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    "textoCompleto" => "<p class="elsevierStylePara">Dear Editor&#44;</p><p class="elsevierStylePara">An increase in amylase is a marker for acute pancreatitis&#46; However in patients with Chronic Renal Failure &#40;CRF&#41; it is not uncommon to find increased levels&#44; yet these rarely exceed two or three times the maximum normal limit&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">The link between hyperamylasaemia and neoplasia has been known for years and has been described in tumours of different histological strains<span class="elsevierStyleSup">2</span> and in multiple myeloma also&#46;<span class="elsevierStyleSup">3&#44;4</span>We present a patient Figure 1&#46; Resolution of calciphylaxis&#46; with CRF secondary to myeloma kidney in periodic haemodialysis &#40;HD&#41; who presented with hyperamylasaemia and rapid evolution of their disease&#46;</p><p class="elsevierStylePara">77 year old male patient diagnosed with Lambda light chain-associated multiple myeloma in November 2002&#46; At this time he presented with creatinine 2&#46;8mg&#47;dl and Bence Jones proteinuria&#46; The patient received different lines of treatment &#40;vincristine-adriamycin-dexamethasone&#59; melphalan-prednisone&#59; bortezomib&#41; with clinical responses that were increasingly poorer&#46; Administration of chemotherapy drugs was discontinued two years later&#46; In July 2004&#44; the patient started HD treatment&#44; 12 hours a week with an average Kt&#47;v of &#62; 1&#46;2&#46; Residual diuresis was maintained at 700-1000cc&#47;day&#46;</p><p class="elsevierStylePara">The patient was admitted in November 2007 due to the deterioration of his general health with intense asthenia&#44; epigastrium pain and significant bone pain with difficulties in deambulation&#46; Physical examination found BP 140&#47;80mmHg&#44; no fever&#44; pale skin and mucosa and without any other significant findings&#46; Blood tests&#58; Hb 7&#46;9g&#47;dl&#59; hematocrit 23&#46;3&#37;&#59; platelets 56&#44;000&#47;mm&#59;<span class="elsevierStyleSup">3</span> leukocytes 6000&#47;mm<span class="elsevierStyleSup">3</span> with normal formula&#46; ESR 84 mm during the first hour&#59; no schistocytes or blastos were observed in the peripheral blood&#46; Iron 93&#956;g&#47;dl&#59; ferritin 6603ng&#47;ml&#59; transferrin saturation rate 45&#37;&#46; Creatinine 7&#46;91&#59; urea 130&#59; Ca 9&#46;30&#59; P 2&#59; uric acid 7&#46;5 &#40;mg&#47;dl&#41;&#59; total proteins 6&#46;50&#59; albumin 3&#46;32g&#47;dl&#59; IgG 370&#59; IgA 43&#59; IgM 15&#59; IgD 1 &#40;mg&#47;dl&#46;&#41; Serum immunofixation&#58; Lambda monoclonal band&#46; C-reactive protein 13&#46;8mg&#47;dl&#46; GOT 56&#59; GPT 33&#59; GGT 480&#59; alkaline phosphatase 139&#44; LDH 780&#44; amylase 3779&#59; lipase 449 &#40;IU&#47;L&#46;&#41; Two months before&#44; amylase levels were normal&#46; Amylasuria 276 IU&#47;L&#44; with urinary excretion of amylase 6&#37;&#46;</p><p class="elsevierStylePara">Ultrasound and abdominal Computerised Axial Tomography &#40;CAT&#41; did not show findings of pancreatic disease&#46; Due to the persistence of hyperamylasaemia&#44; the pancreatic enzymes were studied&#58; pancreatic isozyme 132&#59; salivary isozyme 3607 IU&#47;l&#46; In light of the patient&#8217;s general condition&#44; treatment was started with high doses of steroids and morphine chloride with the aim of decompressing the bone marrow and alleviating pain in the bones&#44; which were increasing&#46; The clinical situation worsened and the patient died 10 days after admission&#46;</p><p class="elsevierStylePara">Acute pancreatitis is the first diagnosis suspect with respect to an acute increase in amylase levels&#46; Its incidence in CRF is six times greater than in the general population&#46;<span class="elsevierStyleSup">5</span> Hypercalcaemia&#44; hyperparathyroidism&#44; dyslipidaemia and treatment with diuretics are predisposing factors&#46; In HD&#44; cases of pancreatitis associated with haemolysis have also been described&#46;<span class="elsevierStyleSup">6</span> In the present case&#44; the clinical picture and the abdominal CAT ruled out acute pancreatitis&#46;<br></br><br></br>Macroamylasaemia is a biochemical abnormality of unknown aetiology&#46; It is characterised by the presence of amylase complexes