Treatment of confirmed B12 deficiency in hemodialysis patients improves Epogen® requirements.

BACKGROUND: Vitamin B12 deficiency may have deleterious effects on end stage renal disease (ESRD) patients on maintenance hemodialysis, and may increase erythropoietin stimulating agent (ESA) resistance, yet little is known about its prevalence in this population. METHODS: Serum vitamin B12 and methylmalonic acid (MMA) levels were drawn from ESRD patients prior to hemodialysis. All patients with MMA levels greater than 800 nmol/L had peripheral smears evaluated for B12 deficiency. Those with confirmatory smears were considered to be deficient and received intramuscular vitamin B12 injections for 4 months. Post-treatment MMA levels and smears were obtained. Erythropoietin dosages were monitored throughout the treatment period. RESULTS: There was a 58% (60/103) prevalence of vitamin B12 deficiency as defined by a positive MMA level and a positive blood smear. Out of 52 patients with positive smears, 36 (69.2%) were negative on repeat analysis after B12 treatment. Mean Epogen® (EPO) dosages significantly decreased by 16,572 ± 41,902 units per month from baseline to the post-B12 t reatment period (P = 0.0082, Wilcoxon signed-rank test). Three months prior to treatment, the mean monthly EPO dose was 82,067 ± 47,906 and post, the mean EPO usage was 65,495 ± 39,691. Post treatment hemoglobin levels were not significantly different from baseline. CONCLUSION: Vitamin B12 supplementation was associated with a decrease in the mean dose of ESA administration while maintaining a stable hemoglobin level. Maintaining serum vitamin B12 levels improves functionality, and may allow a decrease in the use of ESA's, avoiding their toxicities and significant costs.

Use of continuous venovenous hemofiltration for acute renal failure due to multiple myeloma cast nephropathy.

Renal insufficiency is associated with high morbidity and mortality in multiple myeloma. One of the common causes for acute renal failure in multiple myeloma is cast nephropathy. It is important to reduce the levels of light chains to improve renal failure and also the overall outcome. Plasmapheresis has failed to show any significant improvement in renal failure due to cast nephropathy as demonstrated in a recent randomized control trial. Here, we present a case series of three patients who were treated with continuous venovenous hemofiltration as a modality to remove these free light chains. There was improvement in renal failure in these patients with decrease in the levels of free light chains. These patients remained off hemodialysis on follow-up and two of them were able to undergo hematopoietic stem cell transplantation.

Severe oxalosis with systemic manifestations.

UNLABELLED: Ethylene glycol toxicity can have various clinical presentations with different organ system involvements. These presentations are independent of the level of toxicity. We describe a 31 years old male who presented with ethylene glycol toxicity manifesting as anuric renal failure who subsequently developed neurological sequela of its toxicity. Ethylene glycol is known to be metabolized to various metabolites and is ultimately converted to oxalate which results in crystal deposition the renal parenchyma causing renal failure. Oxalate deposition can occur in various organs including the nervous system as seen in our patient. The majority of patients do not recover from severe oxalosis despite the supportive care of hemodialysis in removing the parent compounds. Despite severe oxalosis, our patient was fortunate enough to be left with minimal neurological sequelae, and eventually was able to cease hemodialysis treatments. KEYWORDS: Ethylene glycol; Oxalate; Oxalosis; Glyoxylic acid.

Current concepts in triglyceride metabolism, pathophysiology, and treatment.

It is becoming more evident that age, gender, and race play a significant role in the metabolic profiles that are seen among individuals in a clinical setting. It is important to understand these variances in metabolic profiles; and with these variances in mind it is now possible to understand why a single diet might not decrease cardiovascular disease risk profiles uniformly for everyone. Much is now understood about triglyceride metabolism and its contribution to energy storage. In this review we will focus on triglycerides; their production, metabolism and influence on daily life, as well as the various methods for the treatment of hypertryglyceridemia and prevention of its sequelae.