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210: Salicylate Toxicity and Early Hemodialysis
NKF 2009 Spring Clinical Meetings Abstracts 209 HIGH PREVALENCE OF MICROALBUMINURIA AMONG OBESE PATIENTS SHOWS IMPROVEMENT FOLLOWING BARIATRIC SURGERY Jennifer Tan, Sumit Mohan, Saritha Gorantla, Leaque Ahmed, Velvie Pogue, Constance Park. Depts of Medicine and Surgery, Harlem Hospital Center, Columbia University, NY, NY. The association of obesity and microalbuminuria is widely accepted but the effect of bariatric surgery has not been extensively studied. We reviewed the charts of 205 patients who underwent the Roux-en-Y procedure between Jan 2006 and July 2008. We found 55 pts (91% female, 43.5 ± 11.4 yrs, 121 ± 21.4 Kgs, BMI 45.5 ± 7.7, 40% HTN, 27% DM) who had pre- and post-operative urinary albumin excretion measured within a year of surgery. Significant UAE (>20mg/g) was noted pre-op in 22 (40%) pts, 5 of whom had HTN, 1 had DM and 4 had both. These 22 pts did not differ from those with UAE<20 mg/g with respect to time elapsed between surgery and the postoperative UAE (66±68 vs. 102±103 days), age (45 vs. 43 yrs), gender (96% vs. 87% female), baseline BMI (45.5 vs. 45.7), change in weight (14.3 vs. 17.2 Kgs), the prevalence of DM (18% vs. 33%), HTN (36% vs. 42%). Among these 22 pts with UAE > 20mg/g we noted a significant decrease in the level of UAE (98.6 to 33.4 mg/g, p=0.04), and BMI (45.5 to 39.5, p<0.001), with no significant correlation. Pts without significant UAE did not have a significant change in UAE postoperatively. The drop in UAE for pts with UAE > 20mg/g significantly correlated with the baseline UAE (ρ=0.937, p<0.001) and was not influenced by DM or HTN. The post-op prevalence of UAE > 20 mg/g was significantly lower (40 vs. 20%, p<0.01) and closer to that of the general population. Larger cohorts of bariatric surgery pts could provide an opportunity to study the inter-related influences of BP, glucose tolerance and obesity on microalbuminuria.
210 SALICYLATE TOXICITY AND EARLY HEMODIALYSIS Beje Thomas, Maria Regina Valcarcel, Fabio Aglieco, Purva Kumar, Michael Dunn, University of Connecticut Health Center, Farmington, CT, USA Early hemodialysis is an important intervention in clinically significant salicylate toxicity. In our case, early hemodialysis was performed in the care of a 47 y/o female presenting 12 hours after ingesting 65,000mg of aspirin with a salicylate level of 92 mg/dl. The arterial blood gas showed respiratory alkalosis with concomitant anion gap metabolic acidosis. She was started on a bicarbonate drip and underwent hemodialysis twice for a total of 8 hours until the salicylate was less than 40 mg/dl. Her clinical course was complicated by oliguric renal failure that improved after dialysis. Salicylate intoxication in adults usually causes a respiratory alkalosis, mixed metabolic-respiratory alkalosis or a pure anion gap metabolic acidosis. The CNS is the most vulnerable organ and its involvement can lead to cerebral edema and death and thus, prompt diagnosis and early aggressive treatment is crucial. Administration of hypertonic sodium bicarbonate has been widely used as first line treatment. Initially considered as a means of alkalinizing the patient’s urine to trap ionized salicylate in the renal tubules and promote its excretion. Recent data has shown that patients have died with only mild elevations of serum salicylate levels, and that most of deaths happened on patients who did not receive dialysis in an appropriate time frame. Findings that should prompt consideration of hemodialysis include: Serum concentrations >100 mg/dl even without clinical findings, or serum concentration in or above the therapeutic range (>40mg/dl) if associated with CNS dysfunction with no other explanation, renal failure, pulmonary edema or hypoxia, severe hyperventilation (PCO2 <25 mm/hg) or severe acid-base imbalance with no other explanation. This case shows the importance of early diagnosis and intervention with hemodialysis in salicylate toxicity in decreasing morbidity.
