1
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Ma B, Jin G, Mao F, Zhou M, Li Y, Hu W, Cai X. Development of a nomogram to predict the incidence of acute kidney injury among ischemic stroke individuals during ICU hospitalization. Heliyon 2024; 10:e25566. [PMID: 38352771 PMCID: PMC10862667 DOI: 10.1016/j.heliyon.2024.e25566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 12/26/2023] [Accepted: 01/29/2024] [Indexed: 02/16/2024] Open
Abstract
Background Limited clinical prediction models exist to assess the likelihood of acute kidney injury (AKI) occurrence in ischemic stroke individuals. In this retrospective study, our aim was to construct a nomogram that utilizes commonly available clinical features to predict the occurrence of AKI during intensive care unit hospitalization among this patient population. Methods In this study, the MIMIC-IV database was utilized to investigate potential risk factors associated with the incidence of AKI among ischemic stroke individuals. A predictive nomogram was developed based on these identified risk factors. The discriminative performance of the constructed nomogram was assessed. Calibration analysis was utilized to evaluate the calibration performance of the constructed model, assessing the agreement between predicted probabilities and actual outcomes. Furthermore, decision curve analysis (DCA) was employed to assess the clinical net benefit, taking into account the potential risks and benefits associated with different decision thresholds. Results A total of 2089 ischemic stroke individuals were included and randomly allocated into developing (n = 1452) and verification cohorts (n = 637). Risk factors for AKI incidence in ischemic stroke individuals, determined through LASSO and logistic regression. The constructed nomogram had good performance in predicting the occurrence of AKI among ischemic stroke patients and provided significant improvement compared to existing scoring systems. DCA demonstrated satisfactory clinical net benefit of the constructed nomogram in both the validation and development cohorts. Conclusions The developed nomogram exhibits robust predictive performance in forecasting AKI occurrence in ischemic stroke individuals.
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Affiliation(s)
- Buqing Ma
- Department of Critical Care Medicine, Hangzhou First People's Hospital, Hangzhou, China
| | - Guangyong Jin
- Department of Critical Care Medicine, Hangzhou First People's Hospital, Hangzhou, China
| | - Fengkai Mao
- Affiliated Hospital of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, China
| | - Menglu Zhou
- Department of Neurology, Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Yiwei Li
- Department of Critical Care Medicine, Hangzhou First People's Hospital, Hangzhou, China
| | - Wei Hu
- Department of Critical Care Medicine, Hangzhou First People's Hospital, Hangzhou, China
| | - Xuwen Cai
- Department of Critical Care Medicine, Hangzhou First People's Hospital, Hangzhou, China
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2
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Goto Y, Uchiyama Y, Fujikura T, Tashiro T, Yasuda H. Teriparatide-Associated Hypercalcemia Concomitant With Acute Kidney Injury: A Case-Report. Cureus 2024; 16:e54263. [PMID: 38496066 PMCID: PMC10944349 DOI: 10.7759/cureus.54263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 03/19/2024] Open
Abstract
Teriparatide, a recombinant human parathyroid hormone, is an anabolic treatment for osteoporosis with a high risk of fractures. Transient hypercalcemia is an adverse effect of teriparatide and usually resolves within 16h of teriparatide administration owing to its rapid absorption and elimination. Some cases of prolonged hypercalcemia have been reported, but these improved rapidly after teriparatide discontinuation. Here, we describe a rare case of teriparatide-induced hypercalcemia concomitant with acute kidney injury that persisted for four weeks. An 83-year-old woman began taking teriparatide for a vertebral fracture. The patient was immobilized by the fracture. Three weeks later, the patient developed hypercalcemia and acute kidney injury. However, hypercalcemia persisted for four weeks despite the discontinuation of teriparatide and fluid administration. Clinicians should be aware that teriparatide can induce severe hypercalcemia, especially in the setting of immobilization, and that hypercalcemia can persist for more than 3-4 weeks in patients with decreased kidney function.
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Affiliation(s)
- Yuya Goto
- Internal Medicine 1, Hamamatsu University School of Medicine, Shizuoka, JPN
| | - Yuri Uchiyama
- Internal Medicine 1, Hamamatsu University School of Medicine, Shizuoka, JPN
| | - Tomoyuki Fujikura
- Internal Medicine 1, Hamamatsu University School of Medicine, Shizuoka, JPN
| | - Takeshi Tashiro
- Internal Medicine 1, Hamamatsu University School of Medicine, Shizuoka, JPN
| | - Hideo Yasuda
- Internal Medicine 1, Hamamatsu University School of Medicine, Shizuoka, JPN
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3
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Ravioli S, Lafranchi A, Exadaktylos AK, Haidinger M, Lindner G. Characteristics and outcome of severe hypercalcemia on admission to the emergency department: a retrospective cohort study. Swiss Med Wkly 2023; 153:40069. [PMID: 37191138 DOI: 10.57187/smw.2023.40069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
AIMS OF THE STUDY To investigate the prevalence of hypercalcemia (>2.60 mmol/l) and severe hypercalcemia (≥2.80 mmol/l) on admission. Symptoms, causes, course of serum calcium, treatment and outcome of severe hypercalcemia were evaluated and compared to historical data from previous studies. METHODS In this retrospective cohort study, all patients presenting to the interdisciplinary emergency department of the Buergerspital Solothurn between 01 January 2017 and 31 December 2020 with measurements of serum calcium were included. Chart reviews were performed for patients with calcium ≥2.80 mmol/l to assess clinical presentation, course of disease and treatment for severe hypercalcemia. RESULTS Of 31,963 tested patients, 869 patients (2.7%) had hypercalcemia on the admission, of which 161 had severe hypercalcemia. Non-albumin corrected calcium was 3.07 (0.32) while albumin corrected calcium was 3.34 (0.44). Calcium was higher in patients with malignancy-related hypercalcemia (3.18 [0.34] versus 3.00 [0.3], p <0.001). Neuropsychiatric (35%) and gastrointestinal (24%) were the leading symptoms. Malignancy was the most common identifiable cause of hypercalcemia (40%), with lung cancer (20%), multiple myeloma (14%) and renal cell carcinoma (11%) being the main cancer types. 36% of patients with severe hypercalcemia took calcium supplements. Bisphosphonate treatment was an independent predictor of a fall in calcium until day 5 (regression coefficient: -0.404, standard error 0.11, p <0.001). Hypercalcemia was not mentioned in the final discharge report in 38% of cases. CONCLUSION Severe hypercalcemia is common and malignancy-related in almost half of the cases. Neuropsychiatric and gastrointestinal symptoms were most prevalent. Awareness of hypercalcemia, particularly in cancer patients and those with known triggering factors, should be raised in order to identify and treat this harmful disorder early.
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Affiliation(s)
- Svenja Ravioli
- Department of Emergency Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Anne Lafranchi
- Department of Nephrology, Bürgerspital Solothurn, Switzerland
| | | | - Michael Haidinger
- Department of Internal and Emergency Medicine, Bürgerspital Solothurn, Switzerland
| | - Gregor Lindner
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Switzerland
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4
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Habas E, Akbar R, Farfar K, Arrayes N, Habas A, Rayani A, Alfitori G, Habas E, Magassabi Y, Ghazouani H, Aladab A, Elzouki AN. Malignancy diseases and kidneys: A nephrologist prospect and updated review. Medicine (Baltimore) 2023; 102:e33505. [PMID: 37058030 PMCID: PMC10101313 DOI: 10.1097/md.0000000000033505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/21/2023] [Indexed: 04/15/2023] Open
Abstract
Acute kidney injury (AKI), chronic renal failure, and tubular abnormalities represent the kidney disease spectrum of malignancy. Prompt diagnosis and treatment may prevent or reverse these complications. The pathogenesis of AKI in cancer is multifactorial. AKI affects outcomes in cancer, oncological therapy withdrawal, increased hospitalization rate, and hospital stay. Renal function derangement can be recovered with early detection and targeted therapy of cancers. Identifying patients at higher risk of renal damage and implementing preventive measures without sacrificing the benefits of oncological therapy improve survival. Multidisciplinary approaches, such as relieving obstruction, hydration, etc., are required to minimize the kidney injury rate. Different keywords, texts, and phrases were used to search Google, EMBASE, PubMed, Scopus, and Google Scholar for related original and review articles that serve the article's aim well. In this nonsystematic article, we aimed to review the published data on cancer-associated kidney complications, their pathogenesis, management, prevention, and the latest updates. Kidney involvement in cancer occurs due to tumor therapy, direct kidney invasion by tumor, or tumor complications. Early diagnosis and therapy improve the survival rate. Pathogenesis of cancer-related kidney involvement is different and complicated. Clinicians' awareness of all the potential causes of cancer-related complications is essential, and a kidney biopsy should be conducted to confirm the kidney pathologies. Chronic kidney disease is a known complication in malignancy and therapies. Hence, avoiding nephrotoxic drugs, dose standardization, and early cancer detection are mandatory measures to prevent renal involvement.
