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BACKGROUND: The aim of our study was to describe seasonal trends of acute kidney injury (AKI) and its relationship with weather conditions in a hospitalized population. METHODS: We retrospectively collected demographic (age, sex), clinical (ICD-9-CM codes of diagnosis discharge) and laboratory data (creatinine values) from the inpatient population admitted to Fondazione Policlinico Universitario A. Gemelli IRCCS between January 2010 and December 2014 with inclusion of all patients ≥18 years with at least two values available for creatinine. The outcome of interest was AKI development, defined according to creatinine kinetics criteria. The exposures of interest were the months and seasons of the year; air temperature and humidity level were also evaluated. Log-binomial regression models adjusted for age, sex, eGFR, comorbidities, Charlson/Deyo index score, year of hospitalization were used to estimate risk ratios (RR) and 95% confidential intervals (CI). RESULTS: A total of 64,610 patients met the inclusion criteria. AKI occurred in 2864 (4.4%) hospital admissions. After full adjustment, winter period was associated with increased risk of AKI (RR 1.16, 95% CI 1.05, 1.29, p=0.003). Lower air temperature and higher humidity level were associated with risk of AKI, however in multivariable-adjusted models only higher humidity level showed a significant and independent association. CONCLUSIONS: AKI is one of the most common complications of hospitalized populations with a defined seasonal pattern and a significant increase in incidence during wintertime; weather conditions, particularly higher humidity level, are independent predictors of AKI and could partially justify the observed seasonal variations.
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Lesión Renal Aguda/epidemiología , Hospitalización/estadística & datos numéricos , Estaciones del Año , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Incidencia , Italia/epidemiología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Centros de Atención TerciariaRESUMEN
BACKGROUND/AIMS: Aim of our study was to describe the association between natremia (Na) fluctuation and hospital mortality in a general population admitted to a tertiary medical center. METHODS: We performed a retrospective observational cohort study on the patient population admitted to the Fondazione Policlinico A. Gemelli IRCCS Hospital between January 2010 and December 2014 with inclusion of adult patients with at least 2 Na values available and with a normonatremic condition at hospital admission. Patients were categorized according to all Na values recorded during hospital stay in the following groups: normonatremia, hyponatremia, hypernatremia, and mixed dysnatremia. The difference between the highest or the lowest Na value reached during hospital stay and the Na value read at hospital admission was used to identify the maximum Na fluctuation. Cox proportional hazards models were used to estimate hazard ratios (HRs) for in-hospital death in the groups with dysnatremias and across quartiles of Na fluctuation. Covariates assessed were age, sex, highest and lowest Na level, Charlson/Deyo score, cardiovascular diseases, cerebrovascular diseases, dementia, congestive heart failure, severe kidney disease, estimated glomerular filtration rate, and number of Na measurements during hospital stay. RESULTS: 46,634 admissions matched inclusion criteria. Incident dysnatremia was independently associated with in-hospital mortality (hyponatremia: HR 3.11, 95% CI 2.53, 3.84, p < 0.001; hypernatremia: HR 5.12, 95% CI 3.94, 6.65, p < 0.001; mixed-dysnatremia: HR 4.94, 95% CI 3.08, 7.92, p < 0.001). We found a higher risk of in-hospital death by linear increase of quartile of Na fluctuation (p trend <0.001) irrespective of severity of dysnatremia (HR 2.34, 95% CI 1.55, 3.54, p < 0.001, for the highest quartile of Na fluctuation compared with the lowest). CONCLUSIONS: Incident dysnatremia is associated with higher hospital mortality. Fluctuation of Na during hospital stay is a prognostic marker for hospital death independent of dysnatremia severity.
