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114 CASE REPORT: SODIUM BROMATE, A SILENT NEPHROTOXIN
1ST ASIA PACIFIC AKI CRRT 2017
092 A STUDY ON THE PREVALENCE OF SERUM 25(OH)-VITAMIN D DEFICIENCY IN PATIENTS ON MAINTENANCE HEMODIALYSIS AND PERITONEAL DIALYSIS IN SARAWAK GENERAL HOSPITAL Lai, KH1, Florence Tan, HS2, Phui, VE2, Chew, KF2, Lawrence Hii, WS2, Laura Ngu, LS2, Lee, J2, Clare Tan, HH2 1
Department of Medicine, UNIMAS, 2Sarawak General Hospital
Category: Other Presenter: Dr KEE HOE LAI Keywords: Vitamin D deficiency, Hemodialysis, peritoneal dialysis Introduction: Patients on hemodialysis (HD) or peritoneal dialysis (PD)
were consistently reported to have a high prevalence of vitamin D deficiency. However, there are limited data among Asian population. Objective: To assess the prevalence of Serum 25(OH)-vitamin D deficiency in patients on maintenance HD and PD in Sarawak General Hospital. Methods: This cross sectional study was conducted from November 2015 to September 2016. Patients were classified as vitamin D deficient (<20 ng/ml), insufficient (21 and 29 ng/ml) or sufficient (>30 ng/ml). Results: Of the 170 patients, 101 were on HD and 69 were on CAPD. In HD patients, vitamin D deficiency was found in 7.9% of the patients (n ¼ 8), and insufficiency in 22.8% (n ¼ 23). In CAPD patients, vitamin D deficiency was found in 49.3% of the patients (n ¼ 34), and insufficiency in 30.4% (n ¼ 21). Among HD patients, those with serum 25(OH)D concentrations of <30 ng/ml were predominantly female (p¼ 0.000) and diabetic (p¼0.003). There were significant correlation between serum 25(OH)D and body mass index (p ¼ 0.026), waist circumference (p ¼ 0.031), dialysis vintage (p ¼ 0.005), and magnesium (p ¼ 0.001). There was no correlation with age, corrected calcium, albumin, phosphate, alkaline phosphatase, or intact parathyroid hormone level. Among PD patients, those with serum 25(OH)D concentrations of <30 ng/ml were predominantly female (p¼ 0.004), Malay race (p ¼0.000), urban locality (P ¼0.013) and diabetic (p¼0.000). There was no significant correlation with all the other demographic or laboratory parameters. Conclusions: Our study showed that vitamin D deficiency/insufficiency is highly prevalent among PD patients. However, the majority of our HD patients are not vitamin D deficient. Other risk factors identified include diabetes, female gender, and urban locality. Interestingly, the prevalence of vitamin D deficiency is very low among the Bidayuh patients. Further studies are needed to explore the reason for this and also the consequences of vitamin D deficiency and possible therapeutic interventions.
111 A LUPUS NEPHRITIS PATIENT WITH BREATHLESSNESS FOLLOWING PLASMA EXCHANGE Arbaei, Nabilah Che, Makhtar, Nur Hidayah, Yusof, Maznah, Halimi, Wan Hasnul Department Of Nephrology, Hospital Raja Perempuan Zainab II, Kota Bharu
Category: Other Presenter: Dr WAN HASNUL HALIMI WAN HASSAN Keywords: SLE, lupus nephritis, plasma exchange, fluid overload
A 17 years old girl, diagnosed with Lupus nephritis since 2014. She had Lupus Nephritis class III , in partial remission following treatment with t.mycophenolate mofetil (MMF). She was transferred to high dependency ward requiring non invasive ventilation after 4th cycle of plasmapharesis. This is due to fluid overload and her condition improves after hemodialysis and ultrafiltration. She initially presented with symptoms of facial puffiness and leg swelling for 2 weeks. She was admitted was started on high dose prednisolone (60mg OD) and t.MMF 1g BD. Progressive worsening renal function was noted (urea 29/creat 190; baseline renal function was normal urea/creat) Renal biopsy results shows Crescentric Lupus Nephritis, ISN/RPS class IV-G (A/C). activity index 15/24, chronicity index 4/12. (57% cellular crescent, 15% global sclerosis). IV cyclophosphamide induction and plasma exchange was initiated. She completed total of 10 plasmapheresis cycle and is currently still ongoing 3rd cyclophosphamide induction. Her renal profile shows improvement (urea 15.7/creatinine 116). Discussion: Plasma Exchange is a recognized modality of treatment in more severe and/or resistant lupus nephritis, moreover for crescentic Kidney International Reports (2017) 2, S1–S41