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Affiliation(s)
- Elmukhtar Habas
- Facharzt Internal Medicine, Facharzt Nephrology, Medical Department, Hamad General Hospital, Doha, Qatar
| | - Raza Akbar
- Medical Department, Hamad General Hospital, Doha, Qatar
| | - Kalifa Farfar
- Facharzt Internal Medicine, Medical Department, Alwakra General Hospital, Alwakra, Qatar
| | - Nada Arrayes
- Medical Education Fellow, Lincoln Medical School, University of Lincoln, Lincoln, UK
| | - Aml Habas
- Hematology-Oncology Department, Tripoli Children Hospital, Tripoli, Libya
| | - Amnna Rayani
- Facharzt Pediatric, Facharzt Hemotoncology, Hematology-Oncology Department, Tripoli Children Hospital, Tripoli, Libya
| | | | - Eshrak Habas
- Medical Department, Tripoli Central Hospital, University of Tripoli, Tripoli, Libya
| | | | - Hafidh Ghazouani
- Quality Department, Senior Epidemiologist, Hamad Medical Corporation, Doha, Qatar
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5
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Almuradova E, Cicin I. Cancer-related hypercalcemia and potential treatments. Front Endocrinol (Lausanne) 2023; 14:1039490. [PMID: 37033238 PMCID: PMC10073684 DOI: 10.3389/fendo.2023.1039490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 03/13/2023] [Indexed: 04/11/2023] Open
Abstract
Cancer-related hypercalcemia is a common finding typically seen in patients with advanced cancer and occurs in about 20 to 30 percent of cases. The most common cause of hypercalcemia in hospitalized patients is hypercalcemia due to malignancy.This clinical problem is seen in patients with both solid tumors and patients with hematologic malignancies. Hypercalcemia is associated with a poor prognosis in oncology patients. This pathologic condition can occur due to many different mechanisms but is usually caused by abnormal calcium use resulting from bone resorption, intestinal absorption, or renal excretion. Hypercalcemia may present with a wide range of symptoms ranging from gastrointestinal system symptoms to neurologic symptoms. Timely diagnosis and initiation of treatment by the physician significantly reduce the risk of complications. Treatment aims to decrease serum calcium by increasing calciuresis, decreasing bone resorption, and decreasing intestinal calcium absorption. The mainstays of treatment are IV hydration, bisphosphonates and calcitonin, denosumab, and in some patients, prednisone, and cinacalcet. Patients with underlying advanced kidney disease and refractory severe hypercalcemia should be evaluated for hemodialysis. Every physician dealing with oncology patients should know the fastest and most effective management of hypercalcemia. We aimed to contribute in this sense.
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Affiliation(s)
| | - Irfan Cicin
- Medical Oncology Department, Faculty of Medicine, Trakya University, Trakya, Türkiye
- *Correspondence: Irfan Cicin,
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6
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van den Broek DHN, Geddes RF, Lötter NS, Chang YM, Elliott J, Jepson RE. Ionized hypercalcemia in cats with azotemic chronic kidney disease (2012-2018). J Vet Intern Med 2022; 36:1312-1321. [PMID: 35608146 PMCID: PMC9308412 DOI: 10.1111/jvim.16430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 04/04/2022] [Accepted: 04/11/2022] [Indexed: 11/30/2022] Open
Abstract
Background Hypercalcemia is associated with chronic kidney disease (CKD) in cats, but studies assessing the physiologically relevant ionized calcium fraction are lacking. Objectives To describe the prevalence and incidence rate of ionized hypercalcemia, and to explore predictor variables to identify cats at risk of ionized hypercalcemia in a cohort of cats diagnosed with azotemic CKD. Animals One hundred sixty‐four client‐owned cats with azotemic CKD. Methods Variables independently associated with ionized hypercalcemia at diagnosis of azotemic CKD were explored by binary logistic regression. Cats that were normocalcemic at diagnosis of azotemic CKD were followed over a 12‐month period or until ionized hypercalcemia occurred and baseline predictor variables for ionized hypercalcemia explored using Cox proportional hazards and receiver operating characteristic curve analysis. Results Ionized hypercalcemia (median, 1.41 mmol/L; range, 1.38‐1.68) was observed in 33/164 (20%) cats at diagnosis of azotemic CKD and was associated with male sex, higher plasma total calcium and potassium concentrations, and lower plasma parathyroid hormone concentrations. Twenty‐five of 96 initially normocalcemic (26%) cats followed for minimum 90 days developed ionized hypercalcemia (median, 1.46 mmol/L; range, 1.38‐1.80) at a median of 140 days after diagnosis of azotemic CKD (incidence rate, 0.48 per feline patient‐year). Only body condition score was independently associated with incident ionized hypercalcemia. Conclusions and Clinical Importance The occurrence of ionized hypercalcemia is high in cats with CKD. Continued monitoring of blood ionized calcium concentrations is advised.
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Affiliation(s)
| | - Rebecca F Geddes
- Department of Clinical Science and Services, Royal Veterinary College, University of London, London, United Kingdom
| | - Nicola S Lötter
- Department of Comparative Biomedical Science, Royal Veterinary College, University of London, London, United Kingdom
| | - Yu-Mei Chang
- Research Support Office, Royal Veterinary College, University of London, London, United Kingdom
| | - Jonathan Elliott
- Department of Comparative Biomedical Science, Royal Veterinary College, University of London, London, United Kingdom
| | - Rosanne E Jepson
- Department of Clinical Science and Services, Royal Veterinary College, University of London, London, United Kingdom
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7
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Tidmas V, Brazier J, Hawkins J, Forbes SC, Bottoms L, Farrington K. Nutritional and Non-Nutritional Strategies in Bodybuilding: Impact on Kidney Function. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074288. [PMID: 35409969 PMCID: PMC8998289 DOI: 10.3390/ijerph19074288] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/23/2022] [Accepted: 03/29/2022] [Indexed: 12/10/2022]
Abstract
Bodybuilders routinely engage in many dietary and other practices purported to be harmful to kidney health. The development of acute kidney injury, focal segmental glomerular sclerosis (FSGS) and nephrocalcinosis may be particular risks. There is little evidence that high-protein diets and moderate creatine supplementation pose risks to individuals with normal kidney function though long-term high protein intake in those with underlying impairment of kidney function is inadvisable. The links between anabolic androgenic steroid use and FSGS are stronger, and there are undoubted dangers of nephrocalcinosis in those taking high doses of vitamins A, D and E. Dehydrating practices, including diuretic misuse, and NSAID use also carry potential risks. It is difficult to predict the effects of multiple practices carried out in concert. Investigations into subclinical kidney damage associated with these practices have rarely been undertaken. Future research is warranted to identify the clinical and subclinical harm associated with individual practices and combinations to enable appropriate and timely advice.
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Affiliation(s)
- Victoria Tidmas
- Centre for Research in Psychology and Sports Science, De Havilland Campus, University of Hertfordshire, Hatfield AL10 9EU, UK; (V.T.); (L.B.)
| | - Jon Brazier
- Centre for Research in Psychology and Sports Science, De Havilland Campus, University of Hertfordshire, Hatfield AL10 9EU, UK; (V.T.); (L.B.)
- Correspondence:
| | - Janine Hawkins
- Centre for Health Services and Clinical Research, De Havilland Campus, University of Hertfordshire, Hatfield AL10 9EU, UK; (J.H.); (K.F.)
| | - Scott C. Forbes
- Department of Physical Education Studies, Brandon University, Brandon, MB R7A 6A9, Canada;
| | - Lindsay Bottoms
- Centre for Research in Psychology and Sports Science, De Havilland Campus, University of Hertfordshire, Hatfield AL10 9EU, UK; (V.T.); (L.B.)
| | - Ken Farrington
- Centre for Health Services and Clinical Research, De Havilland Campus, University of Hertfordshire, Hatfield AL10 9EU, UK; (J.H.); (K.F.)
- Renal Unit, Lister Hospital, East and North Herts Trust, Stevenage SG1 4AB, UK
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8
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Hasparyk UG, Vigil FMB, Bartolomei VS, Nunes VM, Simões e Silva AC. Chronic Kidney Disease-Mineral Bone Disease biomarkers in kidney transplant patients. Curr Med Chem 2022; 29:5230-5253. [DOI: 10.2174/0929867329666220318105856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/16/2022] [Accepted: 01/20/2022] [Indexed: 11/22/2022]
Abstract
Background:
Chronic Kidney Disease associated with Mineral Bone Disease (CKD-MBD) is frequent in kidney transplant patients. Post-transplantation bone disease is complex, especially in patients with pre-existing metabolic bone disorders that are further affected by immunosuppressive medications and changes in renal allograft function. Main biochemical abnormalities of mineral metabolism in kidney transplantation (KTx) include hypophosphatemia, hyperparathyroidism (HPTH), insufficiency or deficiency of vitamin D, and hypercalcemia.
Objective:
This review aimed to summarize the pathophysiology and main biomarkers of CKD-MBD in KTx.
Methods:
A comprehensive and non-systematic search in PubMed was independently made with an emphasis on biomarkers in mineral bone disease in KTx.
Results:
CKD-MBD can be associated with numerous factors including secondary HPTH, metabolic dysregulations before KTx, and glucocorticoids therapy in post-transplant subjects. Fibroblast growth factor 23 (FGF23) reaches normal levels after KTx with good allograft function, while calcium, vitamin D and phosphorus, ultimately, result in hypercalcemia, persistent vitamin D insufficiency, and hypophosphatemia respectively. As for PTH levels, there is an initial tendency of a significant decrease, followed by a raise due to secondary or tertiary HPTH. In regard to sclerostin levels, there is no consensus in the literature.
Conclusion:
KTx patients should be continuously evaluated for mineral homeostasis and bone status, both cases with successful kidney transplantation and those with reduced functionality. Additional research on CKD-MBD pathophysiology, diagnosis, and management is essential to guarantee long-term graft function, better prognosis, good quality of life, and reduced mortality for KTx patients.
