Get your Health question answered in 3 easy steps
A Doctor will be with you shortly
Ask a Doctor Now
141 Doctors are Online

MBC patient with bone mets. On Tamoxefin and Zoledronic acid. Diagnosed for hyperparathyroidism. Removed adenoma from neck. Suggest?

User rating for this question
Very Good
Answered by

Nephrologist
Practicing since : 2003
Answered : 495 Questions
Question
Hello Doctor,

My mother is Stage 4, MBC patient with bone mets. She has been on Tamoxefin and Zoledronic acid since February 2013. Please see this for more details:

WWW.WWWW.WW

Around 6 weeks back with a complain of High Ca and High PTH, she was diagnosed for hyperparathyroidism and then successfully removed adenoma from her neck. More details here:
WWW.WWWW.WW

Since the removal of ademona she hasn’t really recovered completely and has been complaining about metallic taste, weakness, fever etc. She was being treated for viral and had consumed quite a few paracetamols, antibiotics and few pain killers, almost for 3 weeks. But recently in last 10 days her intake of water and food came down. Last week she was dehydrated and also had swelling all over body with low urine output. On last Thursday, her creatinine level jumped to 5.3- her last creatinine level was tested in August first week which was 0.8, during her high Ca time her Creatinine had gone up to 1.2. She is diabetic and had angioplasty three years back. She also has oliguria history. But she never had problem of high Creatinine. Our nephrologist suspects this condition as Acute renal failure due to persistent use of paracetamol, antibiotics and pain killers.

As advised by nephrologist, first dialysis was done last Friday which brought down her creatinine from 5.3 to 3.5 which again went up on Saturday up to 5.8. 2nd dialysis was performed on Sunday which brought down creatinine to 3.3. Today morning creatinine has again gone up to 4.6. Her blood pressure is stable, Sodium and Potassium are in control. Her urea before first dialysis was 60 which is now 26. Can you please advise if her kidney can come back to normal and how many dialysis she would need, would you advice any other diagnostic tests. Appreciate your early response.

During last 10 days there was a fluctuations in her sugar level and also has nausea and vomiting at least once. Her sugar is now at normal levels.
Posted Wed, 9 Oct 2013 in Kidney Conditions
 
 
Answered by Dr. Aditya Bhabhe 2 hours later
Brief Answer:
See detailed answer

Detailed Answer:
Hi there
Thanks for your query.

Pain killers especially NSAIDs like combiflam, brufen, nise etc. are known to cause Acute Renal Failure and it is more common in patients with dehydration and diabetes (Like your mother's case).

The fact that creatinine is rising on the off-dialysis days implies that the renal failure has not started recovering.

The recovery process can take any where from 1 week to upto 3 months depending on how severe the damage was in the first place. Majority of patients show signs of recovery between 2-6 weeks.

One of the important markers of recovery would be an increase in the volume of urine output along with plateauing of daily serum creatinine values. Till this happens we need to support the kidneys by doing perodic dialysis.

We always do a urine routine and microscopy; Ultrasound of the kidneys and bladder; Serum Calcium, phosphorus, uric acid levels in patients with Acute renal failure.

If there are absolutely no signs of recovery by 2-3 weeks or if there is something suspicious in the above tests then we can order some specialised tests to see if some other diasease is causing kidney failure.

Hope this was helpful
Feel free to contact me if you have any other questions.

Regards and Best wishes.
Above answer was peer-reviewed by
 
Follow-up: MBC patient with bone mets. On Tamoxefin and Zoledronic acid. Diagnosed for hyperparathyroidism. Removed adenoma from neck. Suggest? 43 hours later
Thank you Doctor. Here is an update:

Admitted with Creatinine Levels:5.3 which went upto 5.8

Creatinine One day after 1st dialysis:4.7
Urea One day after 1st dialysis:29

Creatinine One day after 2nd dialysis:4.6
Urea One day after 2nd dialysis:29

Creatinine One day after 3rd dialysis:4.4
Urea One day after 3rd dialysis:29

Currently HB: 11.7, Sodium:132 Potassium: 3.5 Chloride: 87

We have been suggested to monitor tomorrow's progress and then further course of action would be decided. Can you make something out of these numbers?

To add urine output is 1.5 to 2 Ltr. This has been consistent, right after first dialysis.
 
 
Answered by Dr. Aditya Bhabhe 2 hours later
Brief Answer:
Possible recovery

Detailed Answer:
Hi Again

Thank you for the follow up.

The fact that your mother has 1.5-2 L urine output is an encouraging sign.

The lab values are 1 day post dialysis. These are difficult to interpret by themselves. What I do in such situations is monitor them daily and see the trend which gives a better idea of renal recovery.

