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Nephrol Dial Transplant (2008) 23: 1776
disease in cardiology, it should be apparent that a true convergence of clinical cardiology and nephrology has to exist;
however, we also believe that neurology could be added in
this context.
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Conflict of interest statement. None declared.
doi: 10.1093/ndt/gfn017
1
Disciplina de Neurologia
Experimental
2
Departamento de Fisiologia,
Universidade Federal de São
Paulo/Escola, Paulista de Medicina
(UNIFESP/EPM), São Paulo, Brazil
Fulvio A. Scorza1
Ricardo M. Arida2
Esper A.
Cavalheiro1
E-mail: [email protected]
1. Herzog CA. Kidney disease in cardiology. Nephrol Dial Transplant
2008; 23: 41–45
2. Sander JW. The epidemiology of epilepsy revisited. Curr Opin Neurol
2003; 16: 165–170
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Minnesota. Epilepsia 1998; 39: 222
4. Annegers JF. Epidemiology of epilepsy. In: Wyllie E. (ed). The Treatment of Epilepsy: Principles and Practice, 2nd edn. Baltimore, MD:
Williams & Wilkins, 1997, 165–172
5. Yuen AW, Sander JW. Is omega-3 fatty acid deficiency a factor contributing to refractory seizures and SUDEP? A hypothesis. Seizure
2004; 13: 104–107
6. Sander JW. Some aspects of prognosis in the epilepsies: a review.
Epilepsia 1993; 34: 1007–1016
7. Kwan P, Sander JW. The natural history of epilepsy: an epidemiological view. J Neurol Neurosurg Psychiatry 2004; 75: 1376–1381
8. Halatchev VN. Epidemiology of epilepsy—recent achievements and
future. Folia Med (Plovdiv) 2000; 42: 17–22
9. Duncan JS, Sander JW, Sisodiya SM et al. Adult epilepsy. Lancet
2006; 367: 1087–1100
10. Hitiris N, Mohanraj R, Norrie J et al. Mortality in epilepsy. Epilepsy
Behav 2007; 10: 363–376
11. Lhatoo SD, Sander JW. Cause-specific mortality in epilepsy. Epilepsia
2005; 46: 36–39
12. Rugg-Gunn FJ, Simister RJ, Squirrell M et al. Cardiac arrhythmias
in focal epilepsy: a prospective long-term study. Lancet 2004; 364:
2212–2219
13. Harnod T, Yang CC, Hsin YL et al. Heart rate variability in children
with refractory generalized epilepsy. Seizure 2008 (in press).
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Neuropsiquiatr 2005; 63: 1035–1041
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Institutes of Health, National Institute of Diabetes and Digestive and
Kidney Diseases, Bethesda, MD, 2003
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Institutes of Health, National Institute of Diabetes and Digestive and
Kidney Diseases, Bethesda, MD, 1999, 89–100
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F, Posner JB (eds). The Diagnosis of Stupor and Coma. Philadelphia,
PA: Davis, 1972
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14: 367–369
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children and adolescents. Pediatr Nephrol 1992; 6: 182–186
Advanced Access publication 18 February 2008
Reply
Sir,
I thank Drs Scorza, Arida and Cavalheiro for their kind
comments and interesting letter. Their letter underscores the
importance of cerebrovascular disease in ESRD patients, an
area (in my opinion) that has not yet garnered the attention it
deserves in relation to its clinical importance. In particular, I
would highlight the issue of dementia and cognitive decline
as a topic of critical interest for clinicians and patients.
Our correspondents’ point on the convergence of neurology, cardiology and nephrology is well taken, as the
underlying mechanisms of microvascular disease are likely
to overlap in the brain, heart and kidney.
Conflict of interest statement. None declared.
