Saturday, 15 November 2014


In patients with glomerular diseases, irreversible infertility may occur after treatment with alkylating agents, such as oral or intravenous cyclophosphamide and chlorambucil.

Here is a short summary of available recommendations for maintenance of fertility in patients needing alkylating drugs.  

Female sex
Serologic parameters of ovarian reserve include FSH, LH, and estradiol measured at the follicular phase on days 1–3 of the menstrual cycle, and progesterone measured at the luteal phase 7 days before the next menstruation to confirm ovulation.   

In the postpubertal female, options for gonad preservation include hormonal contraceptives, GRH agonists, and embryo and oocyte cryopreservation.  

Therapy with GRH agonists or analogs shows the most promising results for ovarian protection. The GRH agonists or analogs inhibit the pituitary–gonadal axis and subsequently, the complete ovarian suppression reduces the rate of oocyte maturation. Women develop amenorrhea at 3–8 weeks of treatment with GRH agonists or analogs, and menses generally return 6–10 weeks after withdrawal of GRH agonists or analogs.

Commercially available options include:

  - leuprolide 3.75 mg intramuscular every 4 weeks,
  - triptorelin 3.75 mg IM every 4 weeks, or
  - buserelin 200 mg 3 times a day intranasal

Ovarian protection with GRH agonists or analogs for 6 consecutive months during treatment with cytotoxic agents has been reported in patients with autoimmune diseases. The main adverse events associated with GRH agonist or analog therapy include injection site reactions (3–8%), hot flash, dry vagina, and irregular vaginal bleeding. Menopausal symptoms disappear generally 6–10 weeks after GRH agonist or analog withdrawal. The most serious side effect is loss of bone density. Concomitant calcium and vitamin D supplementation., bisphosphonate therapy, or transdermal estrogen supplementation are therefore necessary. Lupus flares may be induced by the increase of estrogen that is observed in the first two weeks of the start of GRH agonist or analog therapy. Anticoagulation in patients with SLE and/or the antiphospholipid syndrome for the first 3 weeks of GRH agonist or analog treatment seems prudent.

Male sex
Cryopreservation of spermatogonial stem cells for future autologous intratesticular transplantation is a preferable method for prepubertal boys, whereas sperm cryopreservation for future ARTs are options for postpubertal males. Importantly, regarding hormonal therapy for testicular preservation, several studies did not show a beneficial effect from hormonal treatment. 

Cryopreservation of semen and subsequent IVF is the only standard available option.

Monday, 10 November 2014


POTASSIUM PHOSPHATE solutions world-wide differ significantly in composition. How to calculate how much P is contained in each specific solution?

Note: Monobasic potassium phosphate (KH2PO4) MW 136, dibasic potassium phosphate (K2HPO4) MW 174, 1 mmol P= 31 mg; 1 mmol P=1 mmol PO4

POTASSIUM PHOSPHATES Injection, USP 3 mM P/mL and 4.4 mEq K+/mL (marketed in US)
Each milliliter contains 224 mg of monobasic potassium phosphate, anhydrous and 236 mg of dibasic potassium phosphate, anhydrous. One mM of phosphorus weighs 31 mg and the product provides 93 mg (approximately 3 mM) of phosphorus/mL, plus 170.3 mg (4.4 mEq) of potassium/mL. 

POTASSIUM PHOSPHATE MONICO (marketed in several European countries, including Italy)
Each 10 mL vial contains 300 mg of monobasic potassium phosphate, anhydrous and 1550 mg of dibasic potassium phosphate, anhydrous. A 10 mL vial of this product provides 344 mg (approximately 11 mmol) of phosphorus plus 20 mEq of potassium.

Saturday, 8 November 2014

The number of patients receiving renal replacement therapy (RRT) world-wide is estimated at more than 1.4 million. The incidence of RRT is continuously growing by approximately 8% annually.

Despite the heavy burden of end-stage renal disease (ESRD) in developing countries, about 80% of the world’s RRT patients live in developed countries (mainly Europe, Japan or North America).

Given the gap between the low per capita spending on public healthcare and high costs of hemodialysis, in developing countries maintenance hemodialysis is often confined to the private sector. Thus, provision of RRT depends primarily on whether the patient can directly afford treatment costs. Consequences are tragic. In India, less than 10% of ESRD patients receive RRT, while more than 70% of those starting on dialysis die or stop treatment, because of the high cost, within the first 3 months.

There is an urgent need to explore ways of providing high quality, lower cost RRT services.