Rhabdomyolysis-induced acute kidney injury in a cancer patient exposed to denosumab and abiraterone: a case report.

BACKGROUND: Denosumab and abiraterone were approved by the United States Food and Drug Administration in 2011 for the treatment of metastatic castration-resistant prostate cancer. Neither denosumab nor abiraterone is known to cause rhabdomyolysis. CASE PRESENTATION: A 76-year-old Caucasian man with metastatic prostate cancer presented with non-oliguric severe acute kidney injury (AKI) 3 weeks after receiving simultaneous therapy with denosumab and abiraterone. The patient had been on statin therapy for more than 1 year with no recent dose adjustments. His physical exam was unremarkable. Blood work on admission revealed hyperkalemia, mild metabolic acidosis, hypocalcemia, and elevated creatine kinase (CK) at 44,476 IU/L. Kidney biopsy confirmed the diagnosis of rhabdomyolysis-induced AKI. The patient responded well to intravenous isotonic fluids and discontinuation of denosumab, abiraterone, and rosuvastatin, with normalization of CK and recovery of kidney function. CONCLUSION: We report the first case of biopsy-proven rhabdomyolysis-induced AKI in a cancer patient acutely exposed to denosumab and abiraterone. Whether one of these drugs individually, or the combination, was the bona fide culprit of muscle breakdown is unknown. Nonetheless, our report is hypothesis-generating for further investigations on the effect of these drugs on muscle cells.

Cocaine induced pleural and pericardial effusion syndrome.

A 42-year-old African American female with chronic cocaine use for 20 years, presented with two-day history of exertional shortness of breath and pleuritic chest pain. She was admitted three years back with acute kidney injury and skin rashes. At that time, skin biopsy was consistent with leukocytoclastic vasculitis and renal biopsy revealed proliferative glomerulonephritis. She responded to oral prednisone and mycophenolate with complete recovery of her kidney functions. Skin rash was waxing and waning over the last two years. On the second admission, patient was found to have large pleural effusion on computerized tomography scan and pericardial effusion on echocardiogram as shown in the figures. Pleural fluid analysis was exudative. Her serology was negative for ANA (antineutrophilic antibody) and anti-dsDNA (double stranded DNA). Complements levels were normal. She had positive low titers of ANCA levels. The patient was started on a course of prednisone for 6 months. Her pleural and pericardial effusion resolved completely on follow-up imaging with computerized tomography scan and echocardiogram. This case is unique since the pericardial and pleural effusions developed without any other etiology in the setting of cocaine; hence, we describe this clinical syndrome as cocaine induced pleural and pericardial effusions syndrome (CIPP).

Collapsing focal segmental glomerulosclerosis resulting from a single dose of zoledronate.

Bisphosphonates are commonly used for the treatment of osteoporosis, Paget's disease, multiple myeloma and hypercalcemia. Collapsing focal segmental glomerulosclerosis (FSGS) is known to occur uncommonly with exposure to bisphosphonates, specifically pamidronate and alendronate; it has rarely and equivocally been reported with zoledronate therapy. We describe the case of a 36-year-old African American female with metastatic breast cancer who presented with nephrotic-range proteinuria and acute kidney injury within 2 weeks of exposure to a single dose of zoledronate. The patient had a partial recovery of her renal function and showed improved proteinuria to a subnephrotic level after discontinuing zoledronate. In contrast to 2 prior reports of zoledronate-induced collapsing FSGS, the causative role of the exposure described here is certain. Our case necessitates the addition of zoledronate to the list of known causes of collapsing FSGS. Furthermore, it highlights the importance of periodically monitoring renal function and urine protein excretion with the use of zoledronate, which allows prompt diagnosis and withdrawal of the drug to increase the probability of renal recovery.

Successful Salvage of a Renal Allograft after Acute Renal Vein Thrombosis due to May-Thurner Syndrome.

A 68-year-old Caucasian female with a past medical history of a deceased donor kidney transplant four months prior was admitted with a two-day history of anuria and acute kidney injury. A renal ultrasound demonstrated thrombus in the transplanted kidney's renal vein that extended into the left iliac vein as well as into the left femoral venous system. Catheter-guided tissue thrombolytics were infused directly into the clot. Within twelve hours of initiating thrombolytic infusion, there was brisk urine output. Interval venography demonstrated decreasing clot burden. At the time of discharge her creatinine was 0.78 mg/dL, similar to her baseline value prior to presentation. The patient was noted to have May-Thurner syndrome on intravascular ultrasound (IVUS). Angioplasty followed by stent placement was done. Unique to our case report was the timing of the presentation of renal vein thrombosis (four months after transplant) and the predisposing anatomy consistent with May-Thurner syndrome, which was diagnosed with IVUS and successfully treated with local thrombolytics.

Role of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in isolated pancreatic metastasis from lung cancer.

