[Non-fatal hyperkalemia in lactic acidosis due to metformin overdose. Report of one case]. / Hiperpotasemia extrema no fatal en un caso de acidosis láctica por sobreingesta de metformina.

We report a 74-year-old man with diabetes mellitus type 2 and hypertension, who recently underwent coronary bypass surgery due to severe triple vessel disease receiving cardiological and combined antidiabetic therapy, including metformin 4 g/day. He was admitted with abdominal pain, nausea, vomiting, diarrhea and loss of consciousness. At admission, he was disoriented and agitated with signs of poor perfusion. His blood pressure was 80/70 mmHg, pulse rate 40 beats/min, respiratory rate 20-breaths/min, and axillary temperature 35 °C. Biochemical profile revealed an extreme hyperkalemia of 15.4 mEq/L (double checked), elevated creatinine, uremia and brain natriuretic peptide; hypoglycemia (blood glucose 68 mg/dl) and normal C Reactive Protein. Arterial blood gases revealed severe lactic acidemia. The electrocardiogram showed sinus bradycardia, simple AV block, widened QRS with prominent T wave and prolonged QT. He was admitted to the Intensive Care Unit (ICU) with the suspicion of lactic acidosis associated with metformin, receiving fluid management, intravenous hypertonic glucose plus insulin and sodium bicarbonate, mechanical ventilation, vasopressor therapy, a temporary pacemaker lead, in addition to continuous venovenous hemodiafiltration. Two days later, the patient experienced a significant clinical improvement with normalization of the acid-base status, plasma lactate and potassium levels. On day 9, diuresis was recovered, creatinine and uremia returned to normal levels and the patient was discharged from the ICU.

Hiperpotasemia extrema no fatal en un caso de acidosis láctica por sobreingesta de metformina / Non-fatal hyperkalemia in lactic acidosis due to metformin overdose. Report of one case

We report a 74-year-old man with diabetes mellitus type 2 and hypertension, who recently underwent coronary bypass surgery due to severe triple vessel disease receiving cardiological and combined antidiabetic therapy, including metformin 4 g/day. He was admitted with abdominal pain, nausea, vomiting, diarrhea and loss of consciousness. At admission, he was disoriented and agitated with signs of poor perfusion. His blood pressure was 80/70 mmHg, pulse rate 40 beats/min, respiratory rate 20-breaths/min, and axillary temperature 35°C. Biochemical profile revealed an extreme hyperkalemia of 15.4 mEq/L (double checked), elevated creatinine, uremia and brain natriuretic peptide; hypoglycemia (blood glucose 68 mg/dl) and normal C Reactive Protein. Arterial blood gases revealed severe lactic acidemia. The electrocardiogram showed sinus bradycardia, simple AV block, widened QRS with prominent T wave and prolonged QT. He was admitted to the Intensive Care Unit (ICU) with the suspicion of lactic acidosis associated with metformin, receiving fluid management, intravenous hypertonic glucose plus insulin and sodium bicarbonate, mechanical ventilation, vasopressor therapy, a temporary pacemaker lead, in addition to continuous venovenous hemodiafiltration. Two days later, the patient experienced a significant clinical improvement with normalization of the acid-base status, plasma lactate and potassium levels. On day 9, diuresis was recovered, creatinine and uremia returned to normal levels and the patient was discharged from the ICU.

Calcificaciones pulmonares metastásicas en un trasplantado renal con un injerto con función renal adecuada: Caso clínico / Metastatic pulmonary calcification in a patient with a functioning kidney allograft: Report of one case

In renal transplants patients, metastatic pulmonary calcifications have been reported occasionally when the grafts are dysfunctional and rarely when they are functioning normally. We report a male who received a renal allograft in 1994 at the age of 61 years. Nineteen years later a routine chest X ray showed diffuse infiltrates and a CT scan showed diffuse calcifications in both lungs. These were interpreted as metastatic pulmonary calcifications. The last available laboratory determinations were a serum creatinine of 1.4 mg/dl and urinary protein excretion of 255 mg/24 hours. No further studies were done since the patient experienced a sudden death due to an acute myocardial infarction.

