- Email: [email protected]
Adverse Perioperative Events in Chronic Hemodialysis Patients: Who is at Highest Risk?
NKF 2016 Spring Clinical Meetings Abstracts
Case Report 257
259
ADVERSE PERIOPERATIVE EVENTS IN CHRONIC HYPOKALEMIA: DO NOT FORGET DIURETIC ABUSE: Sangeeta Pal, Bharat Sachdeva, LSUHSC-Shreveport, LA, USA. HEMODIALYSIS PATIENTS: WHO IS AT HIGHEST RISK? Hypokalemia at times poses a clinical challenge and requires Nishi H Patel, Jesse Goldman, Drexel University College of Medicine, 2 meticulous history and investigations to find the cause. We present two Philadelphia, PA, USA cases of surreptitious diuretic abuse as cause of hypokalemia. Background: The data regarding preoperative risk 1assessment in 1, 1 Laith Al-Rabadi, MBBS, * Rivka Ayalon, MD, G.(HD) Bonegio, PhD, 30 year old female (Case 1) with bulimia nervosa (diagnosed at age chronicRamon hemodialysis patients isMD, inadequate, even though these 2,y 3 4 13 years) was referred for E. evaluation of hypokalemia. Medications patients are known to have a higher operative risk compared with a Jennifer Ballard, MD, Alan M. Fujii, MD, Joel M. Henderson, MD, PhD, included Amitriptyline, Ibuprofen & Potassium (K) and Magnesium 1 1 non-ESRD population. Our goal is to identify predictive factors of David MD,tenderness. and Laurence H. Beck Jr, MD, PhD supplements. Exam was benign, except J. for Salant, mild abdominal perioperative adverse events in HD patients. 36 year old female (Case 2) with hypertension (stopped medications 3 Methods: We retrospectively screened the records of 783 chronic HD years ago) was referred for hypokalemia for 4years. Medications inpatients in our institution and identified 236 non-emergent procedures There is little with membranous nephropathy (MN), included K supplements and information multivitamins.about pregnancy outcomes in patients performed in active stable patients in the year 2013. 39 of these had a Both denied use of any OTC with medication and labsautoantibodies showed event: cardiac arrest, hypotension & mean arterial (PLA2R), the major especially those circulating to M-typeperioperative phospholipase A2 receptor Uri pressure ≤ 65known mmHg,case symptomatic increase pregnancy in blood pressure autoantigen in primary MN. We present what we believe to be the first of successful in ≥ 25% of Urin ne Uri altered arrhythmia, hypoxia, or blood transfusion. MN. In thebaseline, year prior tomentation, pregnancy, the patient developed a 39-year-old woman with Uri PLA2R-associated S.H e C S.Na S.K Results: 23 of the 39 subjects are male and the mean age is 58.1±18.1 Os ne ne Urine g/dL), and proteinuria anasarca,CO3 hypoalbuminemia (albumin, 1.3-2.2 (protein excretion, 29.2 g/d). Kidney biK/Cr a years. The most common comorbidities present in these 39 are m Cl Na Diuretic ratio was seropositive for anti-PLA mmorevealed MN with staining for PLA2R, and the patienthypertension 2R autoantibodies. s mm opsy (35), cardiovascular disease (28), diabetes (25), chronic mmo Screen mm mo therapy respond tomm conservative and was treated with intravenous rituximab (2 doses of 1cerebrovascular g each). e ol/l Shel/ldid not lung disease (9), autoimmune disorders (7), and l/l mmo ol/l ol/l sm/ disease (4). The overall adverse eventfollowed rate is 17%. Several weeks after pregnant and was closely up Cardiac withoutprocedures l/l presentation, she was found to be 6 weeks kg have theprotein lowest event rates (9.4%), that are typically further immunosuppressive treatment. Proteinuria remained with excretion in thewhile 8- toprocedures 12-g/d range. lower risk, such as endoscopy, skin and soft tissue procedures, and were still detectable. At 38 weeks, a healthy baby girl was born, Circulating 1.932-anti-PLA2R levels declined but Furosemide interventional & catheter procedures have a high event rate (22.2%, 1 138 without proteinuria 14.8at birth Na or <10 341subsequent 6-month postnatal at her At comparable the time oftodelivery, themajor mother still 3.0 38 +++ 21.7%, &visit. 