An Exciting Case of Acute on Chronic Hypercalcemia in the Setting of Chronic Primary Hyperparathyroidism: A Case Report and Diagnostic Approach.

Acute worsening of hypercalcemia in patients with chronic primary hyperparathyroidism can be challenging, and availability bias may mislead physicians to diagnose worsening primary hyperparathyroidism, especially if the parathyroid hormone is also trending higher. We report a case of stage-IV non-Hodgkin's lymphoma which presented as acute worsening of hypercalcemia in a patient with chronic primary hyperparathyroidism.

Modifying Beauty Is Not Priceless: A Rare Case of Silicone-Induced Hypercalcemia With Renal Failure.

Silicone implant-induced hypercalcemia is a rather rare pathological entity. There are only a few published reports on the topic. Here, we have reported a case of acute kidney injury in the background of hypercalcemia and elevated vitamin D level in a transgender patient with a history of silicone injections in the breast and buttocks for cosmetic purposes.

Prevalence of abnormalities in electrocardiogram conduction in dialysis patients: a comparative study / Prevalência de anormalidades de condução no eletrocardiograma de pacientes em diálise: um estudo comparativo

ABSTRACT Background: The electrocardiogram (ECG) can aid in identification of chronic kidney disease (CKD) patients at high risk for cardiovascular diseases. Cohort studies describe ECG abnormalities in patients on hemodialysis (HD), but we did not find data comparing ECG abnormalities among patients with normal kidney function or peritoneal dialysis (PD) to those on hemodialysis. We hypothesized that ECG conduction abnormalities would be more common, and cardiac conduction interval times longer, among patients on hemodialysis vs. those on peritoneal dialysis and CKD 1 or 2. Methods: Retrospective review of adult inpatients' charts, comparing those with billing codes for "Hemodialysis" vs. inpatients without those charges, and an outpatient peritoneal dialysis cohort. Patients with CKD 3 or 4 were excluded. Results: One hundred and sixty-seven charts were reviewed. ECG conduction intervals were consistently and statistically longer among hemodialysis patients (n=88) vs. peritoneal dialysis (n=22) and CKD stage 1 and 2 (n=57): PR (175±35 vs 160±44 vs 157±22 msec) (p=0.009), QRS (115±32 vs. 111±31 vs 91±18 msec) (p=0.001), QT (411±71 vs. 403±46 vs 374±55 msec) (p=0.006), QTc (487±49 vs. 464±38 vs 452±52 msec) (p=0.0001). The only significantly different conduction abnormality was prevalence of left bundle branch block: 13.6% among HD patients, 5% in PD, and 2% in CKD 1 and 2 (p=0.03). Conclusion: To our knowledge, this is the first study to report that ECG conduction intervals are significantly longer as one progresses from CKD Stage 1 and 2, to PD, to HD. These and other data support the need for future research to utilize ECG conduction times to identify dialysis patients who could potentially benefit from proactive cardiac evaluations and risk reduction.

RESUMO Introdução: O eletrocardiograma (ECG) pode auxiliar na identificação de pacientes com doença renal crônica (DRC) e alto risco para doenças cardiovasculares. Estudos de coorte descrevem anormalidades no ECG de pacientes em hemodiálise (HD), mas não encontramos dados comparando anormalidades no ECG entre pacientes com função renal normal ou aqueles em diálise peritoneal (DP), com aqueles em hemodiálise. Nossa hipótese foi de que as anormalidades de condução no ECG seriam mais comuns, e o intervalo de condução cardíaca seria mais longo entre os pacientes em hemodiálise comparados àqueles em diálise peritoneal e DRC 1 ou 2. Métodos: revisão retrospectiva dos prontuários de pacientes adultos internados, comparando aqueles com códigos de cobrança para "Hemodiálise" versus pacientes internados sem esses encargos, e uma coorte de pacientes em diálise peritoneal ambulatorial. Pacientes com DRC 3 ou 4 foram excluídos. Resultados: Cento e sessenta e sete prontuários foram revisados. Os intervalos de condução no ECG foram consistente- e estatisticamente mais longos entre os pacientes em hemodiálise (n = 88) vs. em diálise peritoneal (n = 22) e DRC estágios 1 e 2 (n = 57): PR (175 ± 35 vs 160 ± 44 vs 157 ± 22 msec) (p = 0,009); QRS (115 ± 32 vs. 111 ± 31 vs 91 ± 18 ms) (p = 0,001); QT (411 ± 71 vs. 403 ± 46 vs 374 ± 55 ms) (p = 0,006 ), QTc (487 ± 49 vs. 464 ± 38 vs 452 ± 52 ms) (p = 0,0001). A única anormalidade de condução significativamente diferente foi a prevalência de bloqueio do ramo esquerdo: 13,6% nos pacientes em HD, 5% em DP e 2% na DRC 1 e 2 (p = 0,03). Conclusão: Pelo que sabemos, este é o primeiro estudo a relatar que os intervalos de condução no ECG são significativamente maiores à medida que se progride das DRC Estágios 1 e 2, para DP, e para HD. Esses e outros dados corroboram a necessidade de estudos futuros para utilizar os tempos de condução no ECG para identificar pacientes em diálise que poderiam se beneficiar de avaliações cardíacas proativas e assim redução de risco.

