Letter to the Editor
Severe Parkinsonism with respiratory failure in peritoneal dialysis patient
Parkinsonismo severo con insuficiencia respiratoria en paciente de diálisis peritoneal
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] ] ] 1 => array:3 [ "nombre" => "Jorge" "apellidos" => "Ruiz-Criado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Adrián" "apellidos" => "Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Franz" "apellidos" => "Fernandez-Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Antonio" "apellidos" => "Gascón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital General Obispo Polanco, Teruel, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos, Hospital General Obispo Polanco, Teruel, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Parkinsonismo severo con insuficiencia respiratoria en paciente de diálisis peritoneal" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with chronic kidney disease (CKD) are at an increased risk of drug-induced neurotoxicity.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Parkinsonism appears to be more common in patients with CKD, with a higher annual incidence rate in uraemic patients compared with non-uraemic patients.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The drugs that most frequently cause Parkinsonism are calcium antagonists, orthopramides/benzamides and antipsychotics/neuroleptics.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Compared with Parkinson's disease, patients with drug-induced Parkinsonism are predominantly female and elderly.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Sulpiride is a drug used to treat dizziness, which often induces Parkinsonism.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We report the case of a 52-year-old woman with systemic lupus erythematosus (SLE) and associated antiphospholipid syndrome, steroid diabetes and hypertension. The patient had CKD secondary to lupus nephropathy and began continuous ambulatory peritoneal dialysis (CAPD) in 2014, with a regimen of 4 daytime exchanges of 2000<span class="elsevierStyleHsp" style=""></span>ml: 2 Physioneal 40<span class="elsevierStyleSup">®</span> 1.36% and 2 Physioneal 40<span class="elsevierStyleSup">®</span> 2.27% (Baxter), with a dry night.</p><p id="par0020" class="elsevierStylePara elsevierViewall">She went to her clinic due to a 72-h catarrhal disease and began treatment with levofloxacin 500<span class="elsevierStyleHsp" style=""></span>mg, one tablet per day. After the first dose she presented with dizziness syndrome for which she was given an intramuscular ampoule of sulpiride 100<span class="elsevierStyleHsp" style=""></span>mg, followed by 50<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>h orally.</p><p id="par0025" class="elsevierStylePara elsevierViewall">At 36<span class="elsevierStyleHsp" style=""></span>h she experienced respiratory distress with a baseline oxygen saturation of 87%. She was given oxygen therapy, intravenous (IV) corticosteroids and inhalers, without clinical improvement. During the transfer to the hospital, she presented with generalised dystonic movements. At the A&E she had serious difficulty breathing. The laboratory tests revealed mild hypocalcaemia (total corrected calcium of 8.2<span class="elsevierStyleHsp" style=""></span>mg/dl and arterial ionised calcium of 3.6<span class="elsevierStyleHsp" style=""></span>mg/dl), and she was given an IV calcium gluconate ampoule for possible tetany. No significant alterations were observed in the chest X-ray or brain CT scan.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Due to the persistence of respiratory insufficiency and generalised dystonic movements, consultation with the intensive care unit (ICU) was requested. Upon arrival, the patient presented with generalised dystonia with predominantly cervicofacial involvement and language impairment, in addition to severe ventilatory impairment.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Five (5) mg of IV biperiden were administered, which resolved the acute dystonic symptoms and improved pulmonary ventilation. Given the risk of recurrence of the symptoms and the lack of information on the elimination of sulpiride by peritoneal dialysis, it was decided to admit the patient to the ICU and to perform a haemodialysis session using a temporal–femoral catheter, with a 4008<span class="elsevierStyleSup">®</span> dialysis monitor (Fresenius Medical Care), Evodial 1.6<span class="elsevierStyleSup">®</span> dialyser (Gambro), for 3<span class="elsevierStyleHsp" style=""></span>h, with a blood flow of 300<span class="elsevierStyleHsp" style=""></span>ml/min and a bath flow of 500<span class="elsevierStyleHsp" style=""></span>ml/min, without ultrafiltration.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Forty-eight (48) hours after the start of monitoring, the patient was transferred to the nephrology ward, where the usual CAPD regimen was restarted. After 4 days she was discharged with a final diagnosis of severe Parkinsonism with respiratory insufficiency secondary to sulpiride, reversed with biperiden and haemodialysis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">We know that sulpiride is an antipsychotic drug used to treat benign paroxysmal positional vertigo. It works by blocking dopamine D2 receptors. It has an oral bioavailability of 25–35%, with a renal elimination of 92%. The dose should therefore be reduced in kidney failure, with partial elimination by haemodialysis, because less than 40% binds to plasma proteins and its volume of distribution is 0.94<span class="elsevierStyleHsp" style=""></span>l/kg.