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Lachance O, Goyer F, Adhikari NKJ, Masse MH, Bilodeau JF, Lamontagne F, Leclair MA. High-dose vitamin-C induced prolonged factitious hyperglycemia in a peritoneal dialysis patient: a case report. J Med Case Rep 2021; 15:297. [PMID: 34020705 PMCID: PMC8139369 DOI: 10.1186/s13256-021-02869-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 04/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND High-dose vitamin C is increasingly used for sepsis and more recently for coronavirus disease 2019 (COVID-19) infections. Proponents argue that the low cost and near perfect safety profile of vitamin C support its early adoption. Yet, adverse events might be underreported and underappreciated. CASE PRESENTATION We report a 73-year-old non-diabetic white man with end-stage renal disease on peritoneal dialysis admitted to the intensive care unit with septic shock that was suspected to be due to peritonitis. The patient was enrolled in LOVIT (Lessening Organ Dysfunction with VITamin C; ClinicalTrials.gov identifier: NCT03680274), a randomized placebo-controlled trial of high-dose intravenous vitamin C. He developed factitious hyperglycemia, as measured with a point-of-care glucometer, that persisted for 6 days after discontinuation of the study drug, confirmed to be vitamin C after unblinding. He also had short-lived iatrogenic coma because of hypoglycemia secondary to insulin administration. These events triggered a protocol amendment. CONCLUSIONS Although factitious hyperglycemia has been reported before using certain glucometers in patients treated with high-dose vitamin C, the persistence of this phenomenon for 6 days after the discontinuation of the therapy is a distinguishing feature. This case highlights the importance of monitoring glucose with a core laboratory assay for up to a week in specific populations, such as patients on peritoneal dialysis.
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Affiliation(s)
- Olivier Lachance
- Department of Critical Care Medicine, Université de Montréal, 5400 Boul Gouin Ouest, Montreal, QC, H4J 1C5, Canada.
| | - François Goyer
- Department of Medical Biochemistry, Université de Sherbrooke, 3001 12e Avenue N, Sherbrooke, QC, J1H 5H3, Canada
| | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care Medicine, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Marie-Hélène Masse
- Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, 3001 12e Avenue N, Sherbrooke, QC, J1H 5H3, Canada
| | - Jean-François Bilodeau
- Department of Medicine, Université de Sherbrooke, 3001 12e Avenue N, Sherbrooke, QC, J1H 5H3, Canada
| | - François Lamontagne
- Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, 3001 12e Avenue N, Sherbrooke, QC, J1H 5H3, Canada.,Department of Medicine, Université de Sherbrooke, 3001 12e Avenue N, Sherbrooke, QC, J1H 5H3, Canada
| | - Marc-André Leclair
- Department of Medicine, Université de Sherbrooke, 3001 12e Avenue N, Sherbrooke, QC, J1H 5H3, Canada
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Ermer T, Kopp C, Asplin JR, Granja I, Perazella MA, Reichel M, Nolin TD, Eckardt KU, Aronson PS, Finkelstein FO, Knauf F. Impact of Regular or Extended Hemodialysis and Hemodialfiltration on Plasma Oxalate Concentrations in Patients With End-Stage Renal Disease. Kidney Int Rep 2017; 2:1050-1058. [PMID: 29270514 PMCID: PMC5733827 DOI: 10.1016/j.ekir.2017.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/20/2017] [Accepted: 06/01/2017] [Indexed: 11/30/2022] Open
Abstract
Introduction Calcium oxalate supersaturation is regularly exceeded in the plasma of patients with end-stage renal disease (ESRD). Previous reports have indicated that hemodialfiltration (HDF) lowers elevated plasma oxalate (POx) concentrations more effectively compared with hemodialysis (HD). We reevaluate the therapeutic strategy for optimized POx reduction with advanced dialysis equipment and provide data on the effect of extended treatment time on dialytic oxalate kinetics. Methods Fourteen patients with ESRD who underwent HDF 3 times a week for 4 to 4.5 hours (regular HDF; n = 8) or 7 to 7.5 hours (extended HDF; n = 6) were changed to HD for 2 weeks and then back to HDF for another 2 weeks. POx was measured at baseline, pre-, mid-, and postdialysis, and 2 hours after completion of the treatment session. Results Baseline POx for all patients averaged 28.0 ± 7.0 μmol/l. Intradialytic POx reduction was approximately 90% and was not significantly different between groups or treatment modes [F(1) = 0.63; P = 0.44]. Mean postdialysis POx concentrations were 3.3 ± 1.8 μmol/l. A rebound of 2.1 ± 1.9 μmol/l was observed within 2 hours after dialysis. After receiving 2 weeks of the respective treatment, predialysis POx concentrations on HD did not differ significantly from those on HDF [F(1) = 0.21; P = 0.66]. Extended treatment time did not provide any added benefit [F(1) = 0.76; P = 0.40]. Discussion In contrast to earlier observations, our data did not support a benefit of HDF over HD for POx reduction. With new technologies evolving, our results emphasized the need to carefully reevaluate and update traditional therapeutic regimens for optimized uremic toxin removal, including those used for oxalate.
