Comparative effect of 3 different fix-combination antihypertensive treatments in fasting glucose, fasting insulin, OGTT and HbA1c levels, in prediabetic hypertensive patients

Introduction

The effect of various antihypertensive drugs on the glucose homeostasis has been discussed extensively. Dual combination treatment is advised with current guidelines. We present comparative data of the effect of delapril/manidipine versus valsartan/amlodipine versus telmisartan/amlodipine combination treatments, in fasting glucose, fasting insulin, OGTT and HbA1c levels, before and after the 3-month treatment, in hypertensive prediabetic patients.

Methods

Data were collected from 154 patients from the outpatient clinic for patients with lipid disorders, hypertension and diabetes of our hospital, during the period 2014–2018. A number of 53 persons was randomized in the delapril/manidipine group 30/10 mg per day while 51 persons had been randomized in the group of telmisartan/amlodipine 80/5mg per day and 54 patients in the valsartan/amlodipine 160/5 mg per day. All patients successfully completed the study. Baseline characteristics are presented in Table 1A.

Results

The resulting alternations in glucose, insulin, OGTT and HbA1c levels, before and after the 3-month treatment are presented on Table 1B for the 3 groups of treatment.

Conclusions

In the comparison between the groups, a statistically significant difference was found in the change in INS values from the beginning of treatment until 3 months, for the TEL/AMLO treatment group, where a statistically significant difference from the DEL/MANI treatment group (p-value<0.01) and a strong statistically significant difference from the VAL/AMLO treatment group (p-value<0.001) were noted. The TEL/AMLO group had the only decrease in insulin levels compared to the other treatment groups where an increase was observed, after the treatment. The change in OGTT levels showed a statistically significant difference (p-value<0.05) between the DEL/MANI treatment group (a decrease of 6.63%) compared to the TEL/AMLO treatment group (an increase of 1.53%) after 3 months of treatment.

Funding Acknowledgement

Type of funding sources: None.

Changes in TRG/ApoA-1 ratio, TRG/HDL-C ratio and lipid serum profile after combination therapy with telmisartan/amlodipine in prediabetic patients

Funding Acknowledgements

Type of funding sources: None.

Introduction-Purpose

The combination of telmisartan with amlodipine is a commonly administered combination of an agonist ATII (angiotensin receptor II) and CCB (calcium channel blocker) for the management of hypertension. The purpose of this study is to evaluate the effect of the fixed of combination telmisartan/amlodipine 80/5mg per day on the levels of serum lipids, as well as the levels of serum apolipoproteins and the TRG/ApoA-1, TRG/HDL-C ratios, in patients with stage 2 hypertension (systolic blood pressure (SBP) 160-180 mmHg and/or diastolic blood pressure (DBP) 100-110 mmHg) and with prediabetes (IFG/IGT), before and after the 3-month treatment.

Methods

Data from 51 patients who had visited our outpatient clinic for lipid metabolism disorders during the period 2014-2018 and had been randomized in the telmisartan/amlodipine group 80/5mg per day. The patients (35 male/16 female) had BMI: 29.32 [27.37-31.65]. The levels serum lipids and of apolipoproteins B, A1, Lp(a) and E were measured before the beginning of the treatment and 3-months after its administration.

Results

The resulting variations of SBP and DBP levels before and after the 3-month treatment, as well as the variations of serum lipid, apolipoprotein levels and TRG/ApoA-1, TRG/HDL-C ratios are presented on Table 1.

Conclusion

The 3-month telmisartan/amlodipine therapy seems to improved, statistically significant both SBP and DBP levels (decreased by -13.58 % and -13 % respectively, p<0.001, for both values). Serum lipid levels didn’t show any significant variation before and after treatment. Statistically significant changes were not present in apolipoprotein levels, also. Finally, there were no statistically significant variations in either TRG/ApoA-1 or TRG/HDL-C ratios.

Alternations in markers of insulin resistance: HOMA-IR, HOMA-B, QUICKI, after dual therapy combination with delapril/manidipine in prediabetic hypertensive patients

Funding Acknowledgements

Type of funding sources: None.

