Kidney Week

Abstract: SA-PO967

Atypical Presentation of Acute Type A Aortic Dissection in a Peritoneal Dialysis Patient – A Case Report

Session Information

• Fellows/Residents Case Reports: ESRD: HD, PD, Transplant
  November 04, 2017 | Location: Hall H, Morial Convention Center
  Abstract Time: 10:00 AM - 10:00 AM

Category: Nephrology Education

• 1302 Fellows and Residents Case Reports

Authors

• Siddiqui, Waqas Javed, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States

Waqas Javed Siddiqui,

• Aslam, Muhammad, Dow University of Health Sciences, Karachi, Sindh, Pakistan

Muhammad Aslam,

• Bakar, Abu, Dow University of Health Sciences, Karachi, Sindh, Pakistan

Abu Bakar,

• Arif, Hasan, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States

Hasan Arif,

• Aggarwal, Sandeep, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States

Sandeep Aggarwal,

• Kelepouris, Ellie, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States

Ellie Kelepouris,

Background

Clinical presentation in dialysis patients if often atypical. A commonly encountered clinical sign of dyspnea in dialysis patients is often secondary to fluid overload, but this generalization can often times lead to delay in diagnosis of important underlying causes. We present a case of acute aortic dissection (AoD) in a peritoneal dialysis (CCPD) patient with dyspnea refractory to fluid removal as the only presenting clinical symptom.

Methods

53 year old man with a history of HIV, ESRD on CCPD awaiting renal transplant, hypertension, cardiomyopathy and recent culture negative peritonitis presented with 3 days of exertional dyspnea and orthopnea. He is compliant with his CCPD exchanges and medications, having recently started Furosemide 40 mg orally for better volume control. His vitals at presentation were: BP = 140/80 mmHg, heart rate = 100/minute (min), temperature = 98.0 ^oF orally, respiratory rate = 18/min and O₂ saturation on room air = 98%. His EKG showed prolonged QTc = 530 milliseconds. Remaining EKG and blood workup were unremarkable. Chest x-ray revealed mild congestion. The patient was misdiagnosed with fluid overload likely due to CCPD failure. Later he desaturated to 90% on room air requiring high flow O₂ at 6L/min. He was transferred to MICU and started on PD for 4 hours with Dianeal 4.25% solution resulting in net ultrafiltration of 1.2L. His SBP peaked at 158 mmHg. Next morning on cardiac auscultation, loud III/IV diastolic murmur was heard at a left parasternal border. Urgent echo and CT chest with contrast confirmed severe aortic regurgitation with Type-A AoD. An emergent surgical repair was done. Post operatively he received Continuous Veno-venous Hemodialysis, later on, transitioned to intermittent hemodialysis and subsequently discharged.

Conclusion

Acute AoD is a rare but potentially life-threatening vascular catastrophe with a high associated mortality. This case reminds us that dialysis patients can have an atypical presentation of acute AoD and should be considered if a patient is not improving with conventional treatment. Patients at risk of acute AoD include patients with T2DM, advanced age, atherosclerosis, high BUN, connective tissue diseases and uncontrolled hypertension.