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322 Management of Persistent Hyperparathyroidism With Cinacalcet Following Successful Kidney Transplantation: Sixty Months Follow Up
NKF 2011 Spring Clinical Meetings Abstracts
321 RARE CASE PRESENTATION OF RENAL TRANSPLANT TORSION: WHEN IMAGING IS NONDIAGNOSTIC Kim Tran, Samir Nangia, University of California, San Diego, California, USA Renal transplant torsion is a rare complication of intraperitoneal renal transplantation and has been reported to occur as long as 10 years post transplant. Previous case reports suggest that CT scan is more sensitive than ultrasound in detecting renal transplant torsion by showing changes in orientation, swelling, hydronephrosis, or abnormal enhancement. We report a unique case presentation of renal torsion where imaging becomes non-diagnostic and the delay in diagnosis leads to graft loss. A 36 year old Hispanic female with history of ESRD secondary to type 1 diabetes with failed deceased donor kidney transplant in 1997 and simultaneous kidney-pancreas transplant (SKPT) in 2005, presents with 3 days of nausea, vomiting, fevers, and abdominal pain. She had decreased urine output over the previous 24 hours along with tenderness over the graft site on exam. She was on myfortic, cyclosporine, and prednisone for immunosuppression with a baseline serum Cr of 1.05 mg/dL noted on labs 2 weeks prior. On admit, she was noted to have serum Cr of 4.35 mg/dL and a trough cyclosporine of 241 mg/dL. Renal ultrasound showed no doppler flow in the renal artery and vein suggesting thrombosis. Abdominal CT showed inflammation and perinephric stranding of the intraperitoneal renal transplant, but otherwise no changes in orientation or hydronephrosis. Given that imaging was non-diagnostic, the patient was taken by radiology for stenting and/or angioplasty of a possible thrombosis. After unsuccessful attempts, she was the taken for an exploratory laporatomy where the intraperitoneal kidney transplant was found to have a dusky appearance with clockwise torsion. Despite surgical correction of the torsion, post operatively renal function did not improve. Biopsy showed necrosis of the kidney, and the patient was reinitiated on chronic hemodialysis. To our knowledge, this is the second documented case of renal torsion in SKPT occurring more than 5 years post transplant. We have also demonstrated a rare case of renal torsion where imaging becomes non-diagnostic and delay in diagnosis leads to graft loss.
322 MANAGEMENT OF PERSISTENT HYPERPARATHYROIDISM WITH CINACALCET FOLLOWIN G SUCCESSFUL KIDNEY TRANSPLANTATION: SIXTY MONTHS FOLLOW UP Diane Triolo, Patrick Lynch, Deep Patel, Mekdess Abebe, Nand K Wadhwa and Edward P Nord. Medicine/Nephrology, SUNY Stony Brook, Stony Brook, NY. The continued use of cinacalcet over 60 months to optimize persistent hyperparathyroidism (HPT) in patients with a successful kidney transplant was evaluated. Thirty-seven patients with HPT and stable graft function at 3 months were started on cinacalcet 30 mg/day and titrated to a maximum of 120 mg/day. Immunosuppression comprised of alemtuzumab induction (35/37), rapid steroid withdrawal (methylprednisolone 500/250/125 mg/day on days 0/1/2 respectively), followed by maintenance immunotherapy with a calcineurin inhibitor and mycophenolate mofitil 33/37 (89%). Serial serum iPTH, calcium, phosphorus and alkaline phosphatase (AP) levels were measured over 60 months. The data is presented as mean value ± standard deviation. Mean serum iPTH decreased from 230 ± 139 pg/mL (0 months), to 143 ± 229 pg/mL by 12 months (p<0.001) and declined further to 128 ± 44 pg/mL at 60 months (p<0.03 vs 0 months). Serum calcium decreased from 10.26 ± 0.71 mg/dL (0 months) to 9.5 ±0.74 mg/dL at 3 months (p<0.001) and was 9.64 ± 0.73 mg/dL (p<0.01 vs 0 months) at the 60 month mark. Serum phosphorus concomitantly increased from 2.55 ± 0.74 mg/dL to 3.69 ± 3.05 mg/dL at 18 months (p<0.03) and was 3.12 ± 0.58 mg/dL (p <0.01 vs 0 months) at 60 months. Serum AP levels decreased from 110 ± 38.7 U/L (0 months) to 92 ± 33.71 U/L at 24 months (p<0.04) and was 77 ± 24.4 U/L (p<0.01 vs 0 months) at 60 months. By 60 months 19/37 patients remained on cinacalcet with a mean dosage of 56 ± 30 mg/day, and 13/37 discontinued treatment and maintained an iPTH level appropriate for their CKD stage. Three patients were lost to follow up and 2 discontinued treatment due to side effects. Renal function remained stable throughout: mean serum creatinine and eGFR (MDRD) of 1.55 ± 0.94 mg/dL and 53.3 ± 22.6 ml/min at baseline vs 1.52 ± 0.75 mg/dL and 51.5 ± 21.4 ml/min at 60 months (NS). Conclusion: Cinacalcet is an effective agent in the long term management of persistent post renal transplant HPT with no deleterious impact on renal function.
