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2018, 20(2)
HighLights More»   
·

Pay attention to vancomycin-associated nephrotoxicity and its prevention

· Analysis of occurrence and risk factors of vancomycin-associated acute kidney injury in patients in the pediatric intensive care unit
· Clinical analysis of drug-induced kidney injury in 20 inpatients
· Analysis on acute kidney injury and its risk factors in very elderly patients after urologic surgery
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  --2018, 20 (2)   Published: 28 April 2018
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Pay attention to vancomycin-associated nephrotoxicity and its prevention Hot!

Zeng Jiawei, Chen Xiao
. 2018, 20 (2): 81-82. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.001
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Analysis of occurrence and risk factors of vancomycin-associated acute kidney injury in patients in the pediatric intensive care unit Hot!
Shen Xiaoju, Zeng Jiawei, Wu Haiyan, Chen Jie, Chen Xiao
. 2018, 20 (2): 83-90. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.002
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ObjectiveTo understand the occurrence of vancomycin-associated acute kidney injury (AKI) in patients in the pediatric intensive care unit (PICU) and explore the risk factors.MethodsMedical records data of children in the PICU receiving vancomycin treatment, treatment course>48 h, and having vancomycin trough concentration monitoring data in the First Affiliated Hospital of Sun Yat-sen University from January 2013 to July 2017 were collected from the hospital information system and retrospectively analyzed. Occurrence of AKI was judged based on Pediatric-Modified RIFLE (pRIFLE) criteria. The children were divided into the AKI group and non-AKI group. The risk factors of vancomycin-associated AKI were analyzed using the multivariable logistic regression model.ResultsA total of 170 patients were entered in this study. Of them, 104 patients were male and 66 were female with ages from 5 days to 15.4 years and the median age was 1.3 years. Thirty-six patients (21.05%) developed AKI, including 31 patients (18.24%) with risk of kidney injury, 4 patients (2.35%) with kidney injury, and 1 patient (0.59%) with kidney failure, no patient with kidney loss and end-stage kidney disease. The results of multivariate logistic regression analysis showed that the elevated estimated creatinine clearance (OR=1.010, P<0.001), more than 5 kinds of concomitant nephrotoxic drugs (OR=2.808, P=0.019), average vancomycin trough level ≥17 mg/L (OR=10.426,P<0.001), combined with carbapenems antibacterial drugs (OR=4.263, P=0.013), and combined with voriconazole injection (OR=3.165, P=0.038) were all the independent risk factors of AKI occurrence.ConclusionsThe incidence of vancomycin-associated AKI was 21.18% in PICU patients in our hospital. Vancomycin trough level ≥17 mg/L and more than 5 kinds of concomitant nephrotoxic drugs would increase risk of AKI in PICU patients.
Clinical analysis of drug-induced kidney injury in 20 inpatients Hot!
Hu Lin, Li Taoming, Dai Tingting, Zou Le, Yin Tao
. 2018, 20 (2): 91-96. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.003
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ObjectiveTo understand the clinical features of drug-induced kidney injury (DIKI) in inpatients.MethodsThe  medical records data of inpatients diagnosed as DIKI from January 31, 2010 to January 31, 2017 were retrospectively analyzed. The main analytic indicators included general conditions of patients, degree of renal damage, outcomes, and suspected drugs causing acute kidney injury (AKI), and so on.ResultsA total of 20 patients were entered into this study, including 16 males (80.0%) at age 8 to 80 years and the average age of (44±20) years, 4 females (20.0%) at age 27 to 71 years and the average age of (49±22) years. Eleven patients (55.0%) were ≤44 years old (young people), 4 patients (20.0%) were 45-59 years old (middle-aged people), 5 patients (25.0%) were ≥60 years old (old people). The kinds of diseases were 2 to 6 in each patient in the 20 patients. Of them, 3 patients (15.0%) had 2 kinds of diseases at the same time, 7 patients (35.0%) had 3 kinds of diseases, 5 patients (25.0%) had 4 kinds of diseases, 4 patients (20.0%) had 5 kinds of diseases, 1 patient (5.0%) had 6 kinds of diseases. The serum creatinine (Scr) and blood urea nitrogen (BUN) values in the 20 patients were 56.0-132.5(89.1±22.1)μmol/L and 2.9-8.5(4.9±1.6)mmol/L before medication, respectively and significantly increased to 128.0-506.0 (241.8±112.8) μmol/L and 4.3-28.0 (13.0±5.9) mmol/L after