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ANESTHESIA FOR LAPAROSCOPIC INSERTION OF PERITONEAL DIALYSIS CATHETER
NKF 2014 Spring Clinical Meetings Abstracts
221 IMMUNOFLUORESCENCE BASED RE-CLASSIFICATION OF MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS, DOES IT MAKE A DIFFERENCE? Fanna Liu, Jiwan K Thapa, Surafel Gebreselassie, Ziad Zaky. Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA Immunofluorescence (IF) based classification has been proposed following recent advances in the role of the alternative complement pathway in the etiology and pathogenesis of membranoproliferative glomerulonephritis (MPGN). We retrospectively reviewed our data base for patients with biopsy proven MPGN. The pathological findings were re-classified based on the recent IF based classification in which C3 only positive cases were grouped under C3 glomerulopathy. 42 adult patients who met the above criteria were included. 21/42 (50%) were female and majority 27/42 (64.3%) were Caucasians with mean age 55.92±17.29 years. At the time of biopsy, serum creatinine was 3.00 ±1.86 mg/dL, serum albumin 2.93±0.67 mg/dL); serum complement C3 was 82.57 ±43.14 mg/dL. All patients had some degree of proteinuria but 18/42 (42.8%) of patients had nephrotic range proteinuria (≥3.5g/24h). Six patients had ≥8 g/24h of proteinuria. In our study 37/42 (88.0%) of the patients had either microscopic or gross hematuria at the time of renal biopsy. Based on the old light microscopy classification, 37/42 (92%) had MPGN type I, 1 patient with MPGN type II and 4 patients with MPGN type III. 10/39 (25.6%) had hepatitis C and 4/39 (10%) had Lupus. We reclassified all the 42 patients using IF. We found only 1 patient with C3 glomerulopathy. The patient was originally reported as MPGN II or Dense Deposit Disease but on further evaluation had multiple myeloma. Although IF is a key part in the evaluation of MPGN pattern of injury, in our cohort of the adult patients, using IF didn’t significantly change the classification. In our opinion, the new IF based classification of MPGN needs to be evaluated in a large data base before uniformly accepted.
222 PATENCY AND COMPLICATIONS OF TRANSLUMBAR DIALYSIS CATHETERS Fanna Liu, Robert Heyka, Susana Arrigain, Stacy Bennett, Gordon McLennan, Sankar D Navaneethan. Radiology and Nephrology, Cleveland Clinic, Cleveland, Ohio, USA. We report our experience with translumbar tunneled dialysis catheters (TLDC) for hemodialysis access in those patients who had exhausted conventional options such as arteriovenous fistula, graft and upper and lower extremity dialysis catheters for longterm dialysis. There were 87 TLDC inserted in 28 patients (M: F, 0.5) with 39 primary insertions and 48 exchanges. Mean age at insertion was 53.6 ± 13.6 years with 21 African Americans and 7 whites undergoing TLDC insertions from 2006 to2013. Patients were on dialysis for 7.6 ± 5.7 years with diabetes and glomerulonephritis being the leading causes of ESRD. Superior Vena Cava syndrome was present in 85.7% of patients at the time of TLDC insertion. All TLDC insertions were technically successful with good blood flows during dialysis (>300 ml/min) and no immediate complications (major bleeding or clotting) were noted. The number of days in place for the first catheter, after reinsertion and the total site interval per patient were 110 + 138, 124 + 131 and 372 + 462 days. The catheter patency rate at 3, 6 and 12 months were 36%, 21% and 7% respectively. The most common reasons for catheter exchange were catheter related sepsis (26/87 insertions), mechanical complications (17/87 insertions), and poor blood flow (20/87 insertions). The infection and catheter malfunction rate were 2.5 and 1.6 per 1000 catheter days respectively. Four patients underwent permanent dialysis access placement during the study period. This data suggest that TLDC might serve as a safe, temporary alternate access for dialysis patients who exhausted conventional vascular access. Future studies might compare its efficacy and safety to other vascular access.
