A 59-year-old man was admitted because of anorexia and massive ascites. He had received peritoneal dialysis for chronic renal failure for 4 years, undergone cadaveric kidney transplantation 18 years earlier, and had been withdrawn from peritoneal dialysis. He had received immunosuppressive agents, such as tacrolimus, azathioprine, and prednisolone. The transplanted kidney was functioning well. For about 10 years after kidney transplantation, the general condition, including renal function, was stable, but the renal function gradually worsened over a period of 3 years before admission. On admission, the serum creatinine level was high, at 8.2 mg/dL. There were massive ascites, and a mass of 10 cm in diameter was observed in the abdominal wall. The abdomen was distended. He vomited repeatedly and was unable to eat. He was diagnosed with paralytic ileus, intubated with a nasogastric tube, and allowed to eat nothing by mouth. A central venous catheter was inserted, and a high-calorie infusion was administered for systemic management of the condition. The ascitic fluid was found to be transudative, its culture was negative for bacteria, and its cytology was negative for malignant cells. Blood tumor markers were measured: CEA was slightly elevated to 12.6 ng/mL (normal, <=5.0 ng/mL), and CA19-9 was 34.2 U/mL (normal, <=37.0 U/mL). Abdominal CT showed massive ascites and a cystic mass in the abdominal wall behind the navel (Figure 1). The cystic mass had a slightly inhomogeneous density and did not communicate with the peritoneal cavity. Contrast-enhanced abdominal CT, performed to determine the underlying cause of the ileus, revealed multiple small-bowel strictures probably due to adhesions and compression. Due to the development of uremic symptoms, an internal shunt was constructed, and hemodialysis was started on the 21st hospital day. Hemodialysis induced a decrease in the ascitic fluid volume but did not diminish the size of the abdominal wall mass (Figure 2). On the 52nd hospital day, hemodialysis was stable, and the patient recovered to the extent that he could eat; therefore, he was discharged. He was scheduled for elective resection of the abdominal wall cystic mass.
After hospital discharge, he received maintenance dialysis three times weekly, and his course on hemodialysis was uneventful. Three months after discharge, he visited the emergency room because of chest pain. He was in cardiopulmonary arrest on arrival, and resuscitation maneuvers were performed. His heartbeat was temporarily restored; however, 3 days later, he developed cardiopulmonary arrest again and was confirmed dead. An autopsy was performed.