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Mortalidad Hospitalaria , Sodio/metabolismo , Adulto , Anciano , Estudios de Cohortes , Femenino , Hospitalización , Humanos , Hipernatremia , Hiponatremia , Masculino , Persona de Mediana Edad , Pronóstico , Modelos de Riesgos ProporcionalesRESUMEN
INTRODUCTION: Dent's disease is a rare X-linked recessive disorder that manifests in childhood or early adulthood and can lead to end-stage renal disease (ESRD). It occurs in males, who are hemizygous. In patients who develop ESRD, a deceased donor kidney transplant cures the disease. Females are obligate carriers of the mutated gene, and some show a mild Dent's disease phenotype. There may be reason for concern when considering a female obligate carrier (i.e., the mother) for kidney donation because of the risk of kidney function deterioration. CASE PRESENTATION: We describe the first successful kidney transplantation involving a patient with type 1 Dent's disease and ESRD given a kidney by an obligate carrier of the gene mutation, his mother. CONCLUSIONS: After careful assessment of the female obligate carriers, intrafamilial kidney donation in Dent's disease type 1 is feasible. No deteriorating renal function in the donor was observed.
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Enfermedad de Dent/terapia , Trasplante de Riñón/métodos , Niño , Femenino , Humanos , Donadores Vivos , Masculino , MadresRESUMEN
Pulmonary-renal syndromes (PRS) are characterized by the simultaneous presence of diffuse alveolar hemorrhage and acute glomerulonephritis. The most common causes of PRS are ANCA-associated vasculitides, Goodpasture's syndrome and systemic lupus erythematosus. The clinical picture of PRS includes hemoptysis (not always present), acute-onset anemia and renal abnormalities ranging from isolated urinary abnormalities to rapidly progressive glomerulonephritis. The severity of the pulmonary involvement determines the mortality risk as well as the need for mechanical ventilation in intensive care. The diagnosis of PRS is based upon clinical, serological, radiological and histological findings. Immunosuppressive therapy, along with an adequate support therapy (especially aimed at avoiding microbial infection), needs to be started promptly and effectively to reduce both the mortality risk and long-term complications such as end-stage renal disease.
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Glomerulonefritis , Hemorragia , Enfermedades Pulmonares , Glomerulonefritis/diagnóstico , Glomerulonefritis/terapia , Hemorragia/diagnóstico , Hemorragia/terapia , Humanos , Enfermedades Pulmonares/diagnóstico , Enfermedades Pulmonares/terapiaRESUMEN
Hyponatremia is one of the most frequent ion and water disorders. It is generally due to disproportionate renal water retention. Severe hyponatremia (<125 mEq/L) is associated with well-known clinical symptoms and manifestations. However, even mild reductions in sodium blood levels have been shown to be associated with increased mortality and with the risk of falls and fractures. The diagnosis of hyponatremia, although requiring simple clinical and laboratory tests, may be complex and difficult. Treatment should be tailored to the clinical manifestations and severity of hyponatremia. Vaptans may be used in euvolemic or hypervolemic hyponatremia and particularly in SIADH.
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Hiponatremia/diagnóstico , Hiponatremia/terapia , Humanos , Hiponatremia/etiología , Hiponatremia/fisiopatología , Guías de Práctica Clínica como AsuntoRESUMEN
Aim of our study was to analyze the association between serum sodium (Na) variability and acute kidney injury (AKI) development. We performed a retrospective observational cohort study on the inpatient population admitted to Fondazione Policlinico Universitario A. Gemelli IRCCS between January 1, 2010 and December 31, 2014 with inclusion of adult patients with ≥ 2 Na and ≥ 2 serum creatinine measurements. We included only patients with ≥ 2 Na measurements before AKI development. The outcome of interest was AKI. The exposures of interest were hyponatremia, hypernatremia and Na fluctuations before AKI development. Na variability was evaluated using the coefficient of variation (CV). Multivariable Cox proportional hazards and logistic regression models were fitted to obtain hazard ratios (HRs), odds ratios (ORs) and 95% confidence intervals (CIs) for the association between the exposures of interest and AKI. Overall, 56,961 patients met our inclusion criteria. During 1541 person-years of follow-up AKI occurred in 1450 patients. In multivariable hazard models, patients with pre-existent dysnatremia and those who developed dysnatremia had a higher risk of AKI compared with patients with normonatremia. Logistic models suggested a higher risk for AKI in the 3rd (OR 1.41, 95% CI 1.18, 1.70, p < 0.001) and 4th (OR 1.53, 95% CI 1.24, 1.91, p < 0.001) highest quartiles of Na CV with a significant linear trend across quartiles (p trend < 0.001). This association was also independent from Na highest and lowest peak value. Dysnatremia is a common condition and is positive associated with AKI development. Furthermore, high Na variability might be considered an independent early indicator for kidney injury development.
