Clinical Analysis Of Two Cases Of Pulmonary Hemorrhage In Elderly Dialysis Patients With Systemic Vasculitis

Objective Through the retrospective analysis of the diversity and complexity of ANCA associated vasculitis with pulmonary hemorrhage in two elderly dialysis patients, providing reference and help for the clinical diagnosis and treatment of such complex cases.Methods We summarized the clinical data of2elderly patients with ANCA associated vasculitis with pulmonary hemorrhage, which were treated by blood purification center of Ji’nan Central Hospital from November2011to November2013. Introducing the clinical features, laboratory and imaging characteristics, treatment options and prognosis of this disease by combining the related literature at home and abroad.Results2cases were passed through a long and tortuous process in early diagnosis.2patients are elderly men, the first patients with chronic renal failure on regular hemodialysis treatment outside the hospital. After12months of regular hemodialysis, intermittent blood in phlegm and worsens occurs without obvious incentive.4days after admission, the patient with sudden massive hemoptysis,about800-1000ml, accompanied by respiratory failure. The second patient with unexplained fever onset. Outside the hospital with a diagnosis of "fever of unknown origin" and conducted a comprehensive inspection, but failed to clear reason.The symptoms slightly improved and discharged. A short period after discharge, the patient appeared perirenal hematoma and acute renal failure readmission, readmission treatment, but still not confirmed. To establish long-term vascular access for hemodialysis transferred to our hospital. After49days of symptomatic treatment, this patient with no incentive to sudden massive hemoptysis, about600ml. The first patient examination ANCA-MPO positive, ANCA-PR3negative. The second case ANCA-MPO negative, ANCA-PR3suspected positive. Two cases of patients with normal rheumatoid series. Anti glomerular basement membrane antibodies are negative. C-reactive protein, erythrocyte sedimentation rate increased.Lung CT showed interstitial disease. The renal biopsies by puncture is not done. The former because of long time of renal failure, the both kidneys have atrophied, the latter because of perinephric hematoma. The two patients received hemostasis, anti infective, phlegm and other general treatment, at the same time have given glucocorticoid and immunosuppressants and gamma globulin as induction therapy. Due to poor general condition of the patient, in the aspect of the selection of immunosuppressants, the two patients were given Tacrolimus Capsules (FK-506) and Mycophenolate Mofetil (MMF) orally.Both immunosuppressive side effects are relatively small.The short-term follow-up period were improved, pulmonary hemorrhage is controlled,ANCA negative. During maintenance therapy, the first patient had appeared right vitreous hemorrhage and pulmonary infection. More than5months after the treatment, this patient because of a sudden multifocal cerebral hemorrhage to death. The other case because of vasculitis relapse,lung infections and herpes zoster repeatedly hospitalized in seven months of maintenance therapy. Now the treatment program has been changed to low-dose of hormone plus cyclophosphamidemaintain regimen therapy six months, is currently in a stable condition.Conclusion Diagnosis and treatment of two patients can prompt us,the clinical manifestations of ANCA-associated vasculitis is complex,diverse and atypical. Since the elderly hemodialysis patients with more basic disease, low immunity, abnormal blood clotting mechanism, when they appear with the ANCA-associated vasculitis related symptoms can be misdiagnosis, delayed treatment easily. The elderly dialysis patients, when in the poor general condition. In order to avoid the routine use of the corticosteroids and cyclophosphamide therapy side effects caused by drugs,such as infection, a relatively low side effects of tacrolimus,mycophenolatemofetil,and gamma globulin combined hormone therapy and also achieved significant results in the induction of remission. Therefore,to improve the clinician ANCA-associated vasculitis,while understanding how to choose the right individualized treatment plan for the disease characteristics (especially the choice of new immunosuppressive agents) to reduce infection and mortality rates, and improve the prognosis is still the focus of future clinical studies.