Further dialysis sessions will be needed only if there is any clinical and/or laboratory indication and this needs a day to day assessment. So I think you are on the right track by monitoring daily labs and patient's clinical condition.

After looking at all the information I think there is a good chance of renal recovery.

Hope this helps

I would be happy to provide more suggestions.

Aditya Bhabhe
Above answer was peer-reviewed by
 
Follow-up: MBC patient with bone mets. On Tamoxefin and Zoledronic acid. Diagnosed for hyperparathyroidism. Removed adenoma from neck. Suggest? 4 days later
Hello Doctor,

Please attached recent Electrophoresis and Immunofixation and Creatinine reports. We are now trying to identify reasons behind my mother's ARF. As I mention earlier she is a CA breast stage 4 patient with bone mets (? although not confirmed with bone biopsy). She is on hormonal therapy with Tamoxifen and Zoledronic acid.

Right after her adenoma (13 July 2013) removal my mother had a complain about Change of Taste and then viral kind of symptoms. She had quite a few paracetamols and antibiotics over a period 3-4 weeks. On August 13, she was given regular dose of Zoledornic acid and around August 19, she also had one tablet of voveran.

We are now trying to understand which medicine/action was a trigger point here:
1.     Zoledronic acid (Assumption that it was induced when Creatinine level was above normal)
2.     Voveran (Assumption that it was induced when Creatinine level was above normal)
3.     Parathyroidectomy
4. Anything else (multiple myeloma)?

Creatinine History:
Date: 12 July 2013 Parathyroid Preoperative Creatinine- 0.8
Date: 22 July 2013 Post op day 10- Creatinine 1.25
Date: 5 August 2013 Creatinine- 1.40
Date: 22 August 2013 Creatinine- 5.3


My questions to you:
1. Are the numbers going in right direction as we felt Creatinine is now taking sometime to shoot up?
2. What possible reason do you see for this ARF?
 
 
Answered by Dr. Aditya Bhabhe 38 minutes later
Brief Answer:
See detailed answer

Detailed Answer:
Hi again

I will answer your questions one by one

1) Cause of renal failure: From the information provided it looks like a multifactorial causation i.e., a combination of Voveran, Zolendronic acid and dehydration in a patient with pre-existing with Diabetes.
The reports do not suggest obvious myeloma.
Parathyroidectomy per se should not result in renal failure.

We need to see the reports of urine analysis and Ultrasound of the kidneys as I mentioned in my first reply. These will tell us if we need to suspect anything else.

2) There has been a marginal decline in the rate of rise of serum creatinine. However till the values plateau we have to monitor her clinical condition daily to see if she needs dialysis.

Hope this was helpful

Aditya Bhabhe
Above answer was peer-reviewed by
 
Follow-up: MBC patient with bone mets. On Tamoxefin and Zoledronic acid. Diagnosed for hyperparathyroidism. Removed adenoma from neck. Suggest? 2 hours later
Hello Doctor,

Please find attached report in word document for your review and comments.

Regards,
XXXXX
 
 
Answered by Dr. Aditya Bhabhe 1 hour later
Brief Answer:
Possible baseline disease

Detailed Answer:
Hi

I did not see a result of urine analysis (I think you have uploaded a report of stool exam)

There are two things: 24 hour urine protein is elevated and USG shows bilateral medical disease. Both these things point to a mild chronic renal disease and is seen commonly in patients with diabetes mellitus.

However I do not think that this should affect the eventual prognosis.

The presence of eosinophils in the urine is of questionable diagnostic importance. It can represent allergic disease of the kidneys due to medications but at this stage I would not pursue it too much.

Hope this helps
Dr Aditya

Above answer was peer-reviewed by
 
Follow-up: MBC patient with bone mets. On Tamoxefin and Zoledronic acid. Diagnosed for hyperparathyroidism. Removed adenoma from neck. Suggest? 2 days later
Hello Doctor,

Is it common to have leg pain and feverish feeling after dialysis? These are few things my mother is complaining about. We are seeing improvement in her intake (both solid and liquid) and has urine output of 1.5 to 2L per day. Please let me know if you have any suggestions on this.

Actually thermometer doesn't record any fever but she feels very warm with head ache.

Thanks,
XXXXX
 
 
Answered by Dr. Aditya Bhabhe 11 hours later
Brief Answer:
Complications of dialysis

Detailed Answer:
Hi again

1) Fever during and after dialysis: This is a common problem in patients on dialysis especially if they have a hemodialysis catheters and it may be a sign of infection.
Initial measures include using a new dialyser and tubings. If fever persists we administer antibiotics like Vancomycin and as a last option change the hemodialysis catheter.

