Emanuel Ferreira

Gitelman syndrome with hiponatremia, a rare presentation.

CASE REPORT A 34 year old caucasian woman with no prior medical presented with severe hypokalemia; hypomagnesemia and mild hyponatremia. Her past medical and family history were unremarkable. She was on no medication and denied any symptoms, unless for occasionally muscle cramps. Water intake ≥3L/ day. She was normotensive, no edemas and normal urine output. The review of systems was otherwise negative.

Sodium and Potassium Intake, the First Step to Control Arterial Hypertension

In Portugal, Hypertension affects 43% of adults. Salt intake reduction and potassium increase are recommended for prevention and treatment of hypertension. This study was designed to determine how dietary sodium and potassium affects blood pressure (BP). Cross-sectional study of 41 patients was made in Centro Hospitalar de Coimbra. Patients BP, as well as their 24-hour urinary excretion of sodium (UNa) and potassium (UK); UNa/UK ratio was calculated. There were highly significant differences for both diastolic BP (DBP) and sistolic BP (SBP) means according to 24h-UNa and UNa/UK values (p 0.001). There was a highly correlation between BP and 24h-UNa, as well as, UNa/UK; stronger with this latest factor. Among BP values, SBP was strongly influenced by 24h-UNa and UNa/UK than DBP (Pearson 0.608 > 0.578 and 0.675 > 0.633, respectively). So, increased potassium intake should be considered as a recommendation for prevention and treatment of hypertension, especially in those who are unable to reduce their intake of sodium.

Subcapsular liver hematoma as a complication of an atypical hemolytic uremic syndrome.

Atypical hemolytic uremic syndrome (aHUS) is a rare, lifethreatening systemic inflammatory disease that presents classically with microangiopathic hemolytic anemia, thrombocytopenia and acute kidney injury.1 Extra renal manifestations are observed in 20% of patients.2 A 42-year-old woman with unremarkable past medical history presented in our hospital reporting a 6-day history of headache, nausea and vomiting. Physical examination showed hypertension (220/120 mmHg), cutaneous pallor and moderate lower limbs edema. Laboratory results revealed anemia (hemoglobin 8.4 g/dl), thrombocytopenia (76,000/ l), severe azotemia (urea 16.9 mmol/l, creatinine 448.8 mol/l), schistocytosis, a negative Coombs test, low blood haptoglobin (<0.07 g/L) and high lactate dehydrogenase levels (1234 U/l). Renal ultrasonography was normal. Blood pressure was hardly controlled with oral medication. A diagnosis of acute thrombotic microangiopathy (ATM) was made and daily plasma exchange (PEX) was started. Investigations for secondary causes of ATM (pregnancy, auto-immune disease, malignancy, drug-induced), infectioninduced HUS and thrombotic thrombocytopenic purpura were normal. A presumptive diagnosis of aHUS was made and the administrative process of Eculizumab acquisition was initiated. On the 15th day of admission (D15), hemodialysis was started due to progressive renal failure. All attempts to stop PEX resulted in increased hemolytic activity, forcing to maintain 3 sessions a week. On the D72, after performing 44 PEX sessions, we were still waiting for Eculizumab acquisition. Attending to clinical and analytical stability (Fig. 1), the patient was discharged home to continue hemodialysis and PEX three times a week as an outpatient. Four days after discharge, she was admitted in the emergency room with a 12-hour history of severe right upper quadrant pain and vomiting without history of trauma. Laboratory results revealed stabilized hemoglobin (11.1 g/dl) and both normal platelet count (157,000/mm3) and coagulation tests. Abdominal ultrasonography and Computed Tomography scan showed a large subcapsular liver hematoma (SLH) (Fig. 2). She was transferred to the Intensive Care Unit (ICU). Attending to hemodynamic stability, a conservative approach was attempted. PEX was suspended to prevent increased