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2.
Am J Kidney Dis ; 74(3): 390-398, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31040091

RESUMO

Neurologic complications are common after solid-organ transplantation, occurring in one-third of patients. Immunosuppression-related neurotoxicity (involving calcineurin inhibitors and corticosteroids), opportunistic central nervous system infections, seizures, and delirium are some of the causes of neurologic symptoms following solid-organ transplantation. An uncommon often missed complication posttransplantation involves buildup of ammonia levels that can lead to rapid clinical deterioration even when treated. Ammonia levels are not routinely checked due to the myriad of other explanations for encephalopathy in a transplant recipient. A treatment of choice for severe hyperammonemia involves renal replacement therapy (RRT), but there are no guidelines on the mode or parameters of RRT for reducing ammonia levels. Hyperammonemia in a transplant recipient poses specific challenges beyond the actual condition because the treatment (RRT) involves significant hemodynamic fluctuations that may affect the graft. In this review, we describe a patient with posttransplantation hyperammonemia and discuss the pathways of ammonia metabolism, potential factors underlying the development of hyperammonemia posttransplantation, and choice of appropriate therapeutic options in these patients.

3.
Proc (Bayl Univ Med Cent) ; 32(1): 131-133, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30956609

RESUMO

Creatinine-based equations are used as standard ways to estimate glomerular filtration rate and kidney function. Unfortunately, serum creatinine varies based on factors such as age, gender, and muscle mass. Overestimation of renal function by creatinine-based equations can be dangerous for renally dosed medications, such as enoxaparin. We present a patient who developed spontaneous bleeding on enoxaparin where kidney function was significantly overestimated by creatinine-based equations. The use of cystatin C levels, which are creatinine independent, can provide a better prediction of renal function.

5.
South Med J ; 111(12): 754-757, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30512129

RESUMO

We present the case of a 47-year-old man with a history of diabetes mellitus and diabetic nephropathy who was admitted to our hospital with acute uremic myopericarditis. Echocardiography demonstrated a fibrinous pericardial effusion. The patient was initiated on hemodialysis for hyperkalemia, metabolic acidosis, and uremia. He subsequently developed shock from cardiac tamponade, which required emergent pericardiocentesis. He was notably without tachycardia while he was hypotensive, and his admission electrocardiogram did not show typical ST- or PR-segment changes typically associated with acute pericarditis. This case highlights important differences between uremic pericarditis and other prevalent types of acute pericarditis, including the lack of tachycardia during tamponade and normal electrocardiography. Uremic pericarditis is now a less common diagnosis. It is often seen in the setting of previously undiagnosed advanced kidney disease or when patients are ineffectively dialyzed. Given its atypical features, low incidence, and adverse attendant complications, internists must maintain a high degree of suspicion to correctly diagnose acute uremic pericarditis.


Assuntos
Pericardite/diagnóstico , Uremia/diagnóstico , Doença Aguda , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome
7.
Proc (Bayl Univ Med Cent) ; 31(3): 324-325, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29904299

RESUMO

Acute pancreatitis is an inflammatory condition of the pancreas manifesting with abdominal pain and elevated serum levels of pancreatic enzymes. Gallstones and chronic alcohol use are the most commonly described causes. A less studied cause is cholesterolosis, gallbladder polyps that cause mechanical obstruction of the sphincter of Oddi. Here, we present the case of a 55-year-old woman who presented with acute pancreatitis and was found to have cholesterol polyps in her gallbladder with no evidence of gallstones. The patient underwent cholecystectomy with complete resolution of her symptoms.

11.
Hosp Pract (1995) ; 45(5): 192-195, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28828886

RESUMO

Topiramate is an anticonvulsant that is being increasingly used for a number of different off-label indications. Its inhibition of carbonic anhydrase isoenzymes can lead to metabolic acidosis, elevated urine pH, reduced urine citrate, and hypercalciuria, thereby creating a milieu that is ripe for calcium phosphate stone formation. In this review, we describe a case of topiramate-induced metabolic acidosis. We review the frequency of metabolic acidosis among children and adults, as well as the mechanism of hyperchloremic metabolic acidosis and renal tubular acidosis in topiramate users. Finally, we describe the long-term effects of topiramate-induced metabolic acidosis, including nephrolithiasis, nephrocalcinosis, and bone degradation. Patients who are prescribed topiramate should be carefully monitored for metabolic derangements, and they may benefit from alkali supplementation, or in extreme cases, discontinuation of the drug altogether.