Am J Kidney Dis. 2011;57(4):A1-A108
323 ORAL SUPPLEMENTATION OF 15 GRAMS OF AMINO ACIDS ADMINISTERED THRICE WEEKLY INCREASES SERUM ALBUMIN LEVELS IN CHRONIC HEMODIALYSIS PATIENTS Ruchir Trivedi, Meredith Marinaro, James Reid, Andre A. Kaplan: UConn Dialysis Center, Dialysis Clinics, Inc, and the University of Connecticut Health Center, Farmington, CT We report on the results of providing an oral supplementation of 15 gms of amino acids to chronic hemodialysis patients for a maximum of 6 months. Oral supplementation was in the form of Pro Stat 101 ™ containing 15 gms of amino acids and 101 kcal per ounce. The supplement was given thrice weekly at the initiation of each hemodialysis session. Doses provided in 1 ounce cups were checked at the end of each treatment for compliance. Sixteen patients received at least 75% of prescribed supplements for a period of between 2 to 6 months. The total number of doses per patient ranged from 13 to 59, with a mean of 35 +14 doses (X +sd). Percent compliance with ingestion of doses provided was between 75 and 100%, with a mean of 91 +8%. Initial mean serum albumin levels and protein catabolic rate (PCR) determinations were taken prior to the initiation of the supplement and at the end of the first 6 months. Mean serum albumin levels prior to initiation of supplements was 3.1 +0.3 gm/dL. Mean serurm albumin at the end of 6 months was 3.5 +0.3 gm/dL. (paired t-test: p<0.01). Mean PCR values taken prior to initiation of supplements was 0.86 +0.18 gm/kg/day and 0.97 +0.20 gm/kg/day at the end of 6 months (p<0.05). We conclude that oral supplementation of 15 grams of amino acids in the form of Pro Stat 101 TM administered thrice weekly is associated with an increase in PCR and results in a significant increase in serum albumin levels in chronic hemodialysis patients.
324 PROLONGED SYMPTOMATIC HYPOCALCEMIA FROM HUNGRY BONE SYNDROME (HBS) AFTER PARATHYROIDECTOMY (PTX) Ruchir Trivedi, Francisco Padilla, Andre A.Kaplan, University of Connecticut, Farmington, CT 06032 It has been reported that 1% to 28% of patients who have hemodialysis develop significant secondary hyperparathyroidism (HPT). Parathyroidectomy (PTX) improves bone mineral density scores and reduces the incidence of fractures by 30% in patients receiving dialysis. Post-operative hypocalcemia complicates up to 95% of “renal” PTX requiring intravenous calcium and Vitamin D treatment. HBS is characterized by severe and prolonged, sometimes life-threatening hypocalcemia. The incidence of HBS is approximately 12%. It is related to a sudden decrease in PTH release and attenuation of its effect on bone’s contribution to serum calcium concentration. A 40 year old, AA male, with a history of ADPKD on hemodialysis presented, after long standing history of dietary and pharmacological noncompliance, with tertiary HPT Patient was dialyzed for 5 hours TIW with Kt/V of 1.4. He was treated with calcium acetate, sevelamer, calcitriol, paracalcitriol and cinacalcet. The patient had peak intact PTH level of 4225 pg/mL. His ionized calcium was in the 1.09-1.27 mmol/L range with total calcium of 8.6-9.3 mg/dL and 25 OH vitamin D levels of 18-20. Parathyroid scan suggested increased metabolic activity within the medial upper pole of the right thyroid gland without evident adenoma. Ultrasound showed an ill-defined hypoechoic mass inferior to the lower pole measuring 1.4 x 1.2 x 1.1 cm. Patient underwent 3.5 gland PTX with ½ gland auto-transplantation in sternocleidomastoid. Twelve hours after surgery he developed perioral paresthesia and spontaneous Chvostek’s sign and critical low ionized calcium of 0.7 mmol/L. He required intravenous calcium, high dose calcitriol, high dose oral calcium and hemodialysis with 3-3.5 mEq/L calcium bath for 30 days after surgery. Two months after PTX patient continued to have symptoms of hypocalcemia with ionized calcium of 0.9-1.03, increasing iPTH up to 80-85 and elevated alkaline phosphatase of about 400, on 3 mcg of calcitriol, 4200mg of calcium citrate and 3.0 calcium dialysate. HBS in post “renal” PTX can be prolonged, requiring aggressive calcium replacement therapy.