16.7%) that of other surgeries, (IgG1),orthopedic IgG3, and IgG4(16.7%). subclasses, although at intense had detectable circulating anti-PLA2R of immunoglobulin G1 including surgery This may reflect more found in management cord blood.in Potential reasons forsurgery. the Patients low2.8titers.23-Only 13trace amounts of IgG4 HCTZ+ anti-PLA2R werepreoperative those undergoing major 2 138 discrepancy between anti-PLA 55 63 2R450 undergoing procedures before HD have a lower event rate compared to levels in the maternal and fetal circulation are discussed. Hydroflumeth 3.0 33 30 those undergoing procedures Am J Kidney Dis. 67(5):775-778. ª 2016azide by the Foundation, Inc. post-HD (within 90 minutes) or on non+ National Kidney HD days (7.7% vs 16.92% & 17.91%, p < 0.05). Patients suffering cardiac arrest are more likely to have serum K+ values outside the Hypokalemia associated with renal K wasting is confirmed by 24 INDEX WORDS: Membranous nephropathy (MN); nephrotic syndrome; pregnancy; M-type phospholipase normal range (mode: 5.4 mEq/L, normal 3.5–5 mEq/L), A2 hour urine K greater than 25-30 meq/l or urine K/Cr of >13mmol/g. receptor (PLA autoantibody; placenta; Gour (Igstudy, G) subclass. 2R);vomiting Summary: In those undergoing postoperative HD have a Gitelman’s, Bartter’s, chronic and diuretic abuse rituximab; should be immunoglobulin lower risk of adverse events compared to those who have preoperative considered when hypotension is associated with hypokalemic metabolic HD or a procedure on a non-HD day, but those undergoing even minor alkalosis. Urine chloride can be variable with diuretic use and low in procedures and those with abnormal K+ may benefit from preoperative vomiting. Diuretic abuse should be ruled out before proceeding with evaluation and intervention to minimize complications. further testing patients for inheritedwith syndromes. regnant autoimmune disease may CASE REPORT
Pregnancy in a Patient With Primary Membranous Nephropathy and Circulating Anti-PLA R Antibodies: A Case Report
P
deliver newborns with a spectrum of clinical manifestations due to the transplacental passage of 258 circulating autoantibodies. Pregnant patients with GERMLINE VARIATION IN GENES KNOWN TO CAUSE lupus or myasthenia gravis NEPHROLITHIASIS can deliver babies with FAMILIAL CALCIUM OXALATE AND RISK 1,2 OF IDIOPATHIC,disease NON-FAMILIAL CALCIUM OXALATE corresponding in the neonate. Neonatal NEPHROLITHIASIS: Alexander S. Parker1,4, Michael G. Heckman2, 2 3 membranous (MN) not associated with Nancy D. Diehlnephropathy , Arta Palaj3,William E. Haley 1 Division of Epidemiology, Department of in Health Affiliations:infection congenital was first described 1990 and Sciences Research, 2Division of Biomedical Statistics and Informatics, 3 attributed to the passive transfer of maternal Department of Health Sciences Research, Division of Nephrology,antiMayo Clinic3Center forthan Individualized Department of Medicine, and 4antigens. bodies to putative renal More a decade Medicine, Mayo Clinic, 4 Jacksonville, FL later,Germline Debiec et al identified the first antigen involved alterations in certain genes are known to cause monogenic, of calcium oxalate nephrolithiasis (CaO-NL).