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European Journal of Radiology 72 (2009) 306–313

Contents lists available at ScienceDirect

European Journal of Radiology

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pectrum of abdominal pathologies detected withT in long term dialysis patients

sra Meltem Kayahan Ulu a,∗, N. Cagla Tarhan a, Elif Hocaoglu b, Beril Akman c,eyla Basaran a, Fuldem Yildirim Donmez a, Emin Alp Niron a

Baskent University Faculty of Medicine, Department of Radiology, Fevzi Cakmak cad. No.: 45, Bahcelievler/Ankara, TurkeyBakirkoy Dr Sadi Konuk Training and Research Hospital, Department of Radiology, Zuhurat Baba mah, Bakirkoy/Istanbul, TurkeyDepartment of Nephrology, Fevzi Cakmak cad. No.: 45, Bahcelievler/Ankara, Turkey

r t i c l e i n f o a b s t r a c t

rticle history:eceived 11 June 2008ccepted 4 July 2008

eywords:

As a consequence of the expanded use of long term hemodialysis and continuous ambulatory peritonealdialysis (CAPD) treatments and extended life spans, complications of end-stage renal disease and dialysistreatments are being encountered with increasing frequency in these patients. Computed tomographycan accurately depict many of the potential complications of end-stage renal disease on dialysis. Thisarticle presents the abdominal CT findings of 429 end-stage renal disease patients who are on either

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. Introduction

The number of patients with end-stage renal disease whoequire dialytic treatment is rising. Two major treatment modal-ties, hemodialysis and continuous ambulatory peritoneal dialysisCAPD) along with renal transplantation, have improved the prog-osis for these patients. However as a consequence of the expandedse of long term hemodialysis and continuous ambulatory peri-oneal dialysis treatments and extended life spans, complications ofnd-stage renal disease and dialysis treatments are being encoun-ered with increasing frequency in these patients [1]. It is importanto know the frequency of these complications and to diagnosehem rapidly to minimize morbidity and to increase the life qual-ty. Computed tomography (CT) is becoming more widely used forhe diagnosis of complications in patients with end-stage renal dis-ase on dialysis. In this study, we retrospectively documented thebdominal CT findings of 429 end-stage renal disease patients whore on either hemodialysis or continuous ambulatory peritonealialysis treatment.

. Materials and methods

Four-hundred-twenty-nine dialysis patients (263 men, 166oman; age range 7–92 years, mean age 46 years) who under-ent abdominal CT examination within a 6-year period were

∗ Corresponding author. Tel.: +90 3122126868; fax: +90 3122237333.E-mail address: emkayahanulu@yahoo.com (E.M.K. Ulu).

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720-048X/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved.oi:10.1016/j.ejrad.2008.07.005

bulatory peritoneal dialysis treatment.© 2008 Elsevier Ireland Ltd. All rights reserved.

ncluded in the study. Among all patients, 352 were on hemodial-sis treatment 3 times per week or 2 times per week, and 77 ofhem were on CAPD treatment. With the complaints of abdominalain, tenderness, nausea and/or vomiting, 429 patients under-ent 635 abdominal CT examination. Sixty patients had rejected

enal transplants and returned to dialysis. All CT studies were per-ormed using either Somatom Plus 4S scanner or Volume Zoomcanner (Siemens, Erlangen, Germany). Helical scanning was car-ied out in all patients. Pre- and post-contrast portal-phase CTmages of 5- or 8 mm slice thickness were obtained in all cases.rterial- and late venous-phase images were obtained as needed.ne hundred and fifty mililiters of non-ionic contrast materialere injected in all subjects. The CT findings were retrospectivelyocumented using Microsoft Access program and grouped accord-

ng to different organ systems. The organs or systems that werevaluated were liver, biliary system, kidneys, pancreas, spleen andastrointestinal system. We also evaluated the helical CT imagesor presence of vascular pathologies, loculated fluid collections,eritonitis, hematoma, malignancy, and hernias of abdominal wall.he frequency of findings were documented for each organ systemnd for each pathology within all patients. CT findings were thenompared with laboratory, clinical or pathological findings of theatients when available for confirmation.