attached to proteins&#44; which form a molecule with greater molecular weight&#44; which accumulate in the plasma&#44; since filtration decreases&#46;<span class="elsevierStyleSup">7</span> Amylase levels are normally lower than two times the normal limit&#46; Diagnosis is established by determining the molecular weight of the serum amylase&#44; with immunological techniques&#44; and indirectly&#44; by determining the fractional excretion of amylase in the urine&#46; Avalue &#60; 1&#37; is indicative of macroamylasaemia&#46; The absence of monoclonal peak in the blood and urinary excretion of amylase of 6&#37; exclude this diagnosis&#46;</p><p class="elsevierStylePara">Paraneoplastic hyperamylasaemia is a rare manifestation of multiple myeloma&#46; A total of 21 cases have been described with an average age of 66&#46; It is more commonly associated with the IgA type &#40;40&#37;&#41;&#44; followed by IgG &#40;30&#37;&#41; and it has only been described in two patients with light chain myeloma&#46;<span class="elsevierStyleSup">3&#44;4</span> The lambda light chain isotype predominates in proportions of 3&#58;1 in comparison with the kappa type and amylase detected in all saliva originating cases&#46; It is the tumour cells that cause the ectopic segregation of salivary amylase and the secretion mechanism is similar to that of immunoglobulins&#46;<span class="elsevierStyleSup">8</span> It has been seen in patients with hyperamylasaemia the myeloma is more aggressive&#44; it has greater extramedullary extension&#44; a poorer response to chemotherapy treatment and therefore lower survival rate &#40;&#60; 24 months&#46;&#41; Amylase in the myeloma has been used as a marker for progression and response to treatment&#46;</p><p class="elsevierStylePara">Although the incidence of acute pancreatitis in patients with CRF is high&#44; the appearance of hyperamylasaemia of salivary origin forces to considering paraneoplastic origin&#46;</p>"
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Hyperamylasaemia in a patient with multiple myeloma in haemodialysis
Hiperamilasemia en un paciente con mieloma múltiple en hemodiálisis
Florencio García Martína, Ana Huerta Arroyoa, José María Alcázar de la Ossaa, Manuel Praga Terentea
a Servicio de Nefología, Hospital 12 de Octubre, Madrid, Madrid, España,
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    "textoCompleto" => "<p class="elsevierStylePara">Dear Editor&#44;</p><p class="elsevierStylePara">An increase in amylase is a marker for acute pancreatitis&#46; However in patients with Chronic Renal Failure &#40;CRF&#41; it is not uncommon to find increased levels&#44; yet these rarely exceed two or three times the maximum normal limit&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">The link between hyperamylasaemia and neoplasia has been known for years and has been described in tumours of different histological strains<span class="elsevierStyleSup">2</span> and in multiple myeloma also&#46;<span class="elsevierStyleSup">3&#44;4</span>We present a patient Figure 1&#46; Resolution of calciphylaxis&#46; with CRF secondary to myeloma kidney in periodic haemodialysis &#40;HD&#41; who presented with hyperamylasaemia and rapid evolution of their disease&#46;</p><p class="elsevierStylePara">77 year old male patient diagnosed with Lambda light chain-associated multiple myeloma in November 2002&#46; At this time he presented with creatinine 2&#46;8mg&#47;dl and Bence Jones proteinuria&#46; The patient received different lines of treatment &#40;vincristine-adriamycin-dexamethasone&#59; melphalan-prednisone&#59; bortezomib&#41; with clinical responses that were increasingly poorer&#46; Administration of chemotherapy drugs was discontinued two years later&#46; In July 2004&#44; the patient started HD treatment&#44; 12 hours a week with an average Kt&#47;v of &#62; 1&#46;2&#46; Residual diuresis was maintained at 700-1000cc&#47;day&#46;</p><p class="elsevierStylePara">The patient was admitted in November 2007 due to the deterioration of his general health with intense asthenia&#44; epigastrium pain and significant bone pain with difficulties in deambulation&#46; Physical examination found BP 140&#47;80mmHg&#44; no fever&#44; pale skin and mucosa and without any other significant findings&#46; Blood tests&#58; Hb 7&#46;9g&#47;dl&#59; hematocrit 23&#46;3&#37;&#59; platelets 