Purpose

The administration of the 30mg hydrochloric delapril and 10mg hydrochloric manidipine formulation is indicated for patients with idiopathic hypertension whose arterial pressure cannot be sufficiently managed with monotherapy. The purpose of this study is to investigate the effect of the premade combination delapril/manidipine 30/10mg per day on the variation of HOMA-IR, HOMA-B and QUICKI values, in patients with stage 2 hypertension (systolic blood pressure (SBP) 160-180 mmHg and/or diastolic blood pressure (DBP) 100-110 mmHg) and with prediabetes (IFG/IGT) before and after the 3-month treatment with the fixed combination dual-therapy.

Methods

53 patients (30 male/23 female, from whom 12 smokers and 7 alcohol users) who visited our outpatient clinic for lipid metabolism disorders and fulfilled the study’s criteria joined the study’s sample. They were randomized in the delapril/manidipine group. The patients’ BMI was 28.73 [27.73-30.3] and the SBP and DBP values were: 156 [151-161] and 100 [88-101] mmHg respectively.

Results

The resulting variations of SBP and DBP levels, as well as the variations of glucose and insulin levels and HOMA-IR, HOMA-B and QUICKI are presented on Table 1.

Results

From the sampled patients it seems that the 3-month treatment with delapril/manidipine improved statistically significantly the levels of both SBP and DBP (reduction by -11.54% and -12% respectively, p<0.001 for both values). Glucose levels witnessed a 1.55% decrease with statistical significance while a notable increase in insulin by 4.65% was also observed after the 3-month treatment, albeit without any statistical significance. Concerning HOMA-IR and QUICKI, there were no significant variance, while HOMA-B values showed a statistically significant increase (7%, p=0.006)

Clinical application of the new cardiovascular risk prediction algorithms SCORE2 and SCORE2-OP in patients with dyslipidemia

Funding Acknowledgements

Type of funding sources: None.

Introduction

European Society of Cardiology (ESC) has recently launched the SCORE2 and SCORE2-OP cardiovascular risk prediction algorithms.

Purpose

Cardiovascular risk assessment of patients with dyslipidemia according to SCORE2 and SCORE2-OP in comparison with the HELLENIC SCORE.

Methods

A retrospective observational study involving 1334 dyslipidemic patients followed-up for ≥3 years at our outpatient lipid clinic in our university general hospital. After excluding patients with established cardiovascular disease, diabetes mellitus, familial hypercholesterolemia, chronic renal disease, and those receiving hypolipidemic treatment, patients were categorized according to HELLENIC SCORE and SCORE2 / SCORE2-OP into the following cardiovascular risk groups: low-moderate, high and very high.

Results

A total of 532 patients were included in the present analysis (40% male, 17% smokers, mean age 55 [48-62] years, 8.6%> 70 years). Subjects’ mean cholesterol levels were 257 (228-291) mg/dL, triglycerides 136 (99-196) mg/dL, high-density lipoprotein cholesterol 52 (45-62) mg/dL, and low-density lipoprotein cholesterol 173 (149-200) mg/dL. According to SCORE calculation, 428 patients (80%) were classified into low-moderate, 87 (17%) high and 17 (3%) very high cardiovascular risk group. According to SCORE2 and SCORE2-OP algorithms, the proportion of those considered as high (n=230, 43%) and very high cardiovascular risk (n=89, 17%) increased (Figure).

Conclusions

The proportion of patients classified into high and very cardiovascular risk groups is anticipated to increase by implementing the new SCORE2 and SCORE2-OP.

Alternations in markers of insulin resistance: HOMA-IR, HOMA-B, QUICKI, after dual therapy combination with telmisartan/amlodipine in prediabetic hypertensive patients

Funding Acknowledgements

Type of funding sources: None.

Introduction-Purpose

The combination of telmisartan and amlodipine in tablet form indicated for patients whose arterial blood pressure cannot be fully managed with monotreatment. The purpose of this study was to investigate the effect of the fixed combination telmisartan/amlodipine 80/5mg per day on arterial pressure levels and the variation of HOMA-IR, HOMA-B and QUICKI values in patients with stage 2 hypertension (systolic blood pressure (SBP) 160-179 mmHg and/or diastolic blood pressure (DBP) 100-109 mmHg) and with prediabetes (IFG/IGT) before and after the 3-month treatment with the administration of the fixed combination.