. Results

Most common pathologies detected were renal pathologies with8%. The frequencies of the other organ pathologies in order were as

E.M.K. Ulu et al. / European Journal of Radiology 72 (2009) 306–313 307

Table 1The frequencies of all organ pathologies

Organs Total number (%) CAPD number (%) HD number (%)

Kidney 250 (58.2) 43 (55.8) 207 (58.8)Liver 199 (46.3) 32 (41.5) 167 (47.4)Spleen 127 (29.6) 23 (29.8) 104 (29.5)Biliary system 79 (18.4) 14 (18.2) 65 (18.5)Stomach and intestines 62 (14.4) 19 (23.3) 44 (12.5)PM

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APD: continous ambulatory peritoneal dialysis, HD: hemodialysis.

ollows: liver 46%, spleen 30%, biliary system 18%, gastrointestinalystem 15% and pancreas 6%. The frequencies of all organ patholo-ies are shown in Table 1.

When we considered renal pathologies, most common one wascquired simple renal cyst formation named as Acquired Cystic Dis-ase of Kidney (ACDK) in 162 patients (37.8%). The cysts varied inize from 1 mm to 2 cm most ranging in diameter from 1 mm to0 mm. They are mostly observed at the corticomedullary junc-ion. Other pathologies were renal stones (12.1%), polycystic kidneyisease (3.7%), complicated cysts (3.5%), and renal cell carcinoma1.2%). With CT imaging, renal stones were detected on precon-rast images. Fifteen patients had complicated cysts either infectedr hemorrhagic. Infected cysts had wall thickening and enhance-ent with helical CT. Hemorrhagic cysts were seen as hyperdenseasses on precontrast images. Sixteen patients had polycystic kid-

ey disease (3.7%) (Fig. 1) Thirteen of them also had liver cysts (81%)nd 2 of them pancreatic cysts (12.5%). Five patients had renal cellarcinoma (1.2%) that developed after dialysis treatment (Fig. 2).ean dialysis period of renal cell carcinoma patients was 6 years

between 10 months to 10 years). All the masses were confined tohe kidney with no involvement of perirenal soft tissues and onlyne had bilateral adrenal metastasis at the time of diagnosis. Allhe patients had nephrectomy and had been followed for 3–4 yearsith no new lesion.

Liver pathologies were detected in 199 patients (46.4%). Mostommon liver pathologies were hepatomegaly (22.1%), calcifica-ions (10.3%), simple cysts (7.2%), and fatty liver (3.3%). Otheretected pathologies of the liver were hydatid cysts (1.2%), com-

licated cysts (0.5%), metastasis to liver (0.5%), amyloidosis (0.5%),bscess formation (0.5%), infarction (0.5%) and hemosiderosis0.5%). On CT imaging in two patients there were calcifications ateriphery of the liver that had a lacy pattern (Figs. 3 and 4). In

ig. 1. Axial CT image shows multiple cysts in both kidneys in the patient with poly-ystic kidney disease on hemodialysis. There was also a cyst in the liver parenchyma.

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ig. 2. Postcontrast axial image shows a contrast enhancing mass measuring 3 cmn the lower pole of right kidney in the patient on hemodialysis. The biopsy showedenal cell carcinoma.

ne of these patients, the amount of calcification was increasedn the follow-up CT imaging. These two patients were diagnosed

ith amyloidosis based on biopsy findings. In two patients multipleypodense nodular lesions with peripheral contrast enhancementere diagnosed as abscess formation. In one patient with multipleodular calcifications, liver biopsy revealed granulomatous hepati-is.

In spleen most common pathologies were splenomegaly (21%),alcifications (4.4%), and infarction (2.6%). In one patient withultiple splenic calcifications on CT imaging, renal biopsy demon-

trated amyloidosis (Fig. 5). In one patient with tuberculosis, thereere multiple hypodense granulomas in spleen.

Most common biliary system pathologies were cholelithiasis7.9%), and gall bladder sludge (1.9%). There were two patientsho had acute abdominal symptoms that was diagnosed with

holecystitis (0.5%). One of them developed perforation after theholecystitis attack. In 27 patients (6.3%), there were dilatations ofntrahepatic bile ducts and/or common bile duct. Cholangitis waseen in one of them. In eight of the patients, benign stricture ofommon bile duct were present and sphincterotomy was madey ERCP to three of them. In 3 of these 27 patients, cholecystec-omy operation had been performed. In other 16 patients the causef dilatations of biliary system were unknown and thought to beelated to infectious pathologies.