A75 211 FIRST YEAR DIALYSIS MORTALITY IN PATIENTS PREVIOUSLY ENROLLED IN A STRUCTURED CHRONIC KIDNEY DISEASE (CKD) PROGRAM Joel M. Topf1, Robert Provenzano3, Steve Wilson2, Ajay Chokshi2 and Amy Bogan2 1 St. John Hospital & Medical Center, Detroit, Michigan,2 DaVita Inc., El Segundo, CA, 3Office of the Chief Medical Officer, DaVita Inc., El Segundo, CA A structured CKD program will lead to better patient outcomes on dialysis. CKD programs offer specific therapy and education to lower blood pressure, improve anemia, control metabolic bone disease, and prepare patients for dialysis or transplantation. Currently, little data is available on the impact or effectiveness of pre-dialysis care or what the optimal timing of CKD care prior to starting dialysis should be. To investigate these questions we retrospectively followed patients who were enrolled in a Detroit area CKD clinic and who subsequently developed ESRD and initiated dialysis at Davita run dialysis units. Patients were stratified by the length of time they were enrolled in the CKD clinic: <6, 6-12, 13-24 and >24 months. Outcomes examined included one-year mortality and frequency of transplant in the first year. We also investigated various biochemical measures (albumin, phosphorous, calcium, hemoglobin, iron, ferritin and PTH levels) at 90, 120 and 180 days and assessments of dialysis adequacy (URR and Kt/V) also at 90, 120 and 180 days. A total of 213 patients met enrollment criteria; 141 were female. At one-year 18 (8.5%) died, and 13 (6.5%) patients received a kidney transplant. We were unable to detect any relationship with the length of CKD treatment and biochemical or dialysis measures. Mortality in the first year is typically much higher than found with Network 11 reporting 22.6% for Michigan. Our analysis suggests that something other than established biochemical or adequacy markers has impacted 1-year mortality in patients seen in a CKD clinic. We posit that patient education may trump traditional clinical measures and result in patients that do better with ESRD than patients who present unprepared. The dialysis industry as well as payers should consider a more structured approach to this population.
212 RESOLUTION OF CALCIPHYLAXIS AFTER SUCCESSFUL KIDNEY TRANSPLANTATION 1
1
1
Ahsan Ullah, Prabir Roy-Chaudhury , Gautham Mogilishetty , 2 1 E. Steve Woodle , Amit Govil 1 2 Division of Nephrology and Hypertension and Transplant Surgery, University of Cincinnati Med. Ctr., Cincinnati, OH Calciphylaxis (calcific uremic arteriolopathy) is a devastating complication of ESRD on renal replacement therapy (RRT) and associated with high mortality and morbidity. No definitive treatment is available. Here we describe a case with resolution of calciphylaxis after successful kidney transplant. A 60 year old African-American female with ESRD secondary to HTN on RRT for 3 years developed tender lesion in her buttock and thigh area. The first lesion was on her left buttock as a small palpable tender lesion and slowly grew to about 4 cm in diameter with vialaceous overlying skin. Similar lesions appeared in her other side of the buttock and bilateral thighs (total 6 lesions). Her lesions were assessed by a nephrologist and a dermatologist and clinically concluded as calciphylaxis . Her PTH was elevated ( 432 -776) with average phosphorus 6.2 and corrected calcium 9.7. Biopsy of the lesion was not performed. Patient underwent deceased donor kidney transplantation 2 months after her initial lesion. Her induction therapy consisted of thymoglobulin, steroid and mycophenolate and maintenance therapy included tacrolimus and mycophenolate. Soon after transplantation her all lesions began to regress and disappeared after 6 months from her transplantation. Kidney transplantation with replacement of renal function could be a potential treatment of calciphylaxis.
210 SALICYLATE TOXICITY AND EARLY HEMODIALYSIS Beje Thomas, Maria Regina Valcarcel, Fabio Aglieco, Purva Kumar, Michael Dunn, University of Connecticut Health Center, Farmington, CT, USA Early hemodialysis is an important intervention in clinically significant salicylate toxicity. In our case, early hemodialysis was performed in the care of a 47 y/o female presenting 12 hours after ingesting 65,000mg of aspirin with a salicylate level of 92 mg/dl. The arterial blood gas showed respiratory alkalosis with concomitant anion gap metabolic acidosis. She was started on a bicarbonate drip and underwent hemodialysis twice for a total of 8 hours until the salicylate was less than 40 mg/dl. Her clinical course was complicated by oliguric renal failure that improved after dialysis. Salicylate intoxication in adults usually causes a respiratory alkalosis, mixed metabolic-respiratory alkalosis or a pure anion gap metabolic acidosis. The CNS is the most vulnerable organ and its involvement can lead to cerebral edema and death and thus, prompt diagnosis and early aggressive treatment is crucial. Administration of hypertonic sodium bicarbonate has been widely used as first line treatment. Initially considered as a means of alkalinizing the patient’s urine to trap ionized salicylate in the renal tubules and promote its excretion. Recent data has shown that patients have died with only mild elevations of serum salicylate levels, and that most of deaths happened on patients who did not receive dialysis in an appropriate time frame. Findings that should prompt consideration of hemodialysis include: Serum concentrations >100 mg/dl even without clinical findings, or serum concentration in or above the therapeutic range (>40mg/dl) if associated with CNS dysfunction with no other explanation, renal failure, pulmonary edema or hypoxia, severe hyperventilation (PCO2 <25 mm/hg) or severe acid-base imbalance with no other explanation. This case shows the importance of early diagnosis and intervention with hemodialysis in salicylate toxicity in decreasing morbidity.