glomerulonephritis. The complication rate of is not high. The Swedish registry reported no fatalities during 20,485 procedures, and an overall adverse incidence rate of only 4.3% of all exchanges (0.9% for severe adverse events) of which 27% were paresthesias, 19% transient hypotension, 13% urticaria, and 8% nausea. An overall complication rate of 1.4% has been reported in more than 15,000 treatments in patients receiving albumin, and 20% in patients receiving FFP. There’s increases the risk of bleeding as a result of depletion of coagulation factors in patients receiving albumin as sole replacement colloid. A study in Japan looking at 53 kidney transplant recipients receiving plasma exchange for desensitization, recorded the were no severe adverse event, milder events were pruritus 53%, numbness 40% and mild dyspnea 5%. The incidence of numbness during plasma exchange was less in patients receiving combined hemodialysis. In our case, fluid overload was noted as a major complication requiring non invasive ventilation and hemodialysis. This is due to the large volume exchange and associated renal impairment. Conclusion: Although uncommon, fluid overload and other complication related to large volume plasma exchange is needed to be taken under account in a renal impaired patient.
114 CASE REPORT: SODIUM BROMATE, A SILENT NEPHROTOXIN Mah, DY1, Cheong, WS1, Tay, SY1 1 Medical Department, Hospital Sultanah Nora Ismail, Batu Pahat, Johor, Malaysia
Category: Other Presenter: Dr MAH DOO YEE Keywords: Sodium Bromate, nephrotoxin, AKI, Dialysis Background: Bromate is commonly used as neutralizers in cosmetic
hair wave preparations during the second step of hair perming. The first step is to hydrolyse the keratin disulphide bonds to make the hair more flexible by using ammonium thioglycolate solution followed by the use of bromated-contained neutralizing agent for oxidation of the sulfhydryl groups back to disulphide bonds in order to stabilize the new form of hair. Previous literature had showed oral ingestion of sodium bromate leading to intoxification but prolonged skin contact may also cause systemic effects as a result of absorption. We reported a case of ototoxicity and nephrotoxicity associated with central nervous system manifestation of hallucination after prolonged application of sodium bromate-contained protein neutralizing lotion. Methods: A 38-year-old Indian housewife presented with gastrointestinal symptoms associated with sudden bilateral hearing loss and hallucination. She gave a history of excoriation of the scalp after she applying hair-perming solution which contained bromate and left it overnight few days prior of admission. Upon arrival, she had creatinine of 812 umol/L requiring acute haemodialysis. The autoimmune screening, renal biopsy and imaging were unremarkable. Her pure tone audiometry showed profound bilateral sensorineural hearing loss. She was discharged on day 17 of admission with creatinine 400 umol/L. Her psychotic symptom improved and her creatinine improved to 220 umol/L one month later. However, her hearing loss did not recover. Discussion: Literature reviews showed that bromate intoxication commonly occurs via oral route but skin absorption can be an alternative route which occurred in our patient.Common symptoms of bromate intoxication include gastrointestinal upset, nephrotoxicity, ototoxicity and central nervous system manifestations were presented. Conclusions: Clinician who is mindful of possibility of bromate poisoning will institute early haemodialysis in order to avoid irreversible nephrotoxicity and ototoxicity.
