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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]

case studies

Severe refeeding syndrome after starvation ketoacidosis requiring stopping feeds

Bana Hadid, Farid Arman, and Shayan Shirazian

Volume 11 (2023) p. 104 - 109

Abstract

Clinical Nephrology – Case Studies, Vol. 11/2023 (104-109)

Severe refeeding syndrome after starvation ketoacidosis requiring stopping feeds

Bana Hadid¹, Farid Arman², and Shayan Shirazian²

¹State University of New York Downstate Health Sciences University, College of Medicine, Brooklyn, and ²Columbia University, Department of Nephrology, NY, USA
Introduction: Starvation ketoacidosis (SKA) is a rare cause of ketoacidosis in the general population but can be seen with malignancy. Patients often respond well to treatment, but some rarely develop refeeding syndrome (RFS) as their electrolytes drop to dangerous levels causing organ failure. Typically, RFS can be managed with low-calorie feeds, but sometimes patients require a halt in feeds until their electrolyte imbalances are managed. Case report: We discuss a woman with synovial sarcoma on chemotherapy who was diagnosed with SKA and then developed severe RFS after treatment with intravenous dextrose. Phosphorus, potassium, and magnesium levels dropped precipitously and remained fluctuant for 6 days. She also developed normal sinus ventricular tachycardia, premature ventricular beats, and bigeminy. She could not tolerate calorie supplementation at that time. She was managed with electrolyte repletions until clinically stable and then progressed to a liquid diet. Discussion: We present a unique case of severe SKA that resulted in RFS requiring nihil per orem (NPO) treatment for 6 days. There are no specific guidelines for SKA or RFS management. Patients with pH < 7.3 may benefit from baseline serum phosphorus, potassium, and magnesium levels. Clinical trials are needed to further study which patients may benefit from starting at a low-calorie intake versus those that require holding nutrition until clinically stable. Conclusion: Completely stopping caloric intake until a patient’s electrolyte imbalance improves is an important management aspect of RFS to underscore and study, as grave complications can occur even with cautious refeeding regimens.Correspondence to:
Bana Hadid, ScB, State University of New York Downstate Health Sciences University, College of Medicine, 450 Clarkson Ave, Brooklyn, NY 11203
Email: [email protected]

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