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Affiliation(s)
- Ursula Gramiscelli Hasparyk
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Flávia Maria Borges Vigil
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Victória Soares Bartolomei
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Vitor Moreira Nunes
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Ana Cristina Simões e Silva
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
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9
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Bhat NA, Mustafa F, Sheikh RY, Wani I. Incidence, etiology, and course of hypercalcemia-induced AKI in a tertiary care center from northern India. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2021. [DOI: 10.1186/s43162-021-00067-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hypercalcemia is known to cause acute kidney injury (AKI). Literature related to hypercalcemic AKI is predominantly in the form of case reports and case series. The purpose of this study is to find the incidence, etiology, and course of hypercalcemia-induced AKI in a non-critical care setting. To our knowledge, this is the first study done to look for the incidence, etiology, and course of hypercalcemia-induced AKI in a non-critical care setting. This is a prospective observational study conducted in the Department of Medicine in a tertiary care center from Jammu and Kashmir, India, from June 2010 to June 2012. Patients admitted with hypercalcemia were assessed for AKI and evaluated and treated for hypercalcemia. Renal function was monitored during hospitalization and at 1 month of discharge. AKI and hypercalcemia were arbitrarily defined as serum creatinine > 1.5 mg/dl and corrected serum calcium of ≥ 11.5 mg/dl (as per reference hospital lab), respectively.
Results
Thirty patients are included. Hyperparathyroidism and multiple myeloma accounted for 13(43.3%) and 10 (33.3%) cases, respectively. Mean ±SD corrected serum calcium at diagnosis and after treatment at 1 month was 13.56 ± 1.86 mg/dl and 9.49±1.35 mg/dl, respectively; p < 0.001. Mean ±SD serum creatinine at baseline and after treatment of hypercalcemia was 2.87 ±1.68 mg/dl and 1.49±1.34 mg/dl, respectively; p < 0.001. Twenty-three (76.7%) patients had AKI. AKI recovered after treating hypercalcemia in 25 (83.3 %) patients. Mean ± SD days taken for the decrease in serum creatinine to ≤ 1.5 mg/dl was 8.28 ± 4.17 days. Mean ± SD serum creatinine after treatment of hypercalcemia in hyperparathyroidism group versus non-parathyroid group was 0.97 ± 0.35 mg/dl and 1.88 ±1.67 mg/dl, respectively; p value 0.009.
Conclusions
Hypercalcemia is commonly associated with AKI. Primary hyperparathyroidism and multiple myeloma account for the majority of the cases. Hypercalcemic AKI with primary hyperparathyroidism is less common and the outcome is better, as compared to non-hyperparathyroidism-related causes. AKI is reversible in most cases.
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10
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Schauf S, Coltherd JC, Atwal J, Gilham M, Carvell-Miller LJ, Renfrew H, Elliott J, Elliott D, Bijsmans ES, Biourge VC, Watson P, Bakke AM. Clinical progression of cats with early-stage chronic kidney disease fed diets with varying protein and phosphorus contents and calcium to phosphorus ratios. J Vet Intern Med 2021; 35:2797-2811. [PMID: 34545958 PMCID: PMC8692190 DOI: 10.1111/jvim.16263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 08/06/2021] [Accepted: 08/30/2021] [Indexed: 12/28/2022] Open
Abstract
Background Dietary protein and phosphorus (P) restriction is the mainstay for nutritional management of chronic kidney disease (CKD). However, adequate restriction levels for cats with early CKD remain unclear. Objectives To investigate responses in cats with early CKD to varying dietary protein, P, and calcium (Ca) : P ratio. Animals Nineteen research colony cats with International Renal Interest Society stages 1‐2 CKD. Methods In an opportunistic longitudinal case study, cats were fed a low protein (59 g/Mcal), low P (0.84 g/Mcal) dry diet (LP‐LP; Ca : P = 1.9) for 18 months and later transitioned onto a moderate protein (76‐98 g/Mcal), moderate P (1.4‐1.6 g/Mcal) dry‐wet diet regimen (MP‐MP; Ca : P = 1.4‐1.6) for 22 months. Fold‐changes in serum creatinine, total Ca (tCa) and P (primary outcomes) and fibroblast growth factor 23 (FGF23) were assessed by linear‐mixed models. Results While feeding LP‐LP, mean serum creatinine decreased (0.87‐fold, 95% confidence interval [CI] 0.81, 0.93, P < .001) to within reference range after 6 months, while increases in total Ca (tCa; 1.16‐fold, 95% CI 1.11, 1.22, P < .001) and FGF23 (2.72‐fold, 95% CI 1.72, 4.31, P < .001), but not in P (1.03‐fold, 95% CI 0.945, 1.124, P = .94), were observed after 17 months. On MP‐MP, mean creatinine, tCa and P remained within reference ranges and did not significantly change (P = .11, P = .98, and P = 1, respectively), while FGF23 significantly decreased (0.58‐fold, 95% CI 0.36, 0.95, P = .02) after 22 months. Conclusions and Clinical Importance Cats with early CKD developed hypercalcemia after long‐term feeding of a highly P‐restricted diet. Increasing dietary P and reducing Ca : P ratio maintained renal markers, while improving Ca‐P balance. Cats with early CKD could benefit from moderately protein‐ and P‐restricted diets.
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Affiliation(s)
- Sofia Schauf
- WALTHAM Petcare Science Institute, Melton Mowbray, Leicestershire, United Kingdom
| | - Jennifer C Coltherd
- WALTHAM Petcare Science Institute, Melton Mowbray, Leicestershire, United Kingdom
| | - Jujhar Atwal
- WALTHAM Petcare Science Institute, Melton Mowbray, Leicestershire, United Kingdom
| | - Matthew Gilham
- WALTHAM Petcare Science Institute, Melton Mowbray, Leicestershire, United Kingdom
| | | | | | - Jonathan Elliott
- Department of Comparative Biomedical Sciences, Royal Veterinary College, University of London, London, United Kingdom
| | | | | | | | - Phillip Watson
- WALTHAM Petcare Science Institute, Melton Mowbray, Leicestershire, United Kingdom
| | - Anne Marie Bakke
- WALTHAM Petcare Science Institute, Melton Mowbray, Leicestershire, United Kingdom
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11
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Rosner MH, DeMauro Renaghan A. Disorders of Divalent Ions (Magnesium, Calcium, and Phosphorous) in Patients With Cancer. Adv Chronic Kidney Dis 2021; 28:447-459.e1. [PMID: 35190111 DOI: 10.1053/j.ackd.2021.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/23/2021] [Accepted: 09/08/2021] [Indexed: 12/15/2022]
Abstract
Disorders of the divalent ions (magnesium, calcium, and phosphorous) are frequently encountered in patients with cancer. Of these, hypomagnesemia, hypocalcemia, hypercalcemia, and hypophosphatemia are seen most commonly. These electrolyte disturbances may be related to the underlying malignancy or due to side effects of anticancer therapy. When caused by a paraneoplastic process, these abnormalities may portend a poor prognosis. Importantly, the development of severe electrolyte derangements may be associated with symptoms that negatively impact quality of life, preclude the administration of critical chemotherapeutic agents, or lead to life-threatening complications that require hospitalization and emergent treatment. In accordance, prompt recognition and treatment of these disorders is key to improving outcomes in patients living with cancer. This review will discuss selected derangements of the divalent ions seen in this population, with a focus on paraneoplastic and therapy-associated etiologies.
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12
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Geddes RF, van den Broek DHN, Chang YM, Biourge V, Elliott J, Jepson RE. The effect of attenuating dietary phosphate restriction on blood ionized calcium concentrations in cats with chronic kidney disease and ionized hypercalcemia. J Vet Intern Med 2021; 35:997-1007. [PMID: 33527601 PMCID: PMC7995425 DOI: 10.1111/jvim.16050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 01/18/2021] [Accepted: 01/18/2021] [Indexed: 12/30/2022] Open
Abstract
Background Hypercalcemia is commonly observed in cats with azotemic chronic kidney disease (CKD). Dietary phosphate restriction is considered standard of care but may contribute to the development of hypercalcemia. The optimal dietary management strategy for these cats is unclear. Objectives To describe the effect of feeding a moderately phosphate‐restricted diet (MP; 1.5 g/Mcal phosphorus; Ca : P ratio, 1.3) to cats with concurrent azotemic CKD and ionized hypercalcemia. Animals Client‐owned cats with ionized hypercalcemia (ionized calcium [iCa] concentration >1.4 mmol/L) at diagnosis of CKD (n = 11; baseline hypercalcemics) or after CKD diagnosis while eating a phosphate‐restricted clinical renal diet (0.8 g/Mcal phosphorus; Ca : P ratio, 1.9; n = 10; RD hypercalcemics). Methods Changes in variables over time, after starting MP at visit 1, were assessed using linear mixed model analysis within each group of cats. Data are reporte as median [25th, 75th percentiles]. Results At visit 1, iCa was 1.47 [1.42, 1.55] mmol/L for baseline hypercalcemics and 1.53 [1.5, 1.67] mmol/L for RD hypercalcemics. Blood iCa decreased (P < .001) when RD hypercalcemics were fed MP, with iCa <1.4 mmol/L in 8/10 cats after 2.2 [1.8, 3.7] months. Plasma phosphate concentrations did not change. In contrast, the baseline hypercalcemic group overall showed no change in iCa but a decrease in plasma phosphate concentration during 8.8 [5.5, 10.6] months on the MP diet, although 4/11 individual cats achieved iCa <1.4 mmol/L by 3.4 [1.0, 6.2] months. Conclusions and Clinical Importance Attenuation of dietary phosphate restriction could result in normalization of iCa in cats that develop hypercalcemia while eating a clinical renal diet.
