Predicting postoperative total calcium requirements after parathyroidectomy in secondary hyperparathyroidism

BACKGROUND/AIMS: To prevent hypocalcemia after parathyroidectomy (PTX), parenteral calcium is required in addition to oral calcitriol and calcium. After switching to oral calcium, patients can be discharged from the hospital. The aim of this study was to analyze the clinical characteristics and outcomes of PTX performed at a single Korean center and to investigate the associated laboratory factors used to analyze the total amount of postoperative calcium required. METHODS: We enrolled 91 hemodialysis patients undergoing PTX from November 2003 to December 2011. We collected clinical and laboratory data preoperatively, 12 and 48 hours postoperatively, at discharge, and 3 and 6 months postoperatively. RESULTS: In total, 59 patients underwent PTX with autotransplantation (AT), 6 underwent total PTX without AT, 11 underwent subtotal PTX, and 15 underwent limited PTX. Total PTX without AT showed the lowest recurrence rate. At all postoperative time points, the mean levels of serum calcium, phosphorus, and intact parathyroid hormone (iPTH) decreased significantly, compared with preoperative levels; however, alkaline phosphatase (ALP) increased significantly from 48 hours postoperatively to discharge (p < 0.001). On multiple linear regression analysis, the total amount of injected calcium during hospitalization showed a significant correlation with preoperative ALP (p < 0.001), preoperative iPTH (p = 0.037), and Deltaphosphorus at 48 hours (p < 0.001). We developed an equation for estimating the total calcium requirement after PTX. CONCLUSIONS: Preoperative ALP, preoperative iPTH, and Deltaphosphorus at 48 hours may be significant factors in estimating the postoperative calcium requirement. The formula for postoperative calcium requirement after PTX may help to predict the duration of postoperative hospitalization.

Optimal hemoglobin level for anemia treatment in a cohort of hemodialysis patients

BACKGROUND: Anemia is a major risk factor that contributes to mortality in patients with chronic kidney disease. There is controversy over the optimal hemoglobin (Hb) target in these patients. This study investigated the association between Hb level and mortality in a cohort of hemodialysis (HD) patients in Korea. METHODS: This study was a multicenter prospective observational study of maintenance HD patients that was performed for 5 years in western Seoul, Korea. Three hundred and sixty-two participants were enrolled. Laboratory values and mortality were accessed every 6 months. Repeated measures of laboratory values in each interval were averaged to obtain one semiannual mean value. The Hb values were divided into six groups: (1) Hb or =13 g/dL. We analyzed the odds ratio for all-cause mortality, based on the Hb group, and adjusted for demographics and various laboratory values. Statistics were performed with SAS, version 9.1 software (SAS Institute Inc., Cary, NC, USA). RESULTS: Mortality odds ratios relative to the reference group (10-11 g/dL) in the fully adjusted model were 3.61 for or =13 g/dL (* indicates P<0.05). CONCLUSION: In this study, a Hb level of 10-11 g/dL was associated with the lowest mortality among the groups with Hb level<13 g/dL. Larger interventional trials are warranted to determine the optimal Hb target for Korean HD patients.

A Case of Late Onset-Acute Tubulointerstitial Nephritis with Infliximab and Mesalazine Treatment in a Patient with Crohn's Disease / 대한소화기학회지

Infliximab is a chimeric anti-tumor necrosis factor-alpha monoclonal antibody. Infusion related reactions and infection are well known side effects of infliximab; however, renal complications have not been well recognized. We report on a patient with late onset-acute tubulointerstitial nephritis (ATIN) after treatment with infliximab and mesalazine for Crohn's disease. A 25-year-old woman was admitted with a purpuric rash on both lower extremities and arthralgia. She had been diagnosed with Crohn's disease 5.6 years previously and had been treated with mesalazine and infliximab. Serum creatinine level, last measured one year ago, was elevated from 0.6 mg/dL to 1.9 mg/dL. Results of urinalysis, ultrasound, and serologic examinations were normal. With a tentative diagnosis of Henoch-Schonlein purpura, oral prednisolone was given, and serum creatinine decreased to 1.46 mg/dL, but was elevated to 2.6 mg/dL again at two months after discontinuation of prednisolone. Renal biopsy indicated that ATIN was probably induced by drug, considering significant infiltration of eosinophils. Concomitant use of infliximab with mesalazine was supposed to trigger ATIN. Oral prednisolone was administered, and serum creatinine level showed partial recovery. Thus, ATIN should be suspected as a cause of renal impairment in Crohn's disease even after a long period of maintenance treatment with infliximab and mesalazine.