(NEP), Whether a in familial such forms cases as neutral endopeptidase variation in these same genes affects risk of idiopathic (ie, non-familial) metalloprotease present on the surface of the podocyte CaO-NL remains poorly understood. We performed a pilot case-control andstudy involved thenucleotide proteolytic regulation vasoacevaluatingin single polymorphisms (SNP) inof7 familial CaO-NL genes (AGXT, GRHPR, CLCN5, OCRL1,aSLC3A1, SLC7A9, tiveand peptides. Debiec et al described mother with a APRT) and risk of idiopathic, non-familial CaO-NL. mutation preventing NEP expression who had formed We collected data and DNA on 280 Caucasian cases presenting with CaO-NL asantibodies well as 511 age/gender Caucasian controls with no anti-NEP due tomatched fetomaternal alloimmuhistory of any NL. Technicians genotyped 27 common SNPs in our 7 nization from a previous miscarriage; these antibodies genes of interest. We assessed single-variant associations with risk of CaO-NL using odds ratios (ORs) and 95% (CIs) were to cross the placenta andconfidence cause intervals subepithelial from logistic regression models adjusted for age, gender, and BMI. We deposits in the fetal kidney of a subsequent pregconsidered variants under additive, dominant and recessive models. Under a recessivephospholipase model, we noted preliminary evidence of(PLA decrease nancy. M-type A2 receptor 2R) in risk of CaO-NL for individuals with the G allele at rs12695032 in wasAGXT later identified as the major autoantigen for pri(OR:0.67, 95% CI 0.45–0.98; p=0.04). We observed evidence of 5 an increased risk of CaO-NL for the A allele at rs11084677 (SLC7A9) mary MN in adults. Little literature exists about under an additive model (OR:1.45, 95% CI 0.95–2.15; p=0.07), the C pregnancy outcomes in patients with nephrotic synallele at rs8191487 (APRT) under an additive and dominant model (OR: drome dueCI to primary MN, with noat rs34347941 data available 2.37, 95% 0.94–6.00; p=0.07), and the T allele (SLC7A9) under an additive and dominant model (OR: 1.91, 95% CI about pregnancy in PLA 2R-associated disease. We 0.95–3.85; p=0.09). present what we believe to beto cause the first known Germline variation in genes known familial CaO-NLcase may of play a role inin determining risk of non-familial If confirmedMN in pregnancy a patient with PLACaO-NL. R-associated 2 a larger study accounting for multiple testing, these data could be used whoto inform was more seropositive for anti-PLA R autoantibodies 2 efforts for CaO-NL. targeted screening and prevention throughout the course of her pregnancy. Am J Kidney Dis. 2016;67(5):A1-A118
A 39-year-old multiparous woman with morbid obesity presented for workup of severe nephrotic syndrome several months 260
before her current pregnancy. She had been treated for resistant HEIGHTS (HT) OF HEMODIALYSIS (HD) PATIENTS (PTS) hypertension andOUTCOMES: lower-extremity edema AFFECT THEIR RESULTS FROMduring THE the past year, but her proteinuria had been overlooked. At presentation, MONITORING DIALYSIS OUTCOMES (MONDO) INITIATIVE. serum S. Patel, A. level Topping, X. Ye, B. mg/dL Canaud, D. Marcelli, A. Grassmann, C. creatinine was 1.52 (corresponding to estimated Marelli, A. Guinsburg, X. Xu, A. Power, N. Duncan, J.2Kooman, F. van glomerular filtration rate of 46 mL/min/1.73 m as calculated by der Sande, L. A. Usvyat, Y. Wang, P. Kotanko, J. G. Raimann and the theMONDO isotope-dilution spectrometry –traceable 4-variable Initiative. Renalmass Research Institute, NYC, USA; FMC NA, MDRD [Modification of Diet Renal Germany, Disease] Imperial Study equaWaltham, USA; FMC EMEALA, BadinHomburg, College, London, UK; Maastricht University, Netherlands; Santaprotein tion); serum albumin level, 1.5 g/dL; and 24-hourUC urine Barbara, USA. excretion, 29.2 g. The kidney biopsy specimen revealed features Tall people have better outcomes in the general population. This typical of primary MN with additional strong staining for the relationship is inverted in HD patients (Shapiro CJASN 2015, Elsayed PLA2R antigen within immune deposits (Fig S1). Many of the JASN 2015).We investigated the relationship between height(ht) and subepithelial deposits were completely surrounded by new outcomes in male (M) and female (F) incident HD pts in this analysis basement membrane material of the international MONDO database.