Diagnosis and radioablation treatment of toxic multinodular goiter in a hemodialysis patient.

Toxic multinodular goiter is rare in hemodialysis patients. In addition, establishing the diagnosis of hyperthyroidism in the elderly patient with renal failure is difficult because abnormal thyroid function tests can erroneously be attributed to euthyroid sick syndrome. Treatment of hyperthyroidism in dialysis patients by radioiodine ablation involves careful calculation of 131I dose, determination of interval between 131I administration and its removal by hemodialysis, and minimization of radiation hazards during dialytic removal of 131I. We described the clinical presentation of an elderly dialysis patient with toxic multinodular goiter and discussed our diagnostic and therapeutic approaches. The patient's recovery after 131I ablation was complete and uneventful.

Pure red cell aplasia due to parvovirus B19 infection in solid organ transplantation.

Human parvovirus B19 disease is an infrequent but recognized rare cause of anemia in immunocompromised patients. A few cases of parvovirus B19 infections have been reported in transplant recipients, of those only four patients underwent renal transplantation. The primary immunosuppressive therapy in these patients included prednisone with either cyclosporine or tacrolimus. In one patient the disease was self-limiting, while in three others the hematocrit improved following 10-15 d of treatment with commercial intravenous immunoglobulin (IVIG). Herein, we report the fifth case of pure red cell aplasia due to parvovirus B19 infection in a renal transplant recipient who responded to a 5-d course of IVIG. To our knowledge, this is the first case of parvovirus B19 infection in a patient with solid-organ transplantation whose immunosuppressive regimen included both mycophenolate mofetil and tacrolimus and in whom an excellent clinical response was achieved with a short course of IVIG infusion.

Endotheliopathy: a continuum of hemolytic uremic syndrome due to mitomycin therapy.

Hemolytic uremic syndrome (HUS) is a rare, often fatal complication of mitomycin C therapy. It is generally accepted that HUS is, in part, caused by endothelial cell dysfunction. Endothelial cells modulate blood flow, blood pressure, and myointimal proliferation. Endothelial cells synthesize and release products that modulate vascular tone and regulate vascular smooth muscle cell growth. We describe a patient who developed HUS secondary to mitomycin C, resulting in end-stage renal disease and necessitating chronic hemodialysis. Over several months, the patient subsequently developed multisystem organ failure involving the heart, liver, and intestine that was associated with angiographically documented small, distal vessel occlusive disease and ultrasonographically identified coronary artery intimal hyperplasia. We propose that a diffuse ongoing endothelial cell dysfunction (ie, endotheliopathy) is the putative mechanism for this patient's clinical course. To our knowledge, this continuum of HUS presenting as a multisystem, progressive disorder has not been previously reported.

Efficacy of bolus intravenous iron dextran treatment in peritoneal dialysis patients receiving recombinant human erythropoietin.

The efficient use of recombinant human erythropoietin (rHuEPO) requires adequate body stores of iron. In peritoneal dialysis (PD) patients, iron replacement is most commonly administered orally. In this study, we prospectively followed 7 stable PD patients following bolus intravenous infusion of 1 g iron dextran in an outpatient setting. At 12 weeks, significant (p < 0.05) increments in mean hematocrit from 29.13% to 34.85%, transferrin saturation from 10.15% to 29.33%, serum iron from 27.38 to 67.00 micrograms/dL, and serum ferritin from 150.30 to 331.40 ng/mL were observed. Post-treatment, there was less requirement of rHuEPO, and at six months there was a 26% reduction in the mean weekly subcutaneous rHuEPO dose. At 12 weeks, serum albumin increased significantly from 3.50 to 3.76 g/dL (p < 0.05). There was no abnormality in any of the measured liver function tests. No patient developed an adverse or allergic reaction. We concluded that bolus intravenous infusion of iron dextran is an effective and well-tolerated method of repleting iron stores, and will allow a more efficient and economic use of rHuEPO in PD patients.