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the prognosis for nephrogenic ascites is very poor&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">Here we present the case of a 66 year-old patient with no toxic habits and a history of arterial hypertension&#44; atrial fibrillation&#44; stroke in the left middle cerebral artery with residual right hemiparesis&#44; aphasia&#44; and dysarthria along with acute myocardial infarction&#46; The patient started haemodialysis treatment in January 2005 due to renal failure secondary to post-streptococcal glomerulonephritis&#46; The patient sought treatment in November 2010 with a progressive increase of the abdominal perimeter&#44; with a physical examination indicative of ascites&#46; We performed an abdominal ultrasound and observed abundant fluid in the abdominal cavity and a possible lesion of the head&#47;body of the pancreas&#46; Under the suspicion of tumour-based ascites&#44; we decided to hospitalise the patient for analysis&#46; We removed 5 litres of serosanguineous fluid by paracentesis and sent samples for testing&#46; Given the cell counts &#40;Table 1&#41; and biochemical properties of the peritoneal fluid&#44; we ruled out the possibility of infection&#59; cultures also resulted sterile&#46; A histological analysis ruled out the possibility of malignant tumour cells&#46; We also confirmed negative serology tests for hepatitis C and B and HIV&#46; Blood analyses &#40;Table 2&#41; did not reveal any significant abnormalities&#46; We performed an abdominal axial computed tomography and magnetic resonance cholangiography&#44; in which we observed a slightly over-sized liver&#44; and the head of the pancreas was not visible&#46; We asked the gastrointestinal department to perform an endoscopy in order to confirm the existence of a lesion on the pancreas as well as to look for evidence of possible oesophageal varices that would indicate portal hypertension from cirrhosis&#44; in light of the liver disease demonstrated by the imaging tests&#46; However&#44; both conditions were ruled out and the patient was discharged&#46;</p><p class="elsevierStylePara">Over a 6-month period&#44; we administered 4 paracentesis sessions and sent samples for microbiological&#44; histological&#44; and laboratory analyses&#44; with no changes from the aforementioned results&#46; Considering the possibility of a cardiological origin for the ascites&#44; we performed an echocardiogram&#44; observing severe biventricular dysfunction with an ejection fraction of 22&#37; and degenerative mitral and aortic disease with no haemodynamic repercussions&#46; Despite a pathological echocardiogram&#44; the patient never showed signs of heart failure&#44; with no oedema or dyspnoea&#46; Since a serum albumin-ascites gradient greater than 1&#46;1 g&#47;dL is indicative of portal hypertension with a 97&#37; accuracy&#44; we performed 2 tests&#44; which resulted in values &#60;1&#46;1&#37; and ruled out both liver disease and heart failure&#46; Even so&#44; we continued screening for a liver disease&#44; ruling out viral&#44; alcoholic&#44; and other possible causes of an autoimmune liver disease&#46; We also ruled out infections and peritoneal carcinomatosis&#46;</p><p class="elsevierStylePara">Given the findings from numerous tests&#44; the diagnosis appears to be compatible with nephrogenic ascites&#46; Given the patient&#8217;s situation and inability for self-care&#44; peritoneal dialysis is not an option&#46; Kidney transplant is not an option either due to the associated comorbidities and the patient&#8217;s important bilateral iliac atherosclerosis&#46; As recommended by the gastrointestinal department&#44; evacuation paracentesis continues to be administered upon demand&#46; We intensified the dialysis treatment and added intra-dialysis parenteral nutrition&#44; with progressive improvements in the patient&#8217;s nutritional parameters and a complete disappearance of the ascites&#46; Currently the patient is asymptomatic&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the content of this article&#46;&#160;</p><p class="elsevierStylePara"><a href="grande&#47;11325&#95;16025&#95;30590&#95;en&#95;t1&#95;911325&#95;copy1&#46;jpg" class="elsevierStyleCrossRefs"><img src="11325_16025_30590_en_t1_911325_copy1.jpg" alt="Characteristics of the ascites fluid"></img></a></p><p class="elsevierStylePara">Table 1&#46; Characteristics of the ascites fluid</p><p class="elsevierStylePara"><a href="grande&#47;11325&#95;16025&#95;30591&#95;en&#95;t2&#95;11325&#46;jpg" class="elsevierStyleCrossRefs"><img src="11325_16025_30591_en_t2_11325.jpg" alt="Blood test results"></img></a></p><p class="elsevierStylePara">Table 2&#46; Blood test results</p>"
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Nephrogenic ascites: a thing of the past?
Ascitis nefrogénica: ¿una entidad del pasado?
