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P0415 STRESSORS AND COPING STRATEGIES IN HEMODIALYSIS PATIENTS
S140
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
output, hiperkaliemic renal tubular acidosis, and hypertension are frequently present. Renal ultrosonography is the test of choice to exclude UTO. Objectives: We asses two cases of unusual presentation of UTO in Internal medicine. Case 1: 59-years old woman with no history of medical or surgycal interest. She consult for a history of several months of asthenia. Laboratoy test reveled elevation in creatinine of 1,55 mg/dL. Complementary images thecniques (abdominal ultrasonigraphy) showed dilatation of the collecting system, cause of de obstruction was not shown. Several days after, the pacient was admitid to the hospital due to a diarrea (3-4 semiliquid stools a day) and progressive symtons of astenia, anorexia and fatigue. Basic laboratory examination showed increase in creatinine. Phisycal examination showed a pelvic organ prolapse.A vaginal pessary was set and renal disease was solved. Diagnosis was urinary tract obstruction due to pelvic organ prolapse. Case 2: 21-years-old men with history of urinary tract infections.He was admited to the hospital due to a history of one month of fever on the range fo 38 to 39°C and urinary incontinence. An abdominal ultrasonography was made and it displayed dilatation of urinary bladder. We decided setting a urynary catheter but it was impossible so that a suprapubic catheterization had to be made. Diagnosis was recurrent urinary tract infections and urethral stenosis solved with a suprapubic catheterization. Discussion & conclusion: Early diagnosis of UTO is important since most cases can be corrected and a delay in therapy can lead to irreversible renal injury. In some cases ecography demostrates hydronefrosis without evident obstruction.Bening prostatic hiperplasia is the most common cause of the urinary tract obstruction but there are nother unfrequent causes (as the ones we show) that must be taken in to account when evaluating urinary tract obstruction.
P0414 TYPE 2 CRYOGLOBUNEMIA COMPLICATED WITH PULMONARY HEAMORHAGE
Arvind Ponnusamy, Ricardo J Jose, Jyothi Kondlapudi, David Lewis, Puchimada Uthappa. Salford Royal Foundation Trust, Salford, United Kingdom 60 year lady was transferred from the local hospital with the history acute kidney injury and purpuric looking lesion. According to the patient, the skin lesion were present for over 6 months. On presentation she was in acute renal failure and there were numerous vasculitic lesion all around the body. Investigation revealed creatinine 417mmol/l.The skin lesion was biopsied and it showed leukocytoclastic vasculitis. Immunological investigation showed low C4 and C3,positive rheumatoid factor, Ig M Kappa paraprotein. In view of this immunology, cryoglobulin was sent. Cryoglobulin Type 2 was identified. Hepatitis B and C was negative.Renal function continued to deteriorate and she required dialysis. She was given cyclophosphomide and steroids. One day later, she developed heamoptysis and bilateral fluffy shadows in chest x-ray consistent with pulmonary haemorrhage and She was started on plasma exchange. She failed to maintained oxygen saturation despite being noninvasive positive pressure ventilation.She subsequently transferred to Intensive Care Unit and was attached to mechanical ventilation. She was then put on heamofilter.Despite receiving plasma exchange, she continued to deteriorate and died. Discussion: Pulmonary involvement in cryoglobulinemia usually is mild.We present a rare case of pulmonary haemorrhage associated with cryoglobulinemia.Pulmonary harmorrhage was diagnosed based on clinical symptoms,CXR finding and presence of blood while intubating the patient.No evidence base for treatment of Cryoglobulinemia.Plasma exchange,cyclophosphomide and steroid was given to based on ANCA positive vasculitus protocol.
