Letter to the Editor
Acute vision loss on hemodialysis: Mönckeberg arteriosclerosis
Pérdida de visión aguda en hemodiálisis: arterioesclerosis de Mönckeberg
Álvaro Pérez Fernández
, Inmaculada Poveda García, Maria Teresa Cantón Yebra
Corresponding author
UGC (Unidad de Gestión Clínica), Nefrología, Complejo Hospitalario Torrecárdenas, Almería, Spain
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=> array:1 [ 0 => array:2 [ "paginaInicial" => "485" "paginaFinal" => "487" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Álvaro Pérez Fernández, Inmaculada Poveda García, Maria Teresa Cantón Yebra" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Álvaro" "apellidos" => "Pérez Fernández" "email" => array:2 [ 0 => "alvaroperfdez@gmail.com" 1 => "alvaro.perez.fernandez.sspa@juntadeandalucia.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Inmaculada" "apellidos" => "Poveda García" ] 2 => array:2 [ "nombre" => "Maria Teresa" "apellidos" => "Cantón Yebra" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "UGC (Unidad de Gestión Clínica), Nefrología, Complejo Hospitalario Torrecárdenas, Almería, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pérdida de visión aguda en hemodiálisis: arterioesclerosis de Mönckeberg" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 754 "Ancho" => 1007 "Tamanyo" => 149973 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transverse section of the temporal artery revealing marked intimal thickening, with isolated calcifications in the tunica media and on the periphery of the internal elastic lamina.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Regarding the article published in the journal <span class="elsevierStyleSmallCaps">Nefrología [</span>“Acute vision loss in patients with kidney failure”,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and taking into account the scarcity of cases published in the bibliography, we propose the presentation of the following case of amaurosis in a patient on regular haemodialysis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 73-year-old woman with a medical history of allergy to iodinated contrast, chronic myeloid leukaemia, insulin-dependent type II diabetes mellitus and chronic kidney disease without histological assessment, on haemodialysis since 2018, with poor tolerance to haemodialysis sessions (hypotension), secondary hyperparathyroidism and glaucoma.</p><p id="par0015" class="elsevierStylePara elsevierViewall">During a haemodialysis session and coinciding with an episode of severe hypotension, the patient had onset of holocranial headache accompanied by acute loss of vision of the left eye. Cranial CT without IV contrast was performed with no findings of interest. She was assessed by Ophthalmology and examination of the eye fundi revealed “bilateral papilloedema with retinal haemorrhagic papillitis as a consequence of left retinal infarction” and she was discharged with a follow-up by the ophthalmology unit.</p><p id="par0020" class="elsevierStylePara elsevierViewall">After three weeks, she presented with the same clinical picture in the right eye, reporting an altitudinal loss with progression to total amaurosis. Assessed by Neurology, a Doppler ultrasound of the supra-aortic trunks was performed without findings of interest and a temporal artery biopsy was performed, three boluses of 500<span class="elsevierStyleHsp" style=""></span>mg of methylprednisolone were started due to the suspicion that the patient might be suffering from temporal arteritis.</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Laboratory testing</span><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">Acute phase reactants: CRP and ESR in normal range</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">Total protein corrected serum calcium (mean): 10.5<span class="elsevierStyleHsp" style=""></span>mg/dl</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">Serum phosphorus (mean): 5–6 (mg/dl)</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">i-PTH serum: 850<span class="elsevierStyleHsp" style=""></span>pg/mL</p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Temporal artery biopsy</span></p><p id="par0055" class="elsevierStylePara elsevierViewall">No signs of inflammation. There were calcium deposits in the middle layer of the temporal artery (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Given these findings, she was diagnosed with Mönckeberg's arteriopathy, and finally the patient did not regain her vision.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Mönckeberg's arteriosclerosis, or Mönckeberg's medial sclerosis, was described for the first time in 1903 by Johann Georg Mönckeberg, as a calcification of the tunica media of the medium and small muscular arteries of the lower extremities and, less frequently, in the visceral or coronary arteries.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> It is the calcification that has been commonly associated with kidney disease.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The aetiology of this condition is unknown.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">It is mainly related to age, diabetes, time on dialysis, and mineral metabolism. It causes stiffness of the arterial wall and, with it, an increase in systolic blood pressure as well as an increase in pulse pressure and pulse wave velocity. It contributes to the development of left ventricular hypertrophy, fibrosis, ventricular dysfunction, decreased coronary flow during diastole, and heart failure.