Calcium (Ca +2 ) is a divalent cation that plays a critical role in numerous body functions such as skeletal mineralization, signal transduction, nerve conduction, muscle contraction, and blood coagulation. Ca +2 metabolism is linked to magnesium (Mg +2 ) and phosphate metabolism. Ca +2 homeostasis is dependent on intestinal absorption, bone turnover, and renal reabsorption. The hormonal regulators of these processes are the parathyroid hormone (PTH), calcitriol {1,25-dihydroxyvitamin D [1,25(OH) 2 D]}, and serum ionized Ca +2 . Cloning of the Ca +2 -sensing receptor (CaSR) has greatly advanced the understanding of Ca +2 metabolism. Disorders of Ca +2 metabolism are easily recognized because Ca +2 is included in routine chemistry panels. Measurement of ionized Ca +2 is the preferred way to ascertain the diagnosis of hypocalcemia and hypercalcemia.

We prospectively compared the absorption of ferrous sulfate to that of a polysaccharide ferric complex (Niferex®) in 5 healthy controls and 7 stable patients on continuous ambulatory peritoneal dialysis (CAPD). All study subjects received an equivalent of 150 mg of elemental iron of either preparation, in a random fashion. After a baseline fasting serum iron level was obtained, the serum iron concentration was measured at 2 h in the control group and at 2 and 4h in the CAPD patients. One to 2 months later, all study subjects received the alternative iron compound and were studied in an identical manner. A significant rise in serum iron was only observed in the healthy subjects after the ingestion of ferrous sulfate and not Niferex (ferrous sulfate 102 ± (SE) 9 vs. 142 ± 7 Mg/dl, p = 0.0005; Niferex 96 ± (SE) 10 vs. 102 ± 12 mg/dl; baseline vs. 2 h, respecitvely). The absorption of both compounds was poor in the patients on CAPD, with the 2- and 4-hour serum iron levels not significantly higher than the baseline values (ferrous sulfate 73 ± 7 vs. 107 ± 21 vs. 109 ± 21 mg/dl, p = NS; Niferex 57 ± 11 vs. 65 ± 14 vs. 60 ± 11 mg/dl, p = NS; baseline vs. 2 vs. 4 h, respectively). Our data suggest that the absorption of both ferrous sulfate and ferric polysaccharide complex is poor in patients on CAPD.

Introduction: Immune checkpoint inhibitors (CPIs) represent novel new cancer immunotherapy agents. The use of nivolumab has been linked with immune mediated acute interstitial nephritis (AIN). Case Presentation: We present the case of a patients with recurrent hepatocellular carcinoma who developed severe Fanconi syndrome, as evidenced by hyperchloremic metabolic acidosis, hypokalemia, hypophosphatemia, glucosuria, aminoaciduria, 8 months after initiating treatment with nivolumab, without any evidence of acute renal insufficiency. Conclusion: Clinicians need to be aware of the renal side effects of new novel cancer immunotherapy agents, such as, immune CPIs

Severe dysnatremias are perplexing problems in patients undergoing renal replacement therapy on a chronic or acute basis. The ability to manipulate sodium concentration in the dialysate or replacement solutions is limited. Compounding dialysate or replacement fluids to alter sodium concentration could result in errors. Rapid correction of hyponatremia or hypernatremia due to equilibrium with dialysate or replacement solutions could lead to osmotic demyelination syndrome or cerebral edema respectively. Continuous renal replacement therapy is the preferred dialysis modality in patients with severe dysnatremias. In this article, we present simple formulas to determine the rate of hypotonic or hypertonic solutions needed to mitigate rapid correction of dysnatremias. These formulas can be used readily by the clinician at bedside.

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