P0413 DIALYSIS DEPENDENT REFACTORY SYSTEMIC POLYARTERITIS NODOSA
Arvind Ponnusamy, Ricardo J Jose, Jyothi Kondlapudi, Aladdin Shurrab, Janet Hegarty. Salford Royal Foundation NHS Trust Introduction: Polyarteritis Nodosa (PAN) is a rare systemic vasculitis which involves mainly medium-sized muscular arteries and can affect several organs. The kidneys are the most commonly involved organs but it very rarely results in dialysis dependence. Case presentation: A 59-year-old Caucasian female presented to hospital with a two month history of feeling unwell with fatigue, weakness and ankle swelling. Initially she was found to have a high CRP of 146 and at presentation her serum creatinine was 50 mmol/l and 10 days later was 298mmol/l. At the same time she developed a right-sided foot drop and nerve conduction studies showed the presence of a generalised sensory-motor polyneuropathy with significant inter and intra limb asymmetry noted in the upper limbs consistent with mononeuritis multiplex. The renal dysfunction continued to deteriorate and within a week the creatinine had reached 429mmol/l and the patient was referred to our hospital for haemodialysis. On presentation she had purpuric vasculitic looking lesions on her right forearm, marked peripheral oedema, cranial nerves were normal but the right-sided foot drop was evident.Serologic test for hepatitis B & C were negative. Immunology tests for myeloperoxidade and proteinase 3 were negative. Renal biopsy was performed and demonstrated fibrinoid necrosis and necrotic vessel wall consistent with a wall of pseudoaneurysm in classical polyarteritis nodosa. The patient was pulsed with intravenous methylprednisolone and intravenous cyclophosphomide (2 doses) and then changed to oral prednisolone 35mg/day and oral cyclophosphomide 100mg/day. Despite treatment and the patient looking clinically better there was no improvement in the inflammatory markers. She then had two episodes of chest pain. Electrocardiogram showed T-wave inversion in lead III and the serum troponin was raised. She was treated as an acute coronary syndrome but this was thought to be due to coronary arteritis. The patient was unfortunately too unwell to have an angiogram. She also developed rectal bleeding (melaena). Colonoscopy and oesophageal-gastroduodenoscopy did not find a source for the bleeding and she underwent a CT angiogram and no bleeding point was identified. The bleeding thought to be from gastrointestinal vasculitis appeared to stop spontaneously after a few days and immunosuppressive treatment. Unfortunately,she then developed neutropaenic gram-negative sepsis and clostridium difficle toxin related diarrhoea and deceased. Conclusions: This case demonstrates the severity of PAN and the poor outcome associated with this condition. This patient was dialysis dependent and despite heavy immunosuppresion she continued to have extra-renal manifestations. Few randomised controlled trials exist on the management of systemic polyarteritis nodosa and a greater evidence base is needed
P0415 STRESSORS AND COPING STRATEGIES IN HEMODIALYSIS PATIENTS
Sezgi Çınar, Gül Ünsal Barlas, Jule Ecevit Alpar. Marmara Üniversitesi Objectives: The aim of the study was to determine relationships among treatment-related stressors and coping strategies of chronic hemodialysis patients. Methods (see table, p. S141) The sample of this study consisted of 224 participants. Data was collected with Hemodialysis Stressors Scale and Carver Coping Scale and analysed by using the linear multiple regression analysis. Results: The most frequent stressors reported were: limitation of vacation (80.4%), followed by fatigue (79.9%) and uncertainty about future (79.0%). The most frequently used coping strategies were turning to religion, active coping and suppression of competing activities. Physical treatment-related stressors were significantly related to behavioural disengagement. Conclusions: This article is shown that the most frequently used coping strategy is “turning to religion” by hemodialysis patients as different from previous studies. The Turkish view the belief as the basic and most important unit of human life so the belief of affects coping in our country as different from the Western Country. Key words: Coping Strategies, Hemodialysis, Stressors
P0416 NEPHROTIC SYNDROME AS THE FIRST MANIFESTATION OF FAMILIAL MEDITERRANEAN FEVER