Maxillofacial Enlargement in Secondary Hyperparathyroidism Successfully Treated by Limited Parathyroidectomy and Paricalcitol / 대한신장학회지

Maxillary enlargement is a rare complication of secondary hyperparathyroidism (SHPT). A 35-year-old Korean man undergoing chronic hemodialysis presented with a painless enlargement involving the maxilla and mandible. Plain radiography and CT scan showed bony expansion at the maxilla and mandible with multiple radiolucency. Serum intact parathyroid hormone (iPTH) was >1,600 pg/mL. Tc-99m sestamibi (MIBI) parathyroid scan and neck sonogram were compatible with SHPT. He underwent limited parathyroidectomy and commenced a course of paricalcitol. Fifteen months after surgery, maxillary enlargement and bony resorptions involving both hands markedly improved. Thirty-six months after the surgery, the serum iPTH level was 109.3 pg/mL. This is the first report in Korea documenting a patient with maxillary enlargement in SHPT who was successfully treated with limited parathyroidectomy and paricalcitol.

Orthorexia Nervosa with Hyponatremia, Subcutaneous Emphysema, Pneumomediastimum, Pneumothorax, and Pancytopenia

30-year-old male was admitted with general weakness and drowsy mental status. He had eaten only 3-4 spoons of brown rice and fresh vegetable without salt for 3 months to treat his tic disorder, and he had been in bed-ridden state. He has had weight loss of 14 kg in the last 3 months. We report a patient with orthorexia nervosa who developed hyponatremia, metabolic acidosis, subcutaneous emphysema, mediastinal emphysema, pneumothorax, and pancytopenia and we will review the literature. Also, we mention to prevent refeeding syndrome, and to start and maintain feeding in malnourished patients.

Serum Globotriaosylceramide Assay as a Screening Test for Fabry Disease in Patients with ESRD on Maintenance Dialysis in Korea

BACKGROUND/AIMS: Fabry disease is an X-linked recessive and progressive disease caused by alpha-galactosidase A (alpha-GaL A) deficiency. We sought to assess the prevalence of unrecognized Fabry disease in dialysis-dependent patients and the efficacy of serum globotriaosylceramide (GL3) screening. METHODS: A total of 480 patients of 1,230 patients among 17 clinics were enrolled. Serum GL3 levels were measured by tandem mass spectrometry. Additionally, we studied the association between increased GL3 levels and cardiovascular disease, cerebrovascular disease, or left ventricular hypertrophy. RESULTS: Twenty-nine patients had elevated serum GL3 levels. The alpha-GaL A activity was determined for the 26 patients with high GL3 levels. The mean alpha-GaL A activity was 64.6 nmol/hr/mg (reference range, 45 to 85), and no patient was identified with decreased alpha-GaL A activity. Among the group with high GL3 levels, 15 women had a alpha-GaL A genetics analysis. No point mutations were discovered among the women with high GL3 levels. No correlation was observed between serum GL3 levels and alpha-GaL A activity; the Pearson correlation coefficient was 0.01352 (p = 0.9478). No significant correlation was observed between increased GL3 levels and the frequency of cardiovascular disease or cerebrovascular disease. CONCLUSIONS: Fabry disease is very rare disease in patients with end-stage renal disease. Serum GL3 measurements as a screening method for Fabry disease showed a high false-positive rate. Thus, serum GL3 levels determined by tandem mass spectrometry may not be useful as a screening method for Fabry disease in patients with end stage renal disease.

