We present the case of a 52-year-old woman, known in our unit since 2008 and who has given informed consent to carry out this work.
As antecedent of interest, he only highlights that he was operated on from teratoma in 1988 with double ooferectomy, which is where a purging behavior begins due to fear of infection in obese after surgical intervention.
No hypertension or diabetes mellitus.
In September 2006, she was referred to the Nephrology Department from the Primary Care clinic due to the presence of high levels of urea and creatinine in a routine analytical, leading to the diagnosis of acute kidney injury secondary to vomiting of chronic renal failure.
In addition, during admission, it is seen by the Psychiatry Department that confirms the diagnosis of nerve palsy.
At this time her weight at admission is 39.5 kg with a height of 167 cm (Body Mass Index: 14.16) and at discharge is 44 kg.
Renal biopsy was performed in February 2007 and chronic renal failure secondary to interstitial nephropathy secondary to hypokalemia due to recurrent vomiting was confirmed.
Since then, it has been monitored on an outpatient basis and in April 2008 a peritoneal catheter was placed to start the renal replacement therapy of choice.
Start home therapy in continuous ambulatory peritoneal dialysis in May (performs three daily exchanges with a volume of 2000 ml, two diurnal glucose 1.5% and nocturnal glucose 2.3%), and so is maintained with peritoneal dialysis volume of 75 minutes.
During this time, in September 2008 parathyroidectomy for severe hyperparathyroidism was performed.
In August 2009 she was admitted due to to tonic-clonic seizure in the context of metabolic alkalosis and once she got discharged home without weight gain from Psiquiatría, where she remained two months control.
During this admission, celiac disease is also diagnosed with severe vesicular disease and high titers of anti-transglutaminase, once a diet without glúten normalized the antibodies, although vomiting became normal.
In January 2010 a surgical repair of left inguinal hernia was performed that required peritoneal rest of a month during which he performed hemodialysis through a temporary catheter.
A normal gastrointestinal transit was performed in May of this year.
In November 2010, peritoneal catheter was replaced after four episodes of peritonitis and suspected bacterial biofilm.
It remains stable in the technique and in July 2012 suffered a peritonitis due to Staphylococcus epidermis with several relapses despite performing sealing with urokinase and retraining.
In April 2013, antibiotic prophylaxis with trimethoprim was initiated with subsequent antibiotic prophylaxis and nonmetoxazole 160mg/800mg daily. No new sealing was performed, this time with taurolidine (2 times a week for 4 weeks).
In December 2013, a capsulendoscopic study was performed without pathological findings.
In July 2014 at the Unit of Mental Disorders, the patient was admitted with a severe emergency burnout syndrome with feelings subtype of loss of control over his situation and fear of dying in the chronic context of restrictive eating disorder.
May not induce vomiting but have frequent vomiting and spontaneous gastroesophageal reflux.
Parenteral feeding weight of 34 kg and poor oral tolerance began with nutritional support and weight gain was achieved up to 38 kg.The diagnostic tests ruled out digestive pathology justifying vomiting and began treatment with sulfonylureas
In addition, if the intra-abdominal pressure generated by the dialysis technique influences the genesis of vomiting, it is temporarily suspended and hemodialysis is performed once the peritoneal catheter is not re-introduced, the patient is maintained.
Finally, in September, during the same admission, the gammagraphy with gastric emptying showed alteration of gastric motility with an intense response, leading to a Unit of gastrointestinal motility disorders of another hospital, due to lack of a good diagnosis.
At discharge in October she weighed 48.3 kg (Body Mass Index:17.32), treatment with cinitapride was prescribed, with little response, after vomiting and constipation persisted.
She was admitted to Nephrology in December 2014 (8 days) and January 2015 (11 days) again due to vomiting, gastric intolerance and severe metabolic alkalosis.
Three days after discharge, the patient was readmitted for the same reasons and weighed 36 kg, 5 kg less than the last hospital discharge.
In February 2015 a permanent catheter was placed for hemodialysis and the dialysis modality was definitively changed following the recommendations of the referral center that considers peritoneal dialysis absolute contraindication for placement and subsequent operation of the gastric stimulator in March 2015, which is considered the best alternative.
The weight at this time is around 43Kg.
During the time that the guidelines are maintained in Peritoneal Dialysis, the adequacy and life parameters are within the recommendations of the guidelines, a KTV of about 1.9 to the last 36-q albumin solution of 1.2dl and a serum test of 1000ml.
Currently, he remains on hemodialysis with good tolerance to the technique, without residual diuresis, with a dry weight of 36 kg and an interdialytic gain of less than one kg (estimated at a weight of 1.6 T. seco).
Three weekly sessions of 240 minutes duration and on-line HDF technique were performed.
The same self-rated health test had the worst ratings.
The stimulator has a correct functioning, but gastric symptoms persist.
