosis before starting CAPD, and prevention of exit site and tunnel infections.

The experience gained with CAPD in a group of 101 patients with terminal renal failure and a subgroup of 19 patients with diabetes mellitus was analysed. The actuarial patient survival was 81% after two years and 50% after five years. The combined patient-technique survival after two years was 48.8%. The most important reasons for drop-out were transplantation (25%) and death (24%). Death was method-related in 4 patients and caused by peritonitis in 2 of them. More often peritonitis was the cause of morbidity and temporary interruption (10 x) or of permanent abandoning of the method (11 x ). The peritonitis frequency during the whole period of nine years was 1 : 11.3 months. Use of the Y-connector Twinbag system and a U.V.-light system reduced the incidence substantially. However, faecal peritonitis remains a dangerous situation which cannot be prevented in this way. The mortality in patients with diabetes mellitus is high but not method-related. The incidence of peritonitis is not significantly different from that among patients without diabetes mellitus.

Acute renal failure is a frequent complication at the Intensive Care Department. For this complication dialysis is often necessary. In our Intensive Care Department we have opted for continuous arteriovenous hemodiafiltration (CAVHD) as the treatment of first choice for patients with acute renal failure. We describe the results in 18 patients treated with CAVHD. In all patients an arterious and a venous catheter were placed, in most cases in the femoral artery and vein. A capillary hemofilter was placed between the catheters. In the filter a counterflow mechanism took place. All patients were successfully treated with CAVHD. Haemodynamic instability as an effect of the treatment did not appear. The fluid and electrolyte balance was perfectly under control. Renal function was recovered in 7 patients. Twelve patients died. The cause of death was never associated with the renal failure or with the CAVHD treatment.

A 53 year old patient in chronic dialysis underwent a left pneumonectomy for bronchial carcinoma. This was followed by a bronchopleural fistula. Despite the very poor condition of the patient closure of the fistula was obtained by means of a flap of the large omentum. This is a simple procedure easily tolerated by the patient and that could also be used in less complicated cases.