[Hemolytic-uremic syndrome associated with gemcitabine use: report of one case]. / Síndrome hemolítico-urémico asociado al uso de gemcitabina: Caso clínico.

Gemcitabine is a widely used drug in the treatment of advanced pancreatic cancer and other malignancies. It is generally well tolerated and exceptionally its use has been associated with hemolytic-uremic syndrome, causing acute kidney injury, hypertension, chronic renal failure requiring dialysis, and death. We report a 60-year-old man with pancreatic carcinoma and regional lymph node invasion, whom after four months of therapy with gemcitabine and after dose number 11, suddenly developed an acute nephritic syndrome with moderate renal impairment, associated with severe anemia (hemoglobin 6.0 g/dL) and thrombocytopenia (20,000 mm³). Renal biopsy showed the classic findings of thrombotic microangiopathy Gemcitabine was discontinued and renal function and hematological parameters gradually improved.

[Nephrotic syndrome and acute kidney injury associated with celiac disease: report of one case]. / Síndrome nefrótico e injuria renal aguda con microangiopatía trombótica en mujer con enfermedad celíaca: Caso clínico.

Celiac disease may be associated with other autoimmune diseases and exceptionally with glomerulopathies and nephrotic syndrome. Associations have been reported with IgA nephropathy, membranoproliferative glomerulonephritis, membranous glomerulopathy and minimal change disease. We report a 63-year-old woman who simultaneously presented with massive nephrotic syndrome (proteinuria 46 g/day) and cachexia due to a malabsorption syndrome secondary to celiac disease. The course of her diseases was complicated with cardiomyopathy due to severe malnutrition, septic shock, acute kidney injury that required dialysis for seven weeks and severe hypertension. A renal biopsy showed a membranoproliferative pattern of injury secondary to a thrombotic microangiopathy and diffuse podocyte damage. Four years later, the patient was in good general health, the glomerular filtration rate was 30 ml/min/1.73m² and there was non-nephrotic proteinuria.

[Hemophagocytic syndrome after kidney transplant in a patient with hereditary nephritis. Report of one case]. / Síndrome hemofagocítico en un trasplantado renal con síndrome de Alport.

We report a 28-year-old mole with a hereditary nephritis (Alport Syndrome) on hemodialysis for 5 years, who received a kidney graft from a deceased donor. Cyclosporine (CsA), mycophenolate mofetil (MMF) and steroids were prescribed. In the postoperative period the patient had thrombophlebitis and diarrhea. A CT sean showed splenomegaly, ascites, bilateral pleural effusion and bowel edema. Laboratory showed hypoalbuminemia, increased C reactive protein (CRP) and panhypogammaglobulinemia. At day 32 after transplantation, an acute rejection (Banff II b) was diagnosed and treated with methylprednisolone, replacing CsA by tacrolimus. The acute rejection was controlled but six days later, high fever, pancytopenia and hyperferritinemia appeared. A bone marrow smear showed numerous histiocytes and hemophagocytosis. Hemophagocytic syndrome was diagnosed. MMF and tacrolimus were withdrawn and CsA was reinstituted. Fever fell quickly, CPR normalized at 24 hours and white blood cell count at 72 hours. Days later, the concentrations of albumin, immunoglobulins and hematological parameters normalized. The patient was discharged on day 57 after admission in good condition.

Síndrome hemolítico-urémico asociado al uso de gemcitabina: Caso clínico / Hemolytic-uremic syndrome associated with gemcitabine use: Report of one case

Gemcitabine is a widely used drug in the treatment of advanced pancreatic cancer and other malignancies. It is generally well tolerated and exceptionally its use has been associated with hemolytic-uremic syndrome, causing acute kidney injury, hipertension, chronic renal failure requiring dialysis, and death. We report a 60-year-old man with pancreatic carcinoma and regional lymph node invasion, whom after four months of therapy with gemcitabine and after dose number 11, suddenly developed an acute nephritic syndrome with moderate renal impairment, associated with severe anemia (hemoglobin 6.0 g/dL) and thrombocytopenia (20,000 mm³). Renal biopsy showed the classic findings of thrombotic micro angiopathy Gemcitabine was discontinued and renal function and hematological parameters gradually improved.