Mandibular Enlargement, Metastatic Pulmonary Calcification and Gastric Mucosal Calcinosis in a Patient with Chronic Kidney Disease-mineral Bone Disorder / 대한신장학회지

Secondary hyperparathyroidism is one of the most common complications of patients with chronic kidney disease (CKD). Mandibular enlargement, metastatic pulmonary calcification, and gastric mucosal calcinosis are rare complications in these patients. The defect of calcium and phosphorus metabolism may precipitate pathologic calcification at diverse organs and soft tissue, and change bone architecture. In case of involving periarticular area, patients usually present with localized swelling, pain, and reduced mobility in affected sites. However, in case of organ involvement, except in an advanced stage of disease, there are no specific symptoms. Among these patients, treatment strategies include tight control of calcium and phosphate levels, parathyroidectomy for hyperparathyroidism, renal transplantation, and local excision of calcific lesions. We report a case of mandibular enlargement, metastatic pulmonary calcification, and gastric mucosal calcinosis due to CKD with improvement 3 months after medical and surgical treatment.

Supernumerary Parathyroid Gland Diagnosed with Contrast-enhanced MDCT after Total Parathyroidectomy / 대한신장학회지

We report a case of a 25-year old man with chronic kidney disease with secondary hyperparathyroidism who had persistent elevation of serum parathyroid hormone level after the immediate total parathyroidectomy and autotransplantation. To localize supernumerary (ectopic) parathyroid gland, we checked Tc-99m MIBI scintigraphy, MDCT and PET-CT. Contrast-enhanced MDCT showed a small strong enhancing lesion over left bracheocephalic vein, and PET-CT showed multiple brown tumors. We removed the supernumerary parathyroid gland and got a rapid drop of parathyroid hormone level.

Peritonitis due to Aspergillus niger in Two Continuous Ambulatory Peritoneal Dialysis Patients / 대한신장학회지

Aspergillus peritonitis is a rare but serious cause of peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients. We report 2 cases of peritonitis caused by Aspergillus niger in CAPD which were treated successfully with voriconazole and caspofungin, respectively, and catheter removal. Both patients initially received amphotericin B; however, they were not cured with the agent. We briefly discuss the proper selection of antifungal agent and the treatment duration. Previously reported cases of the CAPD peritonitis caused by A. Niger are also reviewed in this article.

25-Hydroxyvitamin D Status in Patients with Chronic Kidney Disease in a Single Center / 대한신장학회지

PURPOSE: We checked the levels of serum 25-hydroxyvitmain D (25OHD) in the patients with chronic kidney disease (CKD) to survey the status of vitamin D levels, to see the seasonal variations of 25OHD, and to evaluate the relationships among the levels of intact PTH, corrected calcium, and phosphorus. METHODS: We defined vitamin D insufficiency and vitamin D deficiency as serum 25-hydroxyvitamin D levels between 20 and 30 ng/mL and below 20 ng/mL, respectively. 185 patients in a single center were enlisted who categorized into 3 groups, CKD2-3, CKD4, and CKD5 by eGFR using MDRD7 equation. To see the seasonal differences of the levels of 25OHD, we collected laboratory data two times per each patient during summer division (April to September) and winter division (October to March). RESULTS: Prevalences of hypovitaminosis D were 42.8% (CKD2-3), 66.1% (CKD4), 92.8% (CKD5) in summer division and 48.7% (CKD2-3), 73.1% (CKD4), 92.8% (CKD5) in winter division. Seasonal difference of the levels of 25OHD was evident only in CKD stage 2-3 (p=0.018). Negative correlations were recognized between 25OHD and intact PTH (r=-0.2048, p<0.001), phosphorus (r=-0.1711, p=0.0011). CONCLUSION: Hypovitaminosis D is prevalent even in patients with early stages of CKD. The levels of 25OHD decreased significantly in winter division in patients with CKD stages 2-3. The levels of 25OHD were inversely correlated with those of intact PTH, phosphorus, respectively.