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Affiliation(s)
- Rebecca F Geddes
- Department of Clinical Science and Services, Royal Veterinary College, University of London, North Mymms, Hertfordshire, UK
| | - D Hendrik N van den Broek
- Department of Clinical Science and Services, Royal Veterinary College, University of London, North Mymms, Hertfordshire, UK
| | - Yu-Mei Chang
- Research Support Office, Royal Veterinary College, University of London, London, UK
| | | | - Jonathan Elliott
- Department of Comparative Biomedical Sciences, Royal Veterinary College, University of London, London, UK
| | - Rosanne E Jepson
- Department of Clinical Science and Services, Royal Veterinary College, University of London, North Mymms, Hertfordshire, UK
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13
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Belli M, Martin RM, Brescia MDG, Nascimento CP, Massoni Neto LM, Arap SS, Ferraz-de-Souza B, Moyses RMA, Peacock M, Montenegro FLDM. Acute and long-term kidney function after parathyroidectomy for primary hyperparathyroidism. PLoS One 2020; 15:e0244162. [PMID: 33382714 PMCID: PMC7774859 DOI: 10.1371/journal.pone.0244162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 12/03/2020] [Indexed: 01/22/2023] Open
Abstract
Background In kidney transplant patients, parathyroidectomy is associated with an acute decrease in renal function. Acute and chronic effects of parathyroidectomy on renal function have not been extensively studied in primary hyperparathyroidism (PHPT). Methods This retrospective cohort study included 494 patients undergoing parathyroidectomy for PHPT. Acute renal changes were evaluated daily until day 4 post-parathyroidectomy and were stratified according to acute kidney injury (AKI) criteria. Biochemical assessment included serum creatinine, total and ionized calcium, parathyroid hormone (PTH), and 25-hydroxyvitamin D (25OHD). The estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI equation. We compared preoperative and postoperative renal function up to 5 years of follow-up. Results A total of 391 (79.1%) patients were female, and 422 (85.4%) were non-African American. The median age was 58 years old. The median (first and third quartiles) preoperative serum creatinine, PTH and total calcium levels were 0.81 mg/dL (0.68–1.01), 154.5 pg/mL (106–238.5), and 10.9 mg/dL (10.3–11.5), respectively. The median (first and third quartiles) preoperative eGFR was 86 mL/min/1.73 m2 (65–101.3). After surgery, the median acute decrease in the eGFR was 21 mL/min/1.73 m2 (p<0.0001). Acutely, 41.1% of patients developed stage 1 AKI, 5.9% developed stage 2 AKI, and 1.8% developed stage 3 AKI. The acute eGFR decrease (%) was correlated with age and PTH, calcium and preoperative creatinine levels in univariate analysis. Multivariate analysis showed that the acute change was related to age and preoperative values of ionized calcium, phosphorus and creatinine. The change at 12 months was related to sex, preoperative creatinine and 25OHD. Permanent reduction in the eGFR occurred in 60.7% of patients after an acute episode. Conclusion There was significant acute impairment in renal function after parathyroidectomy for PHPT, and almost half of the patients met the criteria for AKI. Significant eGFR recovery was observed during the first month after surgery, but a small permanent reduction may occur. Patients treated for PHPT seemed to present with prominent renal dysfunction compared to patients who underwent thyroidectomy.
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Affiliation(s)
- Marcelo Belli
- Division of Head and Neck Surgery, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
- * E-mail:
| | - Regina Matsunaga Martin
- Divison of Endocrinology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | | | - Climério Pereira Nascimento
- Division of Head and Neck Surgery, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Ledo Mazzei Massoni Neto
- Division of Head and Neck Surgery, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Sergio Samir Arap
- Division of Head and Neck Surgery, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Bruno Ferraz-de-Souza
- Divison of Nephrology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Rosa Maria Affonso Moyses
- Divison of Nephrology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Munro Peacock
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Fábio Luiz de Menezes Montenegro
- Division of Head and Neck Surgery, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
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14
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Isakov O, Ghinea R, Beckerman P, Mor E, Riella LV, Hod T. Early persistent hyperparathyroidism post-renal transplantation as a predictor of worse graft function and mortality after transplantation. Clin Transplant 2020; 34:e14085. [PMID: 32949044 DOI: 10.1111/ctr.14085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/19/2020] [Accepted: 08/27/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Persistent hyperparathyroidism (pHPT) is frequently seen after transplantation contributing to post-transplant complications. METHODS We conducted a retrospective single center analysis to explore the relationship of early pHPT and long-term allograft outcome. Patients were divided into high (N = 153) and low (N = 252) PTH groups based on serum parathyroid hormone (PTH) level 3 months post-transplant (PTH ≥ 150 and < 150 pg/mL, respectively). RESULTS High PTH was found to be an independent predictor for reduced kidney allograft function up to 3 years post-transplant. eGFR decreased by 11.4 mL/min (P < .001) and the odds of having an eGFR < 60 mL/min 3 years post-transplant were sixfold higher (P < .01) in the high compared to the low PTH group. Subgroup analysis based on eGFR 1 year post-transplant, presence of slow graft function (SGF), and transplant type revealed similar results. High PTH three months post-transplant was also independently associated with an increased risk for overall mortality and for death with a functioning graft (P < .05). CONCLUSIONS pHPT three months post-renal transplantation is an independent predictor for a worse allograft function up to 3 years post-transplant and a risk factor for mortality. This relationship remains statistically significant after accounting for baseline allograft function, presence of SGF and serum mineral levels abnormalities.
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Affiliation(s)
- Ofer Isakov
- Department of Internal Medicine "T", Tel Aviv Souraski Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Ghinea
- Department of Surgery, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel.,Transplant Nephrology Center, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Pazit Beckerman
- Department of Nephrology, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Eytan Mor
- Transplant Nephrology Center, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Leonardo V Riella
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tammy Hod
- Transplant Nephrology Center, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel.,Department of Nephrology, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
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15
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Manfro AG, Lutzky M, Dora JM, Kalil MAS, Manfro RC. Case reports of hypercalcemia and chronic renal disease due to cosmetic injections of polymethylmethacrylate (PMMA). J Bras Nefrol 2020; 43:288-292. [PMID: 32779690 PMCID: PMC8257287 DOI: 10.1590/2175-8239-jbn-2020-0044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 06/05/2020] [Indexed: 11/21/2022] Open
Abstract
Cosmetic injections of fillers are common plastic surgery procedures worldwide.
Polymethylmethacrylate (PMMA) is a filler approved only for minimally invasive
procedures in facial tissue and is among the most frequently used injectable
substances for cosmetic purposes. Injection of a large volume of PMMA may lead
to the development of severe hypercalcemia and chronic kidney damage in a
probably underestimated frequency. In such cases, hypercalcemia develops due to
a granulomatous foreign body reaction with extrarenal production of calcitriol.
In the present report, we describe the cases of two patients who received
injections of large volumes of PMMA and developed severe hypercalcemia and
advanced chronic kidney disease. These reports highlight the importance of
adhering to regulations regarding the use of PMMA and properly informing
patients of the possibility of complications before undertaking such
procedures.
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Affiliation(s)
- Arthur G Manfro
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Mauricio Lutzky
- Hospital Moinhos de Vento, Divisão de Nefrologia, Porto Alegre, RS, Brasil
| | - Jose M Dora
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil.,Unidade de Tireoide, Divisão de Endocrinologia e Medicina Interna, Porto Alegre, RS, Brasil
| | - Milton A S Kalil
- Hospital Moinhos de Vento, Divisão de Nefrologia, Porto Alegre, RS, Brasil
| | - Roberto C Manfro
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil.,Hospital de Clínicas de Porto Alegre, Divisão de Nefrologia, Porto Alegre, RS, Brasil
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16
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Parente Filho SLA, Gomes PEADC, Forte GA, Lima LLL, Silva Júnior GBD, Meneses GC, Martins AMC, Daher EDF. Kidney disease associated with androgenic-anabolic steroids and vitamin supplements abuse: Be aware! Nefrologia 2019; 40:26-31. [PMID: 31585781 DOI: 10.1016/j.nefro.2019.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/28/2019] [Accepted: 06/02/2019] [Indexed: 01/06/2023] Open
Abstract
The excessive chase for beauty standards and the rise of muscle dysmorphia have ultimately led to an increase in androgenic-anabolic steroids (AAS) and intramuscular injections of vitamins A, D and E (ADE) abuse, which is associated with several adverse effects and has become a public health issue. This review of literature discusses kidney injury associated with the use of AAS and ADE, highlighting the mechanisms of acute and chronic renal lesion, such as direct renal toxicity, glomerular hyperfiltration and hypercalcemia. Future perspectives regarding evaluation and early diagnosis of kidney injury in these patients are also discussed.
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Affiliation(s)
- Sérgio Luiz Arruda Parente Filho
- Medical Sciences Post-Graduation Program, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | | | - Guilherme Aguiar Forte
- Medical Sciences Post-Graduation Program, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Laio Ladislau Lopes Lima
- Medical Sciences Post-Graduation Program, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | | | - Gdayllon Cavalcante Meneses
- Department of Clinical and Toxicological Analysis, School of Pharmacy, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Alice Maria Costa Martins
- Department of Clinical and Toxicological Analysis, School of Pharmacy, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Elizabeth De Francesco Daher
- Medical Sciences Post-Graduation Program, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil.
