1. Loads of drugs and tons of complications
Dr Suhas Mondhe
DNB Nephrology

2. Mr S S 30y/m
R/o Old city, Hyderabad
Political party worker

3. Presented to ER
H/o pain abdomen
Vomiting week
Nausea
Reduced apetite

4. Physical examination Bp 130/90 HR 117/min Dehydrated Pallor +
Abd examination- epigastric tenderness +++
Other systems –Normal
Scar marks ++ deltoid region

6. Hb%
10.5
TLC
9800
creatinine
4.95
alb
4.4
S. Calcium
15.1
S. Phosp
4.3
S. Albumin
3.8
Amylase
High
Lipase
High >2000
TSH
0.6

7. CT SCAN …

8. ACE
17.1
PTH
20.3
TSH
0.6
VIT D
>150

9. DIAGNOSIS.. Hypercalcemia -?? Drug induced Acute Severe Pancreatitis
AKI – Oliguric, AKIN 3

10. MANAGEMENT….

11. IV Antibiotics
IV Hydration with NS
IV Furosemide after hydration
Opioid Analgesics

12. History:
Pain abdomen on and off in epigastric region with vomiting and reduced appetite since Dec 2015.
S/P Appendectomy 2015 May
H/o subcutaneous the site of injection +
H/o significant weight loss
Diagnosed as recurrent pancreatitis may 2016

13. Presented to CARE @may 2016….
H/o pain abdomen,
vomiting ,
Shortness Of Breath,
swelling feet and reduced urine output.

14. May last week 2016…. Followed in opd ..
Persistent GI symptoms ,irritability,
Persistent hypervitaminosis D and hyperclacemia and Renal dysfunction
Nonoliguric.
Calcium
15.1
13.8 Hb
10.5
11.8
creat
4.95
4.29

15. Renal Biopsy for persistent high creatinine despite decreasing S
Renal Biopsy for persistent high creatinine despite decreasing S. calcium level
Focal glomerular obsolescence(1/13)
Moderate chronic TI changes
No e/o ATN/Ca deposits
No e/o myeloma

16. Pt Readmitted with Acute Abdomen
Diagnosed as recurrent pancreatitis ..
Hypercalcemia persistent
Serum electrophoresis done was negative for myeloma
1,25 OH vit D levels done was normal

17. On probing, he gave h/o using
Injectable steroids
Injectable Multi vitamin veterinary preparation since 2-3 yrs.

18. Whole body PET scan done –
Found to have activity in pancreas only
No e/o myeloma
No malignancy
No foci of inflammation (conditions like TB, sarcoidosis)

19. Steroids 0.5 mg/kg prednisolone started..

20. Latest labs… Creatinine 1.52 Calcium 9.3 Lipase 72 Albumin 3.6
Hemoglobin
10.6

21. Co morbidities of AKI and Hypercalcemia
Malignancy
multiple myeloma,
Malignancy related hypercalcemia PTHrP
Hyperparathyroidism
Parathyroid adenoma
Granulomatous diseases
sarcoidosis,
Tuberculosis
Leprosy
Drugs
Vitamin D intoxication

24. Past

25. Hypercalcemia causing AKI
Prostaglandins E causing decreased absorption of Na & Cl

27. It is prudent to include vitamin D intoxication and possible foreign body reaction in the differential diagnosis of bodybuilding patients with renal impairment…

29. The exact pathophysiology of this type of AKI remains unclear.
Int Urol Nephrol. 2009;41(3): doi: /s Epub 2009 Apr 23. Acute kidney injury due to anabolic steroid and vitamin supplement abuse: report of two cases and a literature review.
CONCLUSIONS:
AKI is an important complication of anabolic steroid and vitamin supplement abuse.
The exact pathophysiology of this type of AKI remains unclear.
The main cause of renal dysfunction in these cases seems to be the vitamin D intoxication and drug-induced interstitial nephritis.
It is mandatory to start early treatment for serious hypercalcemia, with vigorous venous hydration, diuretics and corticosteroids.