Normal Saline Hydration Research Articles

12492 Clinical Resolution Of Parkinsonism And Dementia Following Radio Frequency Ablation Of A Parathyroid Adenoma

Abstract Disclosure: P. Finny: None. T. George: None. A.K. Francis: None. Background: Parkinsonism is a rare neurological manifestation of primary hyperparathyroidism. Radiofrequency ablation (RFA) of parathyroid adenomas is a novel treatment modality. Clinical Case: A 78 year old lady presented to our Emergency department with hypercalcemic encephalopathy. She had long standing Diabetes mellitus, Bronchial asthma and Parkinsonism with dementia for the past 14 years. She was bed bound with dependence on carers for activities of daily living (ADL). She had been diagnosed elsewhere in 2018 to have primary hyperparathyroidism due to a right inferior parathyroid adenoma and had a right hemithyroidectomy with a failed parathyroidectomy. She was being managed with Cinacalcet 60 mg daily for the past 4 years. Prior to this admission she had discontinued Cinacalcet for a few days. Her initial serum calcium was 15.3 mg/dl (8.7-10.7), phosphorus 1.80 mg/dl (2.5-4.5) and PTH 451 pg/ml (15- 88). She was aggressively treated with intravenous normal saline hydration followed by Furosemide injection. Then she was given Calcitonin injections subcutaneously and IV Zoledronic acid infusion. Her calcium dropped to 11.8 mg/dl within 48 hours of admission, and her sensorium improved. Imaging studies showed no visible parathyroid adenoma on ultrasound, but the 4D CT scan of the neck revealed a left inferior parathyroid adenoma of size 1.1 x 1.2 cm. This was concordant on the Technetium 99m Sestamibi scan. Her MRI Brain showed bilateral globus pallidus calcification. In view of her multiple comorbidities making her a poor candidate for general anaesthesia, non-surgical options were considered. A percutaneous ultrasound guided RFA of the left parathyroid adenoma was successfully performed. Post procedure the PTH dropped from 321 pg/ml to 54.9 pg/ml within 24 hours. The calcium, phosphorus and PTH remained normal. Her Parkinsonism and dementia significantly improved and we could wean her off the anti- parkinsonian and anti-psychotic medication. She became ambulant and regained her cognitive functions. This clinical and biochemical remission was maintained over the next 22 months of follow up. Conclusion: RFA is a novel therapeutic option in treating parathyroid adenomas among surgically unfit patients. Reversal of advanced Parkinsonism following correction of chronic hypercalcemia led to this patient regaining a good quality of life. 4D CT scan of the neck is useful in localizing the parathyroid adenoma when there is discordance between the ultrasound and Sestamibi scan.

Abstract P131: Effect of uncontrolled systolic blood pressure in hypertensive patients as a risk factor for CIN after coronary angiography with preventative management of CIN : single center prospective study

Background: Contrast induced nephropathy(CIN) is associated with poor outcomes like dialysis and prolonged hospitalization and risk of death. Clinical factor for CIN include advanced age, diabetes (DM), female, heart failure(HF) and hypertension(HTN). Many prophylaxis strategies for CIN(normal saline hydration, N-acetylcysteine, NAHCO3) had been studied and their preventive effects had been known to be no difference. Purpose: We tried to evaluate the effects of uncontrolled systolic blood pressure(defined as SBP>160mmHg) in hypertensive patients as a risk factor for CIN after coronary angiography(CAG) with various preventative management of CIN (normal saline hydration, N-acetylcysteine, NAHCO3). Methods: This study included 41patients who performed CAG combined with various preventative management of CIN in single center. All patients were evaluated with serum creatinine(SCr), creatinine clearance(CrCl) before and after coronary angiography at day0, day1, day2 and day30. Definition of CIN include; SCr increase of ≥0.5 mg/dL, a SCr increase ≥25%, an CrCl decrease of ≥25%, or the composite, occurring 48 to 72 hours after contrast exposure. We also analyzed preexisting renal insufficiency(GFR<60ml/min), DM and HTN, age, sex, anemia, contrast volume and HF which are known risk factors for CIN. Results: 11 of 41 patients developed CIN. There was no statistical differences between the two groups in the aspect of baseline Cr, age, sex, body weight, contrast volume and the prevalence of known risk factor for CIN (DM, HTN, HF and preexisting renal failure). Mean baseline SBP in the CIN group was higher than non-CIN group(166.3±31.9 vs142.4±25.7, P-value=0.018). Among 23 patients with HTN, 11 patients (47.8%) had uncontrolled SBP. The multivariable logistic regression analysis showed that an uncontrolled SBP (odds ratio [OR] 12.63, 95% confidence interval [CI] 1.83-87.07) was the independent risk factor for CIN. Conclusions: CIN associate with variety of short-term and long-term complication after CAG. Hypertension is well known as one of the risk factors for CIN. Even if appropriate preventative management of CIN are taken before and after CAG, uncontrolled SBP in hypertensive patients could increase the risk of CIN.