Thirty-two patients have regional (11 patients) or diffuse (21atients) intestinal wall thickening. 11 patients with regional wallhickening had pathological investigation. 3 of them were diag-osed as amyloidosis. There were jejunal and esophageal wallhickening in one of them and colonic wall thickening in two ofhem. In the other 8 patients which were diagnosed as regional col-tis, wall thickening mostly involved the right colon and transverseolon. In one patient rectum involvement was present. The etiologyf diffuse wall thickening that were not examined pathologicallyas thought to be related to edema, enteritis, and adhesions that

ause ischemia clinically (Fig. 6). In nineteen patients (4.4%) thereere small bowel dilatations diagnosed as ileus. We diagnosed

ighteen of them as partial or complete mechanical ileus secondaryo adhesions, all of which had previous intraabdominal operations.o other causative pathology with helical CT could be detected in

hese patients. In one patient internal herniation was detected thataused the ileus. Perforation of bowel was diagnosed in 5 patients

1.2%) with helical CT by demonstration of free air or contrast leak-ge into the peritoneum. In four patients with perforation, it wasroved surgically (Fig. 7). The other patient also had perforationndings on helical CT but the patient had died before surgery.

308 E.M.K. Ulu et al. / European Journal of Radiology 72 (2009) 306–313

Figs. 3 and 4. Axial CT images shows lacy type calcifications in the liver parenchyma in the patients on hemodialysis. The biopsy was consistent with amyloidosis.

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Fig. 5. Precontrast CT image shows calcifications in splee

As we encountered pancreas pathologies, the most commonathology was pancreatitis (2.1%), 6 of them being acute and 3f them chronic. In two hemodialysis patients, findings were con-istent with acute necrotizing pancreatitis. In two CAPD patients,

ig. 6. Postcontrast portal phase CT image shows diffuse ileal wall thickening relatedo the edema in the patient on hemodialysis.

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encyhma in the patients on hemodialysis (amyloidosis).

ancreatitis had occurred after several peritonitis attacks. In all ofhese individuals, serum amylase was high (over 500 IU/L (normalange 30–100 IU/L). Three patients who had pancreatic atrophy,

ultiple calcifications, pseudocyst formation and bile duct dilata-ion on helical CT exams were diagnosed as chronic pancreatitisFig. 8). Pancreatic tumor was detected in one patient (0.2%) withhe pathology of serous cystadenoma.

Patients with acute abdominal symptoms with helical CT find-ngs of peritoneal thickening and enhancement were diagnosed

ith peritonitis. There were 24 patients (5.6%) with peritonitis (20APD and 4 hemodialysis patients) (Fig. 9).

Loculated fluid collections within the peritoneum or retroperi-oneal space was detected in 31 patients (7.2%). In five of theseatients loculated collections was evaluated as infected collec-ions due to wall enhancement and septal thickening and theseatients also had findings of peritonitis secondary to peritonealialysis. In four patients loculated fluids were hyperdense onrecontrast CT images consistent with hemorrhagic collections.

nfected and hemorrhagic collections were all proved by needle

spiration. In 9 patients who had recurrent attacks of peritonitis,hese loculated fluids were the late sequela of peritonitis attacksFig. 9).

Spontaneous hemorrhage had developed in 5 patients (1.2%)hereas iatrogenic hematomas were detected in 17 (4%) patients.

E.M.K. Ulu et al. / European Journal of Radiology 72 (2009) 306–313 309

Fig. 7. Pre- and postcontrast axial CT images shows fluid-contrast level and free air in the intraabdominal fluid in the patient with ileal perforation. In addition peritonealthickening and enhancement were noticed. Ileal segments were conglomerated centrally and the wall of ileal segments was diffusely thickened.

Fig. 8. Postcontrast portal phase image shows multiple pseudocyst formations in the gastrosplenic ligament, perisplenic and periduodenal region, bursa omentalis minor inthe patients with chronic pancreatitis.

310 E.M.K. Ulu et al. / European Journal of Radiology 72 (2009) 306–313

Fig. 9. Postcontrast CT image shows perihepatic loculated fluid collections containing multiple septations and diffuse peritoneal thickening due to peritonitis in the patienton CAPD.