(Fig S2), and 35% of the Incident patients commencing HD between 01/2006 and 12/2010 were analyzed for outcomes during Year 2 and 3 after initiation. We 1 stratified all subjects into quintiles (Q) of the respective populationand DeFrom the Department of Medicine, Renal Section, 2 (Asia-Pacific North (NA) South America3Pediatrics, (SA), and Europe) partments of (AP), Obstetrics andandGynecology, and 4Paand analyzed using Medicine, Cox regression [adjusted for height Medical thology and outcomes Laboratory Boston University quintileBoston, (Q; reference Center, MA.Q1), age, BMI and DM] for database and gender. *We studied 21,958 patients (62±15 yrs old, 42% F, BMI 26±6 kg/m2, Current affiliation: Department of Internal Medicine, Division ht 1.7±0.1 m) and found an overall trend of increasing hazard ratio of ofdeath Nephrology, University School of F.Medicine, Salt (HR) for each increase inofhtUtah quintile in M and From Q1 to Q5 Lake City, thereUT. was no trend in the HR in F in the overall data, however in NA y [(HR 0.6 (95% CI 0.4 to 0.8)] we saw a decreasing trend and of HR with Current affiliation: Department of Obstetrics Gynecology, greater ht. In AP, an increasing trend of HR Washington, was in F from Q1 to 5 (Q5 Medstar Washington Hospital Center, DC. HR 1.7 (95% CI 0.8 to 3.5). Other databases had no clear trends. Q1 to Received June 29, 2015. Accepted in revised form October 27, Q5 showed an increasing trend in the HR in M in the overall data [Q5: 2015. Originally online December 29, 2015. 1.25 (95% CI 1.04 published to 1.51)], confirmed without significance in Europe Address to Laurence H.AP. Beck Jr, MD, PhD, and SA. Nocorrespondence discernible trends were seen in NA or In FSection, overall, greater ht is notAlbany associated increased of death, Renal X-504, 650 St,with Boston, MArisk 02118. E-mail: however the risk decreased in NA and increased in AP. Taller M are at [email protected] a� greater death. More investigation of dialysis treatment 2016risk byofthe National Kidney Foundation, Inc. parameters (not yet included) may give further insight. 0272-6386
http://dx.doi.org/10.1053/j.ajkd.2015.10.031 775 A83
Case Report 257
259
ADVERSE PERIOPERATIVE EVENTS IN CHRONIC HYPOKALEMIA: DO NOT FORGET DIURETIC ABUSE: Sangeeta Pal, Bharat Sachdeva, LSUHSC-Shreveport, LA, USA. HEMODIALYSIS PATIENTS: WHO IS AT HIGHEST RISK? Hypokalemia at times poses a clinical challenge and requires Nishi H Patel, Jesse Goldman, Drexel University College of Medicine, 2 meticulous history and investigations to find the cause. We present two Philadelphia, PA, USA cases of surreptitious diuretic abuse as cause of hypokalemia. Background: The data regarding preoperative risk 1assessment in 1, 1 Laith Al-Rabadi, MBBS, * Rivka Ayalon, MD, G.(HD) Bonegio, PhD, 30 year old female (Case 1) with bulimia nervosa (diagnosed at age chronicRamon hemodialysis patients isMD, inadequate, even though these 2,y 3 4 13 years) was referred for E. evaluation of hypokalemia. Medications patients are known to have a higher operative risk compared with a Jennifer Ballard, MD, Alan M. Fujii, MD, Joel M. Henderson, MD, PhD, included Amitriptyline, Ibuprofen & Potassium (K) and Magnesium 1 1 non-ESRD population. Our goal is to identify predictive factors of David MD,tenderness. and Laurence H. Beck Jr, MD, PhD supplements. Exam was benign, except J. for Salant, mild abdominal perioperative adverse events in HD patients. 36 year old female (Case 2) with hypertension (stopped medications 3 Methods: We retrospectively screened the records of 783 chronic HD years ago) was referred for hypokalemia for 4years. Medications inpatients in our institution and identified 236 non-emergent procedures There is little with membranous nephropathy (MN), included K supplements and information multivitamins.about pregnancy outcomes in patients performed in active stable patients in the year 2013. 