サムスカと肝機能障害

以下、Medscapeの記事より。

The US Food and Drug Administration (FDA) today announced it has placed restrictions on the use of tolvaptan (Samsca, Otsuka American Pharmaceutical, Inc) because of the risk for serious and potentially fatal liver injury.

Tolvaptan, indicated for treating clinically significant hypervolemic and euvolemic hyponatremia, should be used for no longer than 30 days, and it should not be used in patients with underlying liver disease such as cirrhosis. Such patients are at increased risk for severe liver injury (potentially requiring liver transplantation) or death, according to the FDA.

Today's announcement follows a previous FDA alert released in January, warning of an increased risk for liver injury.

In addition, the FDA reminds healthcare professionals that patients suspected of having liver injury should stop receiving tolvaptan immediately. Clinicians should perform liver tests as soon as possible in patients who report fatigue, anorexia, right upper abdominal discomfort, dark urine, jaundice, or any other symptom that may suggest liver injury, the FDA said in its previous alert.

Tolvaptan received a boxed warning when it was approved that requires drug initiation and re-initiation to entail close monitoring of serum sodium in a hospital setting.

The agency based its warning on a double-blind, 3-year, placebo-controlled trial involving some 1400 patients with autosomal dominant polycystic kidney disease along with an open-label extension trial. Three patients treated with tolvaptan experienced significant increases in serum alanine aminotransferase with concomitant, clinically significant increases in serum total bilirubin. The maximum daily dose of tolvaptan in the trials — 90 mg in the morning and 30 mg in the afternoon — exceeded the maximum daily dose of 60 mg approved for hyponatremia.

Tolvaptan is a selective vasopressin V2-receptor antagonist used to treat patients with clinically significant hypervolemic and euvolemic hyponatremia (serum sodium < 125 mEq/L or less marked hyponatremia that is symptomatic and has resisted correction with fluid restriction), including patients with heart failure and the syndrome of inappropriate antidiuretic hormone.

From the drug's approval in May 2009 through February 2013, approximately 16,000 prescriptions were dispensed to 4500 patients from US outpatient retail pharmacies.

"Sales to outpatient retail pharmacies accounted for approximately 40% of tolvaptan sales; 41% was distributed to non-retail pharmacies, and 18% to mail-order/specialty pharmacies during this time," the FDA said.

使用用量が米国とは違いますが注意したいと思います。

NSAIDと腎臓

Primary care physicians, who are likely to manage both early stage CKD and indications for NSAID use, should be aware of the rates of NSAID use, assess the risk of NSAID use in each patient, and, most importantly, engage each patient in informed decision making about the risks and benefit its of NSAID use. CKD screening in those who use NSAIDs daily and effective communication of the risks of NSAID use among those with CKD may be warranted to prevent further kidney damage and progression of disease.

日本人でもNSAIDを飲んでいる人多いですね。腎臓内科医として常に注意を払いたいところです。

NSAID

指紋採取

米国の医師免許は州ごとに異なっている。実はグリーンカードがないと取れない州もあったりするので職探しのときは注意が必要である。カリフォルニア州は書類が大変というのは一般的な認識である。

私の場合はミネソタ州のフルライセンスは既に持っているのだが、将来のために今回フロリダ州の免許を習得することとなった。そのために、指紋をすべての指から採取されてしまった。指紋の採取は警察署にお願いしました。

面接(形式的なのだが、そこまでいかなくてはいけない)が必要かどうかも州により異なっていて、ミネソタ州の場合は必要であったが、フロリダ州はいらないみたいである。フロリダなら観光がてらに行っても良いので面接であっても喜んでいくのだが。。。


Anuria

Anuriaとは尿量が50ml/日以下の状態。厳密に50ml/日以下の症例はそんなには診ていないかもしれない。。。なんだかんだいって50ml/日以上の尿量があることが多い。どういう基準で50mlなのかは実は知らなかったりします。30mlでも70mlでも100mlでもなく。。。

Anuriaの鑑別診断といえば、

D/D of Anuric AKI
1. Obstruction
2. Obstruction
3. Obstruction
4. ATN with severe sepsis, on pressors and multiple organ failure
5. Cortical necrosis
6. Bilateral renal vein thrombosis

閉塞が大事ですね!

Jeujunoileal Bypass

88691d7e.gifCalcium oxalate renal stones occur commonly following JIB, along with increased colonic absorption of oxalate.

The colonic absorption of oxalate has been attributed to:

Exposure of colonic mucosa to excessive bile salts and possibly bile acids, increasing colonic permeability to oxalate, or

Excessive quantities of fatty acids in the gut form soaps with calcium, reducing its availability to form insoluble calcium oxalate leading to the persistence of soluble and absorbable oxalate in the colon.

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