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Lesión Renal Aguda/sangre , Sodio/sangre , Anciano , Biomarcadores/sangre , Creatinina/sangre , Femenino , Hospitalización , Humanos , Hipernatremia/sangre , Hiponatremia/sangre , Italia , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
Bone disorders are a common complication of chronic kidney disease (CKD), obesity and gut malabsorption. Secondary hyperparathyroidism (SHPT) is defined as an appropriate increase in parathyroid hormone (PTH) secretion, driven by either reduced serum calcium or increased phosphate concentrations, due to an underlying condition. The available evidence on the effects of dietary advice on secondary hyperparathyroidism confirms the benefit of a diet characterized by decreased phosphate intake, avoiding low calcium and vitamin D consumption (recommended intakes 1000-1200 mg/day and 400-800 UI/day, respectively). In addition, low protein intake in CKD patients is associated with a better control of SHPT risk factors, although its strength in avoiding hyperphosphatemia and the resulting outcomes are debated, mostly for dialyzed patients. Ultimately, a consensus on the effect of dietary acid loads in the prevention of SHPT is still lacking. In conclusion, a reasonable approach for reducing the risk for secondary hyperparathyroidism is to individualize dietary manipulation based on existing risk factors and concomitant medical conditions. More studies are needed to evaluate long-term outcomes of a balanced diet on the management and prevention of secondary hyperparathyroidism in at-risk patients at.
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Huesos/fisiopatología , Dieta/efectos adversos , Hiperparatiroidismo Secundario/fisiopatología , Minerales/sangre , Insuficiencia Renal Crónica/sangre , Calcio/sangre , Dieta/métodos , Ingestión de Alimentos/fisiología , Humanos , Hiperparatiroidismo Secundario/etiología , Hiperparatiroidismo Secundario/prevención & control , Fenómenos Fisiológicos de la Nutrición/fisiología , Hormona Paratiroidea/sangre , Fosfatos/sangre , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/dietoterapia , Factores de Riesgo , Vitamina D/sangreRESUMEN
BACKGROUND: Environmental factors have been associated with the outbreak of chronic kidney disease (CKD). We evaluated the association of Cadmium (Cd) exposure with the risk of CKD in U.S. adults who participated in the 1999-2006 National Health and Nutrition Examination Surveys (NHANES). METHODS: 5426 subjects > or = 20 years were stratified for values of urinary and blood Cd and a multivariate logistic regression was performed to test the association between blood and urinary Cd, CKD and albuminuria (ALB) after adjustment for age, gender, race/ethnicity, body mass index and smoking habits. RESULTS: Subjects with urinary Cd > 1 mcg/g and subjects with blood Cd > 1 mcg/L showed a higher association with ALB (OR 1.63, 95% CI 1.23, 2.16; P = 0.001). Subjects with blood Cd > 1 mcg/L showed a higher association with both CKD (OR 1.48, 95% CI 1.01, 2.17; P = 0.046) and ALB (OR 1.41, 95% CI 1.10, 1.82; P = 0.007). An interaction effect on ALB was found for high levels of urinary and blood Cd (P = 0.014). CONCLUSIONS: Moderately high levels of urinary and blood Cd are associated with a higher proportion of CKD and ALB in the United States population.
