Bartter-like Syndrome Induced By Tacrolimus in a Renal Transplanted Boy: A Case Report.

BACKGROUND: Losing-salt tubulopathies, such as Bartter syndrome, are rare and usually inherited due to mutations of tubular reabsorption channels of the nephrons. Despite its scarcity, some cases of acquired losing-salt tubulopathies have been described. In this case report, we discuss the main aspects of Bartter syndrome and present a rare pediatric case of probable tacrolimusinduced Bartter-like syndrome in a renal transplanted boy. CASE PRESENTATION: A ten-year-old male patient with end-stage renal disease due to endo and extra capillary glomerulonephritis was submitted to renal transplantation from a deceased donor. The post-operatory evolution was satisfactory with normalization of serum creatinine levels, mild hypertension, and the absence of metabolic disorders. The immunosuppression protocol included tacrolimus (0.3 mg/kg/day), mycophenolate (455 mg/m2/day) and prednisone (0.5 mg/kg/day). Two months later, the patient was hospitalized due to vomiting, dehydration, intense hypokalemia (1.3 mEq/L), hyponatremia (125 mEq/L), and hypochloremia (84 mmol/L). During hospitalization, he evolved with polydipsia (3000 mL/day) and polyuria (120-160 mL/m2/h) associated with major elevation of urinary potassium excretion, hypercalciuria, mild metabolic alkalosis, hyperfiltration, and proteinuria. The tacrolimus dose was reduced under the suspicion of tubular dysfunction, leading to a better metabolic profile. However, the patient developed a Banff IIb graft rejection, which required pulse therapy and elevation of tacrolimus and mycophenolate doses. Recovery of renal function parameters occurred, but the metabolic disorders worsened following tacrolimus dose elevation. The patient required chronic potassium, chloride, and sodium replacement. CONCLUSION: After administering immunosuppressive medications, physicians should be aware of the possibility of Bartter-like or other losing-salt tubulopathies syndromes that can affect metabolic homeostasis. The suspicion must always be considered in the case of a transplanted patient who presents dehydration and hydroelectrolytic disorders right after the commencement of nephrotoxic immunosuppressive drugs, including tacrolimus and cyclosporine.

Increased circulating levels of angiotensin-(1-7) in severely ill COVID-19 patients.

This letter reports an unexpected increase of the ACE2 product angiotensin-(1-7) and a parallel decrease of its substrate angiotensin II, suggesting a dysregulation of the renin-angiotensin system towards angiotensin-(1-7) formation in #COVID19 patients https://bit.ly/3xFXuTU.

Gastrointestinal dysmotility in a patient with advanced lung cancer: paraneoplastic or drug-induced?

A 75-year-old man was hospitalised for bronchoscopy with biopsy due to a suspicious pulmonary mass at chest tomography. He had significant dyspnoea, constipation, nausea, vomiting, anorexia and a 33% loss of weight in the past 3 months. Biopsy revealed a pulmonary squamous cell carcinoma, which was inoperable. Tramadol used at home for 3 months was replaced by morphine on admission. The patient remained constipated despite prokinetics and laxatives, leading to the diagnostic hypothesis of paraneoplastic motility disorder and opioid-induced constipation. Abdominal tomography ruled out the possibility of mechanical obstruction. As complications, the patient presented superior vena cava syndrome and opioid (morphine) intoxication. The patient died a few days later. The management of this case highlights the importance of multidisciplinary care and the challenges of palliative oncology care. Paraneoplastic motility disorder must always be considered among the mechanisms of intestinal dysfunction in patients with advanced oncological disease.

Medicamentos potencialmente inadequados utilizados no tratamento do diabetes em idosos: uma revisão integrativa / Potentially inappropriate medications used in the diabetes treatment in older patients: an integrative review

Objetiva-se avaliar as evidências acerca do perfil de segurança para idosos dos medicamentos utili-zados no tratamento do Diabetes Mellitus tipo 2, que são considerados medicamentos potencialmen-te inadequados pelo critério de Beers e pela ferramenta STOPP: glibenclamida e clorpropamida. Realizou-se uma revisão integrativa da literatura realizada a partir da base de dados PubMed. Foram utilizados os descritores do banco Medical Subject Headings (MeSH) "chlorpropamide", "glyburide" e "sulfonylureas" combinados ao descritor "aged". Foram incluídos artigos que avaliaram o perfil de segurança do uso de clorpropamida e/ou glibenclamida por idosos. Sete artigos foram selecionados. Não foi encontrado nenhum estudo que avaliasse a clorpropamida. Dois estudos avaliaram a segu-rança cardiovascular e o risco de morte com glibenclamida, mas não foram apontadas diferenças entre o uso deste medicamento e de outros da classe das sulfonilureias. Os demais trabalhos eviden-ciaram uma associação entre o uso de glibenclamida e hipoglicemia, apesar de apresentarem resultados conflitantes quanto à relação da ocorrência deste evento com a função renal dos pacientes ido-sos. Concluí-se que a literatura aponta a necessidade de reavaliação da prescrição de glibenclamida, dada sua comprovada relação com o desenvolvimento de hipoglicemia em pacientes idosos

The aim is to evaluate scientific evidences about the safety profile among older patients of drugs used to treat type 2 Diabetes that are considered potentially inappropriate medications by the Beers criteria and STOPP: glyburide and chlorpropamide. An integrative review was performed on Pub-Med database using Medical Subject Headings (MeSH), using the descriptors: "chlorpropamide", "glyburide", "sulfonylureas" and "aged". Articles that evaluated the safety profile of chlorpropamide and/or glyburide for older patients were included. Seven articles were selected, none of which as-sessed the safety profile of chlorpropamide. Two studies evaluated the cardiovascular safety and the risk of death with glyburide, but no difference between this product and other drugs from the sul-fonylureas class was identified. The other studies showed an association between the use of gly-buride and hypoglycemia, despite showing conflicting results regarding the relationship between this event and renal function of older patients. It concludes that the scientific literature showed the needing for reassessment of glyburide prescription among older patients, given its proven relation-ship with the occurrence of hypoglycemia