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A Hemodialysis Patient with Excruciating Back Pain

A 61 year old woman was admitted to another hospital in November 1994 because of renal failure. She had a history of type I1 diabetes mellitus and hypertension for more than 15 years. The patient had been in her usual state of health until three weeks prior to admission, when she noted increasing abdominal girth, dyspnea on exertion, and paroxysmal nocturnal dyspnea. The admission blood urea nitrogen (BUN) was 46 mg/dL and the serum creatinine (Cr) 4.6 mg/dL. After diuresis, the discharge BUN was 103 mg/dL and the Cr 5.8 mg/dL. It was recommended that permanent vascular access be placed, but she did not permit it. In December 1994 she presented to the Duke University Medical Center with uremic symptoms. A temporary subclavian hemodialysis catheter and a left upper arm polytetrafluoroethylene graft were placed, and maintenance hemodialysis was initiated with an uncomplicated hospital course. In late January 1995, a perigraft hematoma developed, necessitating placement of a temporary right internal jugular hemodialysis catheter which was changed to a subclavian catheter one week later. Unfortunately new attempts to recannulate the graft proved difficult, resulting in numerous perigraft hematomas. Consequently, another temporary hemodialysis catheter was placed in March 1995 and ultimately removed in early April 1995. Thereafter, the synthetic graft was cannulated successfully. In early April 1995, several days after removal of the temporary hemodialysis catheter, the patient presented to the emergency room with excruciating back pain. A radiograph of the lumbar spine demonstrated slight loss of height of the L4 vertebral body, mild degenerative disc disease, and generalized facet osteoarthritic changes. It was concluded that she had osteoarthritis of the lum-