medication, respectively. After treatments with hemodialysis or renal protective drugs, the Scr and BUN values were significantly reduced to 52.0-439.0(174.8±97.5) μmol/L and 1.0-27.6(9.3±7.1)mmol/L, respectively. The differences of Scr and BUN levels between before medication and after medication, before treatment and after treatment were statistically significant (all P<0.05). All DIKI during hospita-lization were AKI. Six patients (30.0%) were in AKI stage 1, 10 patients (50.0%) in AKI stage 2, and 4 patients (20.0%) in AKI stage 3 (acute renal failure). By the time of discharge, 5 patients were cured, in 12 patients the condition was improved, 1 patient had no change, in 1 patient the condition was deteriorated, and 1 patient died. The effective rate of treatments was 85.0%. A total of 29 kinds of drugs were used in combination in the 20 inpatients, and 6-24(14±5) kinds of drugs were used in each patient. Five categories and 12 drugs were found to induce kidney injury in this study, involving antibacterial drugs(15 patients), chemotherapeutic drugs (2 patients), antiviral drugs (2 patients), immunosupp-ressants (3 patients), and anti-gout drugs(1 patient). Kidney damage was clearly documented in the instructions of all above-mentioned drugs. The time from medication to onset of DIKI was 1-56 days and the median time was 9 days.ConclusionsAntibacterial drugs, especially antifungal drugs such as amphotericin B, were the main drugs causing kidney injury in hospital. The DIKI was AKI during hospitalization, and the treatment effect for AKI was good.
Analysis on acute kidney injury and its risk factors in very elderly patients after urologic surgery Hot!
Shen Jianghua, Zhao Simiao, Yan Suying
. 2018, 20 (2): 97-102. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.004
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ObjectiveTo explore the risk factors of acute kidney injury (AKI) in very elderly patients within 48 hours after urologic surgery.MethodsThe data of very elderly patients (≥75 years old) with detection data about renal function before and after urinary surgery in Xuanwu Hospital of Capital Medical University from January 2016 to December 2017 were retrospectively analyzed. AKI was diagnosed according to the guideline released by Kidney Disease: Improving Global Outcomes (KDIGO). The patients were divided into the AKI group and the non-AKI group. The clinical features, operation conditions, and drug use during the operation in patients in the 2 groups were compared, and the factors of P<0.05 in comparisons between groups were analyzed using binary logistic regression, and OR and its 95% confidence interval (CI) were calculated.ResultsA total of 190 patients were entered in the study. Of them, 24 patients developed AKI (the incidence of AKI was 12.6%). The differences in general conditions (sex, age, body weight, chronic diseases), serum creatinine levels, hemoglobin, serum albumin, and creatinine clearance rate before operation, rate of single use of non-steroidal anti-inflammatory drugs, and rate of single use of colloid liquid during the operation in patients in the 2 groups were not statistically significant (P>0.05). The rate of laparoscopic surgery in the AKI group [70.8%(17/24) vs. 16.3%(27/166)] was much higher than that in the non-AKI group; the operation time and the anesthesia time in the AKI group were obviously longer than those in the non-AKI Group [132(13, 203) min vs. 43(2, 328) min, 192(70, 276) min vs. 90(23, 388) min]; blood loss was significantly more than those in the non-AKI group [50 (2, 200) ml vs. 10 (0, 1 200) ml]; the drugs used in operation in the AKI group were obviously more than those in the non-AKI group [(14±4) vs. (12±4)]; the rate of combined use of NSAID and colloid in operation in the AKI group was significantly higher than that in the non-AKI group [25.0% (6/24) vs. 4.8% (8/166)]; the differences in the above-mentioned parameters between the 2 groups were statistically significant (all P<0.05). The binary logistic regression analysis showed that the type of operation (laparoscope) (OR=3.538, 95%CI: 1.047-11.962), the combined use of NSAID and colloid during the operation (OR=5.673, 95%CI: 1.312-24.536) were the independent risk factors of AKI within the 48 h after operation in very elderly patients.ConclusionsThe type of operation (Laparoscope) and the combined use of NSAID and colloid liquid are risk factors of AKI within 48 h after urologic operation in very elderly patients. In order to avoid the occurrence of AKI in very elderly patients, it is necessary to reduce the use of renal toxic drugs in operation, especially the combined use of NSAID and colloid.
