An ethical discussion on a long-term peritoneal dialysis patient
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LESSONS FOR THE CLINICAL NEPHROLOGIST
An ethical discussion on a long‑term peritoneal dialysis patient Hironori Nakamura1 · Mariko Anayama1 · Yasushi Makino1 · Tomomi Sato2 · Masaki Nagasawa1 Received: 17 September 2020 / Accepted: 3 November 2020 © Italian Society of Nephrology 2020
The case
In 1991, when the patient was 29 years old, he reached endstage renal failure because of chronic glomerulonephritis; he refused hemodialysis (HD) treatment, but accepted continuous ambulatory peritoneal dialysis (CAPD). When CAPD was started, he weighed 55 kg and was 1.68 m tall. He was treated with a total of 8 L of 1.5% dextrose. In 1997, he was switched to three changes of 1.5% dextrose 2 L plus 2.5% dextrose 2 L. His general condition was stable until he underwent bilateral nephrectomy due to renal carcinoma in 1998. Approximately 8 years after PD initiation, he was transferred to HD three times per week for 6 months due to severe anemia. CAPD was then resumed in addition to once-weekly HD. He underwent surgery for a right femoral fracture 13 years after PD initiation, after which unroofing was performed due to tunnel infection. He developed severe hyperparathyroidism, with intact parathyroid hormone levels of > 1000 pg/mL; however, for 15 years he refused to undergo surgery for parathyroidectomy which was finally performed 25 years from PD initiation. He then switched to twice-weekly HD to shorten the length of the sessions due to upper extremity pain during HD; CAPD was maintained. He underwent bilateral carpal tunnel syndrome repair 26 and 27 years after PD initiation. Twenty-eight years after PD initiation, his height was 1.60 m and his dry weight was 55.9 kg. Anemia was controlled (hemoglobin, 10.9 g/dL) with darbepoetin 5 μg/ week. His body mass index was 19.6 kg/m2, serum albumin level 3.0 g/dL, total cholesterol level 175 mg/dL, and β2microglobrin level 21.4 mg/L. Over time, his peritoneal function remained consistent, as shown by the dialysate-to-plasma creatinine ratio (D/PCr) of 0.5–0.7. Accordingly, ultrafiltration volume was maintained at 800 mL/day. Bag exchanges were still being performed * Hironori Nakamura [email protected] 1
Department of Nephrology, Shinonoi General Hospital, 666‑1 Ai Shinonoi, Nagano 388‑8004, Japan
Dialysis Center, Shinonoi General Hospital, Nagano, Japan
2
with a manual connecting device (Luer lock type; Baxter, Deerfield, IL, USA) as had been the case since initiation of PD. Overall, the patient’s self-management with regard to body weight control, diet and water intake, was extremely strict but nonetheless excellent despite losing residual renal function at an early stage of PD. The patient had a strong desire to continue PD and, while PD was associated with hemodialysis sessions, he never considered fully transitioning to HD, despite frequent recommendations by his doctors and medical staff. The patient was not waitlisted for kidney transplantation.
Ethical discussion We describe a patient who underwent PD for more than 28 years owing to his strong preference
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