Cardiovascular Special Studies
Center, United States Renal Data
System, Minneapolis, MN,
University of Minnesota, USA
Charles A. Herzog
E-mail: [email protected]
doi: 10.1093/ndt/gfn041
Advanced Access publication 18 February 2008
Radio-opaque appearance of lanthanum carbonate in
a patient with chronic renal failure
Sir,
We have read an interesting case report concerning an
X-ray finding in a patient taking lanthanum carbonate
[1]. David et al. explain the opacification on radiographs
by intestinal calcium phosphate accumulation. However,
such strong opacification with a CT density of 3000 HU
(Hounsfield value) has not been found in patients taking
other types of phosphate binders including those containing
calcium (CT density of bone 600 HU). In our opinion, there
might be another explanation of this finding. Below, we describe a case of radio-opaque appearance of lanthanum in
a patient taking this phosphate binder.
A 77-year-old man was admitted to a hospital for renal failure caused by complete obstructive ureterolithiasis in the solitary kidney. Haemodialysis was indicated
due to elevated renal parameters (urea 28.0 mmol/l,
serum creatinine 1079 µmol/l, phosphorus 2.45 mmol/l).
Treatment with lanthanum carbonate was started in order
Nephrol Dial Transplant (2008) 23: 1777
to normalize serum phosphate levels. Surgical treatment
of ureteral obstruction was necessary but the patient presented with haemodynamically significant supraventricular
tachycardia. The ECG proved atrial flutter that was the indication to electrical cardioversion by cardiologists. Therefore, transesophageal echocardiography had to be carried
out to exclude intracardial thrombi; these were not detected.
The echocardiography also demonstrated an inexplicable
finding on the thoracic aorta, and thus, computed tomography of the aorta was performed. The CT scan did not
reveal any significant pathology of the aorta. However, a
high-contrast substance of unknown origin and significance
was captured in the stomach (Figures 1 and 2). We performed an X-ray of lanthanum pills in a vial and detected
the radio-opacity of lanthanum itself, even without calcium
and phosphate (Figure 3). This confirmed our suspicion
that the high-contrast metallic-like substance in the stomach was a tablet of lanthanum. Lanthanum is a silvery white
metallic element that belongs to group 3 of the periodic table. This drug exhibits little systemic absorption and low
aqueous solubility. It is safe and well tolerated. We should
bear in mind that abdominal X-rays of patients taking lanthanum carbonate may have a radio-opaque appearance typical of imaging agents and may affect abdominal X-ray find-
1777
Fig. 3. X-ray of lanthanum tablets in a vial.
ings (Figure 1, 2). Therefore, we should temporarily switch
patients from lanthanum carbonate to a different phosphate
binder prior to radiological examinations.
Conflict of interest statement. None declared.
1
Department of Nephrology,
Faculty Hospital Motol, Prague,
Czech Republic
2
Department of Radiology, Faculty
Hospital Motol, Prague, Czech
Republic
Pafčugová J1
Horáčková M1
Hrašková M1
Forejt J1
Szabo M1
Pádr R2
E-mail: [email protected]
1. David S, Kirchhoff T, Haller H et al. Heavy metal-rely on gut feelings:
novel diagnostic approach to test drug compliance in patients with
lanthanum intake. Nephrol Dial Transplant 2007; 22: 2091–2092
doi: 10.1093/ndt/gfn015
Fig. 1. Body angiograph showing the higher density of lanthanum (3000
HU) than of the imaging agent in aorta (450 HU).
Advanced Access publication 11 March 2008
Reply
Fig. 2. CT scan of lanthanum carbonate in the stomach.
Sir,
This is a very interesting case report with a valuable medical
observation worth mentioning. We would like to thank Dr
Jana and colleagues for their clinical accuracy of observation and the comments regarding our recent publication in
NDT on radiographic appearance of lanthanum carbonate
[1]. We previously reported that opacifications throughout
the colon occurred after ingestion of lanthanum carbonate tablets in a 46-year-old woman with stage 5 chronic
kidney disease (CKD) requiring chronic haemodialysis [1].
Therein we speculated that these opacifications are related
to intestinal calcium–phosphate accumulations.
We agree with Jana et al. that, possibly, the radioopaque structures we had documented throughout the colon