Establishment of detection method for simultaneous determination of plasma concentrations of paraquat and diquat by high performance liquid chromatography
Zhang Lijuan, Yan Junfeng, Chen Lu, Tu Cuiping
. 2018, 20 (2): 103-109. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.005
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ObjectiveTo establish a detection method for simultaneous determination of plasma concentrations of paraquat and diquat by high performance liquid chromatography (HPLC).MethodsAll the plasma samples were pretreated using 35% perchloric acid and microporous filtering film. The chromatographic peaks of paraquat and diquat were measured by high performance liquid chromatograph (Waters 2695). The mobile phase was acetonitrile∶  buffer (6∶  94). The buffer contained 20 mmol/L reversed-phase ion pair sodium 1-heptane sulfonate and 1.5% phosphoric acid. The buffer′s pH was adjusted to 2.0 with triethylamine. The column temperature was 40 ℃. The flow speed was 0.8 ml/min. The detection wavelengths of paraquat and diquat were 254 nm and 309 nm. The plasma concentrations of paraquat and diquat were calculated according to the chromatographic peak area of paraquat and diquat and the standard curves were run on the same day.ResultsThe paraquat and diquat chromatographic peaks detected by reversed phase ion-pair liquid chromatography showed good shape. The retention times of paraquat and diquat were 4.652 and 5.066 min, respectively. Peaks of paraquat and diquat were separated well and not disturbed by impurity peaks. Paraquat had a good linear relationship between the chromatographic peak area and the concentrations in the range of 0.097 7-50.000 0 μg/ml, the lowest detection concentration was 0.090 0 μg/ml. Diquat had a good linear relationship between the chromatographic peak area and the concentrations in the range of 0.097 7-50.000 0 μg/ml, the lowest detection concentration was 0.070 0 μg/ml. The absolute recovery and relative recovery of paraquat at high, medium and low concentrations were 98.75% to 103.86% and 102.29% to 107.26%, respectively. The absolute recoveries and relative recoveries of diquat at high, medium and low concentrations were 99.67% to 111.55% and 100.85% to 101.94%, respectively. Their relative standard deviations (RSD) were all <3%. The mean values of within-day precision in high, medium, and low concentrations of paraquat were 51.030 0, 6.429 6, and 0.767 0 μg/ml, respectively. The mean values of within-day precision in high, medium, and low concentrations of diquat were 50.178 6, 6.509 1, and 0.829 4 μg/ml, respectively. The RSD of within-day precisions of paraquat and diquat were 0.40%-3.22%. The mean values of day to day precision in high, medium, and low concentrations of paraquat were 52.707 5, 6.442 5 and 0.767 5 μg/ml, respectively. The mean values of day to day precision in high, medium, and low concentrations of diquat were 51.650 1, 6.519 2 and, 0.829 3 μg/ml, respectively. The day to day precisions (RSD) of paraquat and diquat were 0.20%-2.49%. The detection results of the standard plasma samples in high, medium and low concentrations which were repeatedly frozen and thawed (1 and 2 times) at  70 ℃, preserved at -20 ℃ at different time (3 and 7 days), lied  at room temperature at different time (8 and 24 hours), lied at 4 ℃ at different time (1 and 2 days), and the standard plasma samples which were not treated with above-mentioned measures showed that all RSDs were <10%.ConclusionsA detection method for simultaneous determination of plasma concentrations of paraquat and diquat by reversed-phase ion-pair liquid chromatography was established. The method is fast and accurate.