A97
321 RARE CASE PRESENTATION OF RENAL TRANSPLANT TORSION: WHEN IMAGING IS NONDIAGNOSTIC Kim Tran, Samir Nangia, University of California, San Diego, California, USA Renal transplant torsion is a rare complication of intraperitoneal renal transplantation and has been reported to occur as long as 10 years post transplant. Previous case reports suggest that CT scan is more sensitive than ultrasound in detecting renal transplant torsion by showing changes in orientation, swelling, hydronephrosis, or abnormal enhancement. We report a unique case presentation of renal torsion where imaging becomes non-diagnostic and the delay in diagnosis leads to graft loss. A 36 year old Hispanic female with history of ESRD secondary to type 1 diabetes with failed deceased donor kidney transplant in 1997 and simultaneous kidney-pancreas transplant (SKPT) in 2005, presents with 3 days of nausea, vomiting, fevers, and abdominal pain. She had decreased urine output over the previous 24 hours along with tenderness over the graft site on exam. She was on myfortic, cyclosporine, and prednisone for immunosuppression with a baseline serum Cr of 1.05 mg/dL noted on labs 2 weeks prior. On admit, she was noted to have serum Cr of 4.35 mg/dL and a trough cyclosporine of 241 mg/dL. Renal ultrasound showed no doppler flow in the renal artery and vein suggesting thrombosis. Abdominal CT showed inflammation and perinephric stranding of the intraperitoneal renal transplant, but otherwise no changes in orientation or hydronephrosis. Given that imaging was non-diagnostic, the patient was taken by radiology for stenting and/or angioplasty of a possible thrombosis. After unsuccessful attempts, she was the taken for an exploratory laporatomy where the intraperitoneal kidney transplant was found to have a dusky appearance with clockwise torsion. Despite surgical correction of the torsion, post operatively renal function did not improve. Biopsy showed necrosis of the kidney, and the patient was reinitiated on chronic hemodialysis. To our knowledge, this is the second documented case of renal torsion in SKPT occurring more than 5 years post transplant. We have also demonstrated a rare case of renal torsion where imaging becomes non-diagnostic and delay in diagnosis leads to graft loss.
322 MANAGEMENT OF PERSISTENT HYPERPARATHYROIDISM WITH CINACALCET FOLLOWIN G SUCCESSFUL KIDNEY TRANSPLANTATION: SIXTY MONTHS FOLLOW UP Diane Triolo, Patrick Lynch, Deep Patel, Mekdess Abebe, Nand K Wadhwa and Edward P Nord. Medicine/Nephrology, SUNY Stony Brook, Stony Brook, NY. The continued use of cinacalcet over 60 months to optimize persistent hyperparathyroidism (HPT) in patients with a successful kidney transplant was evaluated. Thirty-seven patients with HPT and stable graft function at 3 months were started on cinacalcet 30 mg/day and titrated to a maximum of 120 mg/day. Immunosuppression comprised of alemtuzumab induction (35/37), rapid steroid withdrawal (methylprednisolone 500/250/125 mg/day on days 0/1/2 respectively), followed by maintenance immunotherapy with a calcineurin inhibitor and mycophenolate mofitil 33/37 (89%). Serial serum iPTH, calcium, phosphorus and alkaline phosphatase (AP) levels were measured over 60 months. The data is presented as mean value ± standard deviation. Mean serum iPTH decreased from 230 ± 139 pg/mL (0 months), to 143 ± 229 pg/mL by 12 months (p<0.001) and declined further to 128 ± 44 pg/mL at 60 months (p<0.03 vs 0 months). Serum calcium decreased from 10.26 ± 0.71 mg/dL (0 months) to 9.5 ±0.74 mg/dL at 3 months (p<0.001) and was 9.64 ± 0.73 mg/dL (p<0.01 vs 0 months) at the 60 month mark. Serum phosphorus concomitantly increased from 2.55 ± 0.74 mg/dL to 3.69 ± 3.05 mg/dL at 18 months (p<0.03) and was 3.12 ± 0.58 mg/dL (p <0.01 vs 0 months) at 60 months. Serum AP levels decreased from 110 ± 38.7 U/L (0 months) to 92 ± 33.71 U/L at 24 months (p<0.04) and was 77 ± 24.4 U/L (p<0.01 vs 0 months) at 60 months. By 60 months 19/37 patients remained on cinacalcet with a mean dosage of 56 ± 30 mg/day, and 13/37 discontinued treatment and maintained an iPTH level appropriate for their CKD stage. Three patients were lost to follow up and 2 discontinued treatment due to side effects. Renal function remained stable throughout: mean serum creatinine and eGFR (MDRD) of 1.55 ± 0.94 mg/dL and 53.3 ± 22.6 ml/min at baseline vs 1.52 ± 0.75 mg/dL and 51.5 ± 21.4 ml/min at 60 months (NS). Conclusion: Cinacalcet is an effective agent in the long term management of persistent post renal transplant HPT with no deleterious impact on renal function.
