Acute pancreatitis during haemodialysis

Sir,

Acute pancreatitis tends to develop more frequently in patients with end-stage renal disease (ESRD) than in the general population, even in those managed by haemodialysis [1]. A case of acute pancreatitis in a patient on haemodialysis is presented herein to remind the nephrology community of this critical association.

This 74-year-old woman had been on haemodialysis treatment using cellulose dialyzers and heparin anticoagulation for the last 6 years due to ESRD as a consequence of diabetes mellitus and hypertension. She had no history of alcohol use. Medications included enalapril. While undergoing haemodialysis at a local hospital, blood pressure fell to 64/32 mmHg shortly after commencing the session and she complained of severe epigastralgia. Since serum amylase level was found to be significantly increased (1413 U/dl), she was transferred to our hospital. Laboratory findings on admission were as follows: lipase, 675 U/l; calcium, 8.4 mg/dl; and triglycerides, 89 mg/dl. Pancreatic isoamylase accounted for 96% of total serum amylase. Imaging studies revealed pancreatic enlargement with inflammatory exudates, and excluded the presence of biliary stones. The patient was managed conservatively under a diagnosis of severe acute pancreatitis. Her condition gradually improved and amylase levels on hospital day 36 were within normal range.

In the present case the angiotensin converting enzyme (ACE) inhibitor enalapril might have been one factor contributing to acute pancreatitis. ACE inhibitors are known to increase the generation of bradykinin, a vasoactive substance that induces angioedema, which in turn could cause pancreatic duct obstruction followed by enzyme leakage [2]. Bradykinin and subsequent nitric oxide release also could have been at least partially associated with hypotension during haemodialysis [3]. Hypotension together with underlying arteriosclerosis seen in many haemodialysis patients can induce mesenteric ischaemia represented by abdominal pain during the dialysis session, which has to be considered as another important risk factor for acute pancreatitis [1]. This is because reactive oxygen species such as superoxide released in the ischaemia/reperfusion process [4] can result in pancreatic damage [5].

In general, ESRD patients display multiple risk factors for acute pancreatitis, such as various medications or induced hypercalcaemia responsible for the activation of pancreatic enzymes [1]. Acute pancreatitis in ESRD patients must thus be considered as a multifactorial disease. Finally, whatever the precise pathophysiological mechanisms might have been in the present case, ischaemic events during the haemodialysis session appear to have triggered the process leading to acute pancreatitis in the light of the temporal course. Based on the present case, we would like to emphasize the need to avoid hypotension during the haemodialysis procedure. Removing as many potential risk factors as possible is also important, since acute pancreatitis tends to become life threatening in patients with ESRD [1].

Conflict of interest statement. None declared.

Tomonori Kishino1,2, Kazuhisa Nakamura2, Hideaki Mori2, Yoshikazu Yamaguchi2, Shin'ichi Takahashi2, Hitoshi Ishida2, Shozo Saito2 and Takashi Watanabe1

1 Department of Laboratory Medicine2 The Third Department of Internal Medicine Tokyo Japan Email: kishino{at}kyorin-u.ac.jp

References

  1. Pitchumoni CS, Arguello P, Agarwal N, Yoo J. Acute pancreatitis in chronic renal failure. Am J Gastroenterol 1996; 91: 2477–2482[ISI][Medline]
  2. Madsen JS, Jacobsen IA. Angiotensin converting enzyme inhibitor therapy and acute pancreatitis. Blood Press 1995; 4: 369–371[Medline]
  3. Coppo R, Amore A. Importance of the bradykinin-nitric oxide synthase system in the hypersensitivity reactions of chronic haemodialysis patients. Nephrol Dial Transplant 2000; 15: 1288–1290[Free Full Text]
  4. Ferdinandy P, Schulz R. Nitric oxide, superoxide, and peroxynitrite in myocardial ischaemia-reperfusion injury and preconditioning. Br J Pharmacol 2003; 138: 532–543[CrossRef][ISI][Medline]
  5. Sakorafas GH, Tsiotos GG, Sarr MG. Ischaemia/reperfusion-induced pancreatitis. Dig Surg 2000; 17: 3–14[CrossRef][ISI][Medline]




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