orrelation between sodium-glucose co-transporter protein 2 inhibitors and fracture risk in patients with type 2 diabetes mellitus: a Meta-analysis
Zhao Zinan, Liang Liang, Sun Xuelin, Zhu Yuanchao, Feng Yufei, Zhang Yatong
. 2018, 20 (2): 110-116. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.006
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ObjectiveTo systematically evaluate the correlation between sodium-glucose co-tran-sporter 2 (SGLT2) inhibitors and fracture risk in type 2 diabetes mellitus (T2DM) patients.MethodsThe related databases were searched. The randomized controlled trials (RCTs) which the outcome index included fracture in T2DM patients treated with SGLT2 inhibitors from the inception to August 2017 were enrolled into the study. The documents were selected according to the inclusion and exclusion criteria. After the data extraction and evaluation of methodological quality of RCTs, Meta-analysis was conducted using Rev Man 5.3 software.ResultsA total of 12 RCTs involving 28 181 patients were entered, including 17 747 patients in the test group (SGLT2 inhibitors) and 10 434 in the control group. The drugs used in the test group were canagliflozin (7 RCTs) and empagliflozin (5 RCTs). The drugs used in the control group were non-SGLT2 inhibitors including metformin, glimetazide and/or placebo. The results of Meta-analysis showed that the incidence of fractures in the test group was significantly higher than that in the control group[5.05% (897/17 747) vs. 4.40% (459/10 434), RR=1.27, 95%CI: 1.14-1.42, P<0.01]. Subgroup analysis showed that the incidence of fractures in the canagliflozin group was significantly higher than that in the control group [6.21% (679/10 938) vs. 5.28% (365/6 913), RR=1.31, 95%CI: 1.15-1.48, P<0.01]. There were no significant differences in the incidence of fractures between the empagliflozin group and the control group [3.20% (218/6 809) vs. 2.67% (94/3 521), RR=1.44, 95%CI: 0.35-5.90, P=0.61].ConclusionsCanagliflozin (a kind of SGLT2 inhibitors) can increase the incidence of fractures. It is suggested that the risk assessment should be done before medication for the benefit of patients.
Effects of escitalopram on coagulation function in epression patients
Shen Zhongxia, Zhang Xiaomei, Cai Min, Gen Song, Zhang Zhen, Yang Shengliang, Shen Xinhua
. 2018, 20 (2): 117-121. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.007
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ObjectiveTo explore the effects of escitalopram on coagulation function in depression patients.MethodsThis was a self-controlled prospective study. The subjects were depression patients (Hamilton Depression Scale (HAMD) score>17) who presented to or hospitalized in the Department of Psychosomatic Disorders in the Third People′s Hospital of Huzhou City from June 1, 2016 to June 1, 2017. The patients in accordance with inclusion criteria were treated with escitalopram (initial dose was 5 mg/d and increased to 10-20 mg/d within 2 weeks). HAMD rating scale were performed, prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT) and fibrinogen (FIB) were detected before treatment and 4 weeks after treatment. Response was defined as a  50% reduction in HAMD score.ResultsA total of 95 patients finished the 4 weeks treatment with escitalopram. Of them, 38 patients were male with ages from 21 to 64 years and mean age of (39±12) years, with illness duration from 14 to 60 months and mean illness duration of (32±12) years; 57 cases were female with ages from 20 to 64 years and mean age of (38±13) years, with illness duration from 12 to 54 and mean illness duration of (28±12) years. HAMD score were (21.8±3.4) and (9.1±3.3) before and after 4 weeks treatment, respectively (t=26.125, P<0.001). The levels of PT, APTT, and TT in patients after 4 weeks treatment were significantly higher than those before treatment [(11.14±1.22) s vs. (11.66±1.41) s, (29.45±5.24)s vs. (31.28±5.64) s, (20.32±2.08) s vs. (21.15±2.21) s, respectively, all P<0.05]. However, the FIB level after 4 weeks treatment was significantly decreased than that before treatment[(1.92±0.28) g/L vs. (2.01±0.34) g/L, P<0.05]. There were no significant differences among the indexes of coagulation function among the patients with different sex (P>0.05). After treatment, the increased values of PT and TT levels and the decreased value of FIB level in female patients were significantly higher than those in male patients (all P<0.05). After treatment, there were no significant differences in the increased value of PT, TT and APTT and the decreased value of FIB between the response group (80 cases) and the non-response group (15 cases) (all P>0.05). One 24-year-old female patient presented with upper gastrointestinal bleeding after more than 1 month of escitalopram treatment at a dose of 15 mg/d.ConclusionEscitalopram has an influence on coagulation function in depression patients, especially in female patients, which may increase the risk of bleeding.
