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Immune complex glomerulonephritis in a patient with bartonella henselae endocarditis
TENTH ANNUAL CLINICAL NEPHROLOGY MEETING ABSTRACTS
17 IMMUNE COMPLEX GLOMERULONEPHRITIS 1N A PATIENT WITH BARTONELLA HENSELAE ENDOCARDITIS. Gerardo A Chica IlI, Patrick D Walker2, Margie A Scott2, Mary Jo Shaver 1. 1Division of Nephrology, 2Division of Pathology University of Arkansas for Medical Sciences and Central Arkansas Veterans Healthcare System, Little Rock, AR. Bartonetla species chronic infections including those associated with endocarditis is a well-known entity due to a fastidious gram-negative bacillus that often eludes cnimre isolation. The clinical manifestations of this disorder are varied with insidious onset ofnonspecific symptoms to a more serious illness. Bartonella henselae is known to be associated with cat-scratch disease, bacillary angiomntosis and peliosis hepatis in patients who are itnmtmocompromised, especially those with human immunodeficiency virus disease. Cases of Bartonella endocarditJs are most frequently due to chronic B. quintana infection, occurring primarily in homeless persons. Here we report eu a 65-year-old Caucasian male patient who was referred to the renal service for evaluation of persistent hematuria and an elevated creatinine of 2.0 mg/dL. He had a past history of rheumatic heart disease and on serological evaluation was noted to have