María Josefa Aladrén Regidor

Management of secondary hyperparathyroidism (SHPT) in chronic kidney disease patients on hemodialysis (HD) can be challenging. Conventional treatments can lead to hypercalcemia and hyperphosphatemia, both of which are associated with vascular and soft tissue calcification and increased risk of cardiovascular disease. We report the effect of treatment with the Type II calcimimetic cinacalcet on vascular calcification in a HD patient with SHPT. A 40-year-old male with a 24-year history of kidney failure secondary to mesangial proliferative glomerulonephritis, commenced HD in October 2004 following chronic graft dysfunction. The patient was admitted to hospital with renal insufficiency and metabolic abnormalities. An anatomopathological study showed calcium (Ca) deposits in the alveolar septa, bronchial wall and pulmonary arterioles. Parathyroid methoxy isobutyl isonitrile (MIBI) scintigraphy revealed multiglandular parathyroid disease and an ectopic gland behind the sternal notch. Serum intact parathyroid hormone (iPTH) was repeatedly found to be > or = 2,500 pg/ml, and was accompanied by significant abnormalities in phosphorus (P) and Ca metabolism which were difficult to control. The patient was initially treated with sevelamer, low dose calcium carbonate, a low P and reduced protein diet and high doses of intravenous erythropoietin. In addition, he received HD with a high efficiency membrane for 4.5 hours, 4-times weekly. Treatment with cinacalcet was initiated at 30 mg/day and adjusted to achieve National Kidney Foundation Kidney Disease Outcomes Quality Initiative targets for iPTH, P, Ca and Ca-P product. One year following cinacalcet treatment, a chest x-ray showed a moderate reduction in Ca deposits, a bone X-ray showed a significant reduction in vascular calcifications, and parathyroid MIBI scintigraphy showed a disappearance of ectopic focus and minimal remains of glands. Significant reductions in calcemia were controlled by concomitant modifications to oral Ca supplementation, Ca concentration in the dialysis liquid, and administration of paricalcitriol. In the second year of treatment, iPTH was maintained within the target range, with moderate rises in P and stabilization of serum Ca. An echocardiogram showed an improvement in left ventricular hypertrophy. Chest and hand X-rays showed a progressive reduction in calcifications. Radiology showed an improvement in bone morphology, with reduced trabeculation and better cortical definition in the phalanx bones. In conclusion, the changes in iPTH, P and Ca associated with cinacalcet treatment were accompanied by reduced vascular and soft tissue calcification in this patient. There were no cardiovascular events and the patient experienced a marked improvement in quality of life.

OBJECTIVES: The aim of this study was to describe the possible use of the ultrasound-assisted liposuction and liposuction with the tumescent technique for the contouring and remodelling of superficial fat areas of women in the field of gynaecology. PATIENTS AND METHODS: Between 1997 and 1999 85 healthy female patients underwent a liposuction in the department of gynaecology of the university of Essen. The patients were divided into two groups. Thirty patients (group 1) underwent an ultrasound-assisted liposuction whereas the remaining 55 patients (group 2) were operated using only the tumescent technique. RESULTS: From the operated 582 body areas a large volume liposuction with the aspiration of more than 1,000 cc fat was performed in 48.2% of the cases. In the remaining 51.8% of the cases aspiration volumes between 300 and 1,000 cc fat were obtained. No statistically significant differences could be observed when comparing the aspirat volumes between both treatment groups (p > 0.05). Serious complications were not observed. DISCUSSION: Our data could show, that liposuction is an extremely safe method for eliminating surperficial fat depots in the sense of body contouring in gynaecology, but that it should not be used for the reduction of obese body volumes. If ultrasound-assisted liposuction is really superior to liposuction with the tumescent technique remaining uncertain, no time gain could be observed due to this technique.

Introduction. Erythropoiesis is a complex process that requires the interactions of several factors. The interactions between erythroid precursors and other cells, particularly T lymphocytes, may modulate erythropoiesis. The responsiveness to recombinant human erythropoietin (rHu-EPO) in hemodialysis (HD) patients with lymphopenia remains undetermined. We investigated whether lymphopenia plays a role in the response to rHu-EPO therapy in HD patients. Patients and methods. The study included 126 HD patients on rHuEPO treatment for more than six months. We divided the population in two groups according to the lymphocyte count: group A (n = 75), > 1,200 cells/μL, and group B (n = 51), < 1,200 cells/μL. Results. In patients of groups A and B, the rHuEPO dose (U/kg/week) was 108.5 ± 62.9 versus 136.5 ± 71.4 (p = 0.022); hemoglobin (g/dL) 11.2 ± 1.5 versus 11.1 ± 1.5 (p = 0.6147); age (years) 62.8 ± 15.6 versus 67.5 ± 12.2 (p = 0.0702), and intact parathyroid hormone (iPTH) (pg/mL) 330.3 ± 285.6 versus 514.7 ± 565.0 (p = 0.019). Furthermore, in 60 HD patients on rHu-EPO and calcitriol synergistic therapy, age and iPTH correlated negatively with lymphocyte count (r = –0.379, p = 0.0028; r = –0.309, p = 0.0184), whereas the hemoglobin correlated positively with lymphocyte count (r = 0.277, p = 0.0321). Conclusions. These data suggest that elevated levels of iPTH and age affect the lymphocyte count and that lymphocytes may immunomodulate erythropoiesis. One hypothesis is that older HD patients with severe-moderate secondary hyperparathyroidism showing lymphopenia may have resistance to rHu-EPO, probably mediated via lymphopenia.

Los pacientes en tratamiento con eritropoyetina humana recombinante (rHu-EPO) presentan l/na amplia variabilidad en su respuesta al medicamento. El conocimiento de los factores que influyen en la sensibilidad y respuesta a la rHu-EPO es esencial para el adecuado manejo de la anemia. El estudio incluyo 187 pacientes en hemodialisis (HD) en tratamiento con rHu-EPO desde hacia mas de 12 meses. Dividimos a la poblacion en dos grupos de acuerdo con la dosis de rHu-EPO: grupo A (n= 69), rHu-EPO> 124 Ul/kg/semana, y grupo B (n= 118), rHU-EPO < 125 UI/kg/semana. Se observo que bajos niveles sericos de calcio y elevados niveles sericos de aluminio eran factores predictivos independientes de baja respuesta a la rHu-EPO. Tambien los niveles sericos de calcio eran factores predictivos independientes de los niveles de hemoglobina y del Indice de dosis eritropoyetina: hemoglobina. Estos datos recalcan el papel del calcio en la eritropoyesis. El calcio se requiere para los sucesos intracelulares y extracelulares que ocurren durante la interaccion de la rHu-EPO con sus celulas diana. [