#br# Design and preliminary application of pre-audit system for medical orders in hospitalized patients
Cui Xiaohui, Yan Suying, Jiang Dechun, Guo Jingxian, Zhang He, Liang Zhigang, Fei Xiaolu, Yan Bing, Kong Fancui, Li Lingfeng
. 2018, 20 (2): 122-127. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.008
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ObjectiveTo establish a pre-audit system for medical orders in hospitalized patients and increase the auditing rate in inpatients.MethodsIn the pre-audit system for medical orders, browser/server(B/S) and client/server(C/S) hybrid architecture was adopted and JAVA language was used for programming. The pre-audit system for medical orders was linked to the hospital information system and data integration platform, and audit module was improved on the basis of the pre-audit system for prescriptions which had been successfully operated in Xuanwu Hospital of Capital Medical University. More than 20 thousand related rules were added in the audit think tank for rational drug use of prescriptions and serious errors interception for indications, dosage and administration route, appropriate translation of Chinese patent medicine indications, refinement of compatibility taboos, audit of drug allergy risk, appropriate audit for pain medications, and audit for rational drug use related to height, body weight, body surface area, and test values were performed. The audit think tank for rational drug use was formed, which set up the foundation for intelligent examination of medical orders. The medical orders which were not passed by intelligent examination were transmitted to the pre-audit pharmacist to audit for the second time. By comparing the audit rate of medical orders in hospitalized patients before and after adopting the pre-audit system and the qualification rate at the first 4 months after adopting the system, the application effect was preliminarily evaluated.ResultsAfter launching pre-audit system for medical orders in June 2017, the examination rate of medical orders in inpatients increased from 42.53% (61 139/143 756) to 100% (at the first 4 months, the number of doctor′s orders was 69 183, 74 072, 99 816, and 184 184, respectively). At the first 4 months after the system was launched, the pass rate of audit for medication orders was 69.02% (47 753/69 183), 84.27% (62 416/74 072), 92.69% (92 516/99 816), and 97.21% (179 040/184 184), respectively. The difference in passing rate of audit for medication orders between the 4th month and the first month was statistically significant(χ2=42 548.86, P<0.001).ConclusionsThe pre-audit system for inpatients′ medication orders was successfully established. The intelligent audit for all inpatients realized using this pre-audit system and was of benefit to the rational drug use improvement in hospitals.
Mechanisms, characteristics, prevention and treatment of drug-induced peripheral neuropathy
Han Peng, Zhu Shenyin
. 2018, 20 (2): 128-134. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.009
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Drug-induced peripheral neuropathy (DIPN) is a disease caused by drug′s direct or indirect damage on the structure or function of peripheral nerve. The main clinical characteristics are the dysfunctions of sensory, motor and autonomic nerves in the area of the affected nerves. The sensory nerve abnormality includes paresthesia, burning sensation, and tactile sensitivity reduction. The motor nerve abnormality includes limited mobility, and weakened or disappeared deep tendinous reflect. The autonomic nervous′ symptoms include constipation, abdominal pain, frequent micturition, and sexual dysfunction. The mechanism of DIPN includes the drug′s direct injury on the peripheral nerves, the immune-mediated nerve injury and the inflammatory damage of the neurotrophic vessels. The pathological nerve fibers show that the changes of segmental demyelination, axonal degeneration, dense granule and vacuole. The results of neuroelectrophysiological examinations show that the decrease of the amplitude and conduction velocity of sensory nerve action potential, and the normal or light change of the amplitude and conduction velocity of motor nerve action potential. The diagnosis of DIPN are mainly on the basis of the history of drug exposure, clinical characteristics and the results of neuroelectrophysiological examination. The causality between the drugs and the peripheral neuropathy is evaluated by Naranjo. The treatment of DIPN includes drug withdrawal or decreasing of the dosages of suspected drugs, taking anticonvulsants, antidepressants or opioid drugs, local anesthetics, and lipophilic antioxidants-zinc sulfate at the same time.
Progress on relation between human leukocyte antigen gene and oxcarbazepine induced cutaneous adverse drug reactions
Fan Qingqing, Xie Han, Yan Tianhua, Ge Weihong
. 2018, 20 (2): 135-139.
