Nephrol Dial Transplant (2004) 19: 2921–2922 doi:10.1093/ndt/gfh321
Nephroquiz (Section Editor: M. G. Zeier)
An expensive multifactorial renal failure Case A 56-year-old male with a diagnosis of chronic schizophrenia and a history of at least one suicidal attempt presented with increasing abdominal pain. He reported that he wanted again to kill himself and took ‘sleeping pills’ 3 days earlier. He slept for 48 h on the floor of his apartment and woke up with abdominal discomfort that turned into colicky pain. On examination, the abdomen was distended with tenderness in the left lower region. Bowel sounds were vivacious. A digital rectal examination revealed dry stool without blood. The patient had bruises on both legs and clinically appeared volume depleted (dry oral mucosa, dry axillas, decreased skin turgor, sinus tachycardia of 97/min, blood pressure 110/70 mmHg). Laboratory investigations revealed a haemoglobin of 12.7 g/dl, white cell count 9.1 109/l, serum sodium 139 mmol/l, potassium 3.9 mmol/l, creatinine 5.1 mg/dl, blood urea nitrogen 70 mg/dl, uric acid 13.1 mg/dl, albumin 3.6 g/dl, total creatinine kinase 17900 IU/l, aspartate aminotransferase 347 IU/l, lactate dehydrogenase 515 IU/l and C-reactive protein 57 mg/l. Venous blood gas analysis showed metabolic acidosis (pH 7.31, pCO2 33 mmHg, HCO3 17.5 mmol/l). Urinary analysis demonstrated a positive dipstick (þ) for protein, several hyaline and granular casts, 30 leukocytes per high-power field (400), but no erythrocytes. A blood toxicological screen revealed the presence of barbiturates and the neuroleptic agent olanzapine. An abdominal X-ray in the erect position was taken because of the abdominal symptoms (Figure 1).
What is the likely cause of his acute renal failure? Do the abdominal findings contribute to acute renal failure?
Questions How ‘rich’ is this patient?
Fig. 1. X-ray of the abdomen in the erect position.
Nephrol Dial Transplant Vol. 19 No. 11 ß ERA–EDTA 2004; all rights reserved
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G. Wolf et al.
Answer to the quiz on the preceding page The X-ray of the abdomen showed multiple coins in the colon and rectum. After carefully directed questioning, the patient admitted to having ingested these coins during a suicidal attempt, because he was strongly convinced that ‘money kills everything’. After induction of evacuation with lactulose syrup and oral fluid intake, he spontaneously passed 34 coins, worth 28.65 euro (Figure 2). This patient had acute renal failure due to rhabdomyolysis, probably caused by muscle ischaemia through sleeping on the floor for a prolonged time in an unphysiological position. Furthermore, barbiturates are well-known for inducing rhabdomyolysis [1]. Although the patient presented with dry skin and hypotension, he had on admission no further evidence for neuroleptic poisoning or malignant neuroleptic syndrome, but a contribution of olanzapine to the rhabdomyolysis as well as of other drugs that were not measured could not be excluded. The patient was treated with volume substitution (0.9% sodium chloride substituted with various amounts of sodium bicarbonate to increase the urinary pH >6.5 and potassium substitution as appropriate). A total of 5 l were intravenously infused in the following 24 h. Renal function rapidly improved and the elevated serum levels of creatinine kinase declined. What about the swallowed coins? It has been reported recently that 1 and 2 euro coins can release 300-fold more nickel than is allowed under the European Union Nickel Directives [2]. These coins are made of nickel alloys that consist of nickel, copper and zinc. The novel euro coins may elicit contact eczema in susceptible patients [3]. In addition, handling of 1 and 2 euro coins releases copper and zinc [3]. Since these coins are bimetallic, composed of an outer ring and a central pill of different alloys, a galvanic potential could be measured between these two metals [2]. It is well known that a current can enhance galvanic corrosion, particularly in an acid environment, such as in the stomach, thereby increasing nickel release [2]. Indeed, corrosion of the coins is clearly visible (Figure 2). Nickel chloride impairs renal function in rats by inducing lethal cell injury through a process involving oxidative stress [4,5]. Although we did not measure serum nickel concentration in our patient, it is possible that the ingested coins have released considerable amounts of heavy metals that may have contributed to acute renal failure. The patient was subsequently transferred to a psychiatric ward for further treatment. His serum
Fig. 2. Collected coins after intestinal passage and excretion with stools. The 1 and 2 euro coins show clear signs of corrosion
creatinine was 1.3 mg/dl at this time point. Shortly before transfer, he pleaded to receive all his money back. Conflict of interest statement. None declared.
References 1. Holt SG, Moore KP. Pathogenesis and treatment of renal dysfunction in rhabdomyolysis. Inten Care Med 2001; 27: 803–811 2. Nestle FO, Speidel H, Speidel MO. High nickel release from 1- and 2-euro coins. Nature 2002; 419: 132 3. Fournier PG, Govers TR. Contamination by nickel, copper and zinc during the handling of euro coins. Contact Derma 2003; 48: 181–188 4. M’Bemba Meka P, Chakrabarti SK. Effects of different nickel compounds on the transport of para-aminohippurate ion by rat renal cortical slices. Toxicol Lett 2001; 122: 235–244 5. Chakrabarti SK, Bai C. Role of oxidative stress in nickel chloride-induced cell injury in rat renal cortical slices. Biochem Pharmacol 1999; 58: 1501–1510
Gunter Wolf Tobias N. Meyer Jochen Baumann-Scho¨lzke Rolf A. K. Stahl Department of Medicine, Division of Nephrology and Osteology, University of Hamburg, Germany Email:
[email protected]