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Clinically, the manifestations are extensive, all derived from the vascular occlusion that is generated.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Differential diagnoses are mainly given by vasculitis affecting these vessels, including polyarteritis nodosa and giant cell arteritis. In the literature review, only a total of 10 publications between 1999–2019 have been found on Mönckeberg's syndrome, two of them with ocular involvement.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Symptoms can be so similar that, given the inability to determine alterations in calcium-phosphorus metabolism, tissue biopsy must be drawn upon as a means to achieve a definitive diagnosis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Mönckeberg's arteriopathy has been increasingly recognised in patients with end-stage renal disease in relation to calcium-phosphorus metabolism disorder.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Al-Absi et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> described a case similar to ours with a 50-year-old man on haemodialysis with symptoms of temporal artery arteritis (temporal headache, blurred vision, jaw claudication) who was found to have Mönckeberg's arteritis on temporal artery biopsy.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Korzets et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> describe two cases of anterior ischaemic optic neuropathy in haemodialysis patients with extensive medial calcification. Both patients had hypotension and acute unilateral vision loss.</p><p id="par0110" class="elsevierStylePara elsevierViewall">At present, there are no specific e treatment for Mönckeberg's sclerosis, and actions are only chosen aiming to optimise calcium metabolism, including chelators such as sodium thiosulfate. In our case, despite intensifying medical treatment, the ocular involvement was irreversible.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In conclusion, the development of Mönckeberg's sclerosis is closely linked to senescence, but risk factors such as chronic kidney disease and diabetes mellitus can directly favour its development and progression. In addition, thediagnosis of this condition continues to be an incidental finding in histopathological samples, and there are currently no laboratory diagnostic aids or specific images of the disease. Clinical suspicion will be the cornerstone of diagnosis that may allow for early medical management, thus avoiding an accelerated progression of the disease, and to avoid the prescription of futile treatments.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Poveda García I, Cantón Yebra MT. Pérdida de visión aguda en hemodiálisis: arterioesclerosis de Mönckeberg. Nefrologia. 2021;41:485–487.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 754 "Ancho" => 1007 "Tamanyo" => 149973 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transverse section of the temporal artery revealing marked intimal thickening, with isolated calcifications in the tunica media and on the periphery of the internal elastic lamina.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 757 "Ancho" => 1007 "Tamanyo" => 189350 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Transverse section of the temporal artery showing marked intimal thickening, without other alterations. No inflammation or infiltration by giant cells can be observed.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pérdida aguda de visión en pacientes con insuficiencia renal" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V. Martín" 1 => "G.L. Sención Martínez" 2 => "R. Cañones Zafra" 3 => "K. del Rocío Samillán Sosa" 4 => "M. Velo Plaza" 5 => "M.A. Teus Guezala" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "NefroPlus." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 28 | 38 | 66 |
| 2024 September | 50 | 39 | 89 |
| 2024 August | 57 | 90 | 147 |
| 2024 July | 42 | 41 | 83 |
| 2024 June | 51 | 45 | 96 |
| 2024 May | 47 | 43 | 90 |
| 2024 April | 45 | 34 | 79 |
| 2024 March | 55 | 31 | 86 |
| 2024 February | 35 | 35 | 70 |
| 2024 January | 32 | 22 | 54 |
| 2023 December | 43 | 24 | 67 |
| 2023 November | 58 | 57 | 115 |
| 2023 October | 116 | 22 | 138 |
| 2023 September | 78 | 29 | 107 |
| 2023 August | 70 | 28 | 98 |
| 2023 July | 59 | 18 | 77 |
| 2023 June | 54 | 19 | 73 |
| 2023 May | 52 | 37 | 89 |
| 2023 April | 29 | 14 | 43 |
| 2023 March | 70 | 23 | 93 |
| 2023 February | 43 | 23 | 66 |
| 2023 January | 36 | 32 | 68 |
| 2022 December | 66 | 36 | 102 |
| 2022 November | 46 | 38 | 84 |
| 2022 October | 68 | 54 | 122 |
| 2022 September | 52 | 28 | 80 |
| 2022 August | 40 | 53 | 93 |
| 2022 July | 51 | 47 | 98 |
| 2022 June | 42 | 49 | 91 |
| 2022 May | 49 | 29 | 78 |
| 2022 April | 47 | 54 | 101 |
| 2022 March | 76 | 65 | 141 |
| 2022 February | 69 | 46 | 115 |
| 2022 January | 44 | 43 | 87 |
| 2021 December | 54 | 58 | 112 |
| 2021 November | 77 | 37 | 114 |
| 2021 October | 59 | 68 | 127 |
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