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ig. 10. Pre- and postcontrast CT image shows multiloculated hyperdense hematoemodialysis.

n 3 patients, spontaneous renal hemorrhage was detected withinhe renal parenchyma (Fig. 10) and in one patient it was present atplenic hilus. Another patient had spontaneous hematoma of psoasuscle. All of the spontaneous hemorrhages occurred in hemodial-

sis patients. In four patients, hematomas had developed afteriopsies of kidney, liver or adrenal gland. All of these patients werelso on hemodialysis treatment. In thirteen patients hematomasad developed after intraabdominal operations. Only two of them

ere on CAPD treatment.

Most common vascular pathologies were premature atheroscle-otic changes of abdominal aorta and iliac arteries (45.9%), andascular congestion (6.3%). Atherosclerotic changes were moreommon than the normal population and occurred at earlier ages

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ig. 11. Pre- and postcontrast CT image shows diffuse splenic artery calcifications relatedn hemodialysis.

the posterior part of kidney, displacing it anterior and laterally in the patient on

n patients on dialysis (Fig. 11). All patients with vascular conges-ion were on hemodialysis treatment. Thrombus of main vesselsas detected in 10 patients (2.3%).

31 dialysis patients had various hernias (7.2%). Five of them weremblical, 14 of them inguinal, 7 of them abdominal wall herniasFig. 12) and 5 of them were incisional hernias that developed afterbdominal operations.

The malignancies that were detected on these patients were;

enal cell carcinoma (1.2%), bladder carcinoma (0.5%), gastric car-inoma (0.2%), breast carcinoma (0.2%), ovarian carcinoma (0.2%),astleman’s disease (0.2%), sinus histiocytosis (0.2%), jejunal lym-homa (0.2%), prostat carcinoma (0.2%), and retroperitoneal malignesencymal tumor (0.2%). Increased frequency was found only in

to premature atherosclerosis in the 31-year-old woman with chronic renal failure

E.M.K. Ulu et al. / European Journal of Radiology 72 (2009) 306–313 311

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Fig. 12. Pre- and postcontrast CT image shows abdominal hernia

enal cell carcinoma compared to normal population and all of themere on hemodialysis treatment as mentioned above.

. Discussion

Dialysis is a life-saving treatment for ESRD patients. In hemodial-sis, the patient’s blood is passed through a tube to a semipermeableembrane (dialyser) that filters out waste products. The cleansed

lood is then returned back to the body. The procedure is monitoredy a machine, which also provides the dialysis fluid, mixing it fromconcentrate and water. In peritoneal dialysis, a special solution is

un through a tube into the peritoneal cavity, the abdominal bodyavity around the intestine, where the peritoneal membrane actss a semi-permeable membrane. The fluid is left there for a while tobsorb waste products, and then removed through the tube [2,3].oth treatment options have complications that are mainly relatedo the renal failure itself or related to long term dialysis treatments4–18]. It is very important for the clinician to know about potentialomplications for evaluation of these patients. This article covers aide spectrum of abdominal pathologies detected with CT in ESRD

atients on hemodialysis or peritoneal dialysis.In this study the most common pathologies detected in decreas-

ng order were atherosclerosis of the main vessels (45.9%), ACDK37.8%), hepatomegaly (22.1%), splenomegaly (21%), renal stones12.1%), calcifications of liver (10.3%), hernias (7.9%), intestinal wallhickening (7.5%), simple cysts of the liver (7.2%), loculated fluid col-ections (7.2%), vascular congestion (6.3%), peritonitis (5.6%), andematomas (5.1%). As we looked to acute pathologies detected

n our study; they were peritonitis (5.6%), hematoma (5.1%), ileus4.4%), and pancreatitis (2.1%). These pathologies must be thoughtn the differential diagnosis of acute abdominal pain in dialysisatients. Incidence of intestinal perforation was also found to beigh (1.2%).

In our study atherosclerosis was the most common pathology andhe frequency of it was 45.9%. Patients who have developed chronicenal failure usually have extensive and early atherosclerosis as aesult of diabetes mellitus, hyperlipidemia, and hypertension. Car-iovascular diseases were one of the most common cause of death

n these patients [19]. Hyperosmolar solutions which contain glu-ose used for peritoneal dialysis can cause obesity, hyperglycemia,nd hyperinsulinemia. This glucose load may cause atherosclerosis.n addition to them in literature it was reported that intraperitonealnsulin in peritoneal dialysis patients may cause fat depositionnder hepatic capsul that exposed to peritoneal cavity [11].

