This patient had no evidence of CKD with an eGFR of 101 mL/min/1.72m 2 and a serum creatinine of 0.7 mg/dL. This measurement was drawn 2 weeks after a dose of denosumab was administered, and the importance of supplementation was reinforced to the patient at that time. The last prior vitamin D measurement in our records was 2 years prior and measured <4.0 ng/mL.
Serum chemistries demonstrated a serum total calcium of 4.5 mg/dL, magnesium 1.6 mg/dL, phosphorous of <1.0 mg/dL, ionized calcium 0.89 mmol/L and intact PTH 2,356 pg/mL. Neurological exam revealed 5-/5 strength in all extremities. She had received biannual treatments for 5 years at this point. She presented to the emergency department with profound, debilitating weakness 22 days following her regularly scheduled dose of denosumab. Patient 2 is a 66-year-old woman with a history of Crohn’s disease and an ileostomy. These two changes caused the automated interpretation of the ECG to indicate a heart rate 133/min, while her clinicians interpreted the heart rate to be 75 (Fig. ECG revealed prolonged QT interval of 479 ms and prominent T waves. Two months prior to admission she had a serum calcium of 9.2 mg/dL. Her eGFR on admission was 31 mL/min/1.72m 2, and her serum creatinine was 1.9 mg/dL (baseline between 1.5 and 2 mg/dL). Chemistries revealed a serum total calcium of 4.2 mg/dL, magnesium 1.2 mg/dL, phosphorous 2.4 mg/dL, ionized calcium 0.56 mmol/L (normal 1.11–1.3 mmol/L), 25-hydroxy vitamin D 11.0 ng/mL (normal 30–100 ng/mL), and intact PTH was >3,639 pg/mL (normal 14–60 pg/mL). Neurological exam revealed 4/5 strength in all extremities. She denied seizures, syncope, chest pain, or palpitations. Eighteen days following the second dose, the patient presented to the emergency department with severe weakness that prevented her from getting out of bed. Patient 1 is an 80-year-old woman with stage 3B chronic kidney disease (CKD) who received an inadvertent dose of denosumab 1 month after her regularly scheduled dose.
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