Renal sarcoidosis with normal serum vitamin D and refractory hypercalcemia

Introduction

Sarcoidosis is a multi-system disorder characterized by non-caseating epithelioid granulomas in multiple organs. Renal involvement may usually occur as granulomatous interstitial nephritis, but renal failure is uncommon. We report a case of renal-limited sarcoidosis diagnosed by renal biopsy, associated with abnormal calcium metabolism.

Case presentation

A 30-year-old Caucasian male presented with unexplained renal function impairment and hypercalcemia. The patient did not have any history of kidney disease, cough, skin rash, dysuria, hematuria or any other symptoms. Physical examination was unremarkable. Serum creatinine was 2.2 mg/dl and serum calcium was 11.5 mg/dl. Serum intact parathyroid hormone level (12 pg/mL) was decreased. Serum angiotensin-converting enzyme (ACE), 1,25-dihydroxyvitamin D (1,alpha-25 vit D) and pre-proparathyroid hormone (PTHrP) levels and urinary calcium excretion were all in normal range. The renal biopsy showed severe interstitial nephritis with non-caseating granuloma. The patient was treated with prednisone with starting dose of 1 mg/kg. After 2 months of prednisone therapy, serum creatinine decreased. However, because of continued of hypercalcemia unresponsive to low calcium diet and prednisone, chloroquine was prescribed. Six months after the onset, the patient's serum creatinine is stable at 1.30 mg/dl, serum calcium is 10.8 mg/dl, and serum ACE and 1,alpha-25 vit D levels are in normal range. He does not have any signs of extra-renal relapse.

Conclusion

The mechanisms of abnormal calcium metabolism in this patient with renal-limited sarcoidosis are unclear.     

Simple Renal Cyst Prevalence in Internal Medicine Department and Concomitant Diseases

A total of 684 patients who had not been diagnosed with renal cyst but had undergone abdominal ultrasonography for various reasons were evaluated. Patients with and without renal cyst were classified into two groups and were compared in terms of hypertension (HT), hyperlipidemia (HL), diabetes mellitus (DM) and obesity (body mass index: ≥30 kg/m²) prevalence. Although 94 patients (13.7%) were established with a renal cyst, 590 patients (86.3%) did not have a renal cyst. The mean age of the patients established with a simple renal cyst was 67.3 ± 12.1 years (range: 28–82 years); 54 (57.4%) of them were women and 40 (42.6%) were men. Of the patients established with a simple renal cyst, 64 (68.1%) had HT, 40 (42.6%) had DM, 20 (21.3%) had HL, 42 (44.7%) were obese, 18 (19.1%) had nephrolithiasis, and 6 (6.4%) had urinary tract infection. Of the patients without a cyst, 272 (46.1%) had DM, 212 (35.9%) had HT, 122 (20.7%) had HL, and 96 (16.3%) were obese. HT and obesity were significantly higher in patients with a renal cyst when compared with those without a cyst. However, although HL incidence was higher in patients with a cyst, the difference was not significant statistically. HT, HL, and obesity are more prevalent in patients with a renal cyst when compared with patients without. Consequently, patients with a simple renal cyst should be evaluated and followed up in terms of atherosclerotic risk factors.     

Waist circumference is associated with carotid intima media thickness in peritoneal dialysis patients

Purpose

Atherosclerosis is responsible for the high mortality rate in end-stage renal disease patients. Defining risk factors for atherosclerosis may lead to reduction in cardiovascular disease through modification of these factors. Peritoneal dialysis (PD) patients are subjected to high glucose loads on a daily basis, which results in considerable weight gain and an increase in waist circumference (WC). WC as an indicator of abdominal obesity is a risk factor for atherosclerosis in the general population. Carotid artery intima media thickness (CIMT) measurement is a reliable method for the detection of early atherosclerosis. The aim of this study was to investigate the relationship between WC and CIMT and to define risk factors associated with CIMT in PD patients.

Methods

Fifty-five PD patients and 40 healthy controls were included. Atherosclerosis was assessed using measurement of CIMT. Fasting blood was collected for analysis. Anthropometric parameters (age, weight, BMI, and WC) were measured.

Results

Peritoneal dialysis patients had higher WC (93.9 ± 1.7 vs. 87.3 ± 1.2 cm, p < 0.05) and CIMT (0.70 ± 0.02 vs. 0.57 ± 0.01 mm, p < 0.01) than the control group. On univariate analysis, age, WC, plaque formation, and D/P creatinine were positively correlated with CIMT, whereas residual renal function, albumin, ultrafiltration volume, and D/D0 glucose were negatively correlated. On multivariate analysis, only age, WC, and plaque formation showed correlation (p < 0.001).

Conclusions

Carotid artery intima media thickness is associated with age, plaque formation, and WC in PD patients. WC measurement is a simple, inexpensive, reproducible, and reliable method of evaluating atherosclerosis risk in PD patients and should be assessed at every visit. Appropriate counsel should be provided to patients with greater WC who are deemed to be at risk for atherosclerosis.     