Aldosterone Synthase Gene (CYP11B2) Polymorphism in Korean End-Stage Renal Disease Patients on Hemodialysis

Aldosterone synthase gene (CYP11B2) -344C/T polymorphism has been reported to be associated with serum aldosterone level, urinary aldosterone excretion, blood pressure, and left ventricular size and mass. The aim of this study was to evaluate the relation between CYP11B2 polymorphism and end-stage renal disease (ESRD) in the Korean population and the association with CYP11B2 polymorphism and cardiovascular morbidity in ESRD patients on hemodialysis. Genotyping was performed in 134 control subjects and 271 ESRD patients for CYP11B2 polymorphism using polymerase chain reaction through subsequent cleavage with restriction enzyme. Also current blood pressure, demographic, anthropometric and biochemical variables were investigated. The genotype distribution did not differ between ESRD patients and controls and there were no significant differences in blood pressure, use of antihypertensive medication, left ventricular hypertrophy and cardiovascular disease among the three genotypes in ESRD patients on hemodialysis. Our findings do not support the hypothesis that CYP11B2 polymorphism may be associated with prevalence of ESRD and suggest that CYP11B2 polymorphism may not be a genetic marker for cardiovascular morbidity in Korean ESRD patients.

A Case of Small Bowel Bleeding Treated by Single Balloon Enteroscopy in a Patient on Maintenance Hemodialysis / 대한신장학회지

Anemia is a common complication of hemodialysis. It reduces the quality of life and is recognized as adverse risk factor. The cause of anemia in CKD (chronic kidney disease) include lack of erythropoietin, gastrointestinal (GI) bleeding, hypothyroidism, hidden infection, and blood loss in hemodialysis. GI bleeding is not unusual complication in patient on maintenance hemodialysis, caused by uremia, medicine (NSAIDS, antiplatelet agents, anticoagulants), angiodysplasia, and ulcer. In CKD patients, GI bleeding is found in various sites over the whole bowel. Small bowel bleeding is one of the most common causes of obscure GI bleeding and constitutes 2-10% of all GI bleeding. Regarding the small bowel bleeding, diagnosis and treatment are much improved recently with the help of wireless capsule endoscopy and double or single balloon enteroscopy. We report a case of GI bleeding due to erosion of small bowel, which was diagnosed and treated with the single-balloon enteroscopy in patients on maintenance hemodialysis.

A Case of Splenectomy in a Patient with Refractory Thrombotic Thrombocytopenic Purpura / 대한신장학회지

The introduction of plasma exchange has significantly improved the outcome of thrombotic thrombocytopenic purpura (TTP) and the survival rate was increased from 10 to 80-90%. TTP refractory to plasma exchange therapy, however, is still a therapeutic challenge. We describe here a patient who partially responded to plasma exchange therapy, but remained dependent on plasma infusions. To discontinue plasma therapy, several attempts using agents such as rituximab, vincristine, and cyclosporine A had been tried, but all failed. After splenectomy, serum LDH and blood platelet count were normalized. Plasmapheresis were we able to discontinue after 2 weeks of splenectomy. Steroid and cyclosporine were tapered off after 3 months and 5 months after splenectomy respectively, and the patient has been staying in remission ever since. We suggest that splenectomy is a worthwhile treatment option in patients with refractory TTP.

Acute Renal Failure Complicated by Valaciclovir in a Patient with IgA Nephropathy / 대한신장학회지

Valaciclovir is L-valyl ester of acyclovir which has the antiviral effect against herpes zoster virus and Cytomegalovirus. Its adverse effects were reported as nephrotoxicity and neurotoxicity. Although the mechanism of nephrotoxicity of valaciclovir is indeterminate, several hypotheses such as obstructive uropathy and interstitial nephritis have been suggested. We experienced a 54-year-old female patient with IgA nephropathy who developed acute renal failure after taking valaciclovir. She did not develop either central neuropathy or respiratory muscle weakness. The serum creatinine was normalized after 6 days by withdrawal of valaciclovir and hydration. When we use valaciclovir in the elderly or patients with preexisting renal disease, we should monitor the renal function carefully.

