Search

Background A 48-year-old man with a recent diagnosis of multiple myeloma and rapidly progressive oliguric end-stage renal disease requiring hemodialysis, presented with a serum calcium concentration of 3.4 mmol/l (13.6 mg/dl). Investigations Serum laboratory analysis, electroencephalogram, MRI of the brain and bone marrow, and kidney biopsies. Diagnosis Hypercalcemia secondary to multiple myeloma. Management Short-term intravenous disodium pamidronate therapy (30 mg daily) and daily monitoring of serum calcium concentration.

Background:Helicobacter pylori has been identified as a possible cause of vitamin B12 deficiency in the general population. We assessed any potential relationship between low cyanocobalamin serum levels and Helicobacter pylori status in hemodialysis patients and subsequently correlated these results with the existence of anemia (a common complication in hemodialysis patients), and macrocytosis. Methods: In 29 chronic hemodialysis patients, active H. pylori infection was diagnosed using two different methods regardless of digestive symptoms: by searching for bacterial antigens in stools and by the detection of urea breakdown through breath testing. If these results were non-coincident, gastroscopy was performed and antral biopsies obtained. Patients were subsequently divided into group A (H. pylori-positive, n = 8, 28%) and group B (H. pylori-negative, n = 21, 72%). The corresponding initial values of erythrocytic folic acid, vitamin B12 and homocysteine prior to the first hemodialysis session of each patient were retrospectively collected. Results: Vitamin B12 levels (normal 200– 900 pg/ml) were significantly lower in group A compared to group B (225.4 ± 111.9 vs. 707.9 ± 258.3 pg/ml, p < 0.011). In group A, 5 patients (63%) had vitamin B12 deficiency (154 ± 24.6 pg/ml). Baseline hematocrits, erythrocyte folic acid and serum homocysteine levels were not different between the groups, but mean corpuscular volumes were significantly higher in group A compared to group B (109.7 ±14.1 vs. 91.8 ± 8.8 fl, p = 0.002). Conclusions:H. pylori-positive chronic hemodialysis patients may present with lower vitamin B12 blood levels and macrocytosis. H. pylori infection should be suspected in this population when low or low-normal vitamin B12 levels or macrocytosis exist.

Cytomegalovirus is the most important viral infection in kidney transplants, but rarely affects the allograft after the sixth month posttransplantation. We present a patient who developed renal failure eighteen months posttransplant; a kidney biopsy showed cytomegalovirus inclusions, acute tubular necrosis and mild interstitial nephritis. After intravenous ganciclovir, renal function transiently improved. Cytomegalovirus pp65 antigen was weekly reported as negative. One month later another biopsy was performed due to renal failure. The findings were consistent with tubular atrophy and severe interstitial nephritis. No cytomegalovirus cellular inclusions were found on histology, including immunohistochemical and polymerase chain reaction studies; pp65 antigen studies were persistently negative. Despite an attempt to recover renal function with steroid therapy, the patient restarted hemodialysis 20 months posttransplantation. This report suggests that cytomegalovirus should be considered as a late cause of kidney failure even in the absence of infection-related symptoms. The irreversible allograft damage can be caused despite the successful eradication of the virus with intravenous ganciclovir.

ative to call, or that they used a relative’s touch-tone telephone. Some patients who were unsuccessful in accessing their messages called one of the nurses to do so; even that technique saved physician time. We learned that patients needed more warning that dictations might be delayed at times because of laboratory or physician delay. For the small number of patients who will not be happy without a written report or a personal conversation, physicians can provide that service and might be justified in charging for these personal conferences. Most of the patients who used the message line found it easy to use and were satisfied with it. We encountered no confidentiality problems, and expect none, because patients have control of their access numbers and we use only first names in our messages. We believe our system is more confidential than sending letters or e-mail messages, or calling patients at their place of employment.