Methods

Data collected from 51 patients who have visited our outpatient clinic for lipid metabolism disorders during the period 2014-2018. 51 persons with BMI: 29.32 [27.37-31.65] (25 male, 16 female) had been randomized in the group for telmisartan/amlodipine 80/5mg per day.

The median values for the study’s sample in SBP and DBP were: 163[158-168] and 100[95-106] mmHg, respectively. Their somatometric and demographic characteristics were recorded in the beginning of the study and are presented on Table 1Α.

Results

The results of the variations in SBP and DBP, as well as the variations in glucose, insulin, HOMA-IR, HOMA-B and QUICKI before and after the 3-month treatment are presented on Table 1B.

Conclusions

From the sampled patients it can be observed that the 3-month treatment with telmisartan/amlodipine statistically significantly improved (p=0.005) the HOMA-IR values while improving fasting glucose and insulin levels. Finally, there was a statistically significant reduction in QUICKI values and a statistically insignificant reduction in HOMA-B.

Alternations in markers of insulin resistance: HOMA-IR, HOMA-B, QUICKI, after dual therapy combination with valsartan/amlodipine in prediabetic hypertensive patients

Funding Acknowledgements

Type of funding sources: None.

Introduction-Purpose

The combination of valsartan with amlodipine is more effective than monotherapy for managing HT. The purpose of this study was to investigate the effect of the fixed combination of valsartan/amlodipine 160/5 mg per day on HOMA-IR (homeostatic model assessment for insulin resistance), HOMA-B (HOMA for β cell function) and QUICKI (quantitative insulin-sensitivity check index) values in patients with stage 2 hypertension (systolic arterial pressure 160-179 mmHg and/or diastolic pressure 100-109 mmHg) and prediabetes (IFG/IGT) before and after 3 months of treatment with the dual therapy.

Methods

Data from 54 patients who visited our outpatient clinic for lipid metabolism during the period 2014-2018. 54 persons were randomized in the valsartan/amlodipine group 160/5 mg per day (33 males/21 females from whom 14 were smokers and 8 were alcohol consumers) with BMI: 28.09[26.81-29.89], all of whom successfully completed the study. The median values of systolic and diastolic arterial pressure for the study population: 162 [159.25-165] and 100 [92-103.75] mmHg, respectively.

Results

The resulting variations of systolic and diastolic arterial pressure as well as the variations of HOMA-IR, HOMA-B and QUICKI are presented on Table 1.

Conclusions

From the studied group it is concluded that the 3-month treatment with valsartan/amlodipine improved with statistical significance the values of both systolic and diastolic arterial pressure (reduction by -13.58% and -13% for systolic and diastolic arterial pressure, respectively, p<0.001, for both values). Regarding glucose levels, there has also been a reduction by -0.04%, without statistical significance, while the increase of insulin levels (+16.13%) by the end of the 3-month period was also deemed statistically insignificant. Additionally, there have been noted statistically insignificant increases in HOMA-IR (+12.65%) and HOMA-B (+17%). Finally, no change has been observed in QUICKI values.

Blood pressure target attainment according to the recent ESC cardiovascular prevention guidelines

Funding Acknowledgements

Type of funding sources: None.

Introduction

New cardiovascular prevention guidelines have recently been issued by the European Society of Cardiology (ESC).

Purpose

To record blood pressure (BP) target attainment according to the recent ESC cardiovascular prevention guidelines.

Methods

A retrospective observational study involving 1334 dyslipidemic patients followed-up for ≥3 years at the Outpatient Lipid Clinic in University General Hospital of Ioannina, Greece. BP target attainment was recorded. ESC 2021 guidelines recommend a general target of BP <140/80 mmHg and individual targets of: i) diastolic BP <80 mmHg in all patients and ii) systolic BP 120-130 mmHg in patients 18-69 years of age without chronic kidney disease, or systolic BP 130-140 mmHg in patients 18-69 years of age with chronic kidney disease, or in those ≥70 years of age.