Is Serum Cystatin-C a Useful Marker Predicting the Initiation of Maintenance Dialysis? / 대한신장학회잡지

PURPOSE: Cystatin-C is produced at a constant rate, and has been known to be unaffected by non-renal factors. However, there are limited data on its superiority to serum creatinine as a marker of renal function in ESRD population. The aims of our study were to compare serum cystatin-C and serum creatinine with estimated GFR in ESRD patients at the initiation of dialysis, whether the non-renal factors may influence on serum cystatin-C levels, and whether serum cystatin-C may be a useful marker of the start of dialysis. METHODS: This study was cross-sectional about 163 ESRD patients. We measured serum cystatin-C and serum creatinine levels at the initiation of dialysis, and determined GFR from 24 hour urine collection [G (Ccr)], Cockcroft-Gault [G (C&G)], and the modification of diet in renal disease [G (MDRD)] formula. We considered age, gender, body weight and diabetic nephropathy as non-renal factors. RESULTS: The mean serum cystatin-C was 5.0+/-0.9 mg/dL, serum creatinine 11.4+/-5.9 mg/dL, G (Ccr) 5.0+/-2.9 mL/min/1.73m2, G (C&G) 7.5+/-3.1 mL/min/1.73m2, G (MDRD1) 5.7+/-2.9 mL/min/1.73m2, and G (MDRD2) 5.5+/-2.5 mL/min/1.73m2. We found significant correlation between estimated GFR and serum cystatin-C. However, comparing to serum creatinine, serum cystatin-C had no merits in estimating renal function and in predicting urgent hemodialysis. In the multivariate linear regression models, serum cystatin-C had no significant correlation with gender, body weight, and diabetic nephropathy, but decreased with the age. CONCLUSION: Serum cystatin-C is not superior to serum creatinine for estimating renal function and predicting urgent hemodialysis in ESRD patients. Besides, serum cystatin-C seems to be influenced by non-renal factors, age.

Eosinophilic Peritonitis Followed by Acute Colonic Pseudo-obstruction (Ogilvie's syndrome) in an ESRD Patient on CAPD / 대한신장학회잡지

Acute colonic pseudo-obstruction (Ogilvie's syndrome) is characterized by massive dilatation of the colon with no sign of mechanical obstruction. We report a case of eosinophilic peritonitis with severe abdominal pain followed by acute colonic pseudo- obstruction in an ESRD patient on CAPD. The intravenous administration of neostigmine, an acetylcholinesterase inhibitor, resulted in safe and effective colonic decompression in our patient. In case patients with acute colonic pseudo-obstruction do not respond to conservative therapy, treatment with neostigmine can be considered even for patients on dialysis.

A Case of Hypernatremia by Folk Remedies in a CRF Patient / 대한신장학회잡지

We report a case of chronic hypernatremia caused by excessive salt intake as folk remedies for three months. The patient had chronic tubulointerstitial nephritis (CTIN), but without documented cognitive or psychiatric disorders. She presented with severe hypernatremia 189 mmol/L and general weakness. Fluid therapy was done initially with isotonic and then with 0.45% hypotonic saline until serum sodium level reached to 157 mmol/L. Finally hemodialysis was supplemented to achieve normal serum sodium level, and she recovered without any sequelae. This report might be the first case of chronic hypernatremia due to voluntary ingestion of excessive salt in an adult patient with CTIN but without cognitive or psychiatric disorders.