Assuntos
Acidose/induzido quimicamente , Inibidores da Anidrase Carbônica/efeitos adversos , Frutose/análogos & derivados , Adulto , Inibidores da Anidrase Carbônica/uso terapêutico , Feminino , Frutose/efeitos adversos , Frutose/uso terapêutico , Humanos , Transtornos de Enxaqueca/tratamento farmacológico , Topiramato
13.
Semin Dial ; 30(5): 417-419, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28608984

RESUMO

In many states undocumented immigrants with end stage renal disease (ESRD) do not have access to regular, thrice weekly dialysis. The term "compassionate dialysis" is used to describe dialysis that is provided on an emergent basis, when patients are in extremis from symptoms of volume overload or suffer from life-threatening electrolyte abnormalities. In this editorial, one particularly poignant anecdote is presented from the experience of one of the authors (AZF) as a nephrologist in Texas, a state where undocumented immigrants have faced difficulties in accessing regular dialysis. We then describe the legislation that allows the right to regular dialysis to be determined on a state by state basis. We offer some potential solutions to this challenging issue, and we describe the difficulties that lay ahead given the uncertain future of the Affordable Care Act.


Assuntos
Acesso aos Serviços de Saúde , Necessidades e Demandas de Serviços de Saúde , Falência Renal Crônica/terapia , Diálise Renal , Imigrantes Indocumentados/legislação & jurisprudência , Humanos , Seguro Saúde/legislação & jurisprudência , Patient Protection and Affordable Care Act/legislação & jurisprudência
14.
Proc (Bayl Univ Med Cent) ; 30(2): 167-168, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28405068

RESUMO

Hydroxocobalamin is a recently approved antidote for the treatment of cyanide poisoning. The case presented involves a young patient administered empiric hydroxocobalamin due to suspected cyanide overdose. Due to the development of acute kidney injury and severe metabolic derangement, emergent hemodialysis was initiated. Unfortunately, hemodialysis was confounded by a recurrent "blood leak" alarm. This unforeseen effect was secondary to interference from hydroxocobalamin. Hydroxocobalamin causes orange/red discoloration of bodily fluids and permeates the dialysate. This leads to defraction of light in the effluent path of the blood leak detector from discolored dialysate, which can result in activation of the blood leak alarm and an inability to continue hemodialysis treatment. This case highlights several new and emerging critical concerns with this medication, including the potential consequence of delayed initiation of emergent renal replacement therapy with empiric administration, the need for increased awareness among clinicians of various disciplines, and the need for multidisciplinary communication.

15.
Proc (Bayl Univ Med Cent) ; 30(2): 169-170, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28405069

RESUMO

Acquired 5-oxoprolinemia is increasingly recognized as a cause of anion gap metabolic acidosis. It predominantly occurs in chronically ill, malnourished women with impaired renal function and chronic acetaminophen ingestion. Depletion of glutathione and cysteine stores leads to elevated 5-oxoproline levels. N-acetylcysteine, given its effect in repleting glutathione and cysteine stores, has been proposed as a potential treatment for 5-oxoprolinemia, though reports of its successful use are lacking. We present a case of 5-oxoproline metabolic acidosis that persisted despite discontinuation of acetaminophen. However, the acidosis rapidly resolved with N-acetylcysteine administration.

16.
Proc (Bayl Univ Med Cent) ; 30(1): 41-43, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28127128

RESUMO

Worldwide, there have been <25 reported cases of hyperammonemic encephalopathy associated with Roux-en-Y gastric bypass surgery in the absence of cirrhosis. We describe a 42-year-old woman who presented with subacute but progressive neurological decline late in her postoperative course, which deteriorated despite multiple conservative and aggressive measures, including hemodialysis, in an attempt to reduce measured plasma ammonia levels. This syndrome of hyperammonemic encephalopathy represents a serious, underrecognized, and potentially treatable complication after Roux-en-Y gastric bypass.

17.
Proc (Bayl Univ Med Cent) ; 30(1): 52-53, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28127132

RESUMO

Vascular-type Ehlers-Danlos syndrome (EDS) is a rare inherited connective tissue disorder caused by a mutation in type III procollagen. It has the highest mortality rate among the six types of EDS. Patients with this syndrome often have typical medical histories and a characteristic physical examination. We present two patients with this rare disorder and highlight the diagnostic and treatment challenges.

19.
Clin J Am Soc Nephrol ; 11(10): 1872-1878, 2016 10 07.
Artigo em Inglês | MEDLINE | ID: mdl-27197910

RESUMO

Hyperammonemia is an important cause of cerebral edema in both adults with liver failure and children with inborn errors of metabolism. There are few studies that have analyzed the role of extracorporeal dialysis in reducing blood ammonia levels in the adult population. Furthermore, there are no firm guidelines about when to implement RRT, because many of the conditions that are characterized by hyperammonemia are extremely rare. In this review of existing literature on RRT, we present the body's own mechanisms for clearing ammonia as well as the dialytic properties of ammonia. We review the available literature on the use of continuous venovenous hemofiltration, peritoneal dialysis, and hemodialysis in neonates and adults with conditions characterized by hyperammonemia and discuss some of the controversies that exist over selecting one modality over another.


Assuntos
Amônia/metabolismo , Hiperamonemia/terapia , Terapia de Substituição Renal , Adulto , Amônia/sangue , Encefalopatias/sangue , Encefalopatias/etiologia , Humanos , Hiperamonemia/complicações , Recém-Nascido , Terapia de Substituição Renal/métodos
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