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Oxcarbazepine (OXC) is a new antiepileptic drug developed through structural variation of carbamazepine and widely used for the patient who cannot tolerate carbamazepine. Although OXC has a lower risk of cutaneous adverse drug reactions (cADRs) than carbamazepine, it has been reported that OXC-induced cutaneous adverse drug reactions (OXC-cADRs) are prevalent and may lead to drug discontinua-tion. HLA-B*15:02 is associated with oxcarbazepine-induced SJS/TEN, but not maculopapule, which is similar to carbamazepine. In addition, HLA-A*13:02, HLA-B*38:02 and HLA-B*40:02 are HLAⅠtype genes which is related to oxcarbazepine-induced maculopapule (OXC-MPE), and HLA-DRB1*04:03 was first HLA class II gene found associated with OXC-MPE. The risk factor of OXC-cADRs is still not completely clear. Age, gender, weight and total dose of medication were not correlated with OXC-MPE. Allergy induced by antiepileptic drugs and non-antiepileptic drug induced allergy may be risk factors of OXC-cADRs. Attention should be paid to cross-allergic reactions before using oxcarbazepine for patients with a history of carbamazepine-induced allergy. Genetic test is not currently recommended in patients with maculopapule. Aromatic antiepileptic drugs should be avoided in patients with positive expression of HLA-B*15:02 gene.
Fanconi′s syndrome induced by adefovir dipivoxil
Song Yu, Lu Ya, Yang Xueqin, Kang Xuan, Wang Qi, Shen Huiqin
. 2018, 20 (2): 140-141. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.011
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A 50-year-old female patient with hepatitis B cirrhosis received oral lamivudine (100 mg/d) 8 years ago. Lamivudine resistance appeared one year after the administration. Then adefovir dipivoxil 10 mg/d was added. About 6 years after the combined antiviral treatments, weakness of lower limbs appeared and gradually worsened. At following one year, the patient successively presented with right hypochondrium pain accompanied by difficulty in turning over, limited movement of the lower extremities, and left hypochondrium pain. Laboratory tests showed serum phosphorus 0.55 mmol/L, serum calcium 2.13 mmol/L, and serum uric acid 98  mol/L. Fanconi syndrome (FS) was considered. Adefovir dipivoxil and lamivudine were discontinued and changed to tenofovir disoproxil (300 mg every other day). After one month of treatment, laboratory tests showed serum phosphorus 0.65 mmol/L, serum calcium 2.25 mmol/L, serum uric acid 109  mol/L, urine pH 6.00, 24 hours urine potassium 69 mmol/L, urine sodium 384 mmol/L, and urine chlorine 350 mmol/L. Bone mineral density examination showed osteoporosis. Adefovir dipivoxil-related FS was diagnosed and calcitriol (0.25  g/d) was added. Three months later, weakness of bilateral lower extremities was improved markedly. Tenofovir disoproxil was discontinued and changed to entecavir (0.5 mg/d). Six months after discontinuation of adefovir dipivoxil, weakness of bilateral lower extremities subsided, right hypochondrium pain alleviated, and moderate physical activity could be tolerated, serum phosphorus, calcium, and uric acid levels returned to normal, and urine electrolyte output was obviously reduced.
Hyperbilirubinemia induced by bosentan
Wang Ping, Zhang Wen, Zhao Yong, Zeng Yan
. 2018, 20 (2): 142-143. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.012
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A 79-year-old female patient with a secondary pulmonary hypertension received an oral bosentan 62.5 mg twice daily. Her liver function was normal before medication. On the   day 57 after begining of the medication, laboratory tests showed aspartate aminotransferase(AST) 44 U/L, alanine aminotransferase (ALT) 43 U/L, gamma glutamyl transferase (γ-GT) 166 U/L, alkaline phosphatase (ALP) 249 U/L, glutamate dehydrogenase(GDH)30.8 U/L, albumin 31.7 g/L, total bilirubin(TBil) 50.0 μmol/L, direct bilirubin(DBil) 23.8 μmol/L , and indirect bilirubin(IBil) 26.2 μmol/L. On the   day 62, the patient developed yellowish discoloration of skin and sclera, fatigue and loss of appetite. Laboratory tests showed the following levels: AST 39 U/L, ALT 32 U/L, GGT 276 U/L, ALP 417 U/L, GDH 14.5 U/L, albumin 33.6 g/L, TBil 120.8 μmol/L, DBil 65.3 μmol/L, IBil 55.4 μmol/L. Drug-induced liver injury was diagnosed. Bosentan was withdrawn and hepatoprotective agents were given. Five days after the drug withdrawal, her jaundice disappeared. Thirty-three days after the drug withdrawal, laboratory tests showed AST 25 U/L, ALT 13 U/L, GGT 43 U/L, ALP 125 U/L, GDH 1.8 U/L, albumin 37 g/L, TBil 24.0 μmol/L, DBil 9.2 μmol/L, and IBil 14.8 μmol/L.
