Background: We recently determined that in hemodialysis patients, the use of calcium salts to correct hyperphosphatemia led to progressive coronary artery and aortic calcification as determined by sequential electron beam tomography (EBT) while the use of the non-calcium-containing binder sevelamer did not. Whether the specific calcium preparation (acetate vs. carbonate) might influence the likelihood of progressive calcification was debated. Methods: To determine whether treatment with calcium acetate was specifically associated with hypercalcemia and progressive vascular calcification, we conducted an analysis restricted to 108 hemodialysis patients randomized to calcium acetate or sevelamer and followed for one year. Results: The reduction in serum phosphorus was roughly equivalent with both agents (calcium acetate –2.5 ± 1.8 mg/dl vs. sevelamer –2.8 ± 2.0 mg/dl, p = 0.53). Subjects given calcium acetate were more likely to develop hypercalcemia (defined as an albumin-corrected serum calcium ≧10.5 mg/dl) (36 vs. 13%, p = 0.015). Treatment with calcium acetate (mean 4.6 ± 2.1 g/day – equivalent to 1.2 ± 0.5 g of elemental calcium) led to a significant increase in EBT-determined calcification of the coronary arteries (mean change 182 ± 350, median change +20, p = 0.002) and aorta (mean change 181 ± 855, median change +73, p Conclusion: Despite purported differences in safety and efficacy relative to calcium carbonate, calcium acetate led to hypercalcemia and progressive vascular calcification in hemodialysis patients.

/pdf/the-effects-of-sevelamer-and-calcium-acetate-on-proxies-of-4rif5us9us.pdf

The Effects of Sevelamer and Calcium Acetate on Proxies of Atherosclerotic and Arteriosclerotic Vascular Disease in Hemodialysis Patients

Fungal infections in solid organ transplant recipients.

Urinary tract stone disease , Urinary tract stone disease , کتابخانه دیجیتالی دانشگاه علوم پزشکی و خدمات درمانی شهید بهشتی

Urinary Tract Stone Disease

Chronic kidney disease (CKD) is associated with the development of mineral bone disorder (MBD), osteoporosis, and fragility fractures. Among CKD patients, adynamic bone disease or low bone turnover is the most common type of renal osteodystrophy. The consequences of CKD-MBD include increased fracture risk, greater morbidity, and mortality. Thus, the goal is to prevent the occurrences of fractures by means of alleviating CKD-induced MBD and treating subsequent osteoporosis. Changes in mineral and humoral metabolism as well as bone structure develop early in the course of CKD. CKD-MBD includes abnormalities of calcium, phosphorus, PTH, and/or vitamin D; abnormalities in bone turnover, mineralization, volume, linear growth, or strength; and/or vascular or other soft tissue calcification. In patients with CKD-MBD, using either DXA or FRAX to screen fracture risk should be considered. Biomarkers such as bALP and iPTH may assist to assess bone turnover. Before initiating an antiresorptive or anabolic agent to treat osteoporosis in CKD patients, lifestyle modifications, such as exercise, calcium, and vitamin D supplementation, smoking cessation, and avoidance of excessive alcohol intake are important. Managing hyperphosphatemia and SHPT are also crucial. Understanding the complex pathogenesis of CKD-MBD is crucial in improving one’s short- and long-term outcomes. Treatment strategies for CKD-associated osteoporosis should be patient-centered to determine the type of renal osteodystrophy. This review focuses on the mechanism, evaluation and management of patients with CKD-MBD. However, further studies are needed to explore more details regarding the underlying pathophysiology and to assess the safety and efficacy of agents for treating CKD-MBD.

Osteoporosis in Patients with Chronic Kidney Diseases: A Systemic Review.

passage in 29–98% of stones of < 5 mm diameter above the iliac vessels, and 71–98% of stones of < 5 mm diameter below the iliac vessels. For stones of 5–10 mm diameter, spontaneous passage occurred in 10–53% of proximal calculi and 25–53% of distal calculi. In a multivariate analysis of risk factors associated with spontaneous ureteric stone passage, Miller and Kane [2] found that smaller, more distal stones on the right side were more likely to spontaneously pass and require fewer surgical interventions. In a recent report by Coll et al. [3] spontaneous ureteric stone passage rates, regardless of size, were 48%, 60%, 75% and 79% for stones in the proximal, middle and distal ureter or at the vesico-ureteric junction, respectively.

Management of ureteric stones: issues and controversies.