115 SINGLE CENTER CASE REPORT: ACUTE KIDNEY INJURY (AKI) SECONDARY TO APHANIZOMENAN FLOS AQUAE (AFA) EXTRACT ZulkarnainSim, N1, Tay, HY2, Siaw, YY2, Wong, EFS1 1 Dept of Nephrology, Hospital Tengku Ampuan Rahimah, Klang, Selangor, 41200, Malaysia, 2Dept of Pharmacy, Hospital Tengku Ampuan Rahimah, Klang, Selangor, 41200, Malaysia
Category: Other S31
092 A STUDY ON THE PREVALENCE OF SERUM 25(OH)-VITAMIN D DEFICIENCY IN PATIENTS ON MAINTENANCE HEMODIALYSIS AND PERITONEAL DIALYSIS IN SARAWAK GENERAL HOSPITAL Lai, KH1, Florence Tan, HS2, Phui, VE2, Chew, KF2, Lawrence Hii, WS2, Laura Ngu, LS2, Lee, J2, Clare Tan, HH2 1
Department of Medicine, UNIMAS, 2Sarawak General Hospital
Category: Other Presenter: Dr KEE HOE LAI Keywords: Vitamin D deficiency, Hemodialysis, peritoneal dialysis Introduction: Patients on hemodialysis (HD) or peritoneal dialysis (PD)
were consistently reported to have a high prevalence of vitamin D deficiency. However, there are limited data among Asian population. Objective: To assess the prevalence of Serum 25(OH)-vitamin D deficiency in patients on maintenance HD and PD in Sarawak General Hospital. Methods: This cross sectional study was conducted from November 2015 to September 2016. Patients were classified as vitamin D deficient (<20 ng/ml), insufficient (21 and 29 ng/ml) or sufficient (>30 ng/ml). Results: Of the 170 patients, 101 were on HD and 69 were on CAPD. In HD patients, vitamin D deficiency was found in 7.9% of the patients (n ¼ 8), and insufficiency in 22.8% (n ¼ 23). In CAPD patients, vitamin D deficiency was found in 49.3% of the patients (n ¼ 34), and insufficiency in 30.4% (n ¼ 21). Among HD patients, those with serum 25(OH)D concentrations of <30 ng/ml were predominantly female (p¼ 0.000) and diabetic (p¼0.003). There were significant correlation between serum 25(OH)D and body mass index (p ¼ 0.026), waist circumference (p ¼ 0.031), dialysis vintage (p ¼ 0.005), and magnesium (p ¼ 0.001). There was no correlation with age, corrected calcium, albumin, phosphate, alkaline phosphatase, or intact parathyroid hormone level. Among PD patients, those with serum 25(OH)D concentrations of <30 ng/ml were predominantly female (p¼ 0.004), Malay race (p ¼0.000), urban locality (P ¼0.013) and diabetic (p¼0.000). There was no significant correlation with all the other demographic or laboratory parameters. Conclusions: Our study showed that vitamin D deficiency/insufficiency is highly prevalent among PD patients. However, the majority of our HD patients are not vitamin D deficient. Other risk factors identified include diabetes, female gender, and urban locality. Interestingly, the prevalence of vitamin D deficiency is very low among the Bidayuh patients. Further studies are needed to explore the reason for this and also the consequences of vitamin D deficiency and possible therapeutic interventions.
111 A LUPUS NEPHRITIS PATIENT WITH BREATHLESSNESS FOLLOWING PLASMA EXCHANGE Arbaei, Nabilah Che, Makhtar, Nur Hidayah, Yusof, Maznah, Halimi, Wan Hasnul Department Of Nephrology, Hospital Raja Perempuan Zainab II, Kota Bharu
Category: Other Presenter: Dr WAN HASNUL HALIMI WAN HASSAN Keywords: SLE, lupus nephritis, plasma exchange, fluid overload
A 17 years old girl, diagnosed with Lupus nephritis since 2014. She had Lupus Nephritis class III , in partial remission following treatment with t.mycophenolate mofetil (MMF). She was transferred to high dependency ward requiring non invasive ventilation after 4th cycle of plasmapharesis. This is due to fluid overload and her condition improves after hemodialysis and ultrafiltration. She initially presented with symptoms of facial puffiness and leg swelling for 2 weeks. She was admitted was started on high dose prednisolone (60mg OD) and t.MMF 1g BD. Progressive worsening renal function was noted (urea 29/creat 190; baseline renal function was normal urea/creat) Renal biopsy results shows Crescentric Lupus Nephritis, ISN/RPS class IV-G (A/C). activity index 15/24, chronicity index 4/12. (57% cellular crescent, 15% global sclerosis). IV cyclophosphamide induction and plasma exchange was initiated. She completed total of 10 plasmapheresis cycle and is currently still ongoing 3rd cyclophosphamide induction. Her renal profile shows improvement (urea 15.7/creatinine 116). Discussion: Plasma Exchange is a recognized modality of treatment in more severe and/or resistant lupus nephritis, moreover for crescentic Kidney International Reports (2017) 2, S1–S41