39 of these had a Both denied use of any OTC with medication and labsautoantibodies showed event: cardiac arrest, hypotension & mean arterial (PLA2R), the major especially those circulating to M-typeperioperative phospholipase A2 receptor Uri pressure ≤ 65known mmHg,case symptomatic increase pregnancy in blood pressure autoantigen in primary MN. We present what we believe to be the first of successful in ≥ 25% of Urin ne Uri altered arrhythmia, hypoxia, or blood transfusion. MN. In thebaseline, year prior tomentation, pregnancy, the patient developed a 39-year-old woman with Uri PLA2R-associated S.H e C S.Na S.K Results: 23 of the 39 subjects are male and the mean age is 58.1±18.1 Os ne ne Urine g/dL), and proteinuria anasarca,CO3 hypoalbuminemia (albumin, 1.3-2.2 (protein excretion, 29.2 g/d). Kidney biK/Cr a years. The most common comorbidities present in these 39 are m Cl Na Diuretic ratio was seropositive for anti-PLA mmorevealed MN with staining for PLA2R, and the patienthypertension 2R autoantibodies. s mm opsy (35), cardiovascular disease (28), diabetes (25), chronic mmo Screen mm mo therapy respond tomm conservative and was treated with intravenous rituximab (2 doses of 1cerebrovascular g each). e ol/l Shel/ldid not lung disease (9), autoimmune disorders (7), and l/l mmo ol/l ol/l sm/ disease (4). The overall adverse eventfollowed rate is 17%. Several weeks after pregnant and was closely up Cardiac withoutprocedures l/l presentation, she was found to be 6 weeks kg have theprotein lowest event rates (9.4%), that are typically further immunosuppressive treatment. Proteinuria remained with excretion in thewhile 8- toprocedures 12-g/d range. lower risk, such as endoscopy, skin and soft tissue procedures, and were still detectable. At 38 weeks, a healthy baby girl was born, Circulating 1.932-anti-PLA2R levels declined but Furosemide interventional & catheter procedures have a high event rate (22.2%, 1 138 without proteinuria 14.8at birth Na or <10 341subsequent 6-month postnatal at her At comparable the time oftodelivery, themajor mother still 3.0 38 +++ 21.7%, &visit. 16.7%) that of other surgeries, (IgG1),orthopedic IgG3, and IgG4(16.7%). subclasses, although at intense had detectable circulating anti-PLA2R of immunoglobulin G1 including surgery This may reflect more found in management cord blood.in Potential reasons forsurgery. the Patients low2.8titers.23-Only 13trace amounts of IgG4 HCTZ+ anti-PLA2R werepreoperative those undergoing major 2 138 discrepancy between anti-PLA 55 63 2R450 undergoing procedures before HD have a lower event rate compared to levels in the maternal and fetal circulation are discussed. Hydroflumeth 3.0 33 30 those undergoing procedures Am J Kidney Dis. 67(5):775-778. ª 2016azide by the Foundation, Inc. post-HD (within 90 minutes) or on non+ National Kidney HD days (7.7% vs 16.92% & 17.91%, p < 0.05). Patients suffering cardiac arrest are more likely to have serum K+ values outside the Hypokalemia associated with renal K wasting is confirmed by 24 INDEX WORDS: Membranous nephropathy (MN); nephrotic syndrome; pregnancy; M-type phospholipase normal range (mode: 5.4 mEq/L, normal 3.5–5 mEq/L), A2 hour urine K greater than 25-30 meq/l or urine K/Cr of >13mmol/g. receptor (PLA autoantibody; placenta; Gour (Igstudy, G) subclass. 2R);vomiting Summary: In those undergoing postoperative HD have a Gitelman’s, Bartter’s, chronic and diuretic abuse rituximab; should be immunoglobulin lower risk of adverse events compared to those who have preoperative considered when hypotension is associated with hypokalemic metabolic HD or a procedure on a non-HD day, but those undergoing even minor alkalosis. Urine chloride can be variable with diuretic use and low in procedures and those with abnormal K+ may benefit from preoperative vomiting. Diuretic abuse should be ruled out before proceeding with evaluation and intervention to minimize complications. further testing patients for inheritedwith syndromes. regnant autoimmune disease may CASE REPORT