Results

Among the 1334 subjects, 935 (45% men, 68 [60-75 years old]) were diagnosed with hypertension and received antihypertensive treatment. Of those, 19% were diagnosed with chronic kidney disease, 24% with atherosclerotic cardiovascular disease and 23% with type 2 diabetes. Of those, 75% were receiving an angiotensin receptor blocker, 52% a thiazide diuretic, 52% a calcium channel blocker, 37% a β-blocker, 13% an angiotensin converting enzyme inhibitor, 6% an aldosterone receptor blocker and 2% a centrally acting antihypertensive drug. Half of subjects had BP <140/80 mmHg, but only 21% achieved the individualized BP targets.

Conclusions

A considerable proportion of hypertensive patients do not achieve target BP values.

Changes in TRG/ApoA-1 ratio, TRG/HDL-C ratio and lipid serum profile after combination therapy with valsartan/amlodipine in prediabetic patients

Funding Acknowledgements

Type of funding sources: None.

Introduction-Purpose

The combination of valsartan with amlodipine is a commonly administered combination of an agonist ATII (angiotensin receptor II) and CCB (calcium channel blocker) for the management of hypertension. There is already data from different studies that describe the effect of each of those medications in the lipidemic profile. Ratios TRG/ApoA-1, TRG/HDLC are useful markers of insulin resistance. The purpose of this study is to investigate the effect of the fixed combination of valsartan/amlodipine 160/5mg per day on the levels of serum lipids, as well as the levels of serum apolipoproteins and the TRG/ApoA-1, TRG/HDLC ratios, in patients with stage 2 hypertension (systolic blood pressure (SBP) 160-179 mmHg and/or diastolic blood pressure (DBP) 100-109 mmHg) and prediabetes (IFG/IGT), before and after the 3-month treatment.

Methods

Data from 54 patients who were referred to our outpatient clinic for lipid metabolism disorders during the period 2014-2018 and had been randomized in the valsartan/amlodipine group 160/5mg per day. Those patients (33 male/21 female from whom 14 were smokers and 8 alcohol users) all completed the study successfully with mean BMI: 28.09[26.81-29.89]. The median values of SBP and DBP for the sample group were: 162 [159.25-165] και 100 [92-103.75] mmHg, respectively. The levels of apolipoproteins B, A-1, Lp(a) and E were measured prior to the beginning of treatment and 3-months after its administration.

Results

The resulting alternations of SBP and DBP levels before and after the 3-month treatment, as well as the changes of serum lipid, apolipoprotein levels and TRG/ApoA-1, TRG/HDL-C ratios are presented in Table 1.

Conclusions

From the sample group it seems like that the 3-month therapy with valsartan/amlodipine improved statistically significant both SBP and DBP levels (decreased by -13.58% and -13% respectively, p<0.001 for both values). Concerning lipid levels, no significant variation was observed across the board. Finally, no significant change was observed in apolipoprotein levels and TRG/ApoA-1, TRG/HDL-C ratios.

Statin-associated muscle symptoms in clinical practice: evidence from a 6-year retrospective study

Introduction

There is conflicting evidence regarding the prevalence of statin-associated muscle symptoms (SAMS) in clinical practice and randomized clinical trials.

Aims

We aimed to record SAMS prevalence in the setting of a specialized lipid clinic.

Methods

This was a retrospective study including adults with dyslipidemia who were followed-up for ≥3 years (1999–2015) at the outpatient Lipid Clinic of our University General Hospital, Greece. We evaluated subjects' clinical and laboratory data with an emphasis on the prevalence of SAMS (including myalgias, muscle crumps and creatine kinase, CK, increase >10 upper limit of normal values) and recorded the rates of low-density lipoprotein cholesterol (LDL-C) target attainment according to the current ESC/EAS guidelines.