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Affiliation(s)
- Theresa Ermer
- Department of Nephrology and Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Department of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Christoph Kopp
- Department of Nephrology and Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - John R Asplin
- Litholink Corporation, Laboratory Corporation of America Holdings, Chicago, Illinois, USA
| | - Ignacio Granja
- Litholink Corporation, Laboratory Corporation of America Holdings, Chicago, Illinois, USA
| | - Mark A Perazella
- Department of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Martin Reichel
- Department of Nephrology and Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Peter S Aronson
- Department of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Cellular and Molecular Physiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Fredric O Finkelstein
- Department of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Felix Knauf
- Department of Nephrology and Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Department of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA
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Orimadegun BE, Orimadegun AE, Ademola AD, Agbedana EO. Plasma homocysteine and B vitamins levels in Nigerian children with nephrotic syndrome. Pan Afr Med J 2014; 18:107. [PMID: 25404967 PMCID: PMC4232175 DOI: 10.11604/pamj.2014.18.107.3678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 05/26/2014] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Available data on plasma homocysteine level in patients with nephrotic syndrome (NS) are controversial with increased, decreased and unchanged values reported. Therefore, plasma homocysteine and serum B vitamins in Nigerian children with NS were assessed in this study. METHODS Fasting blood samples were analysed for plasma homocysteine, serum folate and B vitamins in 42 children with NS and 42 age and sex-matched healthy controls in this case control study. Data were compared between NS and control using t test and Chi square. Relationships were tested with regression analysis with p set at 0.05. RESULTS Prevalence of hyperhomocysteinaemia, low folate and cyanocobalamin in NS was 57.1%, 14.3% and 9.5% respectively. The mean homocysteine level was significantly higher in NS than control (11.3±2.6 µmol/L versus 5.5±2.3 µmol/L). Also, NS had lower folate and cyanocobalamin than control: 9.1±3.9 ng/mL versus 11.2±3.1 ng/dL and 268.5±95.7 pg/mL versus 316±117.2 pg/mL respectively. Weak but significant correlation between homocysteine and serum albumin (r = 0.347), folate (r = -0.607) and vitamin B12 (r = -0.185) were found in the NS group. Significant relationship was also found between homocysteine and vitamin B12 (ß = -0.64, 95% CI = -1.20, -0.08) after controlling for folate and vitamin B6 levels. CONCLUSION Clinically important hyperhomocysteinaemia and low B vitamins occur in Nigerian children with nephrotic syndrome. This data suggest that potential usefulness of folate and vitamin B supplementation for reducing high homocysteine levels in nephrotic syndrome need to be further investigated.
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Primary nonfunction of renal allograft secondary to acute oxalate nephropathy. Case Rep Transplant 2011; 2011:876906. [PMID: 23213607 PMCID: PMC3504227 DOI: 10.1155/2011/876906] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Accepted: 07/26/2011] [Indexed: 11/17/2022] Open
Abstract
Primary nonfunction (PNF) accounts for 0.6 to 8% of renal allograft failure, and the focus on causes of PNF has changed from rejection to other causes. Calcium oxalate (CaOx) deposition is common in early allograft biopsies, and it contributes in moderate intensity to higher incidence of acute tubular necrosis and poor graft survival. A-49-year old male with ESRD secondary to polycystic kidney disease underwent extended criteria donor kidney transplantation. Posttransplant, patient developed delayed graft function (DGF), and the biopsy showed moderately intense CaOx deposition that persisted on subsequent biopsies for 16 weeks, eventually resulting in PNF. The serum oxalate level was 3 times more than normal at 85 μmol/L (normal <27 μmol/L). Allograft nephrectomy showed massive aggregates of CaOx crystal deposition in renal collecting system. In conclusion, acute oxalate nephropathy should be considered in the differential diagnosis of DGF since optimal management could change the outcome of the allograft.
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Singer R, Rhodes HC, Chin G, Kulkarni H, Ferrari P. High prevalence of ascorbate deficiency in an Australian peritoneal dialysis population. Nephrology (Carlton) 2008; 13:17-22. [PMID: 18199096 DOI: 10.1111/j.1440-1797.2007.00857.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND An adequate total body pool of ascorbate is essential for optimum health in humans. Requirements for ascorbate are increased in peritoneal dialysis (PD) patients most likely due to a combination of poor nutrition and increased dialysate losses. METHODS We measured serum ascorbate levels in 45 clinically stable PD patients to assess the prevalence of ascorbate insufficiency (level between 2 and 4 mg/L) and deficiency (level <2 mg/L). We also assessed the efficacy of subsequent supplementation and patients' adherence to the prescribed supplementation. All patients were advised on commencement of dialysis to take a multivitamin tablet containing 100-120 mg ascorbate. RESULTS Eighteen (41%) PD patients were regularly taking ascorbate-containing multivitamins, while 27 (59%) patients did not take ascorbate supplements. Serum ascorbate levels ranged from <0.2 to 41 mg/L, with wide variations in serum ascorbate at any given intake level. Ascorbate deficiency was present in 1/3 of the current PD population (44% of patients not taking supplements and in 16% of those on supplements), although none of the patients demonstrated clinical manifestations of scurvy. Targeted supplementation of ascorbate insufficient patients increased the median serum ascorbate level from 1.7 mg/L (IQR 1.2-2.2) to 22.5 mg/L (IQR 16.7-32.9). CONCLUSION Our results show that, in PD patients, ascorbate deficiency is common and can readily be identified with serum ascorbate measurements. Oral supplements in the form of inexpensive multivitamin preparations restore adequate serum ascorbate levels in the majority of these patients. We therefore suggest measurement of ascorbate levels in all PD patients at the commencement of dialysis with a target level in the normal range (4-14 mg/L).
