Parathyroidectomy Versus Cinacalcet for the Treatment of Secondary Hyperparathyroidism in Hemodialysis Patients.

BACKGROUND: Secondary hyperparathyroidism in patients with end stage renal disease on dialysis is associated with bone pain and fractures in addition to cardiovascular morbidity. Cinacalcet is the most commonly used drug to treat such patients, but it has never been compared to surgery. The goal of this study is to compare the long-term outcomes and survival between cinacalcet and parathyroidectomy in the treatment of secondary hyperparathyroidism in hemodialysis patients. METHODS: Adult patients on hemodialysis who were treated with cinacalcet or parathyroidectomy in the United States Renal Data System were included. Patients treated with surgery (n = 2023) were compared using 1:1 propensity score matching ratio to a cohort of patients treated with cinacalcet. A Cox regression analysis was conducted to compare the overall mortality. RESULTS: The propensity score matching successfully created two groups with similar demographics. Patients in the surgery group had a higher mean peak PTH level prior to therapy (2066.8 vs 1425.4, P < 0.001). No difference was observed in the development of new-onset coronary artery disease (7.7% vs 7.9%, P = 0.8) or cerebrovascular disease (7% vs 6.7%, P = 0.8). Surgical patients had a higher rate of pathologic fractures (27.8% vs 24.9%, P = 0.04). Survival analysis showed that patients undergoing surgery had a better 5-year survival (65.6% vs 57.8%) and were less likely to die within the study period (HR 0.77, 95% CI 0.7-0.85, P < 0.0001). CONCLUSIONS: Patients on dialysis undergoing parathyroidectomy for the treatment of secondary hyperparathyroidism have a better overall survival than those treated with cinacalcet.

Alogliptin; a review of a new dipeptidyl peptidase-4 (DPP-4) inhibitor for the treatment of type 2 diabetes mellitus.

Dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors) are effective and safe oral incretin-based antihyperglycemic drugs. In preclinical studies, DPP-4 inhibitors have demonstrated cardiovascular benefits, independent of glycemic control, in patients with type-2 diabetes mellitus. Since 2005, various DPP-4 inhibitors (sitagliptin, linagliptin and saxagliptin) have been clinically available in the United States. Since 2013, alogliptin is the 4(th) approved DPP-4 inhibitor available on the market. Studies have shown that alogliptinis non-inferior to comparator drugs among newly diagnosed type 2 diabetes mellitus patients. Alogliptin can effectively be used as a single agent or as an add-on drug in combination with other glucose lowering drugs with favorable outcomes on glycemic control and HbA1C levels.

Hypertension, renal failure, and edema in a 38-year-old man: light chain deposition disease; a case report and review of the literature.

BACKGROUND: Monoclonal immunoglobulin deposition disease (MIDD) is a rare disease, usually manifesting between the 5(th) and 6(th) decades of life but can also occur earlier. Characteristic feature of MIDD is a non-fibrillar, Congo red negative deposition of monoclonal immunoglobulins in various organs, including the kidneys. Depending on the composition of the deposits, MIDD is classified into 3 types; light chain deposition disease (LCDD), which is the most common form, heavy chain deposition disease (HCDD) and light and heavy chain deposition disease (LHCDD). Kidney involvement is common in MIDD. Renal biopsy reveals nodular sclerosing glomerulopathy on light microscopy and diffuse linear staining of glomerular and tubular basement membranes on immunofluorescence (IF) microscopy. CASE PRESENTATION: A 38-year-old male patient recently diagnosed with hypertension presented with lower extremity edema, shortness of breath, and fatigue. The workup that was performed in a different hospital prior to this admission, demonstrated the presence of significant proteinuria and renal failure. He was intermittently dialyzed and a renal biopsy was obtained, which showed LCDD. Further laboratory workup revealed an increase of IgM, kappa chain and ß2 microglobulin chain, in addition to proteinuria and renal insufficiency. Bone marrow biopsy demonstrated an involvement of 30% with plasma cells. The flow cytometry test showed monotypic plasma cells expressing intracytoplasmic kappa light chain restriction with kappa to lambda ratio of 35/1. The diagnosis of LCDD was established. Treatment with steroids and bortezomib was initiated. CONCLUSIONS: MIDD is an unusual disease and LCDD is the most common form of MIDD. The peak incidence is around the 5(th) and 6(th) decade of life, however, LCDD can also be found in younger patients. Renal involvement, proteinuria, hematuria, and hypertension are markers of the initial clinical presentation. Nodular sclerosing glomerulopathy is found in about 60% of the affected patients. Early diagnosis and early treatment improve the prognostic course of LCDD.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) and LDL lowering in the contemporary management of dyslipidemia.

