Crohn's disease successfully treated with infliximab in a patient receiving hemodialysis: case report and review of the literature

Abstract

There is limited information in the use of antitumor necrosis factor α, infliximab, in patients on hemodialysis. In Crohn's disease (CD), only 3 cases are reported.A 76-year-old man on hemodialysis for renal failure caused by immunoglobulin A nephropathy developed diarrhea and abdominal pains. A marked edema was observed in the pretibia and ankle. An increase of C-reactive protein (CRP) and erythrocyte sedimentation rate, hypoalbuminemia, hypocholesterolemia, and moderate anemia was found. Ultrasonography and computed tomography (CT) found wall thickness in the left colon. Sigmoidoscopy revealed multiple ulcers in the sigmoid colon and noncaseating epithelioid granuloma was found in the biopsy specimen. Barium enema study exhibited collar button signs and longitudinal ulcers in the left colon.A severe form of CD was diagnosed. Metronidazole seemed to decrease CRP but was ineffective in ameliorating diarrhea. Infliximab rather than steroid hormone was chosen for the treatment. Standard induction therapy with infliximab was initiated. Symptoms rapidly improved then disappeared. CD activity index decreased from 747 to a remission level of 134 after 2 infusions of infliximab. Scheduled maintenance infliximab therapy was administered after the induction therapy. Ultrasonography and CT showed a disappearance of the wall thickness of the colon. Adverse reactions were not observed.Infliximab was effective and safe in a patient with CD on hemodialysis. Our case has added additional literature in accordance with previous reports supporting infliximab as effective and safe in patients on hemodialysis.

FIGURE 1

Clinical course. CRP (normal range ≤0.19 mg/dL); ESR (≤10 mm/h); fecal occult blood (<100 ng/mL); T chol (≥120 to ≤220 mg/dL). CDAI = Crohn’s disease activity index; CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; IFX = infliximab; T chol = total cholesterol.

FIGURE 2

Endoscopic pictures of sigmoidoscopy. Inflamed mucosa with (A) multiple irregular-shaped ulcers (arrow) and (B) punched-out ulcer (arrow) was observed in the sigmoid colon.

FIGURE 3

Radiograph of barium enema study. Clear collar button signs were observed in the (A) sigmoid colon (arrows) and the (B) descending colon (short arrows). Long fine arrows in (B) show calcification of the aorta.