Results

Among 1,334 dyslipidemic subjects followed-up for 6 years (4–10), the prevalence of SAMS was 3% (n=41); 2% reported myalgias/crumples and 1% exhibited increased CK levels once. Only 7% (n=3) of those were statin intolerant, whereas the rest were able to receive any maximally tolerated statin dose. The corresponding prescription rates for low-, moderate- and high-intensity statins were 12%, 61% and 20%, respectively, whereas 32% received combination treatment with ezetimibe. None of the statin intolerant patients and 12% of those treated with any tolerated statin dose had optimal LDL-C levels.

Conclusions

The prevalence of SAMS is low in the setting of a specialized lipid clinic. Therefore, physicians should cautiously work-up to identify individuals with clinically relevant SAMS to offer alternative therapeutic regimens satisfactorily addressing their cardiovascular risk.

Funding Acknowledgement

Type of funding sources: None.

Residual cardiovascular risk of patients with dyslipidemia receiving multifactorial cardiovascular prevention therapy

Background

Few studies have reported on the incidence and risk factors of cardiovascular disease (CVD) in patients with dyslipidemia receiving multifactorial treatment.

Purpose

To record CVD incidence and risk factors in patients with dyslipidemia receiving multifactorial CVD prevention therapy.

Methods

This was a retrospective observational study including consecutive adult patients with dyslipidemia who were followed for ≥3 years at the outpatient Lipid Clinic of our University General Hospital. We recorded CVD incidence and compared it with ATTICA study, an epidemiological prospective cohort assessing the 10-year cardiovascular risk in a representative sample of the general population in Greece. Factors that were significantly associated with incident CVD were additionally identified.

Results

A total of 1,334 individuals were included and followed-up for 6 (4–10) years. Lipid-lowering treatment was overall prescribed to 94% of study participants, while 70% were on antihypertensive and 20% on glucose-lowering therapy. During follow-up, 95 subjects (7%) developed CVD events. Despite higher baseline cardiovascular risk, CVD incidence rate in this study was lower compared with ATTICA (10.4 vs 15.7/1,000 person-years, respectively). Diabetes (HR: 2.09, 95% CI: 1.18–3.70, p<0.001), established CVD at baseline (HR: 2.04, 95% CI: 1.21–3.43, p<0.001), smoking (HR: 1.82, 95% CI: 1.17–2.84, p<0.001) and age (HR: 1.07, 95% CI: 1.4–1.9, p<0.001) were independently associated with incident CVD.

Conclusions

CVD incidence rate of high-risk dyslipidemic patients receiving multifactorial treatment was lower compared with general population. Diabetes, smoking, age, and baseline CVD remain the residual CVD risk factors in dyslipidemic patients receiving prevention therapy.

Funding Acknowledgement

Type of funding sources: None.

Increased lipoprotein(a) multiplies coronary heart disease risk in patients with familial hypercholesterolemia

Background

Familial hypercholesterolemia (FH) and elevated lipoprotein(a) (Lp[a]) are individually associated with increased coronary heart disease (CHD) risk.

Purpose

To determine the independent and joint associations of FH and Lp(a) with CHD.

Methods

This was a cross-sectional study including adult patients with dyslipidemia followed at our University General Hospital, Greece. FH diagnosis was based on the Dutch Clinic Lipid Network Criteria (score ≥5), while elevated Lp(a) levels were defined as >30 mg/dL. Independent and joint associations of FH and Lp(a) with CHD prevalence were determined using binary logistic regression models adjusted for traditional cardiovascular risk factors.

Results

Among 941 participants (49 years, 47% males, 54% with FH, 36% with increased Lp[a]), the prevalence of CHD was 7.7% (n=72). Compared with subjects without FH and non-elevated Lp(a) (n=296), those with either FH (adjusted OR: 3.21, 95% CI: 1.35–7.62, n=271) or elevated Lp(a) (adjusted OR: 1.89, 95% CI: 0.76–4.69, n=180) were at higher CHD risk. The patients with both FH and elevated Lp(a) had the highest CHD risk (adjusted OR: 7.31; 95% CI: 3.09–17.32, n=195). Among FH patients, increased Lp(a) doubled CHD risk (adjusted OR: 2.22, 95% CI: 1.02–4.83), whereas among patients with elevated Lp(a), FH was associated with a 5-fold increase in CHD risk (adjusted OR: 4.96, 95% CI: 1.83–13.43).