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Cadmio/sangre , Cadmio/orina , Exposición a Riesgos Ambientales/efectos adversos , Enfermedades Renales/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Cadmio/toxicidad , Niño , Enfermedad Crónica , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Encuestas Nutricionales , Oportunidad Relativa , Riesgo , Estados Unidos/epidemiología , Adulto JovenRESUMEN
The aim of this observational retrospective cohort study was to analyze the association between hyperchloremia and serum chloride variation with in-hospital acute kidney injury (AKI) and mortality in a general, no-ICU hospitalized population. We performed a retrospective study on inpatient population admitted to Fondazione Policlinico Universitario A. Gemelli IRCCS between January 2010 and December 2014 with inclusion of adult patients with at least two values available for chloride, sodium and creatinine. Hyperchloremia was defined as serum chloride concentration ≥ 108 mmol/L (moderate hyperchloremia: chloremia between 108-110 mmol/L, severe hyperchloremia: chloremia > 110 mmol/L). According to the time of onset of the electrolyte disturbance, hyperchloremia was then classified as hospital acquired (HA) and community acquired (CA). In patients with HA-hyperchloremia, chloride variation (ΔCl) was calculated. In-hospital AKI was defined according to creatinine kinetics criteria occurring 48 h after hospital admission. Logistic regression analysis was used to evaluate the association between the exposures of interest and in-hospital AKI and mortality. A total of 24,912 hospital admissions met the inclusion criteria. Regression analyses showed that only severe HA-hyperchloremia was associated with increased risk of in-hospital AKI [odds ratio (OR) 2.60, 95% confidence interval (CI) 1.58, 4.30, p value < 0.001] and death (OR 3.89, 95% CI 2.11, 7.18, p value < 0.001). With increasing ΔCl, the OR of in-hospital AKI increased progressively (p value for trend = 0.005). In conclusion, severe hyperchloremia is an independent predictor for in-hospital AKI and mortality; HA-hyperchloremia is more detrimental for patient outcome; higher ΔCl from hospital admission is associated with increased risk of AKI.
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Lesión Renal Aguda/complicaciones , Cloruros/análisis , Lesión Renal Aguda/sangre , Lesión Renal Aguda/fisiopatología , Anciano , Anciano de 80 o más Años , Cloruros/sangre , Estudios de Cohortes , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Habitaciones de Pacientes/organización & administración , Habitaciones de Pacientes/estadística & datos numéricos , Análisis de Regresión , Estudios Retrospectivos , Factores de Riesgo , Desequilibrio Hidroelectrolítico/sangre , Desequilibrio Hidroelectrolítico/etiologíaRESUMEN
BACKGROUND: Atypical hemolytic uremic syndrome (aHUS) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and renal failure. Mutations in CFI gene coding for complement regulation factors and in THBD gene coding for endothelial cell receptor thrombomodulin could predispose to the disease and hypertension can trigger the onset. CASE PRESENTATION: A 51-year-old female patient who had received kidney transplant eighteen years ago presented with hypertensive peak and hemolysis pattern. Normal ADAMTS13 levels as well as negative culture and serology for Shiga-toxin excluded, respectively, thrombotic thrombocytopenic purpura (TTP) and typical HUS caused by Shiga toxin-producing Escherichia coli (STEC-HUS). In suspicion of aHUS, we administered eculizumab and hemodialysis sessions were started as the patient showed severe renal failure. After an initial response, the patient developed cerebral hemorrhage. After last eculizumab administration, according to hematological parameters, an unsatisfactory response was observed: given the worsening clinical scenario, we withdrew eculizumab. Pathogenic mutations in CFI and THBD genes were found. After eculizumab reinitiation, looking at hemolysis indexes, we observed a suboptimal response as well as an otherwise adequate renal one: renal graft function was recovered despite persistence of hemolysis signs, after 6 months on regular dialysis. CONCLUSION: For the first time, we report an aHUS case in which a peculiar combination of mutations in CFI and THBD is found. We describe the importance of continuing eculizumab despite deterioration of patient's clinical conditions.
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We describe the clinical case of a patient who developed mixed cryoglobulinemia syndrome after hemodialysis treatment with dialysate temperature lower than 36°C despite the negativization of the viral genome for HCV after eradication therapy.
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Crioglobulinemia/etiología , Púrpura/etiología , Diálisis Renal/efectos adversos , Anemia/etiología , Anemia/terapia , Transfusión Sanguínea , Femenino , Glomerulonefritis por IGA/complicaciones , Hepatitis C Crónica/complicaciones , Humanos , Fallo Renal Crónico/etiología , Fallo Renal Crónico/terapia , Trasplante de Riñón , Persona de Mediana Edad , Complicaciones Posoperatorias , Trombocitopenia/etiologíaRESUMEN
Enteric hyperoxaluria is one of the most frequent complications of bariatric surgery. In this setting the prevalence of kidney stones is increased. Currently the treatment of enteric hyperoxaluria is based not only on the reduction of urinary oxalate but even controlling other lithogenic risk factors, like urinary volume and urinary citrate levels. This case report suggests a possible benefit using magnesium citrate in addition to calcium supplementation, in the treatment of hyperoxaluria caused by enteric malabsorption.
