Pulmonary embolism and reactivation of tuberculosis during everolimus therapy in a kidney transplant recipient.

BACKGROUND: Proliferation signal inhibitors (PSIs) - sirolimus and everolimus - are commonly used in kidney transplant patients with co-existing neoplasms. These drugs may have prothrombotic activity, but aside from use in interventional cardiology, their clinical relevance has not been confirmed. In contrast to pulmonitis, an association of everolimus therapy with pulmonary embolism has never been documented. There have also been no reports on the increased risk of tuberculosis reactivation after an introduction of a PSI, and experience with everolimus dosing during antituberculosis treatment is very limited. CASE REPORT: A 72-year-old man, after kidney transplantation, had been converted to everolimus from tacrolimus after being diagnosed with basal cell carcinoma. One month later he was hospitalized with suspected pneumonia. Because of the lack of clinical improvement after antibiotic therapy, computed tomography (CT) angiography of the chest was performed and showed bilateral pulmonary embolism. Initially the patient responded well to the treatment, but shortly thereafter developed fever with rigors and chest pain. Eventually, after extensive diagnostic work-up, tuberculosis was diagnosed. During 6 months of pyrazinamide (PZA) and rifampicin (RFP) treatment, the repeated reduction of everolimus blood concentration was necessary, despite the substantial increase of the drug dose. CONCLUSIONS: This case shows that kidney transplanted patients treated with everolimus presenting symptoms of pneumonia should also be screened for pulmonary embolism. Patients treated with PSIs may be prone to reactivation of tuberculosis. When tuberculosis treatment is started, much larger doses of everolimus are required.

Effect of intradialytic intravenous administration of omega-3 fatty acids on nutritional status and inflammatory response in hemodialysis patients: a pilot study.

OBJECTIVE: Because omega-3 polyunsaturated fatty acids (PUFAs) may have anti-inflammatory properties, we tested the hypothesis that intradialytic, intravenous omega-3 PUFA treatment, combined with dietary supplementation, can modify the inflammatory response to dialysis, and influence the nutritional status of hemodialysis (HD) patients. METHODS: Twenty HD patients with serum albumin at <39g/L received 100mL of 10% omega-3 PUFA emulsion during 11 consecutive HD sessions. Body mass index (BMI), serum albumin, transferrin, and lipids were measured before and after treatment. Serum interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hsCRP) levels were determined before and after the HD session at baseline and after 4 weeks of treatment. RESULTS: No adverse events were evident during the study. There were no significant changes in BMI, serum albumin, transferin, total and low-density lipoprotein cholesterol, and triglycerides. Predialysis hsCRP and IL-6 did not change. There was a significant increase in hsCRP (P=.01) and a tendency of IL-6 concentration to increase during the HD session before treatment (P=.067). In contrast, neither hsCRP (P=.21) nor IL-6 (P=.26) changed during the final HD session. Neither urea reduction ratio nor Kt/V changed significantly during the study, but the normalized protein catabolic ratio increased after treatment (P=.003). CONCLUSIONS: Short-term parenteral administration of omega-3 PUFA is safe and well-tolerated by HD patients. The intervention does not significantly influence markers of inflammation or change the nutritional status of chronic HD patients, but it may attenuate the inflammatory response to HD sessions.

[Hormonal activity of the hypophysial-gonadal axis versus the mineral bone density and specific markers of bone turnover in haemodialysis population]. / Aktywnosc hormonalna osi przysadkowo-gonadalnej a gestosc mineralna kosci i wskazniki metabolizmu kostnego u chorych przewlekle hemodializowanych.

UNLABELLED: Among the numerous complications associated with chronic renal disease both bone and hormonal disturbances have long been recognized. The aim of this study was to assess the relations between bone mineral density, gonadal status and specific markers of bone turnover in haemodialysis (HD) population. MATERIAL AND METHODS: We performed a cross-sectional study involving 40 HD patients: 27 men (mean age 54 +/- 14, 2 years) and 13 women (mean age 58.9 +/- 9.8 years), mean HD time 68 +/- 43 months. Serum levels of testosterone, estradiol, LH, FSH, osteocalcin (OC), beta-CrossLaps, iPTH and alkaline phosphatase (ALP) were measured. Bone mineral density (BMD) was estimated in the lumbar spine and in the femoral neck using dual energy absorptiometry (DXA). RESULTS: 67.5% of HD patients showed a low BMD. Diagnostic criteria of osteoporosis were fulfilled by 32.5% of subjects, they were found more frequently in women (38.5%) than in men (29.6%). Osteopenia was observed in 35% of patients, more frequent in women (46.2%) than in men (29.6%). Mean serum levels of FSH and LH were above the normal range and they were higher in women that in men. The serum levels of estradiol in women were below normal range in 11 from 13 subjects (84.6%). The mean serum testosterone concentrations in HD men were in normal range. We also observed a positive correlation between serum beta-CrossLaps concentrations and PTH (in men p < 0.001, r = 0.66; in women p < 0.006, r = 0.71) and between serum OC levels and PTH (in men p < 0.02, r = 0.44; in women p < 0.01, r = 0.65), respectively. CONCLUSIONS; The frequency of low bone mineral density in haemodialysis patients is high, more common in women. Hypergonadotropic hypogonadism that occurs in dialysis patients may be one of the main risk factors of bone disturbances in these patients. The levels of bone turnover markers are mainly determined by the severity of hyperparathyroidism.

Ionized magnesium in erythrocytes--the best magnesium parameter to observe hypo- or hypermagnesemia.

BACKGROUND: Almost 99% of the body magnesium is inside cells. The concentration of intracellular ionized magnesium (iMg) is physiologically relevant. iMg in erythrocytes is a new parameter that can help to establish reliable information on the functional magnesium status. METHODS: iMg concentration in erythrocytes and serum was measured by ion-selective electrode, in clinical analyzer Microlyte (KONE). Total magnesium (tMg) concentration was measured by atomic absorption spectrometry (AAS). Albumin and total protein concentration were measured colorimetrically. RESULTS: In critically ill postoperative patients, the mean of albumin, protein and hematocrit concentration was significantly lower compared to healthy individuals. Hypomagnesemia was found in 15.9% patients as tMgs, at 22.2% as iMgs and 36.5% as iMge. Significant correlations are between iMgs and tMgs or iMge and iMgs/tMgs. In dialyzed patients, the mean of hematocrit was significantly lower, iMge was significantly higher compared with healthy individuals. Significant negative correlations are between iMgs and tMge or iMge/tMge and tMge. CONCLUSIONS: iMge is the best magnesium parameter to observe hypo- or hypermagnesemia for both groups of patients. The function of magnesium is mainly intracellular and intracellular magnesium concentrations can be the method to evaluate the magnesium status.