Síndrome hemofagocítico en un trasplantado renal con síndrome de Alport / Hemophagocytic syndrome after kidney transplant in a patient with hereditary nephritis. Report of one case

We report a 28-year-old mole with a hereditary nephritis (Alport Syndrome) on hemodialysis for 5 years, who received a kidney graft from a deceased donor. Cyclosporine (CsA), mycophenolate mofetil (MMF) and steroids were prescribed. In thepostoperativeperiod thepatient had thrombophlebitis and diarrhea. A CTsean showed splenomegaly, ascites, bilateral pleural effusion and bowel edema. Laboratory showed hypoalbuminemia, increased C reactive protein (CRP) and panhypogam-maglobulinemia. At day 32 after transplantation, an acute rejection (Banff II b) was diagnosed and treated with methylprednisolone, replacing CsA by tacrolimus. The acute rejection was controlled but six days later, high fever, pancytopenia and hyperferritinemia appeared. A bone marrow smear showed numerous histiocytes and hemophagocytosis. Hemophagocytic syndrome was diagnosed. MMF and tacrolimus were withdrawn and CsA was reinstituted. Fever fell quickly, CPR normalized at 24 hours and white blood cell count at 72 hours. Days later, the concentrations of albumin, immunoglobulins and hematological parameters normalized. The patient was discharged on day 57 after admission in good condition.

Síndrome nefrótico e injuria renal aguda con microangiopatía trombótica en mujer con enfermedad celíaca: Caso clínico / Nephrotic syndrome and acute kidney injury associated with celiac disease: Report of one case

Celiac disease may be associated with other autoimmune diseases and exceptionally with glomerulopathies and nephrotic syndrome. Associations have been reported with IgA nephropathy, membranoproliferative glomerulonephritis, membranous glomerulopathy and minimal change disease. We report a 63-year-old woman who simultaneously presented with massive nephrotic syndrome (proteinuria 46 g/day) and cachexia due to a malabsorption syndrome secondary to celiac disease. The course of her diseases was complicated with cardiomyopathy due to severe malnutrition, septic shock, acute kidney injury that required dialysis for seven weeks and severe hypertension. A renal biopsy showed a membranoproliferative pattern of injury secondary to a thrombotic microangiopathy and diffusepodocyte damage. Fouryears later, the patient was in good general health, the glomerular filtration rate was 30 ml/min/1.73m² and there was non-nephrotic proteinuria.

[Metastatic pulmonary calcification in a patient with a functioning kidney allograft. Report of one case]. / Calcificaciones pulmonares metastásicas en un trasplantado renal con un injerto con función renal adecuada: Caso clínico.

In renal transplants patients, metastatic pulmonary calcifications have been reported occasionally when the grafts are dysfunctional and rarely when they are functioning normally. We report a male who received a renal allograft in 1994 at the age of 61 years. Nineteen years later a routine chest X ray showed diffuse infiltrates and a CT scan showed diffuse calcifications in both lungs. These were interpreted as metastatic pulmonary calcifications. The last available laboratory determinations were a serum creatinine of 1.4 mg/dl and urinary protein excretion of 255 mg/24 hours. No further studies were done since the patient experienced a sudden death due to an acute myocardial infarction.

Nephrotic syndrome and acute tubular necrosis due to meloxicam use.

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used by patients all over the world. Five to eighteen percent of the patients who receive NSAIDs can suffer from kidney-related side effects. Among them, the most relevant are sodium and water retention, hyponatremia, worsening of hypertension or preexisting cardiac failure, hyperkalemia, acute kidney injury, chronic kidney disease, papillary necrosis, nephrotic syndrome (NS), and acute interstitial nephritis. We report the case of a 65-year-old woman who developed acute tubular necrosis and NS a few days after receiving 15 mg of meloxicam (MLX) for 3 days for tendinitis. Steroid therapy was begun with normalization of kidney function after 7 weeks of treatment. NS (minimal change disease) was characterized by frequent remissions and relapses as prednisone was lowered under 30 mg/day. Azathioprine (100 mg/day) was added on the fifth month of diagnosis and a complete remission was finally obtained 4 years after hospital admittance. In her last medical checkup, 8 years after her debut and receiving azathioprine (50 mg) and prednisone (5 mg/day), renal function was normal (creatinine 1.0 mg/dL and creatinine clearance 80 mL/min/1.73 m(2)), proteinuria was 150 mg/day and there was no hematuria or hypertension. The aim of communicating this case is to raise a warning about these renal side effects of MLX. After thorough review of literature, only one other report with the same findings was found.

