ABSTRACT
Aims: To correct renal anemia, subcutaneous (SC) route of recombinant human erythropoietin (rhuEPO) administration has been associated with increased efficacy and decreased dose requirements, when compared with intravenous (IV) route. The effect of obesity as a potential modifier during rhuEPO administration has not been well explored. Study Design: Single-center, Longitudinal Cohort Study. Place and Duration of Study: University of Mississippi Medical Center Outpatient Dialysis Unit, between February and November of 2009. Methodology: We performed IV to SC rhuEPO conversion for 86 in-center dialysis patients and, following a six-month equilibration period, we monitored outcomes over a period of three months. We obtained baseline demographic parameters, calculated Body Mass Index (BMI) and monitored iron saturation, ferritin, hemoglobin (Hgb) along with rhuEPO requirements. Patients were divided into 3 categories based on BMI [<25 (n=27), 25-35 (n=38), >35 (n= 21) kg/m2]. Results are reported either as percents, means with SD or median with 25-75% interquartile range, as appropriate. Results: The cohort was all African-American, 48.8% male, aged 54.7 (13.3) years and BMI calculated at 29.9 (7.4) kg/m2. Baseline iron saturation was 24 (10.6)%, ferritin measured 641 (277) ng/mL. Hgb remained unchanged during the observation period: 11.1 (1.3) vs. 11.2 (1.3) gm/dL. Initial rhuEPO weekly dose for the entire cohort was 19,729 (17,448) Units/week (U/week); final dose 17,482 (14,860) U/week, with close correlation between initial and final doses (r: 0.653, P<0.0001). Weekly rhuEPO dose remained virtually unchanged in BMI categories 1 and 2 [13,927 (10,938) vs. 13,297 (10,247) U/week; 20,684 (15,788) vs. 20,997 (17.917)] (P=NS for both) but decreased in the category 3: 25,459 (24,403) vs. 16,444 (12,749) (P=0.081). However, BMI had no independent effect in linear regression modeling with multiple covariates (age, BMI, iron saturation, ferritin) included. Conclusion: Obesity may affect relative efficacy of rhuEPO conversion; additional studies may be needed.
ABSTRACT
We report the 1st case of severe, symptomatic hypocalcemia after denosumab (RANKL inhibitor) treatment in a peritoneal dialysis patient with secondary hyperparathyroidism and osteoporosis. A 58-year-old Caucasian female has been receiving chronic ambulatory peritoneal dialysis for four years secondary to polycystic kidney disease. Laboratory studies revealed: albumin-corrected calcium 9.0 mg/dL, phosphorus 5 mg/dL, alkaline phosphatase (ALP) 58 U/L [normal, 40-105], albumin 3.4 gm/dL [normal, 3.6-5.4] and intact parathyroid hormone (PTH) 315 pg/mL [normal, 40-72]. Marked osteoporosis was noted on the DXA scan, preventing her from renal transplantation considerations. She had failed conventional medical treatment, including per os calcium, monthly ergocalciferol (50,000 units/month), activated vitamin-D analog (doxercalciferol) and renal-failure adjusted alendronate (70 mg twice a month). She was started on subcutaneous denosumab 60 mg every 6 months. After her first dose, she developed a progressive drop of calcium, phosphorus, bicarbonate and magnesium, in spite of massive escalation of doxercalciferol and calcium supplementation. Hypocalcemia nadired at 6.3 mg/dL with symptomatic tetany, requiring a brief hospitalization approximately 7 weeks after denosumab treatment. Her elevated PTH rose further transiently (647 pg/mL), along with ALP (123 U/L). Bone-mineral parameters normalized approximately 3 months after denosumab administration. The observed phenomenon resembled the phenotype of “hungry bone syndrome” observed after surgical parathyroidectomy. Conclusion: Treatment decisions based on bone densitometry results alone are not transposable between patients with or without end-stage renal disease. Denosumab may lead to critical hypocalcemia in dialysis patients and further aggravate existing secondary hyperparathyroidism.
ABSTRACT
Aims: To recognize the importance of considering perforation of viscus in the differential of peritonitis after upper gastrointestinal endoscopy in peritoneal dialysis patients and to address the potential benefit of antibiotic prophylaxis in PD patients undergoing upper GI procedures. Presentation of Case: We report the case of a 54-year-old African American female with end-stage renal disease on peritoneal dialysis presenting with generalized abdominal pain, along with nausea and vomiting. Peritoneal fluid revealed a WBC count of 1,499/mm3. Two days earlier, she had undergone an esophagogastroduodenoscopy with biopsy. Broad spectrum antibiotics were started to treat possible peritonitis. Surgical exploration revealed no perforation but murky peritoneal fluid was noted and gram stain showed mixed flora (both gram negative and gram positive rods); however, blood and peritoneal fluid culture grew only Streptococcus pneumoniae. Discussion and Conclusion: An occult perforation, which may not be obvious to the naked eye or signs of contrast extravasation can occur after esophagogastroduodenoscopy with manipulations and can lead to peritonitis, especially in high-risk patients such as those with end-stage renal disease on peritoneal dialysis. To our knowledge, this is the first reported case of mixed peritonitis attributable to suspected micro-perforation after esophagogastroduodenoscopy. Whether preprocedure antibiotics are warranted to decrease the occurrence of infectious complications in PD patients undergoing upper gastrointestinal procedures remains uncertain and not well studied. The prompt recognition of possible mixed bacterial infection remains essential after these procedures.