RESUMEN
Heart failure (HF) is characterized by the activation of adverse neurohormonal systems and a high mortality rate. Noteworthy, HF is a well-known complication of chronic kidney disease (CKD), especially in end-stage kidney disease (ESKD), where dialysis patients are seven to eight times more likely to encounter cardiac arrest than the general population. Therefore, it is important to develop efficient treatments to improve cardiac function in dialysis patients and eventually reduce the cardiovascular death toll. Sacubitril/valsartan (Sac/Val) is a dual inhibitor/blocker of the neprilysin and angiotensin II receptors, which exert cardioprotective effects among patients with heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved EF (HFpEF). Unfortunately, the drug is not approved for subjects with advanced CKD or dialysis patients due to safety concerns. The current study examined the cardiac effects of Sac/Val in HD patients. Administration of Sac/Val (100-400 mg/day) to 12 hemodialysis (HD) patients with HFrEF for six months gradually improved ejection fraction (EF) independently of morphological changes in cardiac geometry, as assessed by echocardiography (ECHO), and hemodynamic alterations. Interestingly, the Cardiomyopathy Questionnaire (Kansas City KCCQ-12) revealed that quality of life significantly improved after Sac/Val treatment. No major adverse effects were reported in the present study, supporting the safety of Sac/Val at least in these patients and for the applied follow-up period. Collectively, these findings support the use of Sac/Val as a cardioprotective agent in both HD and peritoneal dialysis (PD) patients. Yet, a more comprehensive study is required to establish these findings and to extend the follow-up period for 12 months in order to solidify these encouraging results.
RESUMEN
BACKGROUND Tumor lysis syndrome is common in hematological malignancy, but less frequent in chronic and solid tumors. Almost always it is observed after chemotherapy or radiotherapy initiation, but rarely occurs spontaneously. CASE REPORT A 89-year-old female with stable chronic lymphocytic leukemia was admitted to the hospital because of worsening dyspnea and dry cough. Her vital signs were normal, except for sinus tachycardia. On physical examination, she appeared distressed, dyspneic, sweaty but afebrile, anxious, but alert and well oriented. Lung examination revealed reduced air entry with bibasilar crackles. No peripheral edema was seen, pulses were normal, and no signs of deep vein thrombosis were observed. Laboratory analysis revealed leukocytosis; but normal hematological and biochemical parameters. Intravenous (IV) furosemide and antibiotics (IV ceftriaxone and orally azithromycin) were started along with steroid therapy (methylprednisolone 62.5 mg, IV). The treatment with steroids lasted for 1 day only, and in the following day, the patient was switched to prednisone (20 mg/day orally) for only 1 additional day. White blood cell count increased on day 1, 2 and 3 after admission, along development of hyperuricemia, hyperphosphatemia, hyperkalemia, acute renal failure and elevated troponin levels. Hemodiafiltration/hemodialysis was initiated, and the patient was discharged after serum concentrations of these electrolytes and kidney function were restored. One month after discharge, the patient denied any malaise and was at stable condition. CONCLUSIONS Herein, we present a case of a patient with stable chronic lymphocytic leukemia, who developed spontaneous tumor lysis syndrome after short low dose of steroid therapy. This case highlights the importance of including spontaneous tumor lysis syndrome in the differential diagnosis of any acute renal failure in the constellation of any malignancy.