The second common pathology in our study was ACDK (37.8%).hronic renal failure is the key to the development of ACDK thategins even before the initiation of dialysis. According to Ishikawat al. a prolonged period of dialysis increases the incidence of ACDK.ransplantation causes regression of ACDKs. ACDK is important dis-

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right side. Right renal cysts and left nephrolithiasis were noted.

ase because it can cause bleeding, tumor (renal adenoma andidney cancer), üreteral stone, and renal abscess formation. Grossematuria may be seen if bleeding in the cystic wall has com-unication with the renal pelvis. In his patient group on dialysis,

shikawa found frequency of acquired cystic disease, benign tumor,nd renal cell carcinoma 47.1%, 4.8%, and 1.5%, respectively [20].licklich found the frequency of renal cell carcinoma as 1.3% inatients with acquired cystic kidney disease [21]. In our study the

requency of renal cell carcinoma was 1.4%, and the finding was con-istent with Glicklich’s and Ishikawa’s study. In our study RCC wasnly seen in hemodialysis patients and better conservation of theunctions of immune system in peritoneal dialysis patients maye cause of it. In addition in peritoneal dialysis patients the renal

unctions are partially protected and this finding can protect theidney. The cause of renal cell carcinoma in hemodialysis patientsas unknown but the relationship of multiple cysts and tumor for-ation was known before [22]. Dialysis treatment supply excretion

f waste products in kidney but the biologically active productshat could not be excreted by dialysis effectively can cause cellularroliferation. In patients with transplanted kidneys, the tumors ofhe urinary tract are the second most frequent, immediately afterhose of the skin. 10 renal tumors found in native kidneys of 1375atients with who had transplanted kidneys functioning for morehan 1 year [23]. Moudouni et al. reported that of the 373 patientsith renal transplant recipient, 12 tumors of the native kidneyere diagnosed in 10 individuals [24]. In our study none of theatients with renal transplants had renal call carcinoma. The meaneriod of dialysis treatment was 6 years (4–9 years) in hemodial-sis patients and the patients may be more prone to malignancyn this time period. Radiological surveillance for CRF patients haveeen advocated.

One of the common CT finding was hepatomegaly (22.1%), andplenomegaly (21%), that can be related to chronic disease itselfr other inflammatory or infectious causes. The other commonathology was renal stones (12.1%). The incidence of renal stones inatients on dialysis, while lower in number compared to the gen-ral population because of decreased renal function, is nonethelessclinical dilemma. In literature it is estimated that between 5 and

3% of all dialysis patients will develop symptomatic renal calculind many more asymptomatic calculi [25].

Hernias (7.9%) and loculated fluid collections (7.2%) are one ofhe most common complications of dialysis especially peritonealialysis. As a general rule increased intraabdominal pressure facil-

tates the occurrence of hernia in patients on CAPD. In literaturehe incidence of hernia reported is 10–25% and the most frequently

ncountered hernias are umblical, inguinal and incisional. Smallernias have risk of bowel incarceration. But large hernias do notarry a great risk but may have some risk of bowel incarcerationn some patients. Therefore hernias of any size should be repairedurgically [11–15]. It is difficult to distinguish an intraperitoneal loc-

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12 E.M.K. Ulu et al. / European Jour

lated fluid collection from residual dialysate fluid by conventionalT in CAPD patient. As an imaging technique, CT peritoneogra-hy has some advantages over conventional CT examination. It isapable of detecting the intraperitoneal loculated fluid collections,eritoneal adhesions, hernias and dialysate leakages which mayause the symptoms. The mixture of contrast agent and dialysateuid encircles the loculated fluid in CT peritoneography and allows

t to be readily recognised [16].In our study the most common acute pathology was peritonitis

hich is the most common complication of CAPD; in 26% of theAPD patients, there were peritonitis as a CT finding. When weheck the clinical and labarotory findings, we have found that CTnding of peritonitis is 100% sensitive. In all of the patients WBC100 in dialysis fluid and all of them clinically has peritonitis orad several peritonitis attacks before. In four hemodialysis patientshere is spontaneous bacterial peritonitis which was very rare1.1%). If we look to infectious agent which causes peritonitis mostommon organisms were staph. aureus, staph. epidermidis andandida albicans. There was no patient with sclerosing peritonitishich is diagnosed by diffuse peritoneal thickening, calcifications

nd intestinal obstruction and it is frequently fatal [12].Anticoagulation with heparin sodium is a routine procedure