Metabolic Acidosis, Hyperkalemia, and Renal Unresponsiveness to Aldosterone Syndrome: Response to Treatment with Low-Potassium Diet.

Gordon syndrome involves hyperkalemia, acidosis, and severe hypertension (HTN) with hypercalciuria, low renin and aldosterone levels. It is commonly observed in children and adolescents. Such patients respond successfully to sodium restriction and thiazide diuretics. In this article, we present three cases of metabolic acidosis, hyperkalemia, and renal unresponsiveness to aldosterone (MeHandRU Syndrome). All three patients did not have HTN or hypercalciuria and demonstrated normal renin and aldosterone levels. These patients did not respond to thiazide-type diuretic therapy and salt restriction. Two males (aged 55- and 62-year) and a female patient (aged 68-year) presented to the clinic with unexplained hyperkalemia (5.9 mEq/L, 5.9 mEq/L and 6.2 mEq/L, respectively). On physical examination, blood pressure (BP) was found to be normal (<140/90 mm Hg). Over the counter potassium supplement, nonsteroidal anti-inflammatory drugs, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, potassium sparing diuretic use, as well as hyporeninemic hypoaldosteronism states such as diabetes mellitus were excluded. Plasma renin and aldosterone levels were normal. All three patients had low transtubular potassium gradient, despite high serum potassium levels. None of the patients reported a family history of hyperkalemia or kidney failure. All failed to demonstrate a response to hydrochlorothiazide and salt restriction. After careful consideration, strict low potassium diet (<2 g/day) was initiated in consultation with the dietician. Diuretic therapy was discontinued while BP remained within normal range (<140/90 mm Hg). At eight weeks, all three patients demonstrated normalization of potassium and correction of acidosis. At follow-up of six months, all patients are maintaining a normal potassium level. We suggest that potassium restriction can be successful in patients presenting with MeHandRU syndrome.

Prevalence of abnormalities in electrocardiogram conduction in dialysis patients: a comparative study.

BACKGROUND: The electrocardiogram (ECG) can aid in identification of chronic kidney disease (CKD) patients at high risk for cardiovascular diseases. Cohort studies describe ECG abnormalities in patients on hemodialysis (HD), but we did not find data comparing ECG abnormalities among patients with normal kidney function or peritoneal dialysis (PD) to those on hemodialysis. We hypothesized that ECG conduction abnormalities would be more common, and cardiac conduction interval times longer, among patients on hemodialysis vs. those on peritoneal dialysis and CKD 1 or 2. METHODS: Retrospective review of adult inpatients' charts, comparing those with billing codes for "Hemodialysis" vs. inpatients without those charges, and an outpatient peritoneal dialysis cohort. Patients with CKD 3 or 4 were excluded. RESULTS: One hundred and sixty-seven charts were reviewed. ECG conduction intervals were consistently and statistically longer among hemodialysis patients (n=88) vs. peritoneal dialysis (n=22) and CKD stage 1 and 2 (n=57): PR (175±35 vs 160±44 vs 157±22 msec) (p=0.009), QRS (115±32 vs. 111±31 vs 91±18 msec) (p=0.001), QT (411±71 vs. 403±46 vs 374±55 msec) (p=0.006), QTc (487±49 vs. 464±38 vs 452±52 msec) (p=0.0001). The only significantly different conduction abnormality was prevalence of left bundle branch block: 13.6% among HD patients, 5% in PD, and 2% in CKD 1 and 2 (p=0.03). CONCLUSION: To our knowledge, this is the first study to report that ECG conduction intervals are significantly longer as one progresses from CKD Stage 1 and 2, to PD, to HD. These and other data support the need for future research to utilize ECG conduction times to identify dialysis patients who could potentially benefit from proactive cardiac evaluations and risk reduction.

Acute kidney injury secondary to thrombotic microangiopathy associated with idiopathic hypereosinophilic syndrome: a case report and review of the literature.