Pregnancy in a Patient With Primary Membranous Nephropathy and Circulating Anti-PLA R Antibodies: A Case Report
P
deliver newborns with a spectrum of clinical manifestations due to the transplacental passage of 258 circulating autoantibodies. Pregnant patients with GERMLINE VARIATION IN GENES KNOWN TO CAUSE lupus or myasthenia gravis NEPHROLITHIASIS can deliver babies with FAMILIAL CALCIUM OXALATE AND RISK 1,2 OF IDIOPATHIC,disease NON-FAMILIAL CALCIUM OXALATE corresponding in the neonate. Neonatal NEPHROLITHIASIS: Alexander S. Parker1,4, Michael G. Heckman2, 2 3 membranous (MN) not associated with Nancy D. Diehlnephropathy , Arta Palaj3,William E. Haley 1 Division of Epidemiology, Department of in Health Affiliations:infection congenital was first described 1990 and Sciences Research, 2Division of Biomedical Statistics and Informatics, 3 attributed to the passive transfer of maternal Department of Health Sciences Research, Division of Nephrology,antiMayo Clinic3Center forthan Individualized Department of Medicine, and 4antigens. bodies to putative renal More a decade Medicine, Mayo Clinic, 4 Jacksonville, FL later,Germline Debiec et al identified the first antigen involved alterations in certain genes are known to cause monogenic, of calcium oxalate nephrolithiasis (CaO-NL).(NEP), Whether a in familial such forms cases as neutral endopeptidase variation in these same genes affects risk of idiopathic (ie, non-familial) metalloprotease present on the surface of the podocyte CaO-NL remains poorly understood. We performed a pilot case-control andstudy involved thenucleotide proteolytic regulation vasoacevaluatingin single polymorphisms (SNP) inof7 familial CaO-NL genes (AGXT, GRHPR, CLCN5, OCRL1,aSLC3A1, SLC7A9, tiveand peptides. Debiec et al described mother with a APRT) and risk of idiopathic, non-familial CaO-NL. mutation preventing NEP expression who had formed We collected data and DNA on 280 Caucasian cases presenting with CaO-NL asantibodies well as 511 age/gender Caucasian controls with no anti-NEP due tomatched fetomaternal alloimmuhistory of any NL. Technicians genotyped 27 common SNPs in our 7 nization from a previous miscarriage; these antibodies genes of interest. We assessed single-variant associations with risk of CaO-NL using odds ratios (ORs) and 95% (CIs) were to cross the placenta andconfidence cause intervals subepithelial from logistic regression models adjusted for age, gender, and BMI. We deposits in the fetal kidney of a subsequent pregconsidered variants under additive, dominant and recessive models. Under a recessivephospholipase model, we noted preliminary evidence of(PLA decrease nancy. M-type A2 receptor 2R) in risk of CaO-NL for individuals with the G allele at rs12695032 in wasAGXT later identified as the major autoantigen for pri(OR:0.67, 95% CI 0.45–0.98; p=0.04). We observed evidence of 5 an increased risk of CaO-NL for the A allele at rs11084677 (SLC7A9) mary MN in adults. Little literature exists about under an additive model (OR:1.45, 95% CI 0.95–2.15; p=0.07), the C pregnancy outcomes in patients with nephrotic synallele at rs8191487 (APRT) under an additive and dominant model (OR: drome dueCI to primary MN, with noat rs34347941 data available 2.37, 95% 0.94–6.00; p=0.07), and the T allele (SLC7A9) under an additive and dominant model (OR: 1.91, 95% CI about pregnancy in PLA 2R-associated disease. We 0.95–3.85; p=0.09). present what we believe to beto cause the first known Germline variation in genes known familial CaO-NLcase may of play a role inin determining risk of non-familial If confirmedMN in pregnancy a patient with PLACaO-NL. R-associated 2 a larger study accounting for multiple testing, these data could be used whoto inform was more seropositive for anti-PLA R autoantibodies 2 efforts for CaO-NL. targeted screening and prevention throughout the course of her pregnancy. Am J Kidney Dis. 2016;67(5):A1-A118