Resultados del trasplante renal en portadores de ríñones poliquísticos / Outcome of renal transplantation in patients with autosomal dominant polycystic kidney disease

Background: Patients with autosomal dominant polycystic kidney disease (ADPKD) have a better survival in chronic dialysis than patients with other etiologies of renal failure. It has been suggested that extra-renal manifestations of ADPKD may increase the odds of complications and mortality, if these patients are transplanted. Aim: To determine whether survival and complications in transplanted patients with ADPKD are different from kidney graft recipients with other etiologies of renal failure. Subjects and Methods: Four hundred six patients with kidney transplantation were followed in three hospitals between 1976 and 2011 and 19 were carriers of ADPKD. The latter were matched by type of donor, gender, age and date of kidney transplant, with 38 graft recipients with other etiologies of renal failure. Results: Graft and patient 1, 5, 10 and 15 years survival were similar in both groups. Hospitalizations due to viral infections and sepsis were more common in patients with ADPKD. There were no differences in the rate of acute rejection, delayed graft function, cancer, gastrointestinal disorders and hospitalizations due to cardiovascular diseases. The frequency of graft loss due to death with a functioning kidney was similar between both groups. Conclusions: Patient and graft survival in transplanted patients with ADPKD were similar to patients with other etiologies of renal failure. The rate and type of complications were similar between groups with the exception of hospitalizations due to sepsis and viral infections, which were more common in ADPKD patients.

[Causes of death with a functioning graft among kidney allograft recipients]. / Causas de muerte en pacientes con un injerto renal funcionante: ¿Han ocurrido cambios en las últimas décadas?

BACKGROUND: Death with a functioning graft (DWGF) is now one of the main causes of renal transplant (RTx) loss. AIM: To determine whether the causes of DWGF, characteristics of donors and recipients and complications of RTx have changed in the last two decades. SUBJECTS AND METHODS: Cooperative study of a cohort of 418 kidney grafts performed between 1968 and 2010. Patients were divided into two groups according to whether their kidney transplants were performed between 1968 and 1992 (Group 1) or 1993 and 2010 (Group 2). RESULTS: Sixty eight patients experienced DWGF. Infections were the leading cause of DWGF in both groups (38 and 41%, respectively), followed by cardiovascular diseases (24 and 23% respectively), gastrointestinal disorders (21 and 26% respectively) and cancer (17 and 10% respectively). There were no significant differences in causes of death between the two groups according to the time elapsed since the renal transplantation. In patients in Group 1, the interval between diagnosis of renal failure and dialysis (HD) and the interval between the start of HD and kidney transplantation were significantly lower than in Group 2. The former had also an increased number of acute rejections in the first five years of kidney transplantation (p < 0.001). In Group 2, patients more often received their kidneys from deceased donors, had previous kidney transplantation, higher rate of antibodies to a panel of lymphocytes and an increased incidence of cardiovascular disorders after five years of RTx. CONCLUSIONS: The proportion of graft loss due to DWGF has increased over the last 2 decades, but its causes have not changed significantly. Infections are the most common causes of DWGF followed by cardiovascular and digestive diseases.

