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with symptoms associated with the abdominal compartment syndrome and compression of other structures&#44; generating satiety&#44; pain and intestinal pseudo-obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Knowledge of this disease has been progressing in recent decades&#46; Since the main ADPKD-related genes&#44; PKD1 and PKD2&#44; were identified in the 1990s&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> a close genotype-phenotype correlation has been established&#44; as well as the identification of those genes that confer a higher risk of progression&#46; In addition&#44; new genes related with cyst generation &#40;GANAB&#44; DNAJB11 and ALG9&#41;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;7</span></a> have been discovered&#44; as well as some of the metabolic pathways involved in cystogenesis&#44; such as the overexpression of cyclic adenosine monophosphate &#40;cAMP&#41;&#46; This has led to the development of drugs such as tolvaptan&#44; a vasopressin V2 receptor antagonist&#44; which reduces cAMP levels in the collecting tubule and distal nephron&#44; thus reducing fluid secretion into the cyst and cell proliferation&#44; leading to a slowing of cystic development and disease progression&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Currently&#44; the indication for tolvaptan is limited to the objective of slowing the progression of renal disease and it is restricted to adult patients with CKD stages 1&#8211;4 and evidence of rapid progression&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;8&#44;9</span></a> However&#44; there are other potential benefits&#44; such as the case we report below&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">This is a 69-year-old woman with a history of hypertension&#44; axonal sensory polyneuropathy due to Cerebellar Ataxia with Neuropathy and Vestibular Areflexia Syndrome &#40;CANVAS&#41; and ADPKD diagnosed at 40 years of age&#44; with subsequent confirmation of PKD2 mutation&#46; Throughout the course of the disease the following incidences stand out&#58; evacuating puncture of the cysts compressing the renal artery approximately 30 years ago and several episodes of intestinal pseudo-obstruction justified by an acquired megacolon secondary to intestinal compression by the renal cysts &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; that required the puncture and sclerosis of a large dominant cyst in the last year&#46; Despite this&#44; the patient continued to have difficulty swallowing and abdominal pain&#46; At that time renal function remained normal and she did not present criteria for rapid progression&#44; precluding the use of tolvaptan according to current indications&#46; However&#44; in September 2022&#44; in agreement with the patient&#44; we decided to trial compassionate treatment with tolvaptan&#44; with the aim of decreasing abdominal volume&#44; as well as better pain control&#46; She was prescribed 45&#8239;mg of tolvaptan in the morning and 15&#8239;mg eight hours later&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">During follow-up in November and December 2022 the patient reported feeling better&#44; with a decrease in the feeling of abdominal pressure&#44; with no new episodes of intestinal pseudo-obstruction and decreased satiety and abdominal pain&#44; which has allowed her to return to sports&#44; travel and gain 1&#8722;2&#8239;kg of weight&#46; The patient reports good tolerance to the aquaretic effects and no biochemical alterations in the analytical controls&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The effect of &#34;emptying&#34; the renal cysts was rapid&#44; as usually occurs in the first 3&#8211;4 weeks after starting treatment with tolvaptan&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> a circumstance that could explain the rapid improvement of the patient&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion&#44; ADPKD is an entity characterized by the appearance of renal cysts&#44; progression to ESRD&#44; associated systemic manifestations and symptomatology secondary to compression of structures by renal cysts&#46; At present&#44; the indications for the use of tolvaptan are restricted to slowing renal progression&#59; however&#44; the benefits may also include improvement of digestive symptoms&#44; as in our case&#46;</p></span>"
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Letter to the Editor
Compassionate use of tolvaptan in acquired megacolon secondary to autosomal dominant polycystic kidney disease (ADPKD)
Uso compasivo de tolvaptán en megacolon adquirido secundario a poliquistosis renal autosómica dominante (PQRAD)
Iris Viejo Boyanoa,
Corresponding author
ivb_1993@hotmail.com

Corresponding author.
, Paul José Hernández Velascob, Eduardo Gutiérrez Martínezb
a Servicio de Nefrología, Hospital Universitari i Politècnic La Fe, Valencia, Spain
b Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, Spain
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with symptoms associated with the abdominal compartment syndrome and compression of other structures&#44; generating satiety&#44; pain and intestinal pseudo-obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Knowledge of this disease has been progressing in recent decades&#46; Since the main ADPKD-related genes&#44; PKD1 and PKD2&#44; were identified in the 1990s&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> a close genotype-phenotype correlation has been established&#44; as well as the identification of those genes that confer a higher risk of progression&#46; In addition&#44; new genes related with cyst generation &#40;GANAB&#44; DNAJB11 and ALG9&#41;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;7</span></a> have been discovered&#44; as well as some of the metabolic pathways involved in cystogenesis&#44; such as the overexpression of cyclic adenosine monophosphate &#40;cAMP&#41;&#46; This has led to the development of drugs such as tolvaptan&#44; a vasopressin V2 receptor antagonist&#44; which reduces cAMP levels in the collecting tubule and distal nephron&#44; thus reducing fluid secretion into the cyst and cell proliferation&#44; leading to a slowing of cystic development and disease progression&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Currently&#44; the indication for tolvaptan is limited to the objective of slowing the progression of renal disease and it is restricted to adult patients with CKD stages 1&#8211;4 and evidence of rapid progression&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;8&#44;9</span></a> However&#44; there are other potential benefits&#44; such as the case we report below&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">This is a 69-year-old woman with a history of hypertension&#44; axonal sensory polyneuropathy due to Cerebellar Ataxia with Neuropathy and Vestibular Areflexia Syndrome &#40;CANVAS&#41; and ADPKD diagnosed at 40 years of age&#44; with subsequent confirmation of PKD2 mutation&#46; Throughout the course of the disease the following incidences stand out&#58; evacuating puncture of the cysts compressing the renal artery approximately 30 years ago and several episodes of intestinal pseudo-obstruction justified by an acquired megacolon secondary to intestinal compression by the renal cysts &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; that required the puncture and sclerosis of a large dominant cyst in the last year&#46; Despite this&#44; the patient continued to have difficulty swallowing and abdominal pain&#46; At that time renal function remained normal and she did not present criteria for rapid progression&#44; precluding the use of tolvaptan according to current indications&#46; However&#44; in September 2022&#44; in agreement with the patient&#44; we decided to trial compassionate treatment with tolvaptan&#44; with the aim of decreasing abdominal volume&#44; as well as better pain control&#46; She was prescribed 45&#8239;mg of tolvaptan in the morning and 15&#8239;mg eight hours later&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">During follow-up in November and December 2022 the patient reported feeling better&#44; with a decrease in the feeling of abdominal pressure&#44; with no new episodes of intestinal pseudo-obstruction and decreased satiety and abdominal pain&#44; which has allowed her to return to sports&#44; travel and gain 1&#8722;2&#8239;kg of weight&#46; The patient reports good tolerance to the aquaretic effects and no biochemical alterations in the analytical controls&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The effect of &#34;emptying&#34; the renal cysts was rapid&#44; as usually occurs in the first 3&#8211;4 weeks after starting treatment with tolvaptan&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> a circumstance that could explain the rapid improvement of the patient&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion&#44; ADPKD is an entity characterized by the appearance of renal cysts&#44; progression to ESRD&#44; associated systemic manifestations and symptomatology secondary to compression of structures by renal cysts&#46; At present&#44; the indications for the use of tolvaptan are restricted to slowing renal progression&#59; however&#44; the benefits may also include improvement of digestive symptoms&#44; as in our case&#46;</p></span>"
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ISSN: 20132514
Original language: English
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