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17
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18
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Araujo MJCLN, Ramalho JAM, Elias RM, Jorgetti V, Nahas W, Custodio M, Moysés RMA, David-Neto E. Persistent hyperparathyroidism as a risk factor for long-term graft failure: the need to discuss indication for parathyroidectomy. Surgery 2018; 163:1144-1150. [PMID: 29331397 DOI: 10.1016/j.surg.2017.12.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 11/28/2017] [Accepted: 12/05/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although a successful kidney transplant (KTx) improves most of the mineral and bone disorders (MBD) produced by chronic kidney disease (CKD), hyperparathyroidism may persist (pHPT). Current guidelines recommend parathyroidectomy if serum parathormone is persistently elevated 1 year after KTx, because pHPT has been recently associated with poor graft outcomes. However, whether patients with pHPT and adequate renal function are at risk for long-term graft failure is unknown. METHODS Longitudinal follow-up of 911 adults submitted to KTx between January 2005 and December 2014, with estimated glomerular filtration rate (eGFR) ≥ 30 mL/min 1 year after surgery. Clinical and laboratory data were collected from electronic database. Graft failure was defined as return to dialysis. RESULTS Overall, 62% of the patients were classified as having pHPT 1 year after KTx. After a mean follow-up time of 47 months, there were 59 graft failures (49 in pHPT and 10 in non-pHPT group, P = .003). At last follow-up, death-censored graft survival was lower in the pHPT group (P = .009), even after adjustment for age at KTx, donor age, donor type, acute rejection, parathyroidectomy, and eGFR at 1 year after transplantation (odds ratio [OR] 1.99; 1.004-3.971; P = .049). A PTH of 150 pg/mL at 6 months was the best cutoff to predict pHPT at 1 year (specificity = 92.1%). CONCLUSION Having pHPT after a successful KTx increases the long-term risk of death-censored graft failure. This result highlights the need for better recognition and management of CKD-MBD before and during the first year after KTx, and opens a discussion on the more appropriate timing to perform parathyroidectomy.
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Affiliation(s)
- Maria Júlia Correia Lima Nepomuceno Araujo
- Renal Transplantation Service, São Paulo University School of Medicine, São Paulo, Brazil; Nephrology Division, São Paulo University School of Medicine, São Paulo, Brazil
| | - Janaina Almeida Mota Ramalho
- Renal Transplantation Service, São Paulo University School of Medicine, São Paulo, Brazil; Nephrology Division, São Paulo University School of Medicine, São Paulo, Brazil
| | | | - Vanda Jorgetti
- Nephrology Division, São Paulo University School of Medicine, São Paulo, Brazil
| | - William Nahas
- Renal Transplantation Service, São Paulo University School of Medicine, São Paulo, Brazil
| | - Melani Custodio
- Nephrology Division, São Paulo University School of Medicine, São Paulo, Brazil
| | - Rosa M A Moysés
- Nephrology Division, São Paulo University School of Medicine, São Paulo, Brazil.
| | - Elias David-Neto
- Renal Transplantation Service, São Paulo University School of Medicine, São Paulo, Brazil; Nephrology Division, São Paulo University School of Medicine, São Paulo, Brazil
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19
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Pawar NH, Chiam PPS, Tan JHY, Loh J, Aw DCW, Baikunje S. Acute Kidney Injury, Hypercalcemia, and Osteolytic Lesions: A Familiar Triad With a Rare Cause Complicated by Posterior Reversible Encephalopathy Syndrome. Am J Kidney Dis 2017; 70:A12-A15. [DOI: 10.1053/j.ajkd.2017.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 07/13/2017] [Indexed: 11/11/2022]
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20
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van den Broek DHN, Chang YM, Elliott J, Jepson RE. Chronic Kidney Disease in Cats and the Risk of Total Hypercalcemia. J Vet Intern Med 2017; 31:465-475. [PMID: 28190275 PMCID: PMC5354036 DOI: 10.1111/jvim.14643] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 09/19/2016] [Accepted: 11/30/2016] [Indexed: 12/18/2022] Open
Abstract
Background Chronic kidney disease (CKD) is a common comorbidity in cats with hypercalcemia, but whether CKD is a risk factor for hypercalcemia is unclear. Hypercalcemia often is diagnosed based on total calcium concentration (tCa), which tends to underestimate the ionized calcium concentration (iCa) in cats. Objectives Assessment of the performance of tCa for the diagnosis of ionized hypercalcemia, and exploration of factors influencing the relationship between iCa and tCa. Determination of risk factors for incident total hypercalcemia (ie, the development of hypercalcemia based on tCa during follow‐up). Animals Records of a cross‐section (n = 477) and observational cohort (n = 367) of client‐owned cats with and without azotemic CKD from first opinion practice. Methods Retrospective cross‐sectional and retrospective cohort study. The diagnostic accuracy of tCa as an index test for ionized hypercalcemia was evaluated, and risk factors for underestimation were explored by binary logistic and linear regression in a cross‐section of cats with and without azotemic CKD. Chronic kidney disease and clinicopathological variables were assessed as predictors of incident total hypercalcemia by both time‐invariant and time‐dependent Cox regression in a cohort of cats. Results Specificity of tCa for identification of ionized hypercalcemia was high (100%), but sensitivity was low. Underestimation was associated with lower venous bicarbonate concentrations. Cats with CKD had increased risk for incident total hypercalcemia (hazard ratio, 4.29; 95% confidence interval, 1.96–9.37; P < .001). Higher tCa predicted incident total hypercalcemia in both azotemic and nonazotemic cats (P < .001). Conclusions and Clinical Importance Chronic kidney disease is a risk factor for incident total hypercalcemia, and most cats with increased tCa had concurrent ionized hypercalcemia. Higher baseline tCa predicts incident total hypercalcemia. Prospective studies assessing changes in iCa are warranted.
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Affiliation(s)
- D H N van den Broek
- Department of Comparative Biomedical Sciences, Royal Veterinary College, University of London, London, UK
| | - Y-M Chang
- Research Support Office, Royal Veterinary College, University of London, London, UK
| | - J Elliott
- Department of Comparative Biomedical Sciences, Royal Veterinary College, University of London, London, UK
| | - R E Jepson
- Department of Clinical Science and Services, Royal Veterinary College, University of London, North Mymms, Hatfield, Hertfordshire, UK
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21
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Granjon D, Bonny O, Edwards A. A model of calcium homeostasis in the rat. Am J Physiol Renal Physiol 2016; 311:F1047-F1062. [PMID: 27358053 DOI: 10.1152/ajprenal.00230.2016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 06/27/2016] [Indexed: 12/14/2022] Open
Abstract
We developed a model of calcium homeostasis in the rat to better understand the impact of dysfunctions such as primary hyperparathyroidism and vitamin D deficiency on calcium balance. The model accounts for the regulation of calcium intestinal uptake, bone resorption, and renal reabsorption by parathyroid hormone (PTH), vitamin D3, and Ca2+ itself. It is the first such model to incorporate recent findings regarding the role of the calcium-sensing receptor (CaSR) in the kidney, the presence of a rapidly exchangeable pool in bone, and the delayed response of vitamin D3 synthesis. Accounting for two (fast and slow) calcium storage compartments in bone allows the model to properly predict the effects of bisphophonates on the plasma levels of Ca2+ ([Ca2+]p), PTH, and vitamin D3 Our model also suggests that Ca2+ exchange rates between plasma and the fast pool vary with both sex and age, allowing [Ca2+]p to remain constant in spite of sex- and age-based hormonal and other differences. Our results suggest that the inconstant hypercalciuria that is observed in primary hyperparathyroidism can be attributed in part to counterbalancing effects of PTH and CaSR in the kidney. Our model also correctly predicts that calcimimetic agents such as cinacalcet bring down [Ca2+]p to within its normal range in primary hyperparathyroidism. In addition, the model provides a simulation of CYP24A1 inactivation that leads to a situation reminiscent of infantile hypercalcemia. In summary, our model of calcium handling can be used to decipher the complex regulation of calcium homeostasis.
