Peritoneal Sclerosis in a Patient on Long-term Continuous Ambulatory Peritoneal Dialysis (CAPD). : An Autopsy Case.

若年性ネフロン癆による慢性腎不全でCAPD (continuous ambulatory peritoneal dialysis)導入し, 6年6ヵ月後に死亡した20歳男性の1剖検例を報告した。CAPD導入数カ月後, 腹膜炎による除水能低下を起こしたが, 約5ヵ月後に回復した。CAPD導入1年5ヵ月以降重症な腹膜炎罹患により除水能低下状態が遷延したが, 次第に回復した。しかし, 体液貯留傾向のため, 3年2ヵ月後より高張透析液を使用し除水量の増加を得たが, 3年9ヵ月後に不可逆的な除水能低下状態となった。一方, クレアチニンの透析排液/血漿濃度比(D/P)から見た溶質除去能は, その約半年後まで保たれており, 血清クレアチニン値の上昇は軽度であった。剖検にて腹膜の線維性肥厚と高度の内腔狭窄を伴う動静脈硬化を認め, 腹膜硬化症と診断した。本例の腹膜硬化症は, 頻回の腹膜炎と高張透析液の使用が主な原因と考えられた。腹膜機能を長期に維持するためには, 腹膜炎の予防と高張透析液の使用を最小限にすることが重要と考えられた。A 20-year-old man, treated with continuous ambulatory peritoneal dialysis (CAPD) for 6.5 years because of-end-stage renal disease due to juvenile nephronophthysis, died of ultrafiltration failure, and the morphological examination of peritoneum was carried out at autopsy. Nine episodes of peritonitis developed, and ultrafiltration transiently decreased after each episodes. At 2 years after the start of CAPD, severe peritonitis occurred, and then his body weight and blood pressure gradually increased. At 4 years after the beginning of CAPD, when hyperosmotic dialysate was frequently used, ultrafiltration was irreversively deteriorated. On the other hand, creatinine dialysate/plasma ratio remained within normal limits for about several months, and the increase in the level of serum creatinine was very little. The peritoneum obtained at autopsy revealed marked fibrous thickening as well as the conspicuous luminal narrowing of arteries and veins due to intimal thickening. The development of peritoneal sclerosis seemed to be related with the frequency and severity of peritonitis and the use of hyperosmotic dialysate

Osmotic fragility and deformability of uninfected or <i>P. falciparum</i> infected red blood cells.

<p>Osmotic fragility of a population of ring-iRBCs with 49% parasitemia was slightly decreased (<b>A</b>). Ektacytometer analysis showed that trophozoite-iRBCs were totally rigid, while ring-iRBCs were moderately, but significantly less deformable than control RBCs (uRBCs or hRBCs) (<b>B</b>).</p

Geometry and functional alterations of uninfected or <i>P. falciparum</i> infected red blood cells.

<p>Analysis of uninfected (uRBCs or hRBCs) or infected (ring-iRBCs, age <9 hours; or trophozoite-iRBCs, age: 30 to 35 hours) cell dimension and morphology using ImageStream technology (<b>A–G</b>). Before acquisition, parasite nucleus was labeled with Hoechst 33342 (diluted 1∶1000; Invitrogen, Carlsbad, CA; LSR; BD Biosciences, San Jose, CA), allowing differentiation of infected from uninfected co-culture RBCs. For each population of <i>Pf</i>-iRBCs, more than 10000 images were collected and analyzed with ImageStream technology. Captured images of infected RBCs are displayed in (<b>A</b>). There is a shift toward lower values of the distribution of iRBC diameter, perimeter and projected surface area, which increases with parasite maturation (<b>B–D</b>). Ring-iRBCs display a more pronounced surface area loss than uninfected co-culture RBCs (uRBC), but smaller than trophozoite-iRBCs (<b>E</b>). Circularity morphology and/or aspect ratio of iRBCs were increased compared to healthy RBCs (hRBCs) (<b>F–G</b>). The surface area loss of <i>Pf</i>-iRBCs or uRBCs = [1– (mean values of projected surface area of iRBCs or uRBCs/mean values of projected surface area of hRBC)]*100.</p

Retention of ring-iRBCs in microsphilters is linked to surface area loss associated with increased sphericity.

<p>Retention of uRBCs or RBCs hosting ring (age <9 hours) or trophozoite (age: 30 to 35 hours) forms of <i>P. falciparum</i> in the microspheres (<b>A</b>) (mean of 4 independent experiments). Analysis with ImageStream technology of the circularity, aspect ratio (sphericity) and projected surface area of unfractionated (Usptream) or flow through (Downstream) ring-iRBCs from microspheres (<b>B–F</b>) (shown is a representative experiment out of 3). For each population of ring-iRBCs, more than 1000 images were collected and analyzed with ImageStream technology. Captured images of upstream and downstream ring-RBCs are displayed in (<b>B</b>). There is a shift toward normal values of morphological and dimension parameters of flow-through ring-iRBCs (<b>C–F</b>). Surface area loss of unfractionated (upstream) or flow through (downstream) ring-iRBCs (<b>F</b>) (n = 3 independent experiments). The surface area loss of upstream or downstream ring-iRBCs = [1– (mean values of projected surface area of upstream or downstream ring-iRBCs/mean values of projected surface area of hRBC)]*100.</p

Retention of LPC-treated RBCs in microsphilters increases with the degree of surface area loss and sphericity.

<p>Analysis of LPC-treated RBC projected surface area, diameter, aspect ratio and circularity using ImageStream technology (<b>A–D</b>) (shown is one representative experiment out of 4). For each population of RBCs (LPC-treated RBCs or untreated control), at least 10000 cells were collected and analyzed with ImageStream technology. There is a concentration-dependent shift toward lower values of the distribution of projected surface area (<b>A</b>) and diameter (<b>B</b>). Aspect ratio (<b>C</b>) and circularity (<b>D</b>) of LPC-treated RBCs increase with the degree of surface area loss. LPC treatment results in dose-dependent reduction of RBC deformability measured by Ektacytometer analysis (<b>E</b>) (one representative experiment out of 4). Linear regression fit of the correlation between surface area loss and the level of LPC-treated RBCs retention in the microspheres (<b>F</b>) (n = 4 independent experiments). The surface area loss of LPC-treated RBCs = [1– (mean values of projected surface area of LPC-treated RBCs/mean values of projected surface area of hRBC)]*100.</p