Causas de muerte en pacientes con un injerto renal funcionante: ¿Han ocurrido cambios en las últimas décadas? / Causes of death with a functioning graft among kidney allograft recipients

Background: Death with a functioning graft (DWGF) is now one of the main causes of renal transplant (RTx) loss. Aim: To determine whether the causes of DWGF, characteristics of donors and recipients and complications of RTx have changed in the last two decades. Subjects and Methods: Cooperative study of a cohort of 418 kidney grafts performed between 1968 and 2010. Patients were divided into two groups according to whether their kidney transplants were performed between 1968 and 1992 (Group 1) or 1993 and 2010 (Group 2). Results: Sixty eight patients experienced DWGF. Infections were the leading cause of DWGF in both groups (38 and 41%, respectively), followed by cardiovascular diseases (24 and 23% respectively), gastrointestinal disorders (21 and 26% respectively) and cancer (17 and 10% respectively). There were no significant differences in causes of death between the two groups according to the time elapsed since the renal transplantation. In patients in Group 1, the interval between diagnosis of renal failure and dialysis (HD) and the interval between the start of HD and kidney transplantation were significantly lower than in Group 2. The former had also an increased number of acute rejections in the first five years of kidney transplantation (p < 0.001). In Group 2, patients more often received their kidneys from deceased donors, had previous kidney transplantation, higher rate of antibodies to a panel of lymphocytes and an increased incidence of cardiovascular disorders after five years of RTx. Conclusions: The proportion of graft loss due to DWGF has increased over the last 2 decades, but its causes have not changed significantly. Infections are the most common causes of DWGF followed by cardiovascular and digestive diseases.

[Outcome of renal transplantation in patients with autosomal dominant polycystic kidney disease]. / Resultados del trasplante renal en portadores de ríñones poliquísticos.

BACKGROUND: Patients with autosomal dominant polycystic kidney disease (ADPKD) have a better survival in chronic dialysis than patients with other etiologies of renal failure. It has been suggested that extra-renal manifestations of ADPKD may increase the odds of complications and mortality, if these patients are transplanted. AIM: To determine whether survival and complications in transplanted patients with ADPKD are different from kidney graft recipients with other etiologies of renal failure. SUBJECTS AND METHODS: Four hundred six patients with kidney transplantation were followed in three hospitals between 1976 and 2011 and 19 were carriers of ADPKD. The latter were matched by type of donor, gender, age and date of kidney transplant, with 38 graft recipients with other etiologies of renal failure. RESULTS: Graft and patient 1, 5, 10 and 15 years survival were similar in both groups. Hospitalizations due to viral infections and sepsis were more common in patients with ADPKD. There were no differences in the rate of acute rejection, delayed graft function, cancer, gastrointestinal disorders and hospitalizations due to cardiovascular diseases. The frequency of graft loss due to death with a functioning kidney was similar between both groups. CONCLUSIONS: Patient and graft survival in transplanted patients with ADPKD were similar to patients with other etiologies of renal failure. The rate and type of complications were similar between groups with the exception of hospitalizations due to sepsis and viral infections, which were more common in ADPKD patients.

Kidney transplantation during a twin pregnancy. Case report and review of the literature.

Kidney transplant in a pregnant woman is exceptional, with only six cases being reported. Pregnancy was not known at the time of the transplant in five of these cases. We report the case of a 26-year-old woman who was diagnosed as carrying a twin pregnancy 4 months after starting hemodialysis. In order to improve the survival chances for the twins, she underwent an orthotopic renal transplant from a living donor at 20 weeks of gestation. The allograft functioned immediately and 4 weeks passed without incident. At the 26th week of gestation, the patient had a precipitous labor, delivering two male babies with no malformations, weighing 755 and 890 g, who died due to respiratory failure. The allograft worked normally afterwards. Sixteen months later, the patient delivered a normal 37 weeks' gestation baby. The renal graft continued working normally for the next 20 years, after which signs of chronic allograft nephropathy developed. Azathioprine was replaced with mycophenolate mofetil. At the last evaluation, 23 years after transplant, the patient's serum creatinine was 2.9 mg/dl and her estimated glomerular filtration rate (eGFR) was 22 ml/min/1.73 m2. This unique case demonstrates that it is possible to perform an orthotopic kidney transplant in a 20-week twin-gestation, with a long graft survival time.

[Thalidomide for recurrent gastrointestinal bleeding caused by angiodysplasia: report of one case]. / Uso de talidomida en sangrado recurrente por angiodisplasias gastrointestinales: Caso clínico.