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Affiliation(s)
- David Granjon
- Sorbonne Universités, UPMC Univ Paris 06, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMRS 1138, CNRS ERL 8228, Centre de Recherche des Cordeliers, Paris, France; and.,Department of Pharmacology and Toxicology, University of Lausanne, and Service of Nephrology, Lausanne University Hospital, Lausanne, Switzerland
| | - Olivier Bonny
- Department of Pharmacology and Toxicology, University of Lausanne, and Service of Nephrology, Lausanne University Hospital, Lausanne, Switzerland
| | - Aurélie Edwards
- Sorbonne Universités, UPMC Univ Paris 06, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMRS 1138, CNRS ERL 8228, Centre de Recherche des Cordeliers, Paris, France; and
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22
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Chronic Vitamin D Intoxication in Captive Iberian Lynx (Lynx pardinus). PLoS One 2016; 11:e0156331. [PMID: 27243456 PMCID: PMC4887036 DOI: 10.1371/journal.pone.0156331] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 05/12/2016] [Indexed: 12/05/2022] Open
Abstract
To document the biochemical and pathologic features of vitamin D intoxication in lynx and to characterize mineral metabolism in healthy lynx, blood samples were obtained from 40 captive lynx that had been receiving excessive (approximately 30 times the recommended dose) vitamin D3 in the diet, and from 29 healthy free ranging lynx. Tissue samples (kidney, stomach, lung, heart and aorta) were collected from 13 captive lynx that died as a result of renal disease and from 3 controls. Vitamin D intoxication resulted in renal failure in most lynx (n = 28), and widespread extraskeletal calcification was most severe in the kidneys and less prominent in cardiovascular tissues. Blood minerals and calciotropic hormones in healthy lynx were similar to values reported in domestic cats except for calcitriol which was higher in healthy lynx. Changes in mineral metabolism after vitamin D intoxication included hypercalcemia (12.0 ± 0.3 mg/dL), hyperphosphatemia (6.3 ± 0.4 mg/dL), increased plasma calcidiol (381.5 ± 28.2 ng/mL) and decreased plasma parathyroid hormone (1.2 ± 0.7 pg/mL). Hypercalcemia and, particularly, hyperphosphatemia were of lower magnitude that what has been previously reported in the course of vitamin D intoxication in other species. However, extraskeletal calcifications were severe. The data suggest that lynx are sensitive to excessive vitamin D and extreme care should be taken when supplementing this vitamin in captive lynx diets.
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23
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Gonsalves WI, Godby K, Kumar SK, Costa LJ. Limiting early mortality: Do's and don'ts in the management of patients with newly diagnosed multiple myeloma. Am J Hematol 2016. [PMID: 26214377 DOI: 10.1002/ajh.24129] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
In the era of novel biological agents, multiple myeloma (MM) is often approached as a chronic condition. While survival continues to improve, population-level data indicate that early mortality remains a substantial barrier to advances in MM outcomes. Here we provide "do's and don'ts" management recommendations that may minimize the risk of early mortality and ensure that patients have the opportunity to benefit from the long term impact of new effective MM agents. Such recommendations encompass the early introduction of novel agents even in the presence of comorbidities and advanced age and aggressive management of MM-related complications.
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Affiliation(s)
| | - Kelly Godby
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
| | - Shaji K. Kumar
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | - Luciano J. Costa
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
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Abstract
Hypercalcemia of malignancy affects up to one in five cancer patients during the course of their disease. It is associated with both liquid malignancies, commonly multiple myeloma, leukemia, and non-Hodgkins lymphoma and solid cancers, particularly breast and renal carcinomas as well as squamous cell carcinomas of any organ. The clinical manifestations of hypercalcemia are generally constitutional in nature and not specific to the inciting malignancy. Such physical manifestations can range from malaise to lethargy and confusion. Constipation and anorexia are common. Acute kidney injury is likely the most frequently encountered manifestation of end organ damage. Symptomatology is closely linked to both the absolute elevation of serum calcium levels and the rapidity of calcium rise. The majority of cases are humoral in etiology and related to parathyroid hormone-related protein (PTHrP). Approximately 20% of cases are the result of direct bone metastasis with extra-renal 1,25-dihydroxyvitamin D (calcitriol) and ectopic parathyroid hormone production likely accounting for less than 1% of cases. The diagnosis of hypercalcemia of malignancy is confirmed either by an elevated PTHrP or by an evidence of bone metastasis in the appropriate clinical setting. Treatment is predicated on the patient’s symptoms and absolute serum calcium level. Interventions are aimed at lowering the serum calcium concentration by inhibiting bone resorption and increasing urinary calcium excretion, the former accomplished via bisphosphonate therapy and the latter with aggressive hydration. Novel therapies for refractory disease include denosumab, a monoclonal antibody against the receptor activator of nuclear factor κB ligand, and the calcimimetic cinacalcet. Finally, anti-PTHrP antibodies have been successfully deployed in animal models of disease. Despite the efficacy of the above therapies, hypercalcemia of malignancy portends an ominous prognosis, indicating advanced and often refractory cancer with survival on the order of months.
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Affiliation(s)
- Hillel Sternlicht
- Division of Nephrology and Hypertension, Weill Cornell Medical College
| | - Ilya G Glezerman
- Division of Nephrology and Hypertension, Weill Cornell Medical College ; Renal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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25
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Atchison DK, Harding P, Beierwaltes WH. Vitamin D increases plasma renin activity independently of plasma Ca2+ via hypovolemia and β-adrenergic activity. Am J Physiol Renal Physiol 2013; 305:F1109-17. [PMID: 23926179 DOI: 10.1152/ajprenal.00010.2013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
1, 25-Dihydroxycholechalciferol (calcitriol) and 19-nor-1, 25-dihydroxyvitamin D2 (paricalcitol) are vitamin D receptor (VDR) agonists. Previous data suggest VDR agonists may actually increase renin-angiotensin activity, and this has always been assumed to be mediated by hypercalcemia. We hypothesized that calcitriol and paricalcitol would increase plasma renin activity (PRA) independently of plasma Ca(2+) via hypercalciuria-mediated polyuria, hypovolemia, and subsequent increased β-adrenergic sympathetic activity. We found that both calcitriol and paricalcitol increased PRA threefold (P < 0.01). Calcitriol caused hypercalcemia, but paricalcitol did not. Both calcitriol and paricalcitol caused hypercalciuria (9- and 7-fold vs. control, P < 0.01) and polyuria (increasing 2.6- and 2.2-fold vs. control, P < 0.01). Paricalcitol increased renal calcium-sensing receptor (CaSR) expression, suggesting a potential cause of paricalcitol-mediated hypercalciuria and polyuria. Volume replacement completely normalized calcitriol-stimulated PRA and lowered plasma epinephrine by 43% (P < 0.05). β-Adrenergic blockade also normalized calcitriol-stimulated PRA. Cyclooxygenase-2 inhibition had no effect on calcitriol-stimulated PRA. Our data demonstrate that vitamin D increases PRA independently of plasma Ca(2+) via hypercalciuria, polyuria, hypovolemia, and increased β-adrenergic activity.
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Affiliation(s)
- Douglas K Atchison
- Dept. of Internal Medicine, Hypertension and Vascular Research Div., Henry Ford Hospital, 7121 E&R Bldg., 2799 W. Grand Blvd., Detroit, MI 48202.
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Cai MM, McMahon LP, Smith ER, Williams DS, Holt SG. Hyperparathyroidism in chronic kidney disease: complexities within the commonplace. Clin Med (Lond) 2012; 12:333-7. [PMID: 22930877 PMCID: PMC4952121 DOI: 10.7861/clinmedicine.12-4-333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Secondary hyperparathyroidism in patients with chronic kidney disease (CKD) is common and usually caused by associated metabolic abnormalities, in particular, hypocalcaemia and hyperphosphataemia. Nevertheless, other causes of hyperparathyroidism can exist concurrently with CKD, challenging diagnostic interpretation and therapeutic intervention. We present four cases of hyperparathyroidism in patients with CKD that highlight some of these dilemmas.
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Affiliation(s)
- Michael M Cai
- Department of Renal Medicine, Eastern Health Clinical School, Monash University, Melbourne, Australia.
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Atchison DK, Beierwaltes WH. The influence of extracellular and intracellular calcium on the secretion of renin. Pflugers Arch 2012; 465:59-69. [PMID: 22538344 DOI: 10.1007/s00424-012-1107-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 04/03/2012] [Indexed: 12/29/2022]
Abstract
Changes in plasma, extracellular, and intracellular calcium can affect renin secretion from the renal juxtaglomerular (JG) cells. Elevated intracellular calcium directly inhibits renin release from JG cells by decreasing the dominant second messenger intracellular cyclic adenosine monophosphate (cAMP) via actions on calcium-inhibitable adenylyl cyclases and calcium-activated phosphodiesterases. Increased extracellular calcium also directly inhibits renin release by stimulating the calcium-sensing receptor (CaSR) on JG cells, resulting in parallel changes in the intracellular environment and decreasing intracellular cAMP. In vivo, acutely elevated plasma calcium inhibits plasma renin activity (PRA) via parathyroid hormone-mediated elevations in renal cortical interstitial calcium that stimulate the JG cell CaSR. However, chronically elevated plasma calcium or CaSR activation may actually stimulate PRA. This elevation in PRA may be a compensatory mechanism resulting from calcium-mediated polyuria. Thus, changing the extracellular calcium in vitro or in vivo results in inversely related acute changes in cAMP, and therefore renin release, but chronic changes in calcium may result in more complex interactions dependent upon the duration of changes and the integration of the body's response to these changes.
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Affiliation(s)
- Douglas K Atchison
- Hypertension and Vascular Research Division, Department Internal Medicine, Henry Ford Hospital, 7121 E&R Bldg., 2799 W. Grand Blvd., Detroit, MI 48202, USA
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Weller RE, Hoffinan WE. Renal function in dogs with lymphosarcoma and associated hypercalcaemia. J Small Anim Pract 2008. [DOI: 10.1111/j.1748-5827.1992.tb01075.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Tuon FF, Nihei CH, Gryschek RC, Seguro AC. Vitamin D intoxication: a cause of hypocalcaemia and acute renal failure in a HIV patient. Int J STD AIDS 2008; 19:137-8. [PMID: 18334075 DOI: 10.1258/ijsa.2007.007161] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hypercalcaemia in patients with HIV infection is usually associated with specific conditions such as lymphoma and granulomatous diseases. We described a case of severe hypercalcaemia consequent to vitamin D intoxication and secondary renal failure in a HIV patient under tenofovir using. Serum creatinine and calcium returned to near normal levels after vitamin D discontinuation, saline and furosemide administration. Some aspects of the drug-induced nephropathy are discussed.
