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PMMA (polymethyl methacrylate) is a thermolabile synthetic polymer composed of high biocompatibility microspheres used for aesthetic purposes. The consequences of the use have been described over the years and the indiscriminate use can lead to medium to long-term harm due to permanent nature. After PMMA body implantation, macrophages identify the microspheres as incompatible with phagocytosis, leading to the formation of a granuloma—a complication described between 0.01-2.5% of applications according to various product manufacturers. The polymer injection can result in acute kidney injury (AKI) and severe hypercalcemia, secondary to granulomatous reaction and extra-renal production of calcitriol. Hypercalcemia is produced because of the presence of 1α-hydroxylase enzyme in macrophages and giant cells that form part of the granuloma in granulomatous disease.
The present study describes three cases involving adult women who received injections of large volumes of PMMA and subsequently developed hypercalcemia and renal disease.
CASE REPORTS:
Case 1: A 33-year-old female was referred for nephrological evaluation due to hypercalcemia and renal dysfunction. Under endocrinological follow-up for weight control—using Semaglutide, Growth Hormone, and Testosterone. Nodules in the buttocks were found on physical examination on admission. History of PMMA implant for aesthetic purposes 2 years prior. Laboratory evaluation showed AKI—glomerular filtration rate by CKD-EPI 22.6 mL/min/1.73m²—and hypercalcemia with suppressed PTH and increased calcitriol—no evidence of intoxication by 25(OH)vitamin D. Ultrasound(USG) of kidneys with normal dimensions and increased reflectivity of the pyramids suggesting nephrocalcinosis. Magnetic resonance imaging(MRI) with hypodense nodular areas with edema and peripheral contrast enhancement, suggestive of granulomatous reaction.
Case 2: A 38-year-old female sought medical attention complaining of fatigue, malaise, and myalgia. Previous history of non-obstructive nephrolithiasis. Using injectable hormonal contraceptive. History of PMMA implant in the glutes 6 months prior for aesthetic purposes. Laboratory evaluation showed AKI—CKD-EPI 15.9—and hypercalcemia with suppressed PTH, 25(OH)vitamin D within the normal range, and increased calcitriol. Abdominal ultrasound showed normal-sized kidneys and hyperechoic cortex with the presence of non-obstructive bilateral kidney stones. MRI with evidence of granulomas in the gluteal region.
Case 3: A 62-year-old female sought medical attention for lower limb edema. Reported PMMA implant in the glutes for aesthetic purposes 6 months prior and previously dyslipidemic with hypothyroidism and left renal atrophy already under nephrologist follow-up. Baseline creatinine 1.16 mg/dL. Laboratory evaluation revealed AKI—CKD EPI 18.4—hypercalcemia, normal PTH and 25 (OH) vitamin D, protein electrophoresis without monoclonal peak and imaging confirming the presence of granulomas. No history of nephrotoxic drug use.
The use of PMMA for aesthetic purposes is harmful to individuals’ health, causing serious changes in calcium metabolism and renal function. The consequences still require further studies. There is literature describing risk factors for granulomatous disease development, among with the use of hormonal therapy stands out in a significant number of cases described.