PCSK9 proprotein convertase subtilisin/kexin type (PCSK9) protein plays an important role in LDL cholesterol (LDL-C) metabolism, due to its role in the degradation of the LDL receptor. Preliminary clinical data of PCSK9 inhibition are quite promising and indicate that PCSK9 inhibition may be a novel strategy for the treatment of dyslipidemia particularly for those with refractory hypercholesterolemia, statin intolerance, or an elevated lipoprotein (a) level and associated cardiovascular diseases. Furthermore, development of PCSK9 inhibitor is an excellent example of "bench to bedside" concept where discovery of a genetic mutation was translated into a novel therapy to address unmet clinical needs. Although several approaches have been attempted to inhibit PCSK9 activity including small molecules, gene silencing and inhibitory antibodies, the most promising approach appears to be the use of monoclonal antibodies with a 50 -70% LDL cholesterol reduction on top of maximal doses of statins. In this article, we review the pharmacology of PCSK9 and summarize findings from key clinical studies using PCSK9 inhibitors.

Lessons learned from a fatal case of mercury intoxication.

CONTEXT: While many cases of metallic mercury poisoning have been reported, cases of metallic mercury poisoning from multiple exposure routes are rare. CASE PRESENTATION: We report the case of a 36-year-old Latin American male who presented with rash, sore throat, fever, chills, cough, and diarrhea after chronic mercury vapor exposure and likely intravenous injection. Despite chelation treatment with meso-2,3-dimercaptosuccinic acid (DMSA) and 2,3-dimercaptopropanesulfonic acid (DMPS), the patient's clinical course was complicated by renal failure and he passed away after 18 days. DISCUSSION: The most striking aspect of this case is that despite use of chelators, a dramatic increase in blood mercury level occurred. We discuss the rationale for combined use of chelators with hemodialysis and other treatments such as plasma exchange in the setting of acute mercury poisoning. This case also illustrated the potentially serious side effects of the chelation drug DMSA, and we discuss the potential relevance of dosing frequency to the occurrence rates of such side effects. RELEVANCE TO CLINICAL PRACTICE: Despite the tragic outcome, on review of case literature, we believe this case provides valuable lessons concerning the use of DMSA and DMPS to treat mercury toxicity, particularly with regard to the combined use of chelation agents and hemodialysis.

Psychometric properties of the Spanish Beck Depression Inventory-II in a medical sample.

The authors examined the psychometric properties of the Spanish Beck Depression Inventory-II (BDI-II; A. T. Beck, R. A. Steer, & G. K. Brown, 1996) in a sample of individuals undergoing hemodialysis. They performed a confirmatory factor analysis of a previously reported 2-factor solution for the English BDI-II derived from a medical sample. Results indicate that the established model for the English-speaking medical sample provided adequate fit in the present sample. Spanish BDI-II scores were not significantly associated with age or gender in their sample, but they were significantly associated with disease severity. Bilingual participants completed the inventory in both Spanish and English, and their data revealed that BDI-II total scores were similar across language administration. The preliminary data suggest that the Spanish BDI-II can be reliably used in medical samples.