A74
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224 IGG4-RELATED TUBULOINTERSTITIAL NEPHRITIS MASQUERADING AS CHRONIC KIDNEY DISEASE Nhan Luu, MD, Darlene Vigil, MD, Konstantin N. Konstantinov, MD, PhD, Antonios H. Tzamaloukas, MD, MACP, and Yijuan Sun, MD. Department of Medicine, Raymond G. Murphy VA Medical Center and University of New Mexico School of Medicine, Albuquerque, New Mexico IgG4-related disease represents a recently recognized group with dense lymphoplasmacytic infiltrates rich in IgG4-positive plasma cells, storiform fibrosis, and elevated serum IgG4 concentration. The low frequency makes IgG4-related renal disease a diagnostic challenge. An 82-year-old male with history of chronic kidney disease secondary to hypertensive nephrosclerosis developed over six months worsening renal function with serum creatinine rising to 2.83mg/dL, from baseline values of 1.54-1.73mg/dL, and no proteinuria or hematuria. Renal ultrasound was unremarkable and urine microscopy disclosed granular casts. Chest x-ray was normal. Serology disclosed elevated levels of serum IgG and IgE and reduced C3 and C4 levels. Renal biopsy disclosed severe immune complex-mediated interstitial nephritis, with IgG4 positive plasma cell-rich infiltrate and tubular basement membrane deposits. Serum creatinine improved from 2.83 to 1.91 mg/dL after 2 weeks and to 1.80mg/dL after six weeks of prednisone. Serum IgG4 level decreased from 340 to 165 mg/dL. This case illustrates the potential for IgG4-related tubulointerstitial nephritis to manifest exclusively with a persistent elevation of serum creatinine. Although decline in renal function without proteinuria or hematuria is most commonly related to nephrosenescence and nephrosclerosis among elderly patients, a rapid and persistent worsening of the renal function warrants renal biopsy for diagnosing rare renal diseases. Recognition of IgG4-related tubulointerstitial nephritis is critical for institution of appropriate therapy and salvage of renal function.
Am J Kidney Dis. 2014;63(5):A1-A121
221 IMMUNOFLUORESCENCE BASED RE-CLASSIFICATION OF MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS, DOES IT MAKE A DIFFERENCE? Fanna Liu, Jiwan K Thapa, Surafel Gebreselassie, Ziad Zaky. Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA Immunofluorescence (IF) based classification has been proposed following recent advances in the role of the alternative complement pathway in the etiology and pathogenesis of membranoproliferative glomerulonephritis (MPGN). We retrospectively reviewed our data base for patients with biopsy proven MPGN. The pathological findings were re-classified based on the recent IF based classification in which C3 only positive cases were grouped under C3 glomerulopathy. 42 adult patients who met the above criteria were included. 21/42 (50%) were female and majority 27/42 (64.3%) were Caucasians with mean age 55.92±17.29 years. At the time of biopsy, serum creatinine was 3.00 ±1.86 mg/dL, serum albumin 2.93±0.67 mg/dL); serum complement C3 was 82.57 ±43.14 mg/dL. All patients had some degree of proteinuria but 18/42 (42.8%) of patients had nephrotic range proteinuria (≥3.5g/24h). Six patients had ≥8 g/24h of proteinuria. In our study 37/42 (88.0%) of the patients had either microscopic or gross hematuria at the time of renal biopsy. Based on the old light microscopy classification, 37/42 (92%) had MPGN type I, 1 patient with MPGN type II and 4 patients with MPGN type III. 10/39 (25.6%) had hepatitis C and 4/39 (10%) had Lupus. We reclassified all the 42 patients using IF. We found only 1 patient with C3 glomerulopathy. The patient was originally reported as MPGN II or Dense Deposit Disease but on further evaluation had multiple myeloma. Although IF is a key part in the evaluation of MPGN pattern of injury, in our cohort of the adult patients, using IF didn’t significantly change the classification. In our opinion, the new IF based classification of MPGN needs to be evaluated in a large data base before uniformly accepted.