glomerulonephritis. The complication rate of is not high. The Swedish registry reported no fatalities during 20,485 procedures, and an overall adverse incidence rate of only 4.3% of all exchanges (0.9% for severe adverse events) of which 27% were paresthesias, 19% transient hypotension, 13% urticaria, and 8% nausea. An overall complication rate of 1.4% has been reported in more than 15,000 treatments in patients receiving albumin, and 20% in patients receiving FFP. There’s increases the risk of bleeding as a result of depletion of coagulation factors in patients receiving albumin as sole replacement colloid. A study in Japan looking at 53 kidney transplant recipients receiving plasma exchange for desensitization, recorded the were no severe adverse event, milder events were pruritus 53%, numbness 40% and mild dyspnea 5%. The incidence of numbness during plasma exchange was less in patients receiving combined hemodialysis. In our case, fluid overload was noted as a major complication requiring non invasive ventilation and hemodialysis. This is due to the large volume exchange and associated renal impairment. Conclusion: Although uncommon, fluid overload and other complication related to large volume plasma exchange is needed to be taken under account in a renal impaired patient.
114 CASE REPORT: SODIUM BROMATE, A SILENT NEPHROTOXIN Mah, DY1, Cheong, WS1, Tay, SY1 1 Medical Department, Hospital Sultanah Nora Ismail, Batu Pahat, Johor, Malaysia
Category: Other Presenter: Dr MAH DOO YEE Keywords: Sodium Bromate, nephrotoxin, AKI, Dialysis Background: Bromate is commonly used as neutralizers in cosmetic
hair wave preparations during the second step of hair perming. The first step is to hydrolyse the keratin disulphide bonds to make the hair more flexible by using ammonium thioglycolate solution followed by the use of bromated-contained neutralizing agent for oxidation of the sulfhydryl groups back to disulphide bonds in order to stabilize the new form of hair. Previous literature had showed oral ingestion of sodium bromate leading to intoxification but prolonged skin contact may also cause systemic effects as a result of absorption. We reported a case of ototoxicity and nephrotoxicity associated with central nervous system manifestation of hallucination after prolonged application of sodium bromate-contained protein neutralizing lotion. Methods: A 38-year-old Indian housewife presented with gastrointestinal symptoms associated with sudden bilateral hearing loss and hallucination. She gave a history of excoriation of the scalp after she applying hair-perming solution which contained bromate and left it overnight few days prior of admission. Upon arrival, she had creatinine of 812 umol/L requiring acute haemodialysis. The autoimmune screening, renal biopsy and imaging were unremarkable. Her pure tone audiometry showed profound bilateral sensorineural hearing loss. She was discharged on day 17 of admission with creatinine 400 umol/L. Her psychotic symptom improved and her creatinine improved to 220 umol/L one month later. However, her hearing loss did not recover. Discussion: Literature reviews showed that bromate intoxication commonly occurs via oral route but skin absorption can be an alternative route which occurred in our patient.Common symptoms of bromate intoxication include gastrointestinal upset, nephrotoxicity, ototoxicity and central nervous system manifestations were presented. Conclusions: Clinician who is mindful of possibility of bromate poisoning will institute early haemodialysis in order to avoid irreversible nephrotoxicity and ototoxicity.
115 SINGLE CENTER CASE REPORT: ACUTE KIDNEY INJURY (AKI) SECONDARY TO APHANIZOMENAN FLOS AQUAE (AFA) EXTRACT ZulkarnainSim, N1, Tay, HY2, Siaw, YY2, Wong, EFS1 1 Dept of Nephrology, Hospital Tengku Ampuan Rahimah, Klang, Selangor, 41200, Malaysia, 2Dept of Pharmacy, Hospital Tengku Ampuan Rahimah, Klang, Selangor, 41200, Malaysia
Category: Other S31