Carolina Lara Neves

Hypercalcemia and acute kidney injury caused by abuse of a parenteral veterinary compound containing vitamins A, D, and E

A previously healthy 19 year-old male presented to the hospital with anorexia, nausea, and vomiting. Laboratory studies were significant for hypercalcemia (peak calcium value of 14.8 mg/dL) and acute kidney injury (peak serum creatinine of 2.88 mg/dL). He admitted to using a parenteral formulation of vitamins A, D and E restricted for veterinary use containing 20,000,000 IU of vitamin A; 5,000,000 IU of vitamin D3; and 6,800 IU of vitamin E per 100 mL vial. The patient stated to have used close to 300 mL of the product over the preceding year. Interestingly, the young man was not interested in the massive amounts of vitamins that the product contained; he was only after the local effects of the oily vehicle. The swelling produced by the injection resulted in a silicone-like effect, which gave the impression of bigger muscles. Nevertheless, the product was absorbed and caused hypervitaminosis. The serum level of 25(OH) vitamin D was clearly elevated at 150 ng/mL (reference range from 30 to 60 ng/mL), but in most published cases of vitamin D toxicity, serum levels have been well above 200 ng/mL. His PTH level was undetectable and other potential causes of hypercalcemia were excluded. Therefore, we posit that the severity of the hypercalcemia observed in this case was the result of a synergistic effect of vitamins A and D. The patient was treated with normal saline, furosemide and zolendronic acid, with rapid normalization of calcium levels and renal function.

Situação do hiperparatireoidismo secundário autônomo no Brasil: dados do Censo Brasileiro de Paratireoidectomia

INTRODUCTION Secondary hyperparathyroidism (SHP) is a common and serious complication of chronic kidney disease (CKD), with a negative impact on morbidity and mortality. Despite advances in the clinical management of SHP, treatment failure still occurs in a significant number of patients. In such cases, parathyroidectomy (PTx) is indicated. OBJECTIVE To have an overview of the prevalence of severe SHP and of its surgical treatment in hemodialysis (HD) patients in Brazil. METHODS This was an observational and descriptive study. Data were obtained from questionnaires posted to 660 dialysis units (DU). RESULTS Results are expressed in absolute values and percentages, or means and standard deviation, as appropriate. 226 (34%) DU answered the questionnaire, providing data about 32,264 HD patients. The prevalence rate of severe SHP (PTH > 1,000 pg/mL) was 10.7 % (n = 3,463). 68 hospitals countrywide perform PTX. Around 40% of them are university centers. 49 (21.7%) DU reported not to have a specialized medical center to refer their patients with severe SHP. 74 (33%) DU reported that the time interval between surgery indication and its performance was over 6 months. The main recognized obstacles to surgery performance were: difficulty to perform the preoperative exams, lack of head and neck surgeons and the long waiting time. CONCLUSIONS Although severe SHP is highly prevalent in Brazil, a significant number of patients do not have access to PTx. Better public health policies and liaison between nephrologists and head and neck surgeons are urgently required to change this reality.INTRODUCTION: Secondary hyperparathyroidism (SHP) is a common and serious complication of chronic kidney disease (CKD), with a negative impact on morbidity and mortality. Despite advances in the clinical management of SHP, treatment failure still occurs in a significant number of patients. In such cases, parathyroidectomy (PTx) is indicated. OBJECTIVE: To have an overview of the prevalence of severe SHP and of its surgical treatment in hemodialysis (HD) patients in Brazil. METHODS: This was an observational and descriptive study. Data were obtained from questionnaires posted to 660 dialysis units (DU). RESULTS: Results are expressed in absolute values and percentages, or means and standard deviation, as appropriate. 226 (34%) DU answered the questionnaire, providing data about 32,264 HD patients. The prevalence rate of severe SHP (PTH > 1,000 pg/mL) was 10.7 % (n = 3,463). 68 hospitals countrywide perform PTX. Around 40% of them are university centers. 49 (21.7%) DU reported not to have a specialized medical center to refer their patients with severe SHP. 74 (33%) DU reported that the time interval between surgery indication and its performance was over 6 months. The main recognized obstacles to surgery performance were: difficulty to perform the preoperative exams, lack of head and neck surgeons and the long waiting time. CONCLUSIONS: Although severe SHP is highly prevalent in Brazil, a significant number of patients do not have access to PTx. Better public health policies and liaison between nephrologists and head and neck surgeons are urgently required to change this reality.