2) Leg pain or cramps post dialysis may be due to removal of excess water on dialysis. Other cause can be a low calcium or potassium. If no obvious cause is found we can try carnitine injections during dialysis.

Its good to know that the urine output is increasing.

Regards
Aditya Bhabhe
Above answer was peer-reviewed by
 
Follow-up: MBC patient with bone mets. On Tamoxefin and Zoledronic acid. Diagnosed for hyperparathyroidism. Removed adenoma from neck. Suggest? 1 hour later
Thank you Doctor.

Today's creatinine is 4.0. Her latest and fifth dialysis was on 2nd Sept. This is the lowest creatinine on the 3rd day of dialysis. If you refer to the creatinine summary report, this trend is downward. Does this signify anything, what would be your suggestion to go forward? One more observation is rise in urea level, although her intake has improved and output is good, urea level 47.

Regards,
XXXXX
 
 
Answered by Dr. Aditya Bhabhe 49 minutes later
Brief Answer:
Monitor for recovery

Detailed Answer:
Hi

I would repeat the labs for the next couple of days. If the creatinine remains steady it is a positive sign of the start of renal recovery.

Urea levels can get affected by protein intake, use of certain medications like lasix etc. So I would not worry too much about it just now.

Let me know how things progress.

Aditya Bhabhe
Above answer was peer-reviewed by
 
Follow-up: MBC patient with bone mets. On Tamoxefin and Zoledronic acid. Diagnosed for hyperparathyroidism. Removed adenoma from neck. Suggest? 32 hours later
Hello Doctor,

Here is an update, my mother's creatinine has come down to 3.8 from yesterday's 4.0. Is this a sign of recovery? FYI- Her last dialysis was on Sept 2nd.

Today she had fever about 100F but doctor feels it was because of cold she is having since last 2-3 days. She was suggested an antibiotic.

Appreciate your thoughts.

Regards,
XXXXX
 
 
Answered by Dr. Aditya Bhabhe 10 minutes later
Brief Answer:
Signs of recovery

Detailed Answer:
Hi

A fall in creatinine is a positive sign and indicates the beginning of renal recovery. If patient's clinical condition permits we can hold off dialysis and monitor her renal function every alternate day.

The definite cause and treatment of fever can be determined by clinical examination only. However in hospitalized patients on dialysis, some of the common sources of infection are urinary catheter and the dialysis catheter itself.

Keep me updated with the progress.

Aditya Bhabhe
Above answer was peer-reviewed by
 
Follow-up: MBC patient with bone mets. On Tamoxefin and Zoledronic acid. Diagnosed for hyperparathyroidism. Removed adenoma from neck. Suggest? 15 hours later
hello doctor , fever continued last night. Yesterday's wbc count was 0000, today she had given antibiotic injectables . She has dialysis catheter but physically it doesn't seem to be catheter infection , also uti ruled out. Can this affect the dropping of creatinine?
 
 
Answered by Dr. Aditya Bhabhe 6 hours later
Brief Answer:
Risk of worsening AKI

Detailed Answer:
Hi

In a patient who is just recovering from renal failure, any infection may delay the recovery. However this is not a rule. We should continue doing serial renal functions and monitor her status.

In any case, the source has to be identified and treated appropriately.

If dialysis is not needed, we could consider removing the catheter.

Hope this is helpful
Aditya Bhabhe.



Above answer was peer-reviewed by
 
Follow-up: MBC patient with bone mets. On Tamoxefin and Zoledronic acid. Diagnosed for hyperparathyroidism. Removed adenoma from neck. Suggest? 48 hours later
Hello Doctor ,

Today's creatinine is 3.67, which has again dropped from 3.8. Dialysis catheter has now removed , no fever episode since Saturday evening. Is this going good ?

regards,
XXXXX
 
 
Answered by Dr. Aditya Bhabhe 28 minutes later
Brief Answer:
Good signs

Detailed Answer:
Hi

It seems that things are settling down.
Its a good sign that there is no fever.
We should continue monitoring urea and creatinine on alternate days for next few days.
If there are no new complications then I feel that the renal function should improve over the next few days to weeks.

Good luck
Aditya Bhabhe
Above answer was peer-reviewed by
 
Follow-up: MBC patient with bone mets. On Tamoxefin and Zoledronic acid. Diagnosed for hyperparathyroidism. Removed adenoma from neck. Suggest? 26 hours later
Hello Doctor,

Today my mother is complaining about acidity, nausea and had vomiting. She has been having drowsy feeling all day. Her BP, blood sugar is normal- what could this mean, could this be because of antibiotics she is having since last 3 days? Her yesterday's lab was good except for Urea at 57.