A case is reported of a 50-year-old woman with a history of small-cell lung cancer admitted with pancreatic head lesions, discovered during investigation for obstructive jaundice. Endoscopic ultrasound assisted fine needle aspiration of the pancreatic mass was consistent with small cell carcinoma, presenting as an isolated metastasis from the previously diagnosed lung cancer. Endoscopic retrograde cholangiopancreatography (ERCP) showed extrinsic compression and a bile duct stricture, requiring sphincterotomy and stent insertion. This case highlights that acute pancreatitis and biliary obstruction can occur as a manifestation of small cell lung cancer metastasizing to the pancreas. EUS is a safe, low risk and rapid diagnostic tool in such cases, and ERCP with stenting offers a safe and effective treatment option.

Effect of renal transplantation for chronic renal disease on left ventricular mass.

Chronic kidney disease is associated with an increased left ventricular (LV) mass. Few data are available regarding the effect of renal transplantation on LV mass regression or the clinical factors associated with LV mass regression. Patients with ≥1 year of chronic kidney disease followed by successful renal transplantation were identified. All patients underwent echocardiography ≥6 months before transplantation with repeat echocardiography ≥1 year after transplantation. An experienced echocardiographer, who was unaware of the clinical data, performed all linear measurements in the parasternal long-axis projection, including systolic and diastolic LV chamber dimensions and LV wall thickness. The LV mass was calculated as follows: 0.8 × {1.04 [(LV internal dimension at end diastole + posterior wall thickness at end diastole + LV wall thickness at the cardiac base for the anteroseptum)(3) - (LV internal dimension at end diastole)(3)]} + 0.6 g. Candidate clinical variables for an association with LV mass regression were assembled, including age, gender, race, donor type, renal disease etiology, medications (insulin, oral hypoglycemics, antihypertensives, statins, and antirejection medications), and co-morbidities. Patients were separated into 2 groups according to presence and absence of LV mass regression. A total of 105 patients (mean age 54 years; 58 men) were included in the study with a mean follow-up of 1.7 years. Of the 105 patients, 57 had significant LV mass regression (mean difference -37.2 ± 31.3 g/m(2)) and 48 had no significant regression (mean difference 15.7 ± 17.1 g/m(2)). The extent of the LV mass before transplantation was the only predictor of mass regression after transplantation (odds ratio 1.50, 95% confidence interval 1.26 to 1.80). In conclusion, significant LV mass regression is present in most patients after renal transplantation. The extent of the LV mass before transplantation was the only clinical predictor of regression.

Risk of bleeding after percutaneous endoscopic gastrostomy (PEG).

BACKGROUND: Patients who undergo percutaneous endoscopic gastrostomy (PEG) placement are often on anticoagulation and/or antiplatelet therapy with a potential thromboembolic risk if these medications are discontinued. Data on the safety of peri-procedural use of these drugs is limited. AIMS: To assess the risk and to identify any predictive factors for post-PEG bleeding, and to determine if clopidogrel increases the risk of bleeding following PEG. METHODS: A retrospective chart audit was conducted from January 1, 2002 to June 30, 2011. RESULTS: A total of 1,541 patients underwent PEG placement during this period. Gastrointestinal bleeding after PEG placement occurred in 51 cases (3.3%) and bleeding directly attributed to PEG was noted in six patients (0.4%). Multivariate logistic regression analysis of variables (age, gender, length of hospitalization, indication for PEG, antiplatelet or anticoagulant medications) showed that heparin infusion (P = 0.018) and length of hospitalization (P = 0.029) were statistically significant predictors of bleeding. The mean period for cessation and resumption of clopidogrel with PEG placement were 2.2 and 1.3 days, respectively. CONCLUSION: Although PEG is classified as a high-risk endoscopic procedure, bleeding with PEG placement was rare, even with use of anticoagulation and antiplatelet medications. In selected patients on heparin infusion undergoing PEG, delaying the procedure, alternative use of low-molecular-weight heparin or close monitoring and frequent assessments should be considered. Clopidogrel did not contribute to an increase in bleeding risk, despite being held for a much shorter peri-procedural period as recommended by expert consensus.

A review of causes and systemic approach to cardiac troponin elevation.

The first American College of Cardiology/European Society of Cardiology task force published recommendations for a universal definition of myocardial infarction (MI) in 2000 based on the measurement of troponin (Tn). Although this rapid and highly sensitive blood test is certainly valuable in the appropriate setting, its widespread use in variety of clinical scenarios may lead to the detection of Tn elevation in absence of thrombotic acute coronary syndrome. In 2007, the joint European Society of Cardiology/American College of Cardiology Foundation/American Heart Association/World Heart Federation task force proposed a new definition for acute MI based on detection of Tn and associated clinical evidence. The goal of this article is to review the universal definition of acute MI and to differentiate type 1 MI, type 2 MI, and non-acute coronary syndrome Tn elevations. The prognosis and a clinical approach to this differential diagnosis will be developed.

Usefulness of multimodality cardiac imaging in the diagnosis of a right atrial angiosarcoma.

A 78-year-old woman presented with progressive dyspnea and atrial flutter and was found to have a right atrial mass. Multimodality cardiac imaging was useful in further characterizing this mass, which was ultimately diagnosed after biopsy as a low-grade angiosarcoma.