Suspected serotonin syndrome induced by fentanyl
Yan Xuelian, Xu Linlin, Mei Dan, Ge Nan
. 2018, 20 (2): 144-146. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.013
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A 64-year-old male lung cancer patient with bone metastasis received oxycodone hydrochloride prolonged-release tablets for pain in right shoulder and back and bilateral hypochondrium. The initial dose was 10 mg twice daily and was increased to 80 mg twice daily gradually. Because of poor analgesic effect, the first fentanyl transdermal patch 4.2 mg was applied and kept pasted for 48 hours. On the third day, the second patch 8.4 mg was given and kept pasted for 72 hours. On the 5th day, the patient developed severe mental symptoms such as agitation and delirium, accompanied by fever and increased heart rate. Midazolam, diazepam, olanzapine, meropenem, and indomethacin suppository were given, but his symptoms were not improved. It was considered that combined use of high dose oxycodone and fentanyl induced delirium. Then, oxycodone hydrochloride prolonged-release tablet was changed to morphine sulfate sustained-release tablet. However, because morphine sulfate sustained-release tablets could not be taken by mouth due to the patient′s agitation, fentanyl was increased to 2 patches (16.8 mg). On the second day, the patient presented with hematuria and serum creatine phosphokinase (CK) increased from 26 U/L 6 days ago to 1 511 U/L. Serotonin syndrome and rhabdomyolysis induced by fentanyl were considered. Fentanyl transdermal patches were removed immediately and continuous intravenous pumping of morphine 2 mg/h was applied. After fentanyl transdermal patch withdrawal, his mental symptoms and hematuria gradually disappeared, body temperature and heart rate returned to normal. Serum creatine phosphokinase decreased to 82 U/L 8 days after fentanyl withdrawal.
Diclofenac sodium associated acute kidney injury
Ye Xiaolan, Zheng Xiaochun, Yang Xiuli, Zhang Guobing
. 2018, 20 (2): 146-147. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.014
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A 63-year-old male patient presented with diarrhea at the previous night after taking colchicine by himself for acute gout attacks and then he changed to take diclofenac sodium himself (75 mg twice daily) for 3 days. On the third day after diclofenac sodium treatment, nausea and vomiting occurred, then the drug was stopped (the total dose was 375 mg). Two days after the drug withdrawal, the patient successively developed reduced urine output and chest discomfort. Laboratory tests showed serum creatinine 758.4 μmol/L, blood urea 13.9 mmol/L, and blood potassium 3.1 mmol/L. He was diagnosed as having acute kidney disease (AKI) and was admitted to the Department of Nephrology. After admission, he received oral compound α-Ketoacid tablets (4 pills thrice daily), benidipine tablets (4 mg once daily) and Jinshuibao capsules (金水宝胶囊, 1.98 g thrice daily), and was asked to drink more water. On the 7th day after the drug withdrawal, renal biopsy was performed and the histopathological examination result of renal tissue showed acute tubular damage. The above-mentioned treatments were continued and the patient′s renal function was improved gradually. On the 24th day after diclofenac sodium withdrawal, his serum creatinine was 89 μmol/L and blood urea was 7.5 mmol/L. Diclofenac sodium-associated AKI was considered.