222 PATENCY AND COMPLICATIONS OF TRANSLUMBAR DIALYSIS CATHETERS Fanna Liu, Robert Heyka, Susana Arrigain, Stacy Bennett, Gordon McLennan, Sankar D Navaneethan. Radiology and Nephrology, Cleveland Clinic, Cleveland, Ohio, USA. We report our experience with translumbar tunneled dialysis catheters (TLDC) for hemodialysis access in those patients who had exhausted conventional options such as arteriovenous fistula, graft and upper and lower extremity dialysis catheters for longterm dialysis. There were 87 TLDC inserted in 28 patients (M: F, 0.5) with 39 primary insertions and 48 exchanges. Mean age at insertion was 53.6 ± 13.6 years with 21 African Americans and 7 whites undergoing TLDC insertions from 2006 to2013. Patients were on dialysis for 7.6 ± 5.7 years with diabetes and glomerulonephritis being the leading causes of ESRD. Superior Vena Cava syndrome was present in 85.7% of patients at the time of TLDC insertion. All TLDC insertions were technically successful with good blood flows during dialysis (>300 ml/min) and no immediate complications (major bleeding or clotting) were noted. The number of days in place for the first catheter, after reinsertion and the total site interval per patient were 110 + 138, 124 + 131 and 372 + 462 days. The catheter patency rate at 3, 6 and 12 months were 36%, 21% and 7% respectively. The most common reasons for catheter exchange were catheter related sepsis (26/87 insertions), mechanical complications (17/87 insertions), and poor blood flow (20/87 insertions). The infection and catheter malfunction rate were 2.5 and 1.6 per 1000 catheter days respectively. Four patients underwent permanent dialysis access placement during the study period. This data suggest that TLDC might serve as a safe, temporary alternate access for dialysis patients who exhausted conventional vascular access. Future studies might compare its efficacy and safety to other vascular access.
A74
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224 IGG4-RELATED TUBULOINTERSTITIAL NEPHRITIS MASQUERADING AS CHRONIC KIDNEY DISEASE Nhan Luu, MD, Darlene Vigil, MD, Konstantin N. Konstantinov, MD, PhD, Antonios H. Tzamaloukas, MD, MACP, and Yijuan Sun, MD. Department of Medicine, Raymond G. Murphy VA Medical Center and University of New Mexico School of Medicine, Albuquerque, New Mexico IgG4-related disease represents a recently recognized group with dense lymphoplasmacytic infiltrates rich in IgG4-positive plasma cells, storiform fibrosis, and elevated serum IgG4 concentration. The low frequency makes IgG4-related renal disease a diagnostic challenge. An 82-year-old male with history of chronic kidney disease secondary to hypertensive nephrosclerosis developed over six months worsening renal function with serum creatinine rising to 2.83mg/dL, from baseline values of 1.54-1.73mg/dL, and no proteinuria or hematuria. Renal ultrasound was unremarkable and urine microscopy disclosed granular casts. Chest x-ray was normal. Serology disclosed elevated levels of serum IgG and IgE and reduced C3 and C4 levels. Renal biopsy disclosed severe immune complex-mediated interstitial nephritis, with IgG4 positive plasma cell-rich infiltrate and tubular basement membrane deposits. Serum creatinine improved from 2.83 to 1.91 mg/dL after 2 weeks and to 1.80mg/dL after six weeks of prednisone. Serum IgG4 level decreased from 340 to 165 mg/dL. This case illustrates the potential for IgG4-related tubulointerstitial nephritis to manifest exclusively with a persistent elevation of serum creatinine. Although decline in renal function without proteinuria or hematuria is most commonly related to nephrosenescence and nephrosclerosis among elderly patients, a rapid and persistent worsening of the renal function warrants renal biopsy for diagnosing rare renal diseases. Recognition of IgG4-related tubulointerstitial nephritis is critical for institution of appropriate therapy and salvage of renal function.
Am J Kidney Dis. 2014;63(5):A1-A121