Raquel Díaz-Manceboa, Rafael Sánchez-Villanuevaa, Elena González-Garcíaa, Marta Ossorio-Gonzáleza, Rafael Selgas-Gutiérreza
a Servicio de Nefrología, Hospital Universitario La Paz, Madrid,
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the prognosis for nephrogenic ascites is very poor&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">Here we present the case of a 66 year-old patient with no toxic habits and a history of arterial hypertension&#44; atrial fibrillation&#44; stroke in the left middle cerebral artery with residual right hemiparesis&#44; aphasia&#44; and dysarthria along with acute myocardial infarction&#46; The patient started haemodialysis treatment in January 2005 due to renal failure secondary to post-streptococcal glomerulonephritis&#46; The patient sought treatment in November 2010 with a progressive increase of the abdominal perimeter&#44; with a physical examination indicative of ascites&#46; We performed an abdominal ultrasound and observed abundant fluid in the abdominal cavity and a possible lesion of the head&#47;body of the pancreas&#46; Under the suspicion of tumour-based ascites&#44; we decided to hospitalise the patient for analysis&#46; We removed 5 litres of serosanguineous fluid by paracentesis and sent samples for testing&#46; Given the cell counts &#40;Table 1&#41; and biochemical properties of the peritoneal fluid&#44; we ruled out the possibility of infection&#59; cultures also resulted sterile&#46; A histological analysis ruled out the possibility of malignant tumour cells&#46; We also confirmed negative serology tests for hepatitis C and B and HIV&#46; Blood analyses &#40;Table 2&#41; did not reveal any significant abnormalities&#46; We performed an abdominal axial computed tomography and magnetic resonance cholangiography&#44; in which we observed a slightly over-sized liver&#44; and the head of the pancreas was not visible&#46; We asked the gastrointestinal department to perform an endoscopy in order to confirm the existence of a lesion on the pancreas as well as to look for evidence of possible oesophageal varices that would indicate portal hypertension from cirrhosis&#44; in light of the liver disease demonstrated by the imaging tests&#46; However&#44; both conditions were ruled out and the patient was discharged&#46;</p><p class="elsevierStylePara">Over a 6-month period&#44; we administered 4 paracentesis sessions and sent samples for microbiological&#44; histological&#44; and laboratory analyses&#44; with no changes from the aforementioned results&#46; Considering the possibility of a cardiological origin for the ascites&#44; we performed an echocardiogram&#44; observing severe biventricular dysfunction with an ejection fraction of 22&#37; and degenerative mitral and aortic disease with no haemodynamic repercussions&#46; Despite a pathological echocardiogram&#44; the patient never showed signs of heart failure&#44; with no oedema or dyspnoea&#46; Since a serum albumin-ascites gradient greater than 1&#46;1 g&#47;dL is indicative of portal hypertension with a 97&#37; accuracy&#44; we performed 2 tests&#44; which resulted in values &#60;1&#46;1&#37; and ruled out both liver disease and heart failure&#46; Even so&#44; we continued screening for a liver disease&#44; ruling out viral&#44; alcoholic&#44; and other possible causes of an autoimmune liver disease&#46; We also ruled out infections and peritoneal carcinomatosis&#46;</p><p class="elsevierStylePara">Given the findings from numerous tests&#44; the diagnosis appears to be compatible with nephrogenic ascites&#46; Given the patient&#8217;s situation and inability for self-care&#44; peritoneal dialysis is not an option&#46; Kidney transplant is not an option either due to the associated comorbidities and the patient&#8217;s important bilateral iliac atherosclerosis&#46; As recommended by the gastrointestinal department&#44; evacuation paracentesis continues to be administered upon demand&#46; We intensified the dialysis treatment and added intra-dialysis parenteral nutrition&#44; with progressive improvements in the patient&#8217;s nutritional parameters and a complete disappearance of the ascites&#46; Currently the patient is asymptomatic&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the content of this article&#46;&#160;</p><p class="elsevierStylePara"><a href="grande&#47;11325&#95;16025&#95;30590&#95;en&#95;t1&#95;911325&#95;copy1&#46;jpg" class="elsevierStyleCrossRefs"><img src="11325_16025_30590_en_t1_911325_copy1.jpg" alt="Characteristics of the ascites fluid"></img></a></p><p class="elsevierStylePara">Table 1&#46; Characteristics of the ascites fluid</p><p class="elsevierStylePara"><a href="grande&#47;11325&#95;16025&#95;30591&#95;en&#95;t2&#95;11325&#46;jpg" class="elsevierStyleCrossRefs"><img src="11325_16025_30591_en_t2_11325.jpg" alt="Blood test results"></img></a></p><p class="elsevierStylePara">Table 2&#46; Blood test results</p>"
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