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Affiliation(s)
- F F Tuon
- Department of Infectious and Parasitic Diseases, School of Medicine, University of Sao Paulo, Brazil.
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Egbuna OI, Taylor JG, Bushinsky DA, Zand MS. Elevated calcium phosphate product after renal transplantation is a risk factor for graft failure. Clin Transplant 2007; 21:558-66. [PMID: 17645720 DOI: 10.1111/j.1399-0012.2007.00690.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Abnormal mineral metabolism is not uncommon after renal transplant (TXP). In dialysis patients, elevated serum phosphorous (P), calcium (Ca), CaP product, and parathyroid hormone (PTH) are associated with increased morbidity and mortality. The effect of these abnormalities on recipient and graft survival after renal transplantation is unknown. METHODS We retrospectively analyzed 422 kidney-only transplants performed between June 1996 and June 2003. Cases with graft or recipient survival less than three months, pre-TXP parathyroidectomy (PTX), cinacalcet therapy and incomplete records were excluded, leaving 303 cases for analysis using Cox models that included post-TXP PTX, levels of albumin-adjusted Ca(Ca(adj)), P, Ca(adj)P product and PTH. RESULTS There was an 11-25% prevalence of abnormal serum Ca(adj), P or Ca(adj)P product within the first year post-TXP. At least 24% of recipients not undergoing PTX with an equation estimated GFR of 40-60 mL/min had PTH levels >130 pg/mL at one yr post-TXP. This is above levels recommended by the U.S National Kidney Foundation kidney disease quality initiative for patients with stages I-IV chronic kidney disease. Adjusted Ca > 10.5 mg/dL at three months post-TXP was an independent risk for recipient death (OR 3.0; 95% CI: 1.2-7.4). A Ca(adj)P product >35 mg(2)/dL(2) at six months (OR 4.0; 95% CI: 1.2-13.1), and Ca >10.5 mg/dL at 12 months post-TXP (OR 4.0; 95% CI: 1.2-14) were independent risks for death-censored graft loss. Twenty-two recipients underwent PTX for severe hyperparathyroidism. CONCLUSION Abnormalities of mineral metabolism are common early after renal TXP. An elevated serum Ca(adj) at three months post-TXP increases the risk for recipient death, while an elevated Ca(adj)P and Ca(adj) later in the first post-TXP year increases the risk of long-term death-censored graft loss.
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Affiliation(s)
- Ogo I Egbuna
- Division of Nephrology, Beth Israel Deaconess Medical Center, and Division of Endocrinology and Hypertension - Calcium and Parathyroid Physiology Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Moysés-Neto M, Guimarães FM, Ayoub FH, Vieira-Neto OM, Costa JAC, Dantas M. Acute renal failure and hypercalcemia. Ren Fail 2006; 28:153-9. [PMID: 16538974 DOI: 10.1080/08860220500531005] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Hypercalcemia can result from excessive bone resorption, renal calcium retention, excessive intestinal calcium absorption, or a combination of these conditions. Hypercalcemia may also provoke acute renal failure (ARF) or hypertension, or aggravate the tubular necrosis that is frequently found in cases of ARF. The association of ARF and hypercalcemia was studied retrospectively in eight patients based in the data in their charts. Data are expressed as median and percentile (25th; 75th). Our results show that ARF associated with hypercalcemia was related with comorbidity in all cases (cancer, multiple myeloma, hyperparathyroidism, sarcoidosis, vitamin D intoxication, and leprosy). Maximum median serum creatinine levels were 3.3 mg/dL (2.7, 3.8 mg/dL) before treatment and 1.1 mg/dL (0.9, 1.3 mg/dL) after treatment. Maximum total median serum calcium was 15.9 mg/dL (13.5, 19.8 mg/dL) before treatment and 9.1 mg/dL (8.4, 9.7 mg/dL) after treatment. Maximum median ionized serum calcium was 2.1 mmol/L (1.8, 2.2 mmol/L) before treatment and 1.1 mmol/L (1.0, 1.2 mmol/L) after treatment. Different kinds of treatment induced a rapid fall in serum calcium concentration. All patients were treated with hydration and diuretics, and three patients also received calcitonin. Serum creatinine concentration always fell simultaneously with the decrease in serum calcium in all cases. All patients progressed with nonoliguric renal failure. In conclusion, in ARF, patients are frequently hypocalcemic. Usually, the presence of hypercalcemia associated with ARF is indicative of the presence of comorbidity, as observed in all eight patients studied here. There was an improvement of renal function in all cases as serum calcium levels decreased.
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Affiliation(s)
- Miguel Moysés-Neto
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil.
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Abstract
BACKGROUND Severe hypercalcemia can be life-threatening. However, its incidence and the underlying causes in the emergency department (ED) have not been determined. In the present study, we investigated these issues and the impacts on renal function and patients' survival. METHODS We performed a retrospective study to analyze the patients with hypercalcemia in the ED for 1 year. Serum total calcium level greater than 10.3 mg/dL was defined as hypercalcemia. RESULTS During the study period, 321 of 4293 patients (7.5%) were found to have hypercalcemia (serum calcium 11.7 +/- 1.6 mg/dL). Most of them had mild hypercalcemia (calcium level < 12.0 g/dL, 70.7%). Malignancy (36.4%) and uremia (32.4%) were the most common underlying causes. Normal renal function was observed in only 75 (23.4%) of all patients with hypercalcemia. The total mortality rate was 23.1%, and death was associated with male gender, higher calcium level, lower hemoglobin, and malignancy (all P < 0.05). Logistic analysis found that serum calcium and hemoglobin levels were independent risk factors for mortality. CONCLUSIONS Severe hypercalcemia is frequently and life-threatening in the ED. Therefore routine determination of serum calcium level is recommended, and immediate therapy should be initiated to treat the patients at high risk.
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Affiliation(s)
- Chien-Te Lee
- Division of Nephrology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taiwan
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Boom H, Mallat MJK, de Fijter JW, Paul LC, Bruijn JA, van Es LA. Calcium levels as a risk factor for delayed graft function. Transplantation 2004; 77:868-73. [PMID: 15077029 DOI: 10.1097/01.tp.0000116417.03114.87] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Delayed graft function (DGF) occurs in up to 50% of renal transplants. Hypercalcemia and hyperparathyroidism are associated with impaired renal function. Little is known on the effects of serum calcium levels on DGF. This issue was addressed in the current study. METHODS Patients receiving a cadaveric renal transplant between 1986 and 1996 were studied. Data on calcium metabolism and histologic characteristics of nephrocalcinosis, acute tubular necrosis (ATN), and acute rejection in biopsies taken within the first week were related to the occurrence of DGF. RESULTS The incidence of DGF in a cohort of 585 cadaveric transplants was 31%. DGF correlated independently with serum calcium levels (odds ratio [OR] 1.14 [95% confidence interval (CI) 1.04-1.26] per 0.1 mmol/L). The use of calcium channel blockers before transplantation protected against DGF (OR 0.5 [95% CI 0.29- 0.87]). In this selected group, we found an association with histologic signs of ATN and DGF. However, most of the biopsies also had features of acute rejection or nephrocalcinosis. Nephrocalcinosis was found in 12 of 71 biopsies and was not associated with serum calcium levels or the occurrence of DGF. CONCLUSIONS In this study, serum calcium levels were independently associated with DGF. This could not be explained by the presence of microscopic nephrocalcinosis. Therefore, DGF is attributed to high intracellular calcium levels. Because calcium supplementation and vitamin D analogues are commonly used in dialysis practice, hypercalcemia influences long-term graft outcome by its effect on DGF. The pretransplant use of calcium channel blockers has a protective effect on the occurrence of DGF.
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Affiliation(s)
- Henk Boom
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands.
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Kruger JM, Osborne CA, Nachreiner RF, Refsal KR. Hypercalcemia and renal failure. Etiology, pathophysiology, diagnosis, and treatment. Vet Clin North Am Small Anim Pract 1996; 26:1417-45. [PMID: 8911026 DOI: 10.1016/s0195-5616(96)50135-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Hypercalcemia is a frequent disorder of calcium metabolism in dogs and cats. Hypercalcemia-induced alterations in renal function and morphology are linked to many of the clinical manifestations observed in hypercalcemic patients. Since many renal effects induced by hypercalcemia are potentially reversible, early recognition and characterization of the problem facilitates rapid therapeutic intervention.