Asymptomatic Cryptococcus and Subsequent Symptomatic Tuberculosis Infection in a Renal Transplant Patient / 대한이식학회지

Cryptococcus is an important opportunistic pathogen of fungal infection after organ transplantation. And, tuberculosis is also a major cause of infection in immunocompromised patients. We experienced a case of asymptomatic cryptococcal pulmonary infection detected by routine chest X-ray in a renal transplant patient, and a subsequent development of symptomatic multi-drug resistant pulmonary tuberculosis during oral fluconazole treatment. For the appropriate infection control, we should make the thorough evaluation in immunocompromised organ-transplant patients.

Efficacy of Protocol-based Erythropoietin Administration in Chronic Hemodialysis Patients / 대한신장학회잡지

BACKGROUND: Anemia is a major contributor to morbidity and mortality in chronic renal failure patients. The benefits of anemia correction using recombinant human erythropoietin (Epo) are well established but because of high cost, several studies increasing the efficacy of it were described. The objective of this study was to evaluate the efficacy of an anemia management protocol using subcutaneous Epo and intravenous iron therapy. METHODS: We enrolled seventy-eight maintenance hemodialysis patients for at least 3 months from January 2000 to November 2002. They received a practice of anemia correction in two other settings. One (control) group performed an irregular administration of Epo and iron, the other (protocol) group performed a regular administration according to anemia management protocol. Clinical and laboratory parameters were analyzed. Dosage of Epo and IV iron were compared. RESULTS: Thirty-one patients in control group and forty-seven patients in protocol group were enrolled. There were no significant differences between two groups in age, gender, existence of diabetic mellitus, vintage of hemodialysis, use of angiotensin-converting enzyme inhibitor, BUN, prealbumin, parathyroid hormone and Kt/Vurea. Mean arterial pressure, creatinine and albumin were significantly lower and hematocrit was significantly higher and well-maintained on the target level in protocol group. There were no significant differences in serum iron, transferrin saturation, ferritin but total iron binding capacity was significantly lower in protocol group. Doses of erythropoietin and IV iron showed no significant differences between two groups. CONCLUSION: The protocol based erythropoietin administration was more efficient in achieving target hematocrit without increment of dosage of erythropoietin and intravenous iron and side effect of hypertension.

Responsiveness of Recombinant Human Erythropoietin in Chronic Renal Failure Patients Undergoing Maintenance Hemodialysis / 대한신장학회잡지

BACKGROUND: Hyporesponsiveness to erythropoietin is an important issue in the treatment of the anemia of chronic renal failure. We tried to identify the factors of erythropoietin responsiveness in chronic renal failure patients undergoing maintenance hemodialysis for the effective treatment of anemia. METHODS: Seventy hemodialysis patients with hemoglobin increment over 2.0 g/dL during erythropoietin treatment were divided into two groups by median erythropoietin dose, 120 IU/kg/week (the low-dose group vs. the high-dose group). We compared age, gender, cause of renal failure, duration of hemodialyis, use of angiotensin-converting enzyme inhibitor, hemoglobin, hematocrit, serum iron, TIBC, transferrin saturation, ferritin, albumin, cholesterol, parathyroid hormone (iPTH), CRP, CO2 content, BUN, creatinine and Kt/V between the two groups. RESULTS: The low-dose group had significantly shorter duration of hemodialysis (40.9 months vs. 66.1 months, p=0.036), higher serum albumin level (3.93 g/dL vs. 3.72 g/dL, p=0.011) and lower iPTH level (94.97 pg/mL vs. 218.52 pg/mL, p=0.013) compared with the high-dose group. Serum creatinine level and Kt/V showed a tendency to be higher in the low-dose group but there were no significant differences (10.53 mg/dL vs. 9.40 mg/dL, p=0.053 and 1.69 vs. 1.38, p=0.080). Other clinical and laboratory parameters were not different between the two groups. CONCLUSION: Adequate nutritional support and prevention of secondary hyperparathyroidism may be helpful to enhance the responsiveness of erythropoietin in chronic renal failure patients undergoing maintenance hemodialysis.