A75 211 FIRST YEAR DIALYSIS MORTALITY IN PATIENTS PREVIOUSLY ENROLLED IN A STRUCTURED CHRONIC KIDNEY DISEASE (CKD) PROGRAM Joel M. Topf1, Robert Provenzano3, Steve Wilson2, Ajay Chokshi2 and Amy Bogan2 1 St. John Hospital & Medical Center, Detroit, Michigan,2 DaVita Inc., El Segundo, CA, 3Office of the Chief Medical Officer, DaVita Inc., El Segundo, CA A structured CKD program will lead to better patient outcomes on dialysis. CKD programs offer specific therapy and education to lower blood pressure, improve anemia, control metabolic bone disease, and prepare patients for dialysis or transplantation. Currently, little data is available on the impact or effectiveness of pre-dialysis care or what the optimal timing of CKD care prior to starting dialysis should be. To investigate these questions we retrospectively followed patients who were enrolled in a Detroit area CKD clinic and who subsequently developed ESRD and initiated dialysis at Davita run dialysis units. Patients were stratified by the length of time they were enrolled in the CKD clinic: <6, 6-12, 13-24 and >24 months. Outcomes examined included one-year mortality and frequency of transplant in the first year. We also investigated various biochemical measures (albumin, phosphorous, calcium, hemoglobin, iron, ferritin and PTH levels) at 90, 120 and 180 days and assessments of dialysis adequacy (URR and Kt/V) also at 90, 120 and 180 days. A total of 213 patients met enrollment criteria; 141 were female. At one-year 18 (8.5%) died, and 13 (6.5%) patients received a kidney transplant. We were unable to detect any relationship with the length of CKD treatment and biochemical or dialysis measures. Mortality in the first year is typically much higher than found with Network 11 reporting 22.6% for Michigan. Our analysis suggests that something other than established biochemical or adequacy markers has impacted 1-year mortality in patients seen in a CKD clinic. We posit that patient education may trump traditional clinical measures and result in patients that do better with ESRD than patients who present unprepared. The dialysis industry as well as payers should consider a more structured approach to this population.
212 RESOLUTION OF CALCIPHYLAXIS AFTER SUCCESSFUL KIDNEY TRANSPLANTATION 1
1
1
Ahsan Ullah, Prabir Roy-Chaudhury , Gautham Mogilishetty , 2 1 E. Steve Woodle , Amit Govil 1 2 Division of Nephrology and Hypertension and Transplant Surgery, University of Cincinnati Med. Ctr., Cincinnati, OH Calciphylaxis (calcific uremic arteriolopathy) is a devastating complication of ESRD on renal replacement therapy (RRT) and associated with high mortality and morbidity. No definitive treatment is available. Here we describe a case with resolution of calciphylaxis after successful kidney transplant. A 60 year old African-American female with ESRD secondary to HTN on RRT for 3 years developed tender lesion in her buttock and thigh area. The first lesion was on her left buttock as a small palpable tender lesion and slowly grew to about 4 cm in diameter with vialaceous overlying skin. Similar lesions appeared in her other side of the buttock and bilateral thighs (total 6 lesions). Her lesions were assessed by a nephrologist and a dermatologist and clinically concluded as calciphylaxis . Her PTH was elevated ( 432 -776) with average phosphorus 6.2 and corrected calcium 9.7. Biopsy of the lesion was not performed. Patient underwent deceased donor kidney transplantation 2 months after her initial lesion. Her induction therapy consisted of thymoglobulin, steroid and mycophenolate and maintenance therapy included tacrolimus and mycophenolate. Soon after transplantation her all lesions began to regress and disappeared after 6 months from her transplantation. Kidney transplantation with replacement of renal function could be a potential treatment of calciphylaxis.