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Cálculos Renales/etiología , Síndromes de Malabsorción/complicaciones , Adulto , Femenino , Humanos , RecurrenciaRESUMEN
ADH is a hormone secreted by neurohypophysis that plays different roles based on the target organ. At the renal level, this peptide is capable of causing electrolyte-free water absorption, thus playing a key role in the hydro-electrolytic balance. There are pathologies and disorders that jeopardize this balance and, in this field, ADH receptor inhibitors such as Vaptans could play a key role. By inhibiting the activation pathway of vasopressin, they are potentially useful in euvolemic and hypervolemic hypotonic hyponatremia. However, clinical trials in heart failure have not given favourable results on clinical outcomes. Even in SIADH, despite their wide use, there is no agreement by experts on their use. Since vaptans inhibit the cAMP pathway in tubular cells, their use has been proposed to inhibit cystogenesis. A clinical trial has shown favourable effects on ADPKD progression. Because vaptans have been shown to be effective in models of renal cysts disorders other than ADPKD, their use has been proposed in diseases such as nephronophthisis and recessive autosomal polycystic disease. Other possible uses of vaptans could be in kidney transplantation and cardiorenal syndrome. Due to the activity of ADH in coagulation and haemostasis, ADH's activation pathway by Desmopressin Acetate could be a useful strategy to reduce the risk of bleeding in biopsies in patients with haemorrhagic risk.
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Antagonistas de los Receptores de Hormonas Antidiuréticas/uso terapéutico , Enfermedades Renales/tratamiento farmacológico , Terapia Molecular Dirigida , Neurofisinas/agonistas , Neurofisinas/antagonistas & inhibidores , Precursores de Proteínas/agonistas , Precursores de Proteínas/antagonistas & inhibidores , Receptores de Vasopresinas/efectos de los fármacos , Vasopresinas/agonistas , Vasopresinas/antagonistas & inhibidores , Desequilibrio Hidroelectrolítico/tratamiento farmacológico , Antagonistas de los Receptores de Hormonas Antidiuréticas/farmacología , Cadáver , AMP Cíclico/fisiología , Predicción , Humanos , Hiponatremia/tratamiento farmacológico , Hiponatremia/fisiopatología , Enfermedades Renales/fisiopatología , Enfermedades Renales Quísticas/tratamiento farmacológico , Trasplante de Riñón , Túbulos Renales Colectores/efectos de los fármacos , Túbulos Renales Colectores/fisiología , Neurofisinas/fisiología , Riñón Poliquístico Autosómico Dominante/tratamiento farmacológico , Riñón Poliquístico Autosómico Dominante/fisiopatología , Precursores de Proteínas/fisiología , Receptores de Vasopresinas/agonistas , Sistemas de Mensajero Secundario/efectos de los fármacos , Donantes de Tejidos , Vasopresinas/fisiologíaRESUMEN
Aim of the study was the definition of a predictive model for the initial diagnosis of thrombotic microangiopathies (TMA). We retrospectively collected data on all adult patients admitted to the Gemelli Hospital from 2010 to 2014. ICD-9 codes from primary diagnoses were used for TMA diagnosis. Demographic and laboratory characteristics on admission of patients with TMA were then compared with a random sample of 500 patients with other diagnoses. The prediction model was externally validated in a cohort from another hospital. Overall, 23 of 187,183 patients admitted during the study period received a primary diagnosis of TMA. LDH (OR 1.26, 95% CI 1.05, 1.63) and platelets (OR 0.96, 95% CI 0.94, 0.98) were the only independent predictors of TMA. The AUROC of the final model including only LDH and platelets was 0.96 (95% CI 0.91, 1.00). The Hosmer-Lemeshow (HL) test (p = 0.54) suggested good calibration. Our model also confirmed good discriminatory power (AUROC 0.72 95% CI 0.60, 0.84) and calibration (HL test p = 0.52) in the validation sample. We present a simple prediction model for use in diagnosing TMA in hospitalized patients. The model performs well and can help clinicians to identify patients at high risk of TMA.
