A man aged 69 years has coronary artery disease, type 2 diabetes, hypertension, multiple myeloma and end-stage renal disease. He started dialysis last year and did very well. About three months after starting dialysis, he complained of painful nipples bilaterally (especially the right nipple).

The pain eventually spread to the entire breast. A mammogram and ultrasound showed tissue growing in both breasts and a mass in the right. The patient was referred to a breast surgeon and an endocrinologist. Is there any association between gynecomastia and hemodialysis. — Eileen Scarinci, DNP, APN ACRN, Scotch Plains, N.J.

Gynecomastia is extremely common in dialysis patients. In one study, almost 50% of the patients on hemodialysis had gynecomastia (J Nephrol. 2012;25:31-42). The cause is multifactorial.

Leydig-cell dysfunction will cause disruption of the pituitary-testicular axis in men (N Engl J Med. 1977;296:1245-1249). Certain medications commonly used in renal patients can also cause gynecomastia, including spironolactone (Aldactone), cimetidine (Tagamet), amiodarone (Cordarone, Pacerone), omeprazole (Losec, Omesec, Prilosec), cyclosporine (Gengraf, Neoral, Sandimmune, Sangcya), ACE inhibitors and angiotensin receptor blockers, calcium channel blockers and highly active antiretroviral therapy. Discontinuation of the offending medication will often reverse the breast enlargement.

The third factor causing gynecomastia in dialysis patients is high serum prolactin levels (Greenberg A. Primer on Kidney Diseases, 5th ed. Philadelphia, Pa.: Saunders Elsivier; 2009:515). The mechanism for the hyperprolactinemia is a decrease in the metabolic clearance of prolactin along with a three-fold increase in production, which can mean a prolactin level six times higher than normal in your standard dialysis patient. These prolactin levels will drop to normal after renal transplant.

When presented with gynecomastia in a dialysis patient, adjust any offending medications, and order a CT scan to rule out a pituitary tumor and a mammogram to rule out breast cancer before referral to endocrinology and/or surgery. — Kim Zuber, PA-C, Chair National Kidney Foundation Council of Advanced Practitioners, Alexandria, Va. (162-4)

These are letters from practitioners around the country who want to share their clinical problems and successes, observations and pearls with their colleagues. We invite you to participate. If you have a question, submit it here.