Irmak Sayin 1 , M. Alper Karaman 1 , A. Kemal O˘guz 1 , Ayla San 2 . 1 Ufuk University School of Medicine, Department of Internal Medicine; 2 Ufuk University School of Medicine, Department of Internal Medicine, Division of Nephrology Introduction: Familial Mediterranean Fever (FMF) is characterized by recurrent explosive attacks of inflammation. Amyloidosis is the most significant potential complication of FMF, leading to nephrotic syndrome and end-stage renal disease (ESRD). Here we present a female patient who never had the classic symptoms of FMF, which usually precedes the renal complications. This case represents the Phenotype II of FMF, which characteristically presents with amyloidosis without prior classic attacks of FMF. Case report: A 52 year old woman was referred with unexplained nephrotic syndrome. Physical examination on admission documented a stage 1 hypertension, mild pitting lower extremity edema, and a pale, waxy appearance. Complete blood count examination demonstrated normochromic normocytic
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
output, hiperkaliemic renal tubular acidosis, and hypertension are frequently present. Renal ultrosonography is the test of choice to exclude UTO. Objectives: We asses two cases of unusual presentation of UTO in Internal medicine. Case 1: 59-years old woman with no history of medical or surgycal interest. She consult for a history of several months of asthenia. Laboratoy test reveled elevation in creatinine of 1,55 mg/dL. Complementary images thecniques (abdominal ultrasonigraphy) showed dilatation of the collecting system, cause of de obstruction was not shown. Several days after, the pacient was admitid to the hospital due to a diarrea (3-4 semiliquid stools a day) and progressive symtons of astenia, anorexia and fatigue. Basic laboratory examination showed increase in creatinine. Phisycal examination showed a pelvic organ prolapse.A vaginal pessary was set and renal disease was solved. Diagnosis was urinary tract obstruction due to pelvic organ prolapse. Case 2: 21-years-old men with history of urinary tract infections.He was admited to the hospital due to a history of one month of fever on the range fo 38 to 39°C and urinary incontinence. An abdominal ultrasonography was made and it displayed dilatation of urinary bladder. We decided setting a urynary catheter but it was impossible so that a suprapubic catheterization had to be made. Diagnosis was recurrent urinary tract infections and urethral stenosis solved with a suprapubic catheterization. Discussion & conclusion: Early diagnosis of UTO is important since most cases can be corrected and a delay in therapy can lead to irreversible renal injury. In some cases ecography demostrates hydronefrosis without evident obstruction.Bening prostatic hiperplasia is the most common cause of the urinary tract obstruction but there are nother unfrequent causes (as the ones we show) that must be taken in to account when evaluating urinary tract obstruction.
P0414 TYPE 2 CRYOGLOBUNEMIA COMPLICATED WITH PULMONARY HEAMORHAGE
Arvind Ponnusamy, Ricardo J Jose, Jyothi Kondlapudi, David Lewis, Puchimada Uthappa. Salford Royal Foundation Trust, Salford, United Kingdom 60 year lady was transferred from the local hospital with the history acute kidney injury and purpuric looking lesion. According to the patient, the skin lesion were present for over 6 months. On presentation she was in acute renal failure and there were numerous vasculitic lesion all around the body. Investigation revealed creatinine 417mmol/l.The skin lesion was biopsied and it showed leukocytoclastic vasculitis. Immunological investigation showed low C4 and C3,positive rheumatoid factor, Ig M Kappa paraprotein. In view of this immunology, cryoglobulin was sent. Cryoglobulin Type 2 was identified. Hepatitis B and C was negative.Renal function continued to deteriorate and she required dialysis. She was given cyclophosphomide and steroids. One day later, she developed heamoptysis and bilateral fluffy shadows in chest x-ray consistent with pulmonary haemorrhage and She was started on plasma exchange. She failed to maintained oxygen saturation despite being noninvasive positive pressure ventilation.She subsequently transferred to Intensive Care Unit and was attached to mechanical ventilation. She was then put on heamofilter.Despite receiving plasma exchange, she continued to deteriorate and died. Discussion: Pulmonary involvement in cryoglobulinemia usually is mild.We present a rare case of pulmonary haemorrhage associated with cryoglobulinemia.Pulmonary harmorrhage was diagnosed based on clinical symptoms,CXR finding and presence of blood while intubating the patient.No evidence base for treatment of Cryoglobulinemia.Plasma exchange,cyclophosphomide and steroid was given to based on ANCA positive vasculitus protocol.
