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case studies

Hypercalcemia-induced acute kidney injury in a Caucasian female due to radiographically silent systemic sarcoidosis

Ramy M. Hanna, Marian Kaldas, Farid Arman, Melissa Wang, Terrance Hammer, Deren Sinkowitz, and Anjay Rastogi

Volume 6 (2018) p. 21 - 26

Abstract

Clinical Nephrology – Case Studies, Vol. 6/2018 (21-26)

Hypercalcemia-induced acute kidney injury in a Caucasian female due to radiographically silent systemic sarcoidosis

Ramy M. Hanna¹, Marian Kaldas², Farid Arman¹, Melissa Wang², Terrance Hammer³, Deren Sinkowitz⁴, and Anjay Rastogi¹

¹Division of Nephrology, ²Division of Rheumatology, Department of Medicine, ³Department of Family Medicine, and ⁴Division of Pulmonary and Critical Care, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA
Sarcoidosis is a rare autoimmune disease resulting in formation of non-necrotizing “non-caseating” granulomas generally in the lung. The disease classically strikes African American females in their fourth and fifth decades. The resulting hypercalcemia is a result of 1-α hydroxylase overexpression in granulomas with increased 1,25-dihydroxy vitamin D levels. This phenomenon can also be observed in mycobacterial and fungal infections that produce granulomas in infected patients. Thus, chronic infectious diseases are part of differential diagnosis of granulomatous processes. We present an elderly Caucasian female who presented with hypercalcemia with serum calcium of 11 – 14 mg/dL and an elevated ionized calcium of 1.4 – 1.5 mmol/L. Initially cholecalciferol supplements were stopped, but hypercalcemia persisted for more than 2 months. 1,25-dihydroxy vitamin D levels were markedly elevated with low normal 25-hydroxy vitamin D levels, angiotensin-converting enzyme levels were also high, and chest computed tomography (CT) imaging was negative for any lymphadenopathy (including perihilar lymphadenopathy). Malignancy and infectious workups were negative for fungal and mycobacterial infections. Positron emission tomography revealed several small lymph nodes in right upper lobe of lung, and biopsy of bone marrow and lung lymph-nodes revealed non-caseating granulomata. We present an atypical case of occult sarcoidosis presenting mainly with biochemical findings without any definitive imaging findings, making diagnosis a clinical challenge.Correspondence to:
Ramy M. Hanna, MD, FACP, FASN, University of California Los Angeles (UCLA), David Geffen School of Medicine, Department of Medicine, Division of Nephrology, 501 Deep Valley Drive, Los Angeles, CA 90274, USA
Email: [email protected]

Original

Arterial stiffness and kidney disease progression in the systolic blood pressure intervention trial 

Kristen L. Nowak, Michel Chonchol, Anna Jovanovich, Zhiying You, Walter T. Ambrosius, Monique E. Cho, Stephen Glasser, James Lash, Debra L. Simmons, Addison Taylor, Daniel Weiner, Anjay Rastogi, Suzanne Oparil, and Mark A. Supiano

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Volume 94 (2020) p. 26 - 35

Abstract

Clinical Nephrology, Vol. 94 – No. 1/2020 (26-35)

Arterial stiffness and kidney disease progression in the systolic blood pressure intervention trial 

Kristen L. Nowak¹, Michel Chonchol¹, Anna Jovanovich¹#², Zhiying You¹, Walter T. Ambrosius³, Monique E. Cho⁴, Stephen Glasser⁵, James Lash⁶, Debra L. Simmons⁴#⁷, Addison Taylor⁸, Daniel Weiner⁹, Anjay Rastogi¹⁰, Suzanne Oparil⁵, and Mark A. Supiano⁴#¹¹

¹Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, ²Rocky Mountain Regional VA, Aurora, CO, ³Department of Biostatistics and Data Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, ⁴University of Utah, Salt Lake City, UT, ⁵University of Alabama at Birmingham, Birmingham, AL, ⁶University of Illinois, Chicago, IL, ⁷VA Salt Lake City, Salt Lake City, UT, ⁸Houston Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, ⁹Tufts Medical Center, Boston, MA, ¹⁰David Geffen School of Medicine, University of California, Los Angeles, CA, and ¹¹VA Salt Lake City Geriatric Research, Education and Clinical Center, Salt Lake City, UT, USA
Aims: Arterial stiffness increases with both advancing age and chronic kidney disease (CKD) and may contribute to kidney function decline, but evidence is inconsistent. We hypothesized that greater baseline arterial stiffness (assessed as pulse pressure (PP) and carotid-femoral pulse-wave velocity CFPWV)) was independently associated with kidney disease progression over the follow-up period (3.8 years) in the Systolic Blood Pressure Intervention Trial (SPRINT).
Materials and methods: 8,815 SPRINT participants were included in the analysis of PP. 592 adults who participated in a SPRINT ancillary study that measured CFPWV were included in subgroup analyses. Cox proportional hazards analysis was used to examine the association between PP and time to kidney disease progression endpoints: (A) incident estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73m² in non-CKD participants at baseline; (B) 50% decline in eGFR, initiation of dialysis, or transplant in those with baseline CKD. Mixed model analyses examined the association of baseline PP/CFPWV with follow-up eGFR.
Results and conclusion: Mean ± SD age was 68 ± 10 years, baseline PP was 62 ± 14 mmHg, and CFPWV was 10.8 ± 2.7 m/s. In the fully adjusted model, PP ≥ median was associated with an increased hazard of kidney disease progression endpoints (HR: 1.93 (1.43 – 2.61)). The association remained significant in individuals without (2.05 (1.47 – 2.87)) but not with baseline CKD (1.28 (0.55 – 2.65)). In fully adjusted models, higher baseline PP associated with eGFR decline (p < 0.0001 (all, CKD, non-CKD)), but baseline CFPWV did not. Among older adults at high risk for cardiovascular events, baseline PP was associated with kidney disease progression.Correspondence to:
 Kristen L. Nowak, PhD, MPH 
Division of Renal Diseases and Hypertension
12700 E 19th Ave C281, Aurora, CO 80045, USA
Email: [email protected]

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