Conclusions

FH and elevated Lp(a) have independent and additive associations with CHD prevalence. This may have therapeutic implications regarding treatment intensity.

Funding Acknowledgement

Type of funding sources: None.

SGLT2 inhibitors-induced electrolyte abnormalities: An analysis of the associated mechanisms

AIMS

Sodium-glucose co-transporter 2 (SGLT2) inhibitors are a new class of antidiabetic drugs that affect serum electrolytes levels. The aim of this review is the detailed presentation of the associated mechanisms of the SGLT2 inhibitors-induced electrolyte abnormalities.

MATERIALS AND METHODS

Eligible trials and relevant articles published in PubMed (last search in July 2017) are included in the review.

RESULTS

SGLT2 inhibitors induce small increases in serum concentrations of magnesium, potassium and phosphate. The small increase in serum phosphate concentration may result in reduced bone density and increased risk of bone fractures, mainly seen with canagliflozin, but recent meta-analyses did not show increased risk of bone fractures with SGLT2 inhibitors.

CONCLUSION

The increases in serum electrolytes levels may play a role in the cardiovascular protection that has been recently reported with empagliflozin and canagliflozin.

MANAGEMENT OF ENDOCRINE DISEASE: Hypothyroidism-associated hyponatremia: mechanisms, implications and treatment

BACKGROUND

Patients with moderate to severe hypothyroidism and mainly patients with myxedema may exhibit reduced sodium levels (<135 mmol/L).

SUMMARY

The aim of this short review is the presentation of the mechanisms of hyponatremia and of the available data regarding its implications and treatment in patients with hypothyroidism. Hypothyroidism is one of the causes of hyponatremia, thus thyroid-stimulating hormone determination is mandatory during the evaluation of patients with reduced serum sodium levels. The main mechanism for the development of hyponatremia in patients with chronic hypothyroidism is the decreased capacity of free water excretion due to elevated antidiuretic hormone levels, which are mainly attributed to the hypothyroidism-induced decrease in cardiac output. However, recent data suggest that the hypothyroidism-induced hyponatremia is rather rare and probably occurs only in severe hypothyroidism and myxedema. Other possible causes and superimposed factors of hyponatremia (e.g. drugs, infections, adrenal insufficiency) should be considered in patients with mild/moderate hypothyroidism. Treatment of hypothyroidism and fluid restriction are usually adequate for the management of mild hyponatremia in patients with hypothyroidism. Patients with possible hyponatremic encephalopathy should be urgently treated according to current guidelines.

CONCLUSIONS

Severe hypothyroidism may be the cause of hyponatremia. All hypothyroid patients with low serum sodium levels should be evaluated for other causes and superimposed factors of hyponatremia and treated accordingly.

Ten common pitfalls in the evaluation of patients with hyponatremia

Hyponatremia is the most common electrolyte disorder in hospitalized patients associated with increased morbidity and mortality. On the other hand, inappropriate treatment of hyponatremia (under- or mainly overtreatment) may also lead to devastating consequences. The appropriate diagnosis of the causative factor is of paramount importance for the proper management and avoidance of treatment pitfalls. Herein, we describe the most common pitfalls in the evaluation of the hyponatremic patient, such as failure to exclude pseudohyponatremia or hypertonic hyponatremia (related to glucose, mannitol or glycine), to properly assess urine sodium concentration and other laboratory findings, to diagnose other causes of hyponatremia (cerebral salt wasting, reset osmostat, nephrogenic syndrome of inappropriate antidiuresis, prolonged strenuous exercise, drugs) as well as inability to measure urine osmolality or delineate the diagnosis and cause of the syndrome of inappropriate antidiuretic hormone secretion. Clinicians should be aware of these common clinical practice pitfalls, which could endanger patients with hyponatremia.