A 39-year-old multiparous woman with morbid obesity presented for workup of severe nephrotic syndrome several months 260
before her current pregnancy. She had been treated for resistant HEIGHTS (HT) OF HEMODIALYSIS (HD) PATIENTS (PTS) hypertension andOUTCOMES: lower-extremity edema AFFECT THEIR RESULTS FROMduring THE the past year, but her proteinuria had been overlooked. At presentation, MONITORING DIALYSIS OUTCOMES (MONDO) INITIATIVE. serum S. Patel, A. level Topping, X. Ye, B. mg/dL Canaud, D. Marcelli, A. Grassmann, C. creatinine was 1.52 (corresponding to estimated Marelli, A. Guinsburg, X. Xu, A. Power, N. Duncan, J.2Kooman, F. van glomerular filtration rate of 46 mL/min/1.73 m as calculated by der Sande, L. A. Usvyat, Y. Wang, P. Kotanko, J. G. Raimann and the theMONDO isotope-dilution spectrometry –traceable 4-variable Initiative. Renalmass Research Institute, NYC, USA; FMC NA, MDRD [Modification of Diet Renal Germany, Disease] Imperial Study equaWaltham, USA; FMC EMEALA, BadinHomburg, College, London, UK; Maastricht University, Netherlands; Santaprotein tion); serum albumin level, 1.5 g/dL; and 24-hourUC urine Barbara, USA. excretion, 29.2 g. The kidney biopsy specimen revealed features Tall people have better outcomes in the general population. This typical of primary MN with additional strong staining for the relationship is inverted in HD patients (Shapiro CJASN 2015, Elsayed PLA2R antigen within immune deposits (Fig S1). Many of the JASN 2015).We investigated the relationship between height(ht) and subepithelial deposits were completely surrounded by new outcomes in male (M) and female (F) incident HD pts in this analysis basement membrane material of the international MONDO database.(Fig S2), and 35% of the Incident patients commencing HD between 01/2006 and 12/2010 were analyzed for outcomes during Year 2 and 3 after initiation. We 1 stratified all subjects into quintiles (Q) of the respective populationand DeFrom the Department of Medicine, Renal Section, 2 (Asia-Pacific North (NA) South America3Pediatrics, (SA), and Europe) partments of (AP), Obstetrics andandGynecology, and 4Paand analyzed using Medicine, Cox regression [adjusted for height Medical thology and outcomes Laboratory Boston University quintileBoston, (Q; reference Center, MA.Q1), age, BMI and DM] for database and gender. *We studied 21,958 patients (62±15 yrs old, 42% F, BMI 26±6 kg/m2, Current affiliation: Department of Internal Medicine, Division ht 1.7±0.1 m) and found an overall trend of increasing hazard ratio of ofdeath Nephrology, University School of F.Medicine, Salt (HR) for each increase inofhtUtah quintile in M and From Q1 to Q5 Lake City, thereUT. was no trend in the HR in F in the overall data, however in NA y [(HR 0.6 (95% CI 0.4 to 0.8)] we saw a decreasing trend and of HR with Current affiliation: Department of Obstetrics Gynecology, greater ht. In AP, an increasing trend of HR Washington, was in F from Q1 to 5 (Q5 Medstar Washington Hospital Center, DC. HR 1.7 (95% CI 0.8 to 3.5). Other databases had no clear trends. Q1 to Received June 29, 2015. Accepted in revised form October 27, Q5 showed an increasing trend in the HR in M in the overall data [Q5: 2015. Originally online December 29, 2015. 1.25 (95% CI 1.04 published to 1.51)], confirmed without significance in Europe Address to Laurence H.AP. Beck Jr, MD, PhD, and SA. Nocorrespondence discernible trends were seen in NA or In FSection, overall, greater ht is notAlbany associated increased of death, Renal X-504, 650 St,with Boston, MArisk 02118. E-mail: however the risk decreased in NA and increased in AP. Taller M are at [email protected] a� greater death. More investigation of dialysis treatment 2016risk byofthe National Kidney Foundation, Inc. parameters (not yet included) may give further insight. 0272-6386
http://dx.doi.org/10.1053/j.ajkd.2015.10.031 775 A83