Use of alkaline calcium salts as phosphate binder in uremic patients

Phosphate retention plays a major role in the pathogenesis of hyperparathyroidism at all stages of renal insufficiency. Dietary phosphate restriction is mandatory only for adults and is not advised for children because of the recommended diet allowance. Dietary restriction is usually not sufficient, and phosphate binders are almost always necessary when the glomerular filtration rate falls below 40 mL/min. Because long-term administration of aluminum phosphate binders is associated with risk of aluminum intoxication despite the use of so-called "safe doses", alternative phosphate binders should be used. Magnesium hydroxide and carbonate can be used only for dialysis patients because a low dialysate magnesium concentration is necessary to prevent the hazards of hypermagnesemia. Therefore, the major alternative is the use of alkaline salts of calcium. The most recently proposed salt, acetate, has a higher phosphate-binding capacity than carbonate but exposes patients to the same incidence of hypercalcemia despite the use of half the dose of elemental calcium. These salts should be taken with meals in order to complex more dietary phosphate and decrease calcium absorption and therefore the risk of hypercalcemia. Oral calcium alone, without 1 alpha OH-vitamin D3 derivatives, can prevent hyperphosphatemia and hyperparathyroidism in most uremic patients before dialysis and in about half of the patients dialyzed with a dialysate calcium of 1.5 to 1.65 mmol/L. 1 alpha OH-vitamin D3 derivatives, which increase intestinal absorption of phosphate, should be used only when hyperphosphatemia has been prevented by oral calcium and diet and when plasma parathyroid hormone levels increase above three times the upper limit of normal. To decrease hypercalcemic risk, patients should be given 1 alpha OH-vitamin D3 derivatives, preferably at night, as an intermittent bolus (intravenous or oral). In dialysis patients, the dialysate concentration of calcium may have to be further decreased in order to prevent hypercalcemia when high doses of oral calcium are necessary to control hyperphosphatemia.

Management of hyperphosphatemia in patients with renal failure.

Extracorporeal shock wave lithotripsy (ESWL) is now used in the treatment of about 90% of renal and ureteral stones. Because of the non-punctual delivery of energy to the stone, a small volume of renal parenchyma is injured giving place to a fibrous scar which can be shown by highly resolutive imaging techniques like magnetic nuclear resonance. Isotopic clearances point to a reduction of 15% in the renal plasma flow on the side of the lithotripsy, but this alteration appears to be transient in nature. In a few cases an abrupt onset of transient hypertension has been reported in clear relation to a compressive perirenal hematoma. The responsibility of ESWL in the late occurrence of permanent hypertension is, however, still uncertain, probably because of the difficulty in showing that this occurrence is not only related to the older age of the patient. The American Food and Drug Administration-sponsored multicentric study begun in 1992 should solve this issue in the future. Recent articles suggest that altered renal function prior to ESWL would predict the late occurrence of hypertension and worsening of renal failure. Furthermore, age and the resistance index of arcuate or interlobar renal arteries (measured by Doppler) could help to screen patients at risk of developing hypertension. In practice in patients over 60 years of age and/or with a plasma creatinine of >to 300 micromol/l, ESWL should be performed with caution, and renal function and blood pressure should be carefully monitored.

Renal and hypertensive complications of extracorporeal shock wave lithotripsy: who is at risk?

Leg granuloma due to Neocosmospora vasinfecta in a renal graft recipient.

Lesions parenchymateuses constantes : La lithotritie extracorporelle (LEC) est maintenant utilisee dans le traitement d'environ 90% des calculs. En raison de l'administration non ponctuelle de l'energie au niveau du calcul, un certain volume de parenchyme renal est toujours lese laissant place a une cicatrice fibreuse. Celle-ci peut etre mise en evidence morphologiquement par des techniques comme la resonance magnetique nucleaire. - Flux plasmatique renal: Les techniques isotopiques peuvent mettre en evidence une reduction de 15 % du flux plasmatique renal du cote de la lithotritie, qui est transitoire dans la majorite des cas. - Hypertension arterielle (HTA): Dans de rares cas, une hypertension d'installation rapide mais transitoire a pu etre reliee avec certitude a un hematome perirenal compressif. La responsabilite de la LEC dans la survenue tardive d'une HTA permanente reste par contre incertaine en raison de la difficulte de prouver que cette HTA n'est pas simplement liee au vieillissement. - Des patients a risque : L'alteration prealable de la fonction renale semble pouvoir predire la survenue d'une HTA et d'une aggravation de la fonction renale. De plus, l'âge et l'index de resistance des arteres renales arquees et interlobaires (mesure par Doppler) pourraient aider a depister les patients a risque de developper une hypertension. En pratique, chez les patients de plus de 60 ans et/ou ayant une creatininemie > 300 μmol/l, la LEC doit etre realisee prudemment et leurs fonction renale et pression arterielle doivent etre soigneusement surveillees.

Renal and hypertensive complications of extracorporeal lithotripsy

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