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Affiliation(s)
- J M Kruger
- Department of Small Animal Clinical Sciences, Michigan State University College of Veterinary Medicine, East Lansing, USA
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Peplow PV. Modification to dietary intake of sodium, potassium, calcium, magnesium and trace elements can influence arachidonic acid metabolism and eicosanoid production. Prostaglandins Leukot Essent Fatty Acids 1992; 45:1-19. [PMID: 1546062 DOI: 10.1016/0952-3278(92)90097-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- P V Peplow
- Department of Anatomy, Medical School, University of Otago, Dunedin, New Zealand
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Rosen S, Greenfeld Z, Bernheim J, Rathaus M, Podjarny E, Brezis M. Hypercalcemic nephropathy: chronic disease with predominant medullary inner stripe injury. Kidney Int 1990; 37:1067-75. [PMID: 2342245 DOI: 10.1038/ki.1990.87] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Because of the recently observed augmentation of medullary hypoxic injury by calcium in isolated perfused rat kidneys (Kidney Int 34:186-194, 1988), renal morphology of chronic, prolonged hypercalcemia was investigated in vivo. Rats were treated with repeated injections of vitamin D2 (400,000 units/week) for two to eight weeks. Chronic elevation of plasma calcium from 2.1 to 2.8 mmol/liter (P less than 0.001) was associated by a fall in maximal urine osmolality with no change in glomerular filtration rate. The most significant morphological alterations occurred in the inner stripe of the outer medulla; these changes were characterized by a sequence of active injury with subsequent destruction and atrophy of the medullary thick ascending limbs, fibroblastic and lymphocytic infiltration, and secondary dilatation of collecting ducts. Similar changes occurred in the medullary rays. These alterations were accompanied by increased renal prostanoid production and a predisposition to acute kidney failure from indomethacin. Because of its selective occurrence in zones of poorest oxygen supply, this inner stripe injury may derive from vulnerability to hypoxia and may play a role in some chronic nephropathies.
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Affiliation(s)
- S Rosen
- Department of Pathology, Beth Israel Hospital, Boston, Massachusetts
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Steel LK, Rafferty MA, Wolfe WW, Egan JE, Kennedy DA, Catravas GN, Jackson WE, Dooley MA. Urinary excretion of cyclic nucleotides, creatinine prostaglandin E2 and thromboxane B2 from mice exposed to whole-body irradiation from an enhanced neutron field. INTERNATIONAL JOURNAL OF RADIATION BIOLOGY AND RELATED STUDIES IN PHYSICS, CHEMISTRY, AND MEDICINE 1986; 50:695-715. [PMID: 3531057 DOI: 10.1080/09553008614551101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Urine volume and excretion of cyclic AMP, cyclic GMP, prostaglandin E2 (PGE2), thromboxane B2 (TxB2) and creatinine were evaluated as potential indicators of radiation damage in mice given 2-5 Gy to the whole body from an enhanced neutron field. In general, urinary cyclic AMP, cyclic GMP, creatinine and urine volumes were positively correlated across time postexposure, for each radiation dose. TxB2 levels positively correlated with urine volume and cyclic AMP excretion only in animals given 2.0 Gy. None of these parameters suggests their use as a prognostic indicator of the extent of radiation damage. Urinary excretion of PGE2 was negatively correlated with other urinary parameters. Biphasic increases in urinary PGE2 were also observed. The initial transient elevation 2-3 days postexposure was not correlated with the dose (2-5 Gy). The second elevation of PGE2 excretion occurred at 6-10 days. The magnitude of the latter increase suggests that urinary PGE2 excretion may be a useful indicator of whole-body or kidney exposure to neutron fields.
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Teitelbaum I, Berl T. Effects of calcium on vasopressin-mediated cyclic adenosine monophosphate formation in cultured rat inner medullary collecting tubule cells. Evidence for the role of intracellular calcium. J Clin Invest 1986; 77:1574-83. [PMID: 3009546 PMCID: PMC424561 DOI: 10.1172/jci112473] [Citation(s) in RCA: 36] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
We explored the effects of alterations in extracellular and intracellular calcium concentration on arginine vasopressin (AVP)-stimulated cAMP formation in cultured rat inner medullary collecting tubule cells. cAMP formation remains constant at extracellular calcium concentrations between 0.5 and 4.0 mM, which did not change intracellular calcium. Maneuvers that alter intracellular calcium concentration are associated with marked changes in cAMP generation. EGTA decreases intracellular calcium and enhances AVP-stimulated cAMP formation, while increasing cellular calcium with 2 microM A23187 decreases AVP-stimulated cAMP formation in the presence, but not in the absence, of extracellular calcium. The changes in cAMP formation observed when intracellular calcium is altered are associated with reciprocal changes in prostaglandin E2 (PGE2) synthesis. Despite greater than 95% inhibition of PGE2 synthesis with 5 microM meclofenamic acid, the changes in cAMP formation accompanying alterations in intracellular calcium concentration are still evident. These studies suggest that intracellular calcium critically influences AVP-stimulated cAMP formation. It does so by a mechanism independent of PG that is probably mediated by a direct effect of the cation on the adenylate cyclase complex.
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Nadler JL, McKay M, Campese V, Vrbanac J, Horton R. Evidence that prostacyclin modulates the vascular actions of calcium in man. J Clin Invest 1986; 77:1278-84. [PMID: 3514678 PMCID: PMC424475 DOI: 10.1172/jci112431] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Increases in extracellular calcium (Ca++) can alter vascular tone, and thus may result in increased blood pressure (Bp) and reduced renal blood flow (RBF). Ca++ can stimulate prostaglandin E2 (PGE2) and/or prostacyclin (PGI2) release in vitro, which may modulate Ca++ vascular effects. However, in man, the effect of Ca++ on PG release is not known. To study this, 14 volunteers received low-dose (2 mg/kg Ca++ gluconate) or high-dose (8 mg/kg) Ca++ infusions. The low-dose Ca++ infusion did not alter systemic or renal hemodynamics, but selectively stimulated PGI2, as reflected by the stable metabolite 6-keto-PGF1 alpha in urine (159 +/- 21-244 +/- 30 ng/g creatinine, P less than 0.02). The same Ca++ infusion given during cyclooxygenase blockade with indomethacin or ibuprofen was not associated with a rise in PGI2 and produced a rise in Bp and fall in RBF. However, sulindac, reported to be a weaker renal PG inhibitor, did not prevent the Ca++ -induced PGI2 stimulation (129 +/- 33-283 +/- 90, P less than 0.02), and RBF was maintained despite similar increases in Bp. The high-dose Ca++ infusion produced an increase in mean Bp without a change in cardiac output, and stimulated urinary 6-keto-PGF1 alpha to values greater than that produced by the 2-mg/kg Ca++ dose (330 +/- 45 vs. 244 +/- 30, P less than 0.05). In contrast, urinary PGE2 levels did not change. A Ca++ blocker, nifedipine, alone had no effect on Bp or urinary 6-keto-PGF1 alpha levels, but completely prevented the Ca++ -induced rise in Bp and 6-keto-PGF1 alpha excretion (158 +/- 30 vs. 182 +/- 38, P greater than 0.2). However, the rise in 6-keto-PGF1 alpha was not altered by the alpha 1 antagonist prazosin (159 +/- 21-258 +/- 23, P less than 0.02), suggesting that calcium entry and not alpha 1 receptor activation mediates Ca++ pressor and PGI2 stimulatory effects. These data indicate a new vascular regulatory system in which PGI2 modulates the systemic and renal vascular actions of calcium in man.
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Berl T, Levi M, Ellis M, Chaimovitz C. Mechanism of acute hypercalcemic hypertension in the conscious rat. Hypertension 1985; 7:923-30. [PMID: 4077224 DOI: 10.1161/01.hyp.7.6.923] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Acute hypercalcemia in the conscious, unanesthetized rat, achieved by a 30-minute infusion of CaCl2 (serum calcium level, 12.8 +/- 0.6 mg/dl) resulted in significant elevation of mean arterial pressure (from 112 +/- 2 mm Hg to 129 +/- 3 mm Hg, p less than 0.001). This pressor response was associated with a significant increase in systemic vascular resistance, from 0.45 +/- 0.02 mm Hg/(ml/min)/kg body weight to 0.50 +/- 0.02 mm Hg/(ml/min)/kg body weight (p less than 0.05), but it caused no alteration in cardiac index. The pressor response to acute hypercalcemia does not appear to be mediated by vasopressor hormones or attenuated by vasodepressor hormones since inhibition of the renin-angiotensin system (nephrectomy), catecholamines (central and peripheral 6-hydroxydopamine), vasopressin (vascular antagonist), prostaglandins (indomethacin), and parathyroid hormone (parathyroidectomy) did not significantly alter the pressor response to infusion of CaCl2 in spite of similar serum calcium levels in all groups of animals. Rather, the pressor response to acute hypercalcemia seems to be mediated by a direct action of calcium ion on smooth muscle and perhaps myocardial cell contractility, since pretreatment with the calcium channel blockers verapamil or nifedipine blocked the pressor response to acute hypercalcemia.
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Iseki K, Massry SG, Campese VM. Evidence for a role of PTH in the reduced pressor response to norepinephrine in chronic renal failure. Kidney Int 1985; 28:11-5. [PMID: 4046321 DOI: 10.1038/ki.1985.111] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Reduced pressor response to norepinephrine (NE) is present in patients with chronic renal failure (CRF) and is responsible partly for some of the manifestations of autonomic nervous system dysfunction in these patients. PTH blunts the pressor response to NE in normal rats, suggesting that excess PTH in CRF may be responsible for this abnormality. However, the relative roles of uremia and of excess PTH in the uremic state in the genesis of this abnormality are not defined. The present study examines this question. Rats with chronic renal failure display reduced pressor response to NE administration, but this derangement can be prevented by prior parathyroidectomy and abolished by administration of indomethacin. The role of PTH in the genesis of this abnormality can also be demonstrated in the hind limb preparation obtained from rats with CRF. Our data show that excess PTH and not other consequences of CRF plays a paramount pathogenetic role in the reduced pressor response to NE and that this effect of PTH is due to a direct action on the blood vessels. Further, this hormone action is most likely mediated through increased production of vasodilating prostaglandins. These observations are constant with the idea that PTH would contribute to the pathogenesis of some of the manifestations of autonomic nervous system dysfunction in CRF.
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