Anything you would advise?

Regards,
XXXXX
 
 
Answered by Dr. Aditya Bhabhe 16 hours later
Brief Answer:
See detailed answer

Detailed Answer:
Hi

It is difficult to ascertain the cause of drowsiness without a thorough clinical examination of the patient.
We could check her serum electrolytes and calcium as these are kidney related parameters which can cause altered sensorium.
Another thing to watch out for is infections. We need to check her CBC to see if the white blood cell count is elevated.

The other symptoms like nausea, vomiting etc., could be caused by some of the medications being administered. As an initial treatment, we could try pantoprazole and emeset.

I would not worry too much about the mild increase in Blood urea levels at this stage.

Aditya Bhabhe
Above answer was peer-reviewed by
 
Follow-up: MBC patient with bone mets. On Tamoxefin and Zoledronic acid. Diagnosed for hyperparathyroidism. Removed adenoma from neck. Suggest? 7 days later
Hello again,

Doctor, My mother has been recovering well- Her Sunday's creatinine was 2.4 but since last two days fever has returned (100-101F). During the fever she feels severe body ache, and her today's creatinine has again gone up to 2.7 (This is the first time going up since last 2 weeks, trend has been downwards). She also has burning urine sensation but urine culture reports are normal, USG is also normal. We are worried about this fever not sure why this keep coming after a period of a week or two. She had been suggested for Levoflox oral antibiotic but she had reaction of that with high acidity, vomiting and short of breath feeling? Now she is on inject-able antibiotics.

We are also monitoring HB and WBC and reports, they have been constantly with following range:
HB 8.5 to 10
WBC- 11,100

Can you give some direction, can this fever be because of bone mets? FYI- She is on Tamoxifen but Zoledronic acid has been on hold since last 1 month. It was due on Sept 13th. Any specific tests or specialists opinion you would advise?
 
 
Answered by Dr. Aditya Bhabhe 5 hours later
Brief Answer:
See detailed answer

Detailed Answer:
Hi there

We have to determine the if the fever is being caused by any infection. For this we could do her blood culture, chest X XXXXXXX Depending on patient's clinical status we sometimes do a CT scan of the chest and abdomen.
Another test which might be helpful is serum procalcitonin level. If procalcitonin is elevated it points to an infective cause.
If bacterial cultures are negative we can test urine/ blood for fungal infections.

If all the cultures are negative and the procalcitonin is normal then we have to look for other causes of fever. The possibilities could be drug fever (due to some of the medications being administered) or due to the cancer mets.

I would recommend the opinion of an infectious disease specialist if there is one available.
Also the use of zolendronic acid would be associated with the risk of worsening renal failure at this stage.

Hope this was helpful

Regards
Aditya Bhabhe
Above answer was peer-reviewed by
 
Follow-up: MBC patient with bone mets. On Tamoxefin and Zoledronic acid. Diagnosed for hyperparathyroidism. Removed adenoma from neck. Suggest? 23 hours later
Hello Doctor,

After a few doses of inject-able antibiotic, fever has stopped. No fever since 24 hrs and so. But creatinine has gone up from 2.7 to 2.9? Trend was downward until last Sunday but it seems after the last high grade fever it is going up again, is it common to have this fluctuation? Will it settle down anytime soon?

 
 
Answered by Dr. Aditya Bhabhe 5 hours later
Brief Answer:
Worsening renal function

Detailed Answer:
Hi

The creatinine can increase after an episode of infection. So the current trend might be a reflection of that.
We need to ensure adequate hydration of the patient along with appropriate treatment of the suspected infection.
We should continue to monitor her renal function and observe the trend.

It is difficult to predict as to when the creatinine will decrease to normal. The decrease has not been very rapid so far. In some patients, following an episode of acute kidney failure, the creatinine may not come down to a comletely normal level. However we wait for as long as 3 months before we come to this conclusion.

Hope this was helpful

Aditya Bhabhe
Above answer was peer-reviewed by
 
Share on Facebook
Share on Twitter
Share on Google+
Question is related to
Drug/Medication
Treatment/Therapy
Medical Procedures
Medical Topics

The user accepted the expert's answer

Ask a Nephrologist

© Ebix, Inc. All Rights Reserved.
All the information, content and live chat provided on the site is intended to be for informational purposes only, and not a substitute for professional or medical advice. You should always speak with your doctor before you follow anything that you read on this website. Any health question asked on this site will be visible to the people who browse this site. Hence, the user assumes the responsibility not to divulge any personally identifiable information in the question. Use of this site is subject to our Terms & Conditions
Already Rated.
Your rating:

Ask a Doctor