56&#44;000&#47;mm&#59;<span class="elsevierStyleSup">3</span> leukocytes 6000&#47;mm<span class="elsevierStyleSup">3</span> with normal formula&#46; ESR 84 mm during the first hour&#59; no schistocytes or blastos were observed in the peripheral blood&#46; Iron 93&#956;g&#47;dl&#59; ferritin 6603ng&#47;ml&#59; transferrin saturation rate 45&#37;&#46; Creatinine 7&#46;91&#59; urea 130&#59; Ca 9&#46;30&#59; P 2&#59; uric acid 7&#46;5 &#40;mg&#47;dl&#41;&#59; total proteins 6&#46;50&#59; albumin 3&#46;32g&#47;dl&#59; IgG 370&#59; IgA 43&#59; IgM 15&#59; IgD 1 &#40;mg&#47;dl&#46;&#41; Serum immunofixation&#58; Lambda monoclonal band&#46; C-reactive protein 13&#46;8mg&#47;dl&#46; GOT 56&#59; GPT 33&#59; GGT 480&#59; alkaline phosphatase 139&#44; LDH 780&#44; amylase 3779&#59; lipase 449 &#40;IU&#47;L&#46;&#41; Two months before&#44; amylase levels were normal&#46; Amylasuria 276 IU&#47;L&#44; with urinary excretion of amylase 6&#37;&#46;</p><p class="elsevierStylePara">Ultrasound and abdominal Computerised Axial Tomography &#40;CAT&#41; did not show findings of pancreatic disease&#46; Due to the persistence of hyperamylasaemia&#44; the pancreatic enzymes were studied&#58; pancreatic isozyme 132&#59; salivary isozyme 3607 IU&#47;l&#46; In light of the patient&#8217;s general condition&#44; treatment was started with high doses of steroids and morphine chloride with the aim of decompressing the bone marrow and alleviating pain in the bones&#44; which were increasing&#46; The clinical situation worsened and the patient died 10 days after admission&#46;</p><p class="elsevierStylePara">Acute pancreatitis is the first diagnosis suspect with respect to an acute increase in amylase levels&#46; Its incidence in CRF is six times greater than in the general population&#46;<span class="elsevierStyleSup">5</span> Hypercalcaemia&#44; hyperparathyroidism&#44; dyslipidaemia and treatment with diuretics are predisposing factors&#46; In HD&#44; cases of pancreatitis associated with haemolysis have also been described&#46;<span class="elsevierStyleSup">6</span> In the present case&#44; the clinical picture and the abdominal CAT ruled out acute pancreatitis&#46;<br></br><br></br>Macroamylasaemia is a biochemical abnormality of unknown aetiology&#46; It is characterised by the presence of amylase complexes attached to proteins&#44; which form a molecule with greater molecular weight&#44; which accumulate in the plasma&#44; since filtration decreases&#46;<span class="elsevierStyleSup">7</span> Amylase levels are normally lower than two times the normal limit&#46; Diagnosis is established by determining the molecular weight of the serum amylase&#44; with immunological techniques&#44; and indirectly&#44; by determining the fractional excretion of amylase in the urine&#46; Avalue &#60; 1&#37; is indicative of macroamylasaemia&#46; The absence of monoclonal peak in the blood and urinary excretion of amylase of 6&#37; exclude this diagnosis&#46;</p><p class="elsevierStylePara">Paraneoplastic hyperamylasaemia is a rare manifestation of multiple myeloma&#46; A total of 21 cases have been described with an average age of 66&#46; It is more commonly associated with the IgA type &#40;40&#37;&#41;&#44; followed by IgG &#40;30&#37;&#41; and it has only been described in two patients with light chain myeloma&#46;<span class="elsevierStyleSup">3&#44;4</span> The lambda light chain isotype predominates in proportions of 3&#58;1 in comparison with the kappa type and amylase detected in all saliva originating cases&#46; It is the tumour cells that cause the ectopic segregation of salivary amylase and the secretion mechanism is similar to that of immunoglobulins&#46;<span class="elsevierStyleSup">8</span> It has been seen in patients with hyperamylasaemia the myeloma is more aggressive&#44; it has greater extramedullary extension&#44; a poorer response to chemotherapy treatment and therefore lower survival rate &#40;&#60; 24 months&#46;&#41; Amylase in the myeloma has been used as a marker for progression and response to treatment&#46;</p><p class="elsevierStylePara">Although the incidence of acute pancreatitis in patients with CRF is high&#44; the appearance of hyperamylasaemia of salivary origin forces to considering paraneoplastic origin&#46;</p>"
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Idiomas
Nefrología (English Edition)