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Affiliation(s)
- Richard Singer
- School of Medicine and Pharmacology, University of Western Australia and Department of Nephrology, Fremantle Hospital, Perth, Western Australia, Australia
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Schiffer L, Bethunaickan R, Ramanujam M, Huang W, Schiffer M, Tao H, Madaio MP, Madaio MM, Bottinger EP, Davidson A. Activated renal macrophages are markers of disease onset and disease remission in lupus nephritis. THE JOURNAL OF IMMUNOLOGY 2008; 180:1938-47. [PMID: 18209092 DOI: 10.4049/jimmunol.180.3.1938] [Citation(s) in RCA: 173] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Costimulatory blockade with CTLA4Ig and anti-CD40L along with a single dose of cyclophosphamide induces remission of systemic lupus erythematosus nephritis in NZB/W F(1) mice. To understand the mechanisms for remission and for impending relapse, we examined the expression profiles of 61 inflammatory molecules in the perfused kidneys of treated mice and untreated mice at different stages of disease. Further studies using flow cytometry and immunohistochemistry allowed us to determine the cellular origins of several key markers. We show that only a limited set of inflammatory mediators is expressed in the kidney following glomerular immune complex deposition but before the onset of proteinuria. Formation of a lymphoid aggregate in the renal pelvis precedes the invasion of the kidney by inflammatory cells. Regulatory molecules are expressed early in the disease process and during remission but do not prevent the inevitable progression of active inflammation. Onset of proliferative glomerulonephritis and proteinuria is associated with activation of the renal endothelium, expression of chemokines that mediate glomerular cell infiltration, and infiltration by activated dendritic cells and macrophages that migrate to different topographical areas of the kidney but express a similar profile of inflammatory cytokines. Increasing interstitial infiltration by macrophages and progressive tubular damage, manifested by production of lipocalin-2, occur later in the disease process. Studies of treated mice identify a type II (M2b)-activated macrophage as a marker of remission induction and impending relapse and suggest that therapy for systemic lupus erythematosus nephritis should include strategies that prevent both activation of monocytes and their migration to the kidney.
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Affiliation(s)
- Lena Schiffer
- Autoimmunity Center, Feinstein Institute for Medical Research, Manhasset, NY 11030, USA
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Xu Z, Duan B, Croker BP, Wakeland EK, Morel L. Genetic dissection of the murine lupus susceptibility locus Sle2: contributions to increased peritoneal B-1a cells and lupus nephritis map to different loci. THE JOURNAL OF IMMUNOLOGY 2005; 175:936-43. [PMID: 16002692 DOI: 10.4049/jimmunol.175.2.936] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Lupus pathogenesis in the NZM2410 mouse model results from the expression of multiple interacting susceptibility loci. Sle2 on chromosome 4 was significantly linked to glomerulonephritis in a linkage analysis of a NZM2410 x B6 cross. Yet, Sle2 expression alone on a C57BL/6 background did not result in any clinical manifestation, but in an abnormal B cell development, including the accumulation of B-1a cells in the peritoneal cavity and spleen. Analysis of B6.Sle2 congenic recombinants showed that at least three independent loci, New Zealand White-derived Sle2a and Sle2b, and New Zealand Black-derived Sle2c, contribute to an elevated number of B-1a cells, with Sle2c contribution being the strongest of the three. To determine the contribution of these three Sle2 loci to lupus pathogenesis, we used a mapping by genetic interaction strategy, in which we bred them to B6.Sle1.Sle3 mice. We then compared the phenotypes of these triple congenic mice with that of previously characterized B6.Sle1.Sle2.Sle3, which express the entire Sle2 interval in combination with Sle1 and Sle3. Sle2a and Sle2b, but not Sle2c, contributed significantly to lupus pathogenesis in terms of survival rate, lymphocytic expansion, and kidney pathology. These results show that the Sle2 locus contains several loci affecting B cell development, with only the two NZW-derived loci having the least effect of B-1a cell accumulation significantly contributing to lupus pathogenesis.
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Affiliation(s)
- Zhiwei Xu
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, 1600 Archer Road, Gainesville, FL 32610, USA
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