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Lactato Deshidrogenasas/sangre , Microangiopatías Trombóticas/sangre , Microangiopatías Trombóticas/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Área Bajo la Curva , Estudios de Casos y Controles , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Recuento de Plaquetas , Valor Predictivo de las Pruebas , Curva ROC , Estudios RetrospectivosRESUMEN
Mutations of the CYP24A1 gene, encoding for the enzyme 25(OH)D-24-hydroxylase, can cause hypercalcemia, hypercalciuria, nephrolithiasis and nephrocalcinosis. We report the case of a 22-year-old male patient with recurrent nephrolithiasis, nephrocalcinosis, hypercalcemia with low parathyroid hormone levels, hypercalciuria and low bone mass. Gene sequencing showed that the patient had compound heterozygous mutations including a novel genotype of the CYP24A1 gene. Genetic CYP24A1 testing and biochemical analyses were offered to other family members; the father was heterozygous for the same novel genotype and was also affected with recurrent nephrolithiasis.
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Hipercalcemia/genética , Hipercalciuria/genética , Nefrocalcinosis/genética , Nefrolitiasis/genética , Osteoporosis/genética , Vitamina D3 24-Hidroxilasa/genética , Adulto , Fosfatos de Calcio/química , Genotipo , Humanos , Hipercalcemia/sangre , Hipercalcemia/orina , Hipercalciuria/sangre , Hipercalciuria/orina , Riñón/metabolismo , Cálculos Renales/química , Masculino , Mutación , Nefrocalcinosis/sangre , Nefrocalcinosis/diagnóstico por imagen , Nefrocalcinosis/orina , Nefrolitiasis/sangre , Nefrolitiasis/diagnóstico por imagen , Nefrolitiasis/orina , Osteoporosis/sangre , Osteoporosis/orina , Hormona Paratiroidea/sangre , Linaje , Recurrencia , Eliminación Renal , Análisis de Secuencia de ADN , Tomografía Computarizada por Rayos X , Adulto JovenRESUMEN
Cardiac calcifications are a frequent finding in hemodialysis for chronic renal failure. Several factors may play a role in the intimal and medial calcification of coronary arteries such as age and some known atherogenetic factors. In addition, Fetuin-A has been proposed as a protective agent through solubilization of calcium phosphate salt. Fetuin-A is also a marker of inflammatory-nutritional state, and its changes could be an expression of this condition. The aim of this cross-sectional study is to evaluate the relative importance of risk factors of calcifications with special regard to Fetuin-A. The study was conducted with 132 hemodialysis patients. They were subjected to multislice computed tomography for evaluation of calcium deposits in the heart. In addition, the patients were sampled for evaluation of calcium-phosphate parameters, lipid profile, nutritional and inflammatory markers, and also Fetuin-A. There was a wide variability of the extent of calcium deposits expressed as Agatston score, with only 9.3% of patients without calcifications. Age, hemodialysis age, sex, calcium-phosphate parameters, and lipid profile were important risk factors, together with nutritional and inflammatory status of the patients. An inverse correlation between coronary calcium score and Fetuin-A emerged from a multiple regression analysis. However, there was no significant difference in serum Fetuin-A among different grades of calcium score. By dividing the patients in tertiles of serum Fetuin-A, an association between low levels of Fetuin-A and high calcification score was found. Fetuin-A as dependent variable was strictly linked to prealbumin serum levels. In addition, there was a clear link between cardiac calcification scores and inflammatory-nutritional markers. Serum calcium and treatment with calcitriol emerged as predictive variables of coronary score.Fetuin-A could be involved in the process of calcification both in the case of markedly low serum levels, due to decreased prevention of calcium phosphate precipitation, and also as a marker of inflammation, a well-known risk factor of atherogenesis. Treatment with intravenous calcitriol could marginally enhance cardiac calcifications, probably through its hypercalcemic effect.