Improvement of right ventricular function with transcatheter aortic valve implantation

Background and aim. It has been demonstrated that right ventricular systolic dysfunction develops soon after surgical aortic valve replacement (s-AVR). While the impact of s-AVR or TAVI on the function of the left ventricle has been studied with various imaging modalities, little is known about the impact on right ventricular function (RVF). In the current study, we evaluated the impact of TAVI on RVF using conventional echocardiography parameters. Methods and results. Echocardiography was performed prior to 24 h, 1 month and 6 months after TAVI. RVF was assessed using (1) tricuspid annular plane systolic excursion (TAPSE); (2) RV Tissue Doppler Imaging (S’); (3) right ventricular systolic pressure (RVSP); (4) Fractional area change (FAC); and (5) RV ejection fraction (RVEF). TAVI was performed through the subclavian artery in two patients and femoral artery in 48 patients with an Edwards Sapien XT valve. TAVI was performed on 50 patients between the dates of December 2012 and June 2013. After TAVI, a statistically significant improvement was observed for all parameters related to RVF (RVSP, RVEF, TAPSE, FAC, RVTDI S’). During the 1st and 6th months this statistically significant improvement continued in TAPSE and FAC, and there was no deterioration in RVSP, RVEF, and RVTDI S during the 1st month but a statistically significant improvement continued in the 6th month. Conclusion. RVF assessed by conventional echocardiography did not deteriorate after TAVI in early and midterm follow-up. Further, TAVI provides improvement of RVF and can safely and efficiently be performed in patients with impaired RVF.     

Use of Stapling Devices for Safe Cholecystectomy in Acute Cholecystitis

Many techniques are described for the ligation of a difficult cystic duct (CD). The aim of this study is to assess the effectiveness and safety of stapling of a difficult CD in acute cholecystitis using Endo-GIA. From January 2008 to June 2012, 1441 patients with cholelithiasis underwent laparoscopic cholecystectomy (LC) at the Department of General Surgery, Haydarpasa Numune Education and Research Hospital. Of these, 19 (0.62%) were identified as having a difficult CD and were ligated using an Endo-GIA stapler. All patients were successfully treated with a laparoscopic approach. The length of hospital stay was 3.4 days. There were umbilical wound infections in 4 patients (21%). The length of follow-up ranged from 1.0 to 50.4 months. In conclusion, Endo-GIA is a safe and easy treatment method for patients with a dilated and difficult CD. The cystic artery should be isolated and ligated if possible before firing the Endo-GIA stapler. If isolation and stapling are not possible, fibrin sealant can be applied to avoid bleeding. The vascular Endo-GIA can be applied in a large CD, but for acute cholecystitis with an edematous CD, the Endo-GIA roticulator 4.8 or 3.5 stapler is preferred.Key words: Cholecystectomy, Endo-GIA, Acute cholecystitis, StaplerAfter the introduction of laparoscopic cholecystectomy (LC) in 1987,¹ LC replaced open cholecystectomy as the gold standard for the treatment of cholelithiasis in international guidelines.² LC was initially considered to be contraindicated for acute gallbladder inflammation, but it is currently a common procedure for acute cholecystitis.Some of the difficult situations a surgeon is likely to face during the performance of a laparoscopic cholecystectomy include anatomic anomalies such as a sessile gallbladder or short cystic duct and pathologic entities such as an empyema, Mirizzi syndrome, or a frozen Calot''s triangle secondary to infection and fibrosis.³It is suggested that laparoscopic surgery should be carried out within 72 hours from the onset of the symptoms because after that time there are higher rates of conversion to open procedures, increased risks of complications, and longer operative times.^4–6 The generally accepted procedure in patients whose symptoms started 72 hours before admission is to “cool down” the patient with appropriate medical therapy and to perform LC after a period of 6 to 12 weeks.^7,8 This approach aims to avoid a potentially more difficult cholecystectomy during an emergency admission and to avoid the difficulties of access to an emergency room.^9,10 However, more than 20% of patients may fail to respond to conservative treatment and require an urgent and rather more difficult cholecystectomy, and a further 25% of patients will require readmission with a severe acute complication of cholelithiasis while awaiting a cholecystectomy.^11,12 The scar formation, distortion, and organized adhesions around the gallbladder occurring secondary to the chronic inflammation in Calot''s triangle make the dissection difficult. The cystic duct (CD) is sometimes edematous, fibrous, or enlarged owing to inflammation and adhesions in acute cholecystitis and may be difficult to manage. Several methods were proposed for ligating the CD, including titanium or absorbable endoclip, endoloop, tie, ultrasonic or bipolar sealer, and the Endo-GIA stapler (Covidien, Mansfield, Massachusetts).^13–19This study proposes an effective, safe, and easy procedure for the stapling of dilated or difficult CD using the Endo-GIA.     

Effect of methylprednisolone, tirilazad mesylate and vitamin E on lipid peroxidation after experimental spinal cord injury

Effect of methylprednisolone (MP), tirilazad mesylate (TM) and vitamin E on lipid peroxidation (LP) was evaluated in an experimental model of spinal cord compression injury in anesthetized rats. Forty rats, divided randomly into four groups, were injured by compressing on the spinal cord at Th 3 for 1 min. Bolus injections of saline solution, MP (30 mg/kg bolus and 5.4 mg/kg/h), TM (10 mg/kg four times per day), or vitamin E (30 mg/ kg four times per day) were begun 1 h after the spinal cord injury (SCI). Twenty-four hours after treatment, the rats were killed, and malondialdehyde (MDA), a LP product, was measured in the spinal cord tissues. Rats treated with MP, TM and vitamin E had significantly decreased MDA levels (P<0.01) than rats in the control group. The lowest MDA levels were found in the TM group. These results suggest that MP, TM and vitamin E may have a protective effect against SCI in rats by its antioxidant effect.