Am J Kidney Dis. 2011;57(4):A1-A108
323 ORAL SUPPLEMENTATION OF 15 GRAMS OF AMINO ACIDS ADMINISTERED THRICE WEEKLY INCREASES SERUM ALBUMIN LEVELS IN CHRONIC HEMODIALYSIS PATIENTS Ruchir Trivedi, Meredith Marinaro, James Reid, Andre A. Kaplan: UConn Dialysis Center, Dialysis Clinics, Inc, and the University of Connecticut Health Center, Farmington, CT We report on the results of providing an oral supplementation of 15 gms of amino acids to chronic hemodialysis patients for a maximum of 6 months. Oral supplementation was in the form of Pro Stat 101 ™ containing 15 gms of amino acids and 101 kcal per ounce. The supplement was given thrice weekly at the initiation of each hemodialysis session. Doses provided in 1 ounce cups were checked at the end of each treatment for compliance. Sixteen patients received at least 75% of prescribed supplements for a period of between 2 to 6 months. The total number of doses per patient ranged from 13 to 59, with a mean of 35 +14 doses (X +sd). Percent compliance with ingestion of doses provided was between 75 and 100%, with a mean of 91 +8%. Initial mean serum albumin levels and protein catabolic rate (PCR) determinations were taken prior to the initiation of the supplement and at the end of the first 6 months. Mean serum albumin levels prior to initiation of supplements was 3.1 +0.3 gm/dL. Mean serurm albumin at the end of 6 months was 3.5 +0.3 gm/dL. (paired t-test: p<0.01). Mean PCR values taken prior to initiation of supplements was 0.86 +0.18 gm/kg/day and 0.97 +0.20 gm/kg/day at the end of 6 months (p<0.05). We conclude that oral supplementation of 15 grams of amino acids in the form of Pro Stat 101 TM administered thrice weekly is associated with an increase in PCR and results in a significant increase in serum albumin levels in chronic hemodialysis patients.
324 PROLONGED SYMPTOMATIC HYPOCALCEMIA FROM HUNGRY BONE SYNDROME (HBS) AFTER PARATHYROIDECTOMY (PTX) Ruchir Trivedi, Francisco Padilla, Andre A.Kaplan, University of Connecticut, Farmington, CT 06032 It has been reported that 1% to 28% of patients who have hemodialysis develop significant secondary hyperparathyroidism (HPT). Parathyroidectomy (PTX) improves bone mineral density scores and reduces the incidence of fractures by 30% in patients receiving dialysis. Post-operative hypocalcemia complicates up to 95% of “renal” PTX requiring intravenous calcium and Vitamin D treatment. HBS is characterized by severe and prolonged, sometimes life-threatening hypocalcemia. The incidence of HBS is approximately 12%. It is related to a sudden decrease in PTH release and attenuation of its effect on bone’s contribution to serum calcium concentration. A 40 year old, AA male, with a history of ADPKD on hemodialysis presented, after long standing history of dietary and pharmacological noncompliance, with tertiary HPT Patient was dialyzed for 5 hours TIW with Kt/V of 1.4. He was treated with calcium acetate, sevelamer, calcitriol, paracalcitriol and cinacalcet. The patient had peak intact PTH level of 4225 pg/mL. His ionized calcium was in the 1.09-1.27 mmol/L range with total calcium of 8.6-9.3 mg/dL and 25 OH vitamin D levels of 18-20. Parathyroid scan suggested increased metabolic activity within the medial upper pole of the right thyroid gland without evident adenoma. Ultrasound showed an ill-defined hypoechoic mass inferior to the lower pole measuring 1.4 x 1.2 x 1.1 cm. Patient underwent 3.5 gland PTX with ½ gland auto-transplantation in sternocleidomastoid. Twelve hours after surgery he developed perioral paresthesia and spontaneous Chvostek’s sign and critical low ionized calcium of 0.7 mmol/L. He required intravenous calcium, high dose calcitriol, high dose oral calcium and hemodialysis with 3-3.5 mEq/L calcium bath for 30 days after surgery. Two months after PTX patient continued to have symptoms of hypocalcemia with ionized calcium of 0.9-1.03, increasing iPTH up to 80-85 and elevated alkaline phosphatase of about 400, on 3 mcg of calcitriol, 4200mg of calcium citrate and 3.0 calcium dialysate. HBS in post “renal” PTX can be prolonged, requiring aggressive calcium replacement therapy.
A97