or hemodialysis. So hemorrhagic complications are common inemodialysis patients. In our study all of the spontaneous hemor-hages occurred in hemodialysis patients and it is thought be dueo anticoagulation. In one patient spontaneous hematoma is seenn retroperitoneal region. In 2 patients spontaneous intraparency-

al renal hemorrhage was seen. One patient is diagnosed as renalracture. In one patient spontaneous hematoma in splenic hilus wasetected. In four patients there was iatrogenic hematomas becausef biopsies of kidney, liver or adrenal gland. All of these patientsere also hemodialysis patients. In thirteen patients hematomaas seen in intraabdominal region after an operation. Except

or two all of them was hemodialysis patients. Milutinovic etl. reported six patients developed spontaneous retroperitonealleeding while on maintenance dialysis. At the time of the bleed-

ng episode, four patients were receiving Coumadin for preventionf recurrent clotting problems in external shunts [26]. Moore andujubo reported that ACDK is one of the cause of retroperitonealemorrhages [27] and all of the patients in our study with hemor-hagic complications found to have ACDK. Most conditions calledidiopathic retroperitoneal hemorrhage’ in hemodialysis patientsre caused by rupture of ACDK into the retroperitoneal space.

In nineteen patients there were small bowel dilatations (% 4.4)iagnosed as ileus. No other causative pathology with helical CTould be detected in these patients except one patient with internalerniation that caused the ileus. The ileus is expected finding inialysis patients due to recurrent peritonitis attacks and abdominalperations.

There are many pancreatic disorders in uremic patients; pan-reatitis, fibrosis, fatty infiltration or hemosiderosis. Patients onialysis present an increased incidence of acute pancreatitis, whenompared with the general population. At present there is no clearxplanation for the increased incidence of pancreatitis in patientsn dialysis, although secondary hyperparathyroidism, acceler-ted atherosclerosis, hyperlipidemia and hypercalcemia have beenlaimed to play a role. The low pH and high glucose concentrationf dialysis solutions, the presence of infectious peritonitis, leak-ge of infected peritoneal fluid via the epiploic foreman into theesser sac, or hematogenous spread of bacteria from the infected

eritoneum into the peripancreatic area have been suggested toe predisposing factors for patients on PD. In the study by Rutskyt al. 2.3% of a wide population on dialysis presented acute pan-reatitis during a period of 10 years [29]. In our series incidencef acute pancreatitis is found as 2.1% and has similar frequency

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Radiology 72 (2009) 306–313

f Rutsky’s study. The clinical presentation of acute pancreatitisn the uremic patients is usually typical, but the patient on CAPD

ay pose diagnostic dilemma. Because the clinical presentation ofancreatitis may be very similar to that of peritonitis and both enti-ies frequently coexist. In addition although serum amylase andipase levels are usually elevated, there is a considerable overlap

ith values observed in uremic patients without pancreatits, mak-ng these biochemical markers of pancreatitis useful only whenhey are markedly abnormal [28–30]. Acute necrotising pancreatitis,he dreaded complications of acute pancreatitis carries mortalityate of up to 60% in both hemodialysed and peritoneally dialysedatients [31]. Therefore the diagnosis of acute pancreatitis muste made quickly in order that supportive treatment be started inhe hope that mortality rates will fall. CT is more useful than USn evaluating patients suspected of having acute pancreatitis. CTetter surveys entire retroperitoneum which may be involved in

ulminant pancreatitis. Normal CT examination does not excludehe diagnosis of acute pancreatitis.

The intestinal perforation is life-dreaded complication in dialy-is patients. Perforation was present in 5 patients. CT imaging oferforation is that air in the intestinal wall, pneumoperitoneum,uid level in peritoeal cavity, damage of mucosa of intestinal wall.

n 2 peritoneal dialysis patients perforation was in small intestinesone in duodenum and jejunum, one in ileum) and occurred aftereveral peritonitis attacks and thought to be related to pressureecrosis of catheter. Two patients with intestinal perforation (one

n duodenum, one in right colon) were hemodialysis patients. Inhese patients colon necrosis and rupture may be due to ischemiaecondary to hypotension attacks during hemodialysis and it isnown that right colon is more prone to it [7]. Even short peri-ds of hypotension during dialysis have been shown to lead toasoconstriction and ischaemia. In addition in our study as weooked to intestinal wall thickening pathologically diagnosed asolitis, is most common in right colon (7 patient on hemodial-sis). This supports the theory of ischemia. Less collateral flownd lack of vasa recta at this localisation may cause sensitiv-ty of this region to nonocclusion ischemia and hemodynamichanges [8,9].