P0413 DIALYSIS DEPENDENT REFACTORY SYSTEMIC POLYARTERITIS NODOSA
Arvind Ponnusamy, Ricardo J Jose, Jyothi Kondlapudi, Aladdin Shurrab, Janet Hegarty. Salford Royal Foundation NHS Trust Introduction: Polyarteritis Nodosa (PAN) is a rare systemic vasculitis which involves mainly medium-sized muscular arteries and can affect several organs. The kidneys are the most commonly involved organs but it very rarely results in dialysis dependence. Case presentation: A 59-year-old Caucasian female presented to hospital with a two month history of feeling unwell with fatigue, weakness and ankle swelling. Initially she was found to have a high CRP of 146 and at presentation her serum creatinine was 50 mmol/l and 10 days later was 298mmol/l. At the same time she developed a right-sided foot drop and nerve conduction studies showed the presence of a generalised sensory-motor polyneuropathy with significant inter and intra limb asymmetry noted in the upper limbs consistent with mononeuritis multiplex. The renal dysfunction continued to deteriorate and within a week the creatinine had reached 429mmol/l and the patient was referred to our hospital for haemodialysis. On presentation she had purpuric vasculitic looking lesions on her right forearm, marked peripheral oedema, cranial nerves were normal but the right-sided foot drop was evident.Serologic test for hepatitis B & C were negative. Immunology tests for myeloperoxidade and proteinase 3 were negative. Renal biopsy was performed and demonstrated fibrinoid necrosis and necrotic vessel wall consistent with a wall of pseudoaneurysm in classical polyarteritis nodosa. The patient was pulsed with intravenous methylprednisolone and intravenous cyclophosphomide (2 doses) and then changed to oral prednisolone 35mg/day and oral cyclophosphomide 100mg/day. Despite treatment and the patient looking clinically better there was no improvement in the inflammatory markers. She then had two episodes of chest pain. Electrocardiogram showed T-wave inversion in lead III and the serum troponin was raised. She was treated as an acute coronary syndrome but this was thought to be due to coronary arteritis. The patient was unfortunately too unwell to have an angiogram. She also developed rectal bleeding (melaena). Colonoscopy and oesophageal-gastroduodenoscopy did not find a source for the bleeding and she underwent a CT angiogram and no bleeding point was identified. The bleeding thought to be from gastrointestinal vasculitis appeared to stop spontaneously after a few days and immunosuppressive treatment. Unfortunately,she then developed neutropaenic gram-negative sepsis and clostridium difficle toxin related diarrhoea and deceased. Conclusions: This case demonstrates the severity of PAN and the poor outcome associated with this condition. This patient was dialysis dependent and despite heavy immunosuppresion she continued to have extra-renal manifestations. Few randomised controlled trials exist on the management of systemic polyarteritis nodosa and a greater evidence base is needed
P0415 STRESSORS AND COPING STRATEGIES IN HEMODIALYSIS PATIENTS
Sezgi Çınar, Gül Ünsal Barlas, Jule Ecevit Alpar. Marmara Üniversitesi Objectives: The aim of the study was to determine relationships among treatment-related stressors and coping strategies of chronic hemodialysis patients. Methods (see table, p. S141) The sample of this study consisted of 224 participants. Data was collected with Hemodialysis Stressors Scale and Carver Coping Scale and analysed by using the linear multiple regression analysis. Results: The most frequent stressors reported were: limitation of vacation (80.4%), followed by fatigue (79.9%) and uncertainty about future (79.0%). The most frequently used coping strategies were turning to religion, active coping and suppression of competing activities. Physical treatment-related stressors were significantly related to behavioural disengagement. Conclusions: This article is shown that the most frequently used coping strategy is “turning to religion” by hemodialysis patients as different from previous studies. The Turkish view the belief as the basic and most important unit of human life so the belief of affects coping in our country as different from the Western Country. Key words: Coping Strategies, Hemodialysis, Stressors
P0416 NEPHROTIC SYNDROME AS THE FIRST MANIFESTATION OF FAMILIAL MEDITERRANEAN FEVER
Irmak Sayin 1 , M. Alper Karaman 1 , A. Kemal O˘guz 1 , Ayla San 2 . 1 Ufuk University School of Medicine, Department of Internal Medicine; 2 Ufuk University School of Medicine, Department of Internal Medicine, Division of Nephrology Introduction: Familial Mediterranean Fever (FMF) is characterized by recurrent explosive attacks of inflammation. Amyloidosis is the most significant potential complication of FMF, leading to nephrotic syndrome and end-stage renal disease (ESRD). Here we present a female patient who never had the classic symptoms of FMF, which usually precedes the renal complications. This case represents the Phenotype II of FMF, which characteristically presents with amyloidosis without prior classic attacks of FMF. Case report: A 52 year old woman was referred with unexplained nephrotic syndrome. Physical examination on admission documented a stage 1 hypertension, mild pitting lower extremity edema, and a pale, waxy appearance. Complete blood count examination demonstrated normochromic normocytic