Management of severe hypercalcaemia secondary to primary hyperparathyroidism: The efficacy of saline hydration, furosemide, and zoledronic acid.

Severe hypercalcaemia is a life-threatening condition that should be managed urgently. The aim of this study was to assess the efficacy of saline hydration, furosemide, and zoledronic acid in the management of severe hypercalcaemia secondary to primary hyperparathyroidism (PHPT). We conducted a retrospective analysis of the management of 65 patients with severe hypercalcaemia (≥3 mmol/L) secondary to PHPT. The efficacy of each therapeutic agent was evaluated according to the variation in serum calcium level calculated as Δ calcium=initial calcium level - minimal calcium level reached after the administration of each agent. The mean age of patients was 56.4± 13.8 years. At baseline, the mean total serum calcium level was 3.42 ± 0.40 mmol/L. After normal saline hydration, calcium level decreased from 3.25 ± 0.21 to 2.98 ± 0.2 mmol/L (p < 10-3 ) in 3.1 ± 1.7 days. Normalization of calcium level did not occur in any patient. Furosemide was prescribed in 35 patients. It resulted in a serum calcium increase of 0.09 ± 0.21 mmol/L. Calcium levels did not reach the normal range in any patient. Forty-five patients received intravenous zoledronic acid. The mean maximal reduction in serum calcium level was 0.57 ± 0.27 mmol/L (from 3.25 ± 0.26 mmol/L to 2.68 ± 0.22 mmol/L, p-value <10-3 ). Normalization of calcium levels occurred in 27 patients (60%). Our results show the absence of a significant additional effect of furosemide on calcium levels in patients with severe hypercalcaemia secondary to PHPT when compared with the effect of saline hydration alone. However, zoledronic acid was more potent. Thus, appropriate normal saline hydration with immediate intravenous bisphosphonates infusion should be considered in the management of severe hypercalcaemia in patients with PHPT.

MO351: Effect of Allopurinol Versus Saline Hydration in Preventing Contrast-Induced Nephropathy