The incidence of amyloidosis in ESRD patients has been grad-ally increasing presumably due to the longer life expectancy ofatients with chronic renal diseases and dialysis itself. Dialysiselated-amyloidosis (DRA) occurs in patients on hemo- or peri-oneal dialysis as a result of accumulation of polymers of b-2

icroglobulin. Interestingly, the risk of developing amyloidosis isot strongly correlated with the serum �-2 microglobulin level,ut may be related to the dialysis membrane used. �-2 M amyloid

s cleared more easily from peritoneal membrane when comparedo hemodialysis membrane and peritoneal membrane does notause stimulation of immune system [11]. Diagnostic radiologistshould be familiar with the diverse imaging findings of this dis-ase and in the proper clinical setting should include it in theifferential diagnosis. In both primary and secondary amyloidosis,he most commonly involved organ system is the gastrointesti-al system, with the colon being the most frequently involvedrgan. Esophageal and gastric involvement usually manifests asysmotility, wall thickening, and gastroesophageal reflux disease.hen the small intestine is involved, the most common finding

s diffuse or nodular wall thickening. In general radiologic signsf liver involvement of amyloidosis are nonspecific. Diffuse infil-ration is the rule, which causes decreased attenuation at CT and

epatomegaly. Splenomegaly is the only finding associated withplenic involvement. This causes increased fragility, and sponta-eous rupture can ensue with life-threatening consequences [32].

n our study there was six patients on hemodialysis treatment withrgan involvement pathologically diagnosed as amyloidosis. Inter-

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stingly, in our study there was lineer lace like calcifications in livern two of these patients and it was not defined in the literatureefore. In our study the imaging findings of amyloidosis of spleenas similar to imaging findings of amyloidosis in liver. There wereultiple calcifications in spleen in one patient on hemodialysis.

n addition three patients with intestinal amyloidosis was also onemodialysis treatments. There were jejunal and esophageal wallhickening in one of them and colonic wall thickening in two ofhem.

In literature there were many reports about relationshipetween malignancy and end-stage renal disease. It was found thathere is increased incidence of hepatocellular carcinoma, renal car-inoma, thyroid carcinoma, myeloma and non-Hodgkin lymphoman end-stage renal disease patients on dialysis [33]. In literature it

as found that renal transplantation and significant immunosu-ression increase the risk of non-Hodgkin lymphoma [34,35]. Inur study the most significant finding was increased incidence ofenal cell carcinoma in hemodialysis patients.

In conclusion we demonstrate for the first time that in ESRDatients on dialysis, there are a wide spectrum of complicationsetected with CT. Uremia and type of dialysis treatment can beelated with some of these complications and CT is preferred imag-ng modality detecting many pathologies fast and effectively inhese patients.

eferences

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[2] Greenwood RN, Farrington K, Tattersall J. Hemodialysis: mechanisms, out-come, and adequacy. In: Johnson RJ, Feehally J, editors. Comprehensive clinicalnephrology, vol. 78. Mosby; 2000. p. 1–12.

[3] Coles GA, Williams JD. Peritoneal dialysis: principles, techniques and adequacy.In: Johnson RJ, Feehally J, editors. Comprehensive clinical nephrology, vol. 80.Mosby; 2000 (p. 1–8).

[4] Jaber BL, Pereira BJ. Acute complications of hemodialysis. In: Johnson RJ, Fee-hally J, editors. Comprehensive clinical nephrology, vol. 79. Mosby; 2000 (p.1–10).

[5] Tielemans CL, Collart FE, Hooghe L, Dratwa M. Renal hematoma in a patientundergoing hemodialysis. Arch Intern Med 1983;143:1623–5.

[6] Levine E, Grantham JJ, MacDougall ML. Spontaneous subcapsular and per-inephric hemorrhage in end-stage kidney disease. AJR Am J Roentgenol1987;148:755–8.

[7] Norden MA, Rabb H. Two hemodialysis patients with unclear abdominal symp-toms of similar origin. Nephrol Dial Transplant 2001;16:2426–8.

[8] Flobert C, Cellier C, Berger A, et al. Right colonic involvement is associated withsevere forms of ischemic colit and occurs frequently in patients with chronic

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