BACKGROUND: Renal involvement in idiopathic hypereosinophilic syndrome is uncommon. The mechanism of kidney damage can be explained as occurring via two distinct pathways: (1) thromboembolic ischemic changes secondary to endocardial disruption mediated by eosinophilic cytotoxicity to the myocardium and (2) direct eosinophilic cytotoxic effect to the kidney. CASE PRESENTATION: We present a case of a 63-year-old Caucasian man who presented to our hospital with 2 weeks of progressively generalized weakness. He was diagnosed with idiopathic hypereosinophilic syndrome with multiorgan involvement and acute kidney injury with biopsy-proven thrombotic microangiopathy. Full remission was achieved after 8 weeks of corticosteroid therapy. CONCLUSION: Further studies are needed to investigate if age and absence of frank thrombocytopenia can serve as a prognostic feature of idiopathic hypereosinophilic syndrome, as seen in this case.

Pregnancy and hemodialysis access: A case for patient satisfaction in favor of a tunneled dialysis catheter.

While an arteriovenous fistula is the best available access, many patients continue to rely on a tunneled hemodialysis catheter for dialysis therapy. Despite the highest risk of catheter-related bacteremia and associated morbidity and mortality, patients often prefer tunneled hemodialysis catheter to avoid pain associated with cannulation of an arteriovenous access. We report three tunneled hemodialysis catheter-dependent end-stage renal disease patients (age: 38, 35, 33 years), who became pregnant. Pregnancy was discovered at 10, 12 and 10 weeks of gestation. All three patients were switched to daily hemodialysis (six sessions/week) as soon as the pregnancy was discovered. The three patients had refused the placement of an arteriovenous access and expressed their strong preference for tunneled hemodialysis catheter. All had been educated about the risks and benefits of catheter, grafts, and fistulas. Patient preference was acknowledged and dialysis therapy was continued with tunneled hemodialysis catheter. Pregnancy was uneventful in two patients with the delivery of a healthy baby. The third patient had a miscarriage. Patient preference for tunneled hemodialysis catheter and satisfaction is important and can result in a successful outcome in pregnant patients. Nonetheless, in keeping with the National Kidney Foundation guidelines as well as the Fistula First, an arteriovenous fistula should be offered to hemodialysis patients. At the same time, patient's preference and wish should be respected and followed.

The Complications of Vascular Access in Hemodialysis.

Complications related to hemodialysis vascular access continue to have a major impact on morbidity and mortality. Vascular access dysfunction is the single most important factor that determines the quality of dialysis treatment. Vascular access stenosis is a common complication that develops in a great majority of patients with an arteriovenous access and leads to access dysfunction. By restricting luminal diameter, this complication leads to a reduction in blood flow and places the access at risk for thrombosis. Similarly, the development of catheter-related fibroepithelial sheath also causes catheter dysfunction with its detrimental effects on blood flow. In this article, we discuss the most common complications associated with dialysis access and provide therapeutic options to manage these problems.

Management of hypertension in patients during percutaneous dialysis access interventions.

Not infrequently, interventionalists are faced with a patient with increased blood pressure who is about to undergo a dialysis access intervention such as tunneled hemodialysis catheter, percutaneous balloon angioplasty, or declotting procedure for a clotted arteriovenous access. This can frequently create a dilemma as functional dialysis access is needed to provide dialysis therapy and delaying treatment could result in a life-threatening situation, particularly in the presence of hyperkalemia. This article investigates hypertension in patients undergoing percutaneous dialysis access interventions and provides guidance to their management.

Ischemic monomelic neuropathy: a long-term follow-up of two cases.

INTRODUCTION: Ischemic monomelic neuropathy (IMN) is the most dreaded complication of an arteriovenous access creation. While uncommon, it can lead to pain, paresthesia or/and hand weakness. Creation of an arteriovenous connection causing a sudden diversion of blood away from the nerves can lead to ischemic injury to the neural tissue and cause IMN. Immediate surgical ligation has been traditionally recommended to limit ongoing neural tissue injury. CASE DESCRIPTION: We present two diabetic patients who developed IMN after the creation of a left upper extremity brachial-cephalic fistula and refused to undergo surgical ligation. The clinical examination revealed paresthesia localized to the volar aspect of the left forearm with mild weakness of the thumb, index and middle finger. Rehabilitation therapy was initiated in both and revealed a significant improvement in weakness but paresthesia persisted. Fistula maturation was achieved in both patients with an access flow of 1100-1200 cc/min. At 4 months, fistula was used successfully for dialysis in both patients. At a follow-up of 11 months, hand weakness did not progress and paresthesia disappeared. CONCLUSIONS: These cases demonstrate sensory-motor improvement with time and rehabilitation therapy and challenge the traditional approach of fistula ligation. The approach presented in this paper also results in the preservation of the lifeline of a patient. Future investigations should focus on identifying candidates who could benefit from physical therapy and rehabilitation.