Protocolo clínico e diretrizes terapêuticas para o tratamento do hiperparatireoidismo secundário em pacientes com doença renal crônica

INTRODUCAO A doenca renal cronica (DRC) afeta 5-10% da populacao mundial e sua incidencia no Brasil tem aumentado, devido ao numero crescente de pacientes diagnosticados, principalmente os portadores de diabetes mellitus, hipertensao arterial, bem como pelo aumento da longevidade da populacao. […] Protocolo clinico e diretrizes terapeuticas para o tratamento do hiperparatireoidismo secundario em pacientes com doenca renal cronica1 Serviço de Nefrologia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil. 2 Serviço de Nefrologia da Universidade Federal de São Paulo, São Paulo, Brasil. 3 Escola de Medicina, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brasil. 4 Departamento de Medicina Interna da Universidade Federal da Bahia, Brasil. 5 Serviço de Nefrologia da Universidade Federal do Rio Grande do Sul, Brasil. 6 Serviço de Nefrologia da Universidade Federal Fluminense, Niterói, RJ, Brasil. 7 Serviço de Nefrologia da Universidade Federal de Pernambuco, Brasil.

Guidelines on Bone Mineral Disorder in Chronic Kidney Disease - Addendum Chapter 2

1 – AVALIACAO DOS NIVEIS DE PARATORMONIO (PTH) E FOSFATASE ALCALINA (FA) NA DRC 1.1 – Os niveis sericos de PTH devem ser analisados em todos os pacientes com DRC, cuja taxa de filtracao glomerular (TFG) for inferior a 60 mL/min/1,73 m2 (Evidencia). Deve-se modificar a frequencia de avaliacao dos niveis sericos de PTH se os resultados das analises mostrarem uma tendencia de elevacao ou de descenso ou apos a instituicao do tratamento, seja ele para reduzir ou elevar os [...]

Distúrbio mineral e ósseo após o transplante renal

O transplante renal (TxR) e a melhor alternativa de tratamento para os pacientes com DRC avancada. Entretanto, apesar do sucesso dessa terapia, os pa-cientes submetidos ao TxR podem apresentar elevada incidencia de complicacoes, dentre elas a persistencia da doenca ossea, piorando a qualidade de vida e au-mentando a morbimortalidade. O TxR bem sucedido geralmente corrige ou melhora os disturbios do meta -bolismo mineral e osseo (DMO) da DRC, e a persis-tencia dessas alteracoes sao determinadas pela magni -tude das anormalidades no periodo dialitico, disfun-cao do enxerto e acao de drogas imunossupressoras. Muitas das alteracoes do metabolismo mineral que ocorrem logo apos o TxR tendem a se normali-zar no decorrer do primeiro ano. A hipofosfatemia, acompanhada de fosfaturia, ocorre em 90% dos pa-cientes transplantados, e geralmente apresenta reso-lucao do quadro ate o terceiro mes, permanecendo no limite inferior da normalidade.

Fórum nacional de discussão das diretrizes do KDIGO para o distúrbio mineral e ósseo da doença renal crônica (DMO-DRC): uma análise crítica frente à relidade brasileira

On November 14th, 2009, the Brazilian Society of Nephrology coordinated the Brazilian Discussion Meeting on the new KDIGO (Kidney Disease: Improving Global Outcomes) guidelines. The purpose of this meeting, which was attended by 64 nephrologists, was to discuss these new guidelines from the Brazilian perspective. This meeting was supported by an unrestricted grant of the biotechnology company Genzyme, which did not have access to the meeting room or to the discussion sections. This article brings a summary of the KDIGO guidelines and of the discussions by the attendees.

Brazilian Registry of Bone Biopsy (REBRABO): design, data elements and methodology

INTRODUCTION Mineral bone disorder (MBD) is a common condition in chronic kidney disease (CKD) patients and causes significant morbidity and mortality. Data involving prevalence of alterations in bone histological patterns, impact of different treatments and its repercussion in outcomes, such as bone fractures, hospitalization, cardiovascular disease and mortality, are scarce. Data bank registry can be a valuable tool to understand epidemiological aspects of MBD CKD. The Brazilian Registry of Bone Biopsy (REBRABO) will be a national registry, coordinating by the Brazilian Society of Nephrology - Committee of MBD-CKD. OBJECTIVE To describe REBRABOs design, elements of data and methodology. METHODS Will be an online national observational and multicentric data registry divided in two phases (retrospective, 1st phase) and prospective (2nd phase), including information from bone tissue histomorphometric analysis and demographics, clinical and laboratorial data from CKD-MBD patients. RESULTS The REBRABOs first phase will explore data on demographics, clinical, laboratorial and bone histomorphometric analysis data from January/1986 to December/2013. The first RESULTS are expected in early 2015. CONCLUSION Studies in the field of CKD-MBD are needed, particularly those analyzing its prevalence, associations between demographic, clinical, histological parameters, and major outcomes. The REBRABO will be a unique retrospective and prospective research platform including bone biopsy data in CKD-MBD patients.