Medication-induced hypophosphatemia: a review

Hypophosphatemia (serum phosphorus concentration <2.5 mg/dl, 0.8 mmol/l), although rare in the general population, is commonly observed in hospitalized patients and may be associated with drug therapy. In fact, hypophosphatemia frequently develops in the course of treatment with drugs used in every-day clinical practice including diuretics and bisphosphonates. Proper diagnostic approach of patients with low serum phosphorus concentrations should involve a detailed medical history with special attention to the recent use of medications. The clinical manifestations of drug-induced hypophosphatemia are usually mild but might also be severe and potentially life-threatening. This review aims at a thorough understanding of the underlying pathophysiological mechanisms and risk factors of drug therapy-related hypophosphatemia thus allowing prevention and effective intervention strategies.

Blood pressure drug therapy and electrolyte disturbances

Antihypertensive pharmacologic treatment may be associated with diverse disturbances of electrolyte homeostasis. These drug-induced disorders are relatively common, typically including hyponatraemia, hypokalaemia, hyperkalaemia, hypomagnesaemia, hypophosphataemia and hypercalcaemia. Diuretics, beta-blockers, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are particularly likely to cause these complications. Recognised risk factors include high-dosage regimens (especially diuretics), old age, diabetes and impairment of renal function. Strategies to prevent these adverse drug reactions involve careful consideration of risk factors and clinical and laboratory evaluation in the course of treatment.

Acute pancreatitis-induced hypomagnesemia

We describe the case of an alcoholic patient admitted to our hospital with alcohol-induced acute pancreatitis who developed severe hypomagnesemia (serum magnesium 0.36 mmol/l) during hospitalization. The underlying pathogenetic mechanisms of hypomagnesemia are discussed.

Reversible tubular dysfunction that mimicked Fanconi's syndrome in a patient with anorexia nervosa

Patients with anorexia nervosa exhibit acid-base and electrolyte disturbances. Hypophosphatemia is commonly found in these patients during nutritional recovery. However, marked, possibly, life-threatening hypophosphatemia associated with proximal tubular dysfunction has not been previously described. We report a case of anorexia nervosa complicated by a nonacidotic proximal tubulopathy, which was manifested by renal glycosuria, as well as inappropriate phosphaturia and uricosuria resulting in hypophosphatemia and hypouricemia.

Partially reversible renal tubular damage in patients with obstructive jaundice

Decreased serum uric acid levels resulting from renal urate wasting have been occasionally encountered in jaundiced patients. However, in these cases, there are no data concerning the underlying renal tubular defects. In the present study, we investigated the renal tubular function in 35 patients with obstructive jaundice of various severity and causes (11 with lithiasis, 17 with carcinoma, and 7 with intrahepatic cholestasis). A detailed study of the renal tubular function was performed. Beyond the conventional methods, (1)H-NMR spectroscopy of urine was used to evaluate noninvasively renal damage by the characteristic perturbation in the excretion pattern of low-molecular weight endogenous metabolites. On admission, patients with obstructive jaundice had significantly lower serum uric acid and phosphate levels and higher bile acid concentrations compared with 40 age- and sex-matched controls. Serum uric acid levels presented a negative correlation with the total and direct bilirubin as well as the fractional excretion of uric acid. Furthermore, a great number of the patients studied developed one or more proximal tubular dysfunction manifestations beyond uricosuria, such as renal glucosuria, phosphaturia, and increased excretion of alpha(1)-microglobulin. (1)H-NMR spectroscopy of the urine showed decreased levels of citrate and hippurate and increased levels of 3-hydroxybutyrate and acetate. In 12 patients partial or complete remission of jaundice was followed by an improvement of the proximal renal tubular damage. In conclusion, obstructive jaundice can cause a partially reversible generalized proximal tubular dysfunction.

Hyperosmolar nonketotic syndrome with hypernatremia: how can we monitor treatment?

We report the case of a 62 year-old symptomatic patient with severe hyperglycemic hyperosmolality associated with hypernatremia. During treatment, the progressive decrease in serum tonicity, which resulted in the amelioration of the neurological symptoms, followed the decrease in serum glucose and mainly the corrected serum sodium levels rather than the decrease in the uncorrected serum sodium levels. The case illustrates the usefulness of glucose - corrected serum sodium levels to monitor treatment in such conditions in order to avoid neurological consequences caused by the decrease in serum osmolality.