Chronic hemodialysis patients may have recurrent bleeding from gastrointestinal angiodysplasia, that often is diffusely located in the digestive tract or in places difficult to reach with traditional endoscopes. Therefore, they cannot be locally treated or removed. We report a 70 years old man on chronic hemodialysis, with severe and persistent anemia due to bleeding from angiodysplasia of the small bowel. Despite administration of high doses of erythropoiesis stimulating agents, intravenous iron, folate, B6 and B12 vitamins, his hemoglobin levels were < 6.5 g/dL, becoming totally dependent on transfusions of red blood cells (up to 46 units per year). Recurrent bleeding was refractory to conventional management and we decided to use thalidomide at doses of 50-100 mg/day achieving rapid control of gastrointestinal bleeding and significant increase of hemoglobin levels, not requiring further transfusions.

[Retroperitoneal fibrosis associated with chronic use of ergotamine: report of one case]. / Fibrosis retroperitoneal asociada a uso crónico de ergotamina. Tratamiento con colchicina y esteroides: Caso clínico.

Retroperitoneal fibrosis (RPF) associated with chronic use of ergotamine is a very rare disorder. We report a 45-year-old woman who presented with a RPf after using, almost daily for 23 years, ergotamine tartrate for migraine relief. FRP presented as a chronic inflammatory state, anemia, abdominal and lumbosacral pain and a hypogastric mass. A CT-Scan showed a periaortic mass and left hydronephrosis. A percutaneous biopsy was obtained and the patient was subjected to a surgical ureterolysis and tissue resection. The biopsy confirmed the presence of RPf. Due to persistent symptoms and increase in the volume of periaortic tissue, treatment with colchicine 1 mg/day and defazacort 30 mg/day was started, resulting in a rapid disappearance of symptoms, disappearance of inflammation and a significant reduction in the volume of the periaortic tissue. The patient remains in complete remission after 29 months of follow up.

La hiponatremia al momento de ingreso como factor de riesgo de mortalidad hospitalaria / Hyponatremia on admission to the emergency room as a risk factor for hospital mortality

Background: Patients who develop hyponatremia during their hospitalization have higher hospital mortality. Aim: To determine if the presence of hyponatremia on admission to the emergency room is a risk factor for hospital mortality. Patients and Methods: Two hundred forty five patients consecutively admitted to the emergency room and then transferred to the Medicine Department, where they finally died, were matched for age and gender with 245 control subjects admitted to the emergency room and hospitalized in the Medicine Department at the same time, but survived. The dependent variable was death, and the exposure variable was hyponatremia. Admission diagnosis and Charlson comorbidity index was considered as confounding variables. Results: Hyponatremia at admission occurred in 30 and 17 percent of patients who died and survived, respectively, rendering an adjusted odds ratio for death of 2.13 (95 percent confidence intervals = 1.27-3.57). Charlson Comorbidity Index according to age score was higher in subjects with hyponatremia compared to those without hyponatremia (8.1 ± 3.1 and 7.2 ± 2.8; p = 0.01). Multivariate analysis showed that age, gender, length of stay, cause of hospitalization and chronic diseases did not significantly modify the effect of hyponatremia on hospital mortality. Conclusions: Hyponatremia on admission at emergency room had a significant association with hospital mortality. Subjects with hyponatremia had a higher Charlson Comorbidity Index score.

Uso de talidomida en sangrado recurrente por angiodisplasias gastrointestinales: Caso clínico / Thalidomide for recurrent gastrointestinal bleeding caused by angiodysplasia: Report of one case

Chronic hemodialysis patients may have recurrent bleeding from gastrointestinal angiodysplasia, that often is diffusely located in the digestive tract or in places difficult to reach with traditional endoscopes. Therefore, they cannot be locally treated or removed. We report a 70 years old man on chronic hemodialysis, with severe and persistent anemia due to bleeding from angiodysplasia of the small bowel. Despite administration of high doses of erythropoiesis stimulating agents, intravenous iron, folate, B6 and B12 vitamins, his hemoglobin levels were < 6.5g/dL, becoming totally dependent on transfusions ofred blood cells (up to 46 units per year). Recurrent bleeding was refractory to conventional management and we decided to use thalidomide at doses of 50-100 mg/day achieving rapid control of gastrointestinal bleeding and significant increase of hemoglobin levels, not requiring further transfusions.