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In case of overdose, extrapyramidal symptoms may occur.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Neuroleptic malignant syndrome is a potentially fatal, yet very rare, complication.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> There is no specific antidote for sulpiride. Although treatment is only symptomatic, support measures should be established. In case of severe extrapyramidal symptoms, anticholinergics should be administered.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Biperiden is an anticholinergic, antimuscarinic drug indicated for Parkinson's disease and drug-induced extrapyramidal symptoms. No adjustment is required for kidney failure.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">After reviewing the literature, we saw that Nishioka et al. reported a case of neuroleptic malignant syndrome and acute kidney failure in a patient treated with thioridazine and sulpiride. Renal function and neurological symptoms were resolved by discontinuing the drugs and performing 17 haemodialysis sessions.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Although there are no data on the elimination of sulpiride by peritoneal dialysis, data from the elimination of a drug from the same family, such as metoclopramide, show minimal elimination (less than 0.1%) in a CAPD regimen of 4 exchanges of 2000<span class="elsevierStyleHsp" style=""></span>cc per day.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Therefore, given the severity and clinical course of our patient, we recommend exercising caution when using sulpiride in patients undergoing peritoneal dialysis, especially in women and the elderly, and constantly adjusting the dose.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In case of sulpiride-induced Parkinsonism in patients on CAPD, we recommend using biperiden and performing conventional haemodialysis to eliminate the drug effectively.</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: Gallegos-Villalobos A, Ruiz-Criado J, Rodríguez A, Fernandez-Rodríguez F, Gascón A. Parkinsonismo severo con insuficiencia respiratoria en paciente de diálisis peritoneal. Nefrologia. 2016;36:721–722.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comprehensive clinical nephrology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Floege" 1 => "R.J. Johnson" 2 => "J. Feehally" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "edicion" => "4th ed." 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| 2024 June | 75 | 35 | 110 |
| 2024 May | 78 | 39 | 117 |
| 2024 April | 75 | 31 | 106 |
| 2024 March | 49 | 23 | 72 |
| 2024 February | 40 | 31 | 71 |
| 2024 January | 51 | 30 | 81 |
| 2023 December | 35 | 25 | 60 |
| 2023 November | 48 | 32 | 80 |
| 2023 October | 59 | 46 | 105 |
| 2023 September | 54 | 44 | 98 |
| 2023 August | 55 | 33 | 88 |
| 2023 July | 56 | 28 | 84 |
| 2023 June | 90 | 26 | 116 |
| 2023 May | 93 | 35 | 128 |
| 2023 April | 66 | 17 | 83 |
| 2023 March | 92 | 23 | 115 |
| 2023 February | 63 | 28 | 91 |
| 2023 January | 40 | 27 | 67 |
| 2022 December | 61 | 31 | 92 |
| 2022 November | 56 | 29 | 85 |
| 2022 October | 56 | 35 | 91 |
| 2022 September | 66 | 37 | 103 |
| 2022 August | 58 | 40 | 98 |
| 2022 July | 49 | 34 | 83 |
| 2022 June | 69 | 20 | 89 |
| 2022 May | 85 | 27 | 112 |
| 2022 April | 94 | 42 | 136 |
| 2022 March | 73 | 28 | 101 |
| 2022 February | 59 | 32 | 91 |
| 2022 January | 58 | 28 | 86 |
| 2021 December | 71 | 37 | 108 |
| 2021 November | 65 | 36 | 101 |
| 2021 October | 57 | 49 | 106 |
| 2021 September | 63 | 34 | 97 |
| 2021 August | 53 | 35 | 88 |
| 2021 July | 35 | 31 | 66 |
| 2021 June | 42 | 29 | 71 |
| 2021 May | 59 | 38 | 97 |
| 2021 April | 147 | 48 | 195 |
| 2021 March | 91 | 28 | 119 |
| 2021 February | 65 | 33 | 98 |
| 2021 January | 53 | 14 | 67 |
| 2020 December | 47 | 24 | 71 |
| 2020 November | 41 | 17 | 58 |
| 2020 October | 50 | 14 | 64 |
| 2020 September | 55 | 14 | 69 |
| 2020 August | 50 | 14 | 64 |
| 2020 July | 43 | 13 | 56 |
| 2020 June | 48 | 20 | 68 |
| 2020 May | 48 | 14 | 62 |
| 2020 April | 41 | 13 | 54 |
| 2020 March | 46 | 18 | 64 |
| 2020 February | 51 | 21 | 72 |
| 2020 January | 49 | 19 | 68 |
| 2019 December | 54 | 25 | 79 |
| 2019 November | 43 | 21 | 64 |
| 2019 October | 41 | 7 | 48 |
| 2019 September | 61 | 16 | 77 |
| 2019 August | 33 | 14 | 47 |
| 2019 July | 41 | 22 | 63 |
| 2019 June | 43 | 17 | 60 |
| 2019 May | 25 | 31 | 56 |
| 2019 April | 45 | 36 | 81 |
| 2019 March | 46 | 21 | 67 |
| 2019 February | 41 | 30 | 71 |
| 2019 January | 28 | 18 | 46 |
| 2018 December | 147 | 41 | 188 |
| 2018 November | 231 | 15 | 246 |
| 2018 October | 231 | 15 | 246 |
| 2018 September | 127 | 18 | 145 |
| 2018 August | 53 | 18 | 71 |
| 2018 July | 48 | 19 | 67 |
| 2018 June | 68 | 16 | 84 |
| 2018 May | 89 | 20 | 109 |
| 2018 April | 126 | 11 | 137 |
| 2018 March | 92 | 11 | 103 |
| 2018 February | 145 | 6 | 151 |
| 2018 January | 90 | 15 | 105 |
| 2017 December | 123 | 13 | 136 |
| 2017 November | 75 | 18 | 93 |
| 2017 October | 40 | 15 | 55 |
| 2017 September | 54 | 11 | 65 |
| 2017 August | 53 | 8 | 61 |
| 2017 July | 57 | 6 | 63 |
| 2017 June | 45 | 17 | 62 |
| 2017 May | 48 | 12 | 60 |
| 2017 April | 40 | 23 | 63 |
| 2017 March | 28 | 24 | 52 |
| 2017 February | 47 | 7 | 54 |
| 2017 January | 17 | 4 | 21 |
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