Anaphylactic shock associated with cisatracurium esilate
Wang Ye, Huang Bing
. 2018, 20 (2): 148-149. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.015
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A 58-year-old female patient with compression fracture of the 12th thoracic vertebra intended to undergo closed reduction and pedicle screw fixation and transvertebral fusion of the posterior approach under general anesthesia. Before the operation, sufentanil, etomidate, and cisatracurium besilate were given for anesthetic induction, remifentanil, propofol, and sevoflurane for anesthetic maintenance. Fifteen minutes after anesthetic induction, hypotension and reddish skin on upper limbs appeared, but were neglected. Flurbiprofen, dezocine, and cisatracurium besilate were added and the patient′s blood pressure sharply declined to 51/28 mmHg, accompanied by rashes on her whole body. An immediate injection of adrenaline, methyl prednisolone, atropine and intravenous pumping of dopamine were given. One hour later, the blood pressure was stable. One and a half hours later, choking, coughing, and body movement appeared, the third injection of cisatracurium besilate 6 mg was given. Then the patient′s blood pressure decreased again (85/50 mmHg) and rashes aggravated. It was considered that the patient developed cisatracurium besilate induced anaphylactic shock. Anti-shock treatments were given continuously. The next day, the patient′s life signs were stable and rashes subsided.
Binocular ciliary body detachment with transient refraction due to indapamide: report of 2 cases
Yu Chunxia, Xu Xinyan, Li Shuchan, Sun Xianyong, Zhang Jie
. 2018, 20 (2): 150-151. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.016
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Two patients with hypertension (patient 1, female, aged 48 years;patient 2, male, aged 37 years) developed binocular vision blur 17 and 14 days after taking indapamide tablets (2.5 mg/d), respectively. Slit-lamp examination showed shallow binoculus anterior chamber. Ultrasound biomicroscopy showed binocular ciliary body detachment. Ophthalmic ultrasonic examination showed mild thickening of choroid in both eyes. The binocular ciliary body detachment and transient refraction were considered to be related to indapamide. Three days after indapamide withdrawal and receiving hormonotherapy, the 2 patients′ binocular ciliary bodies were resetted, anterior chamber depth returned to normal, and the visions returned to the premorbid state.
Urinary incontinence caused by pioglitazone
Yang Wei, Tang Mingming, Suo Lixia
. 2018, 20 (2): 152-153. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.017
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A 47-year-old male patient with type-2 diabetes received metformin (1 g twice daily), acarbose (50 mg thrice daily), and pioglitazone (15 mg once daily) because of poor blood glucose control. On the 5th day of treatments, urinary incontinence appeared and the urine volume was about 200 ml. Pioglitazone was stopped and other treatments were continued. At 24 months of follow-up, urinary incontinence did not recur.
Hemoglobin reduction due to cefoperazone sodium and sulbactam sodium
Yang Jing, Cui Xiangli, Yang Hui, Liu Lihong
. 2018, 20 (2): 153-154. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.018
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A 36-year-old male patient undergoing renal transplantation had postoperative fever and painful urination. Laboratory tests showed the white blood cell count (WBC) 17.1×109/L, neutrophils 0.92, hemoglobin (Hb) 113 g/L, and calcitonin (PCT) 3.04 μg/L. Urinary tract infection was considered and an IV infusion of cefoperazone sodium and sulbactam sodium 1.5 g every 8 hours was given. On day 4 of medication, painful urination was relieved and his body temperature returned to normal. Laboratory tests showed PCT 0.43 μg/L, WBC 8.5×109/L, neutrophils 0.90, and Hb 81 g/L. Anti-infective treatment was continued and subcutaneous injection of recombinant human erythropoietin injection (CHO cell) 4 000 IU every 48 hours was given. On day 7, laboratory tests showed his WBC 9.7×109/L, neutrophils 0.88, PCT 0.15 μg/L, and Hb 74 g/L. The reduction of hemoglobin was considered to be associated with cefoperazone sodium and sulbactam sodium. Cefoperazone sodium and sulbactam sodium was replace by sequential therapy of oral cefuroxime. On day 2 of drug replacement, his Hb was 80 g/L and recombinant human erythropoietin injection (CHO cell) was discontinued. On day 7, his Hb was 90 g/L and on day 12, 97 g/L.

. 2018, 20 (2): 155-156. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.019
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. 2018, 20 (2): 157-159. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.020
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. 2018, 20 (2): 160-160. ;  doi: 10.3760/cma.j.issn.1008-5734.2018.02.021
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