Abstract BACKGROUND AND AIMS Contrast-induced nephropathy (CIN) is a generally reversible form of acute kidney injury that occurs soon after the .administration of radiocontrast media. Several therapies are being used for the prevention of CIN. We aimed to gather the data about protective role of a single oral dose of Allupurinol along with hydration with normal saline as compared with normal saline only in our settings. METHOD Duration of study was 6 months. It was done at Department of Nephrology/Cardiology, Pakistan Institute of Medical Sciences (PIMS), SZABMU, Islamabad. In this randomized controlled trial, a total of 76 (n = 76) adult (age 18–75 years) patients of either gender who were planned to undergo coronary intervention were selected for this study. All the enrolled patients had an eGFR &amp;lt;60 mL/min. Participants were divided into two groups randomly by using random number tables. Patients in group A received a single dose of 300 mg Allopurinol orally 12 h before contrast-based procedure and intravenous normal saline hydration at the rate of 0.5 mL/kg/h in continuous infusion 12 h before and 12 h after contrast-based procedure. Group B received normal saline hydration alone in dose equal to group A. Blood samples were drawn 12 h before procedure. Samples were analyzed for serum creatinine levels. Blood samples were drawn after 48 h and 5 days of procedure for serum creatinine analysis. CIN was assessed in all patients, which was defined as an absolute .increase in .serum creatinine level of &amp;gt; 0.05 mg/dL or a relative increase of &amp;gt; 25% from baseline at 48 h after contrast exposure and compared in both treatment groups. RESULTS Gender distribution was similar in both groups with M:F of 1.71 in group A and 1.53 in group B (P = 0.813). Mean age was 57.6 years ± 7.4 SD in group A, while it was 58.4 years ± 6.5 SD in group B (P = 0.612). There were 63.2% (n = 24/38) patients in group A who were between ≤60 years of age and 36.8% (n = 14/38) had an age &amp;gt;60 years. Mean eGFR at baseline in group A was 53.7 mL/min ± 4.7 SD, and it was 54.8 mL/min/1.73 m2 ± 3.8 SD in group B (P = 0.277). Mean maximal allowable contrast dose (MACD) in group A was 323.3 mL ± 51.7 SD, and it was 313.4 mL ± 0.09 SD in group B (P = 0.445). Mean contrast volume was 55.1 mL ± 5.9 SD in group A, and it was 56.9 mL ± 5.6 SD in group B (P = 0.171). The mean CV/MACD ratio was similar in both groups (0.17 versus 0.19, P = 0.160, Table 7). Contrast-induced nephropathy (CIN) was observed in 5.3% (n = 2/38) patients in group A, while it was observed in 21.1% (n = 8/38) patients in group B as per pour operational definitions (P = 0.042). CIN in both the groups were stratified with respect to age, gender, BMI and baseline comorbids. In patients with baseline uric acid within normal limits, CIN was observed in 3.4% (n = 1/29) patients in group A, while it was observed in 9.7% (n = 3/31) patients in group B (P = 0.334, Table 10). In patients with raised uric acid levels at baseline, CIN was observed in 11.1% (n = 1/9) patients in group A, while it was observed in 71.4% (n = 5/7) patients in group B (P = 0.013). Efficacy of a single dose of Allopurinol dose along with hydration with normal saline was significantly better in patients with raised serum uric acid levels at baseline when compared with normal saline only (P = 0.013). No other significant difference noted across all groups (P&amp;gt;0.05 in all cases). CONCLUSION CIN developed in a significantly lesser number of patients who received a single dose of 30 mg of Allopurinol 12 h before administration of contrast along with saline hydration as compared with patients receiving hydration alone.

Prophylactic hydration to prevent contrast-induced nephropathy: much ado about nothing?

Clinical guidelines recommend prophylactic hydration to reduce the risk of contrast-induced nephropathy in high-risk patients, including those with chronic kidney disease. A recent single-center randomized trial showed no significant difference inthe incidence of contrast-induced nephropathy in ambulatory patients with stage3 chronic kidney disease who were randomized to no prophylactic hydration versusnormal saline hydration. While these results may identify patients who areless likely to benefit from prophylactic hydration, nephrologists and interventionalists should carefully consider the generalizability of these results toindividual patients.

Extreme Hypercalcemia of Malignancy in a Pediatric Patient: Therapeutic Considerations

ABSTRACT Objective: Hypercalcemia of malignancy is rarely seen in children, and therefore few cases are available to illustrate the potential severity of presentation and clinical course. The objective of this report is to present the case of a pediatric patient with extreme hypercalcemia of malignancy and his successful management. Methods: We describe the therapeutic course of a pediatric patient with one of the highest calcium levels (21.4 mg/dL) reported in the literature and provide a review of what is published on pediatric hypercalcemia of malignancy, focusing on aspects of management. Results: Our patient's severe hypercalcemia rapidly responded to aggressive normal saline hydration, calcitonin, and zoledronic acid but was followed by hypocalcemia and hypophosphatemia, which were treated with oral supplementation. Conclusion: This case and review of the literature illustrate the potential severity of hypercalcemia of malignancy and important therapeutic considerations for practitioners.

