Letter to the Editor
Reply
Respuesta
Ignacio Grafia
, Javier Marco-Hernández
Corresponding author
Servicio de Medicina Interna, Hospital Clínic de Barcelona, Barcelona, Spain
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"documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2020;154:374-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the editor</span>" "titulo" => "Answer to: “Asterixis as an atypical expression of hypercalcemia”" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "374" "paginaFinal" => "375" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Respuesta a: «Asterixis como forma de presentación atípica de hipercalcemia»" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Eugenia Ameneiros-Lago, Carmen Carballada-Rico, Francisco-José Fernández-Fernández" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Eugenia" "apellidos" => "Ameneiros-Lago" ] 1 => array:2 [ "nombre" => "Carmen" "apellidos" => "Carballada-Rico" ] 2 => array:2 [ "nombre" => "Francisco-José" "apellidos" => "Fernández-Fernández" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775319303148" "doi" => "10.1016/j.medcli.2019.03.035" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775319303148?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620301236?idApp=UINPBA00004N" "url" => "/23870206/0000015400000009/v2_202005120646/S2387020620301236/v2_202005120646/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Reply" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "375" "paginaFinal" => "376" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ignacio Grafia, Javier Marco-Hernández" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Ignacio" "apellidos" => "Grafia" "email" => array:1 [ 0 => "nacho.grafia@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Javier" "apellidos" => "Marco-Hernández" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Interna, Hospital Clínic de Barcelona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Respuesta" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We are extremely pleased that our letter entitled “Asterixis as an atypical expression of hypercalcaemia”<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> aroused the interest of the readers of <span class="elsevierStyleSmallCaps">Medicina Clínica</span> and that it has given rise to the response by Ameneiros-Lago et al.,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> which undoubtedly complements and enriches the content of the original article.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We would like to highlight that although the paper presented a brief review on the diagnostic and therapeutic approach to hypercalcaemia, our main purpose was to highlight asterixis or negative myoclonus<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> as a rare semiological finding in hypercalcaemia. Although it had been previously described in medical literature as a manifestation of hypercalcaemia,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> it is not usual in clinical practice to carry out a detailed screening of this condition when creating a differential diagnosis of asterixis.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Regarding the observation made by our colleagues in reference to the discrete hypercalcaemia as a cause of neurological manifestations in our patient (especially the corrected plasma calcium, since the ionised calcium 1.45<span class="elsevierStyleHsp" style=""></span>mmol/l was a significant elevation), it was also an eye-opener to us when we faced the real clinical case. For that reason, until the rest of the concomitant metabolic disorders were corrected, the alternative etiologies were ruled out and the fluctuation in the appearance of said clinical sign was confirmed in parallel to the levels of calcaemia, we did not conclude that hypercalcaemia was responsible for asterixis. As is correctly commented, the speed of onset of dyselectrolytemia and the probable previous situation of hypocalcaemia in the context of chronic kidney failure could justify this fact. Unfortunately, such a hypothesis could never be conclusively demonstrated, given the absence of previous calcium determinations.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The chronic renal failure conditioned an abnormal previous situation of the phosphocalcic metabolism, which involved a greater complexity in the interpretations of the results obtained. Indeed, the discrete elevation of parathormone, and not its suppression in the context of malignancy-associated hypercalcaemia, was the most notable finding. This shows that the hyperparathyroidism secondary to pre-existing kidney failure played a determining role in the biochemical results and should remind us that the doctor, especially the internist, has the obligation to contribute that holistic and global vision in the diagnostic and therapeutic approach of the patients.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally, we wish to thank the contributions made regarding the treatment of hypercalcaemia in the context of chronic kidney disease. Indeed, although in the latest guidelines, loop diuretics are not recommended due to their capacity to inhibit bone resorption and volume depletion, there are 2 exceptions in which their use could be justified, always with the intention of avoiding fluid overload (kidney failure and heart failure). In the case of our patient, we opted for close monitoring of fluid therapy in the hospital ward, with fluid balances and daily weight quantification. Regarding the use of intravenous bisphosphonates, its use is not recommended in cases of severe kidney failure (GFR<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ml/min), although dose adjustment is sufficient in mild or moderate cases.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Indeed, denosumab (human monoclonal antibody against RANKL) is an alternative which is already FDA-approved for the treatment of malignancy-associated hypercalcaemia, allowing its use in patients with kidney failure, which makes it especially useful in this patient profile. Its main disadvantage is the latency at the onset of action (9 days median), which compromises its usefulness in cases of symptomatic severe hypercalcaemia that requires urgent treatment. On the other hand, the duration of its action is much more sustained over time than that of the rest of the current treatments for hypercalcaemia, which makes it especially useful in managing chronicity.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Given the severity of the situation, the urgent need to correct calcaemia and the kidney failure, we decided to start calcitonin, whose effect occurs in the first few hours after its administration (whereas the effect of bisphosphonates occurs in 48–72<span class="elsevierStyleHsp" style=""></span>h). In contrast, the short duration of its effect requires controlling the cause of hypercalcaemia in parallel with additional measures, an objective that was not reached in our patient.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In any case, if the patient's progress had been favourable and hypercalcaemia was a persistent condition, denosumab would have been a fundamental therapeutic option in the context of chronic kidney failure.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Grafia I, Marco-Hernández J. Respuesta. Med Clin (Barc). 2020;154:375–376.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Asterixis as an atypical expression of hypercalcemia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "I. Grafia" 1 => "J. Marco-Hernández" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2019" "volumen" => "152" "paginaInicial" => "121" "paginaFinal" => "122" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Answer to: – “Asterixis as an atypical expression of hypercalcemia”" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E. Ameneiros-Lago" 1 => "C. Carballada-Rico" 2 => "F.J. 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Hu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2217/fon.15.232" "Revista" => array:6 [ "tituloSerie" => "Future Oncol" "fecha" => "2015" "volumen" => "11" "paginaInicial" => "2865" "paginaFinal" => "2871" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26403973" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015400000009/v2_202005120646/S2387020620301248/v2_202005120646/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015400000009/v2_202005120646/S2387020620301248/v2_202005120646/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620301248?idApp=UINPBA00004N" ]
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