TCT-835 Sodium bicarbonate versus normal saline hydration for mortality: a meta-analysis of randomized controlled trials

Perioperative infusion of sodium bicarbonate (NaHCO3) has been shown to reduce the risk of contrast-induced nephropathy (CIN). However, it is currently not known the effect NaHCO3 may have on short and long-term mortality. The objective of this research was to conduct a meta-analysis to determine

A Case of Myotonic Dystrophy with Electrolyte Imbalance

Type 1 myotonic dystrophy (DM1) is an autosomal-dominant inherited disorder with a multisystem involvement, caused by an abnormal expansion of the CTG sequence of the dystrophic myotonia protein kinase (DMPK) gene. DM1 is a variable multisystem disorder with muscular and nonmuscular abnormalities. Increasingly, endocrine abnormalities, such as gonadal, pancreatic, and adrenal dysfunction are being reported. But, Electrolytes imbalance is a very rare condition in patients with DM1 yet. Herein we present a 42-yr-old Korean male of DM1 with abnormally elevated serum sodium and potassium. The patient had minimum volume of maximally concentrated urine without water loss. It was only cured by normal saline hydration. The cause of hypernatremia was considered by primary hypodipsia. Hyperkalemic conditions such as renal failure, pseudohyperkalemia, cortisol deficiency and hyperkalemic periodic paralysis were excluded. Further endocrine evaluation suggested selective hyperreninemic hypoaldosteronism as a cause of hyperkalemia.

The effects of different hydration strategies before endovascular treatments to the renal function of the arteriosclerosis obliterans patients

To compare the efficacies of different hydration strategies in protecting the renal function of the arteriosclerosis obliterans (ASO) patients undergoing endovascular treatments. 40 patients who underwent endovascular treatments for arteriosclerosis obliterans of lower extremities in the Vascular Surgery Department of PLA Hospital from January 2009 to October 2009 were divided into normal (serum creatinine < or = 110 micromol/L) and abnormal (serum creatine > 110 micromol/L) groups according to their baseline serum concentration of creatinine before treatments. Each group was treated by different hydration strategies 12 h before procedures. Changes of serum creatinine and creatinine clearance were measured 6, 24, 48 h after procedures to evaluate the changes of renal function and the effects of different hydration strategies. No contrast-induced nephropathy (CIN) was observed among the 40 patients. There are significant differences between normal saline hydration group and control group in the changes of serum creatinine and creatinine clearance 24 h and 48 h after exposure to contrast medium for the normal renal function patients (P < 0.05). For the patients pre-existing renal dysfunction, no significant difference was found between Sodium Bicarbonate + Saline group and Saline group in the changes of Scr and Ccr 6, 24, 48 h after exposure to contrast medium (P > 0.05). Sodium chloride provides a good efficacy for preventing the adverse effect of contrast medium to the renal function of the ASO patients. For the patients pre-existing renal dysfunction, Combination hydration with sodium bicarbonate is not more effective than normal saline alone in preventing contrast-induced renal dysfunction.

Intravenous N-acetylcysteine with Saline Hydration Improves Renal Function and Ameliorates Plasma Total Homocysteine in Patients Undergoing Cardiac Angiography

Proinflammatory cytokines and hyperhomocysteinemia are associated with clinically relevant restenosis in coronary artery disease. N-acetylcysteine (NAC) can decrease proinflammatory cytokines and plasma homocystine as well as reduce contrast-induced nephropathy. The aim of this study, therefore, was to compare normal saline hydration with and without intravenous NAC in terms of changes in renal function, proinflammatory cytokines, inflammatory markers, and plasma total homocysteine during coronary angiography. Forty-six patients who underwent coronary angiography and/or stent implantation for unstable angina were enrolled and assigned to NAC or NS treatment groups based on normal saline hydration with or without intravenous NAC, respectively. The NS group had lower serum creatinine (Cre: p = 0.02) and plasma total homocysteine (tHcy; p < 0.001) and increased glomerular filtration rate (GFR; p = 0.003) after angiography. In the NAC group, the serum blood urea nitrogen (BUN; p = 0.001), Cre (p < 0.001), and plasma tHcy (p < 0.001) were lower, and the GFR (P = 0.013) was increased after angiography. There were no statistically significant differences in serum high-sensitivity C reactive protein (hs-CRP), tumor necrosis factor-α (TNF-α), or interleukin-10 (IL-10) before and after angiography in the NS and NAC groups. Intergroup comparison revealed that plasma tHcy level was lower for the NAC-treated patients (p = 0.002), with lower plasma tHcy level before and after treatment in this group (p < 0.001). Normal saline hydration can improve renal function and decrease plasma tHcy after coronary angiography with or without NAC; however, the combination of the two decreases plasma tHcy more than normal saline hydration alone.

Single-dose intravenous therapy with pamidronate for the treatment of hypercalcemia of malignancy: Comparison of 30-, 60-, and 90-mg dosages

purpose: To determine the efficacy, dose-response relationship, and safety of 30, 60, and 90 mg of a single intravenous dose of an aminobisphosphonate, pamidronate (APD), for the treatment of moderate to severe hypercalcemia of malignancy. patients and methods: Patients with histologically proven cancer and a corrected serum calcium level of at least 12.0 mg/dL after 48 hours of normal saline hydration were enrolled in a double-blind, multicenter, randomized clinical trial. Pamidronate in 30-, 60-, or 90-mg doses was administered as a single 24-hour infusion. Serum calcium corrected for albumin, urine hydroxyproline, and calcium excretion, and serum parathyroid hormone (PTH) (1–84) were determined before and after pamidronate therapy. results: Thirty-two men and 18 women entered the study. A dose-response relationship for normalization of corrected serum calcium was seen after pamidronate administration. Corrected serum calcium normalized in 40% of patients who received 30 mg, in 61% of patients who received 60 mg, and in 100% of patients who received 90 mg of pamidronate. The decline in the serum calcium level was associated with decreased osteoclastic skeletal resorption evidenced by a decrease in urine calcium and hydroxyproline excretion. Among those with a normalized corrected serum calcium level, the mean (median) duration of normalization of the corrected serum calcium value was 9.2 (4), 13.3 (5), and 10.8 (6) days in the 30-, 60-, and 90-mg treatment groups, respectively. The response of hypercalcemia to pamidronate was not significantly influenced by the presence of skeletal metastases. PTH 1–84, suppressed in patients on entry into this study, increased to a greater extent in those patients with osteolytic skeletal metastases compared with those with humoral hypercalcemia of malignancy. Clinical improvement, including improved mental status and decreased anorexia, accompanied the decline in the corrected serum calcium level in all three treatment groups. Side effects included low-grade fever, asymptomatic hypocalcemia, hypomagnesemia, and hypophosphatemia. conclusions: A single-dose infusion of 60 to 90 mg of pamidronate was highly effective and well tolerated and normalized corrected serum calcium in nearly all patients (61% to 100%) with hypercalcemia of malignancy.

Inhibition of cis-diamminedichloroplatinum (II)--induced renal toxicity in the rat.

The hydroxyl-containing dithiocarbamates, sodium (di(hydroxyethl)-dithiocarbamate (NaY) and sodium N-methyl, N-dithiocarboxy-D-glucamine (NaG), appear to possess definite advantages over sodium diethyldithiocarbamate (DDTC) in reducing the cis-dichlorodiammineplatinum (Cis-Pt)-induced renal damage in rats given Cis-Pt as an IV bolus of 7.5 mg/kg 1 h before the IP administration of the dithiocarbamate. Renal damage, as estimated by blood urea nitrogen (BUN) values and serum creatinine levels, was less at all times up until sacrifice in animals given NaY or NaG than in those given DDTC. An even more effective method for suppression of Cis-Pt renal toxicity is to use a combination of procedures. The most efficacious combination involves a 24-h pretreatment with DDTC or NaG plus acetazolamide and normal saline hydration 30 min before administration of Cis-Pt, followed by post-treatment with NaG. With this combination therapy renal function can be almost completely spared. Although DDTC or NaG pretreatment is highly effective when used in conjunction with NaG post-treatment, DDTC or NaG pretreatment alone has no renal sparing effect on renal function or renal platinum accumulation. In experiments in which antidotes were given 1 h after Cis-Pt and the animals were followed up for 75 days, a chronic interstitial nephritis at 75 days, suggesting a persistent cell-mediated immune response to Cis-Pt-induced renal damage, may be the basis for chronically abnormal renal function resulting from Cis-Pt. Treatment with all three dithiocarbamates, NaY, NaG, and DDTC, reduced the intensity of this cellular reaction and also reduced platinum levels in the kidneys. Although NaY and NaG are effective heavy metal chelators and renal function is spared and kidney platinum levels are substantially reduced by the dithiocarbamates, no parallel loss of antineoplastic activity by Cis-Pt on the rat Walker carcinoma was observed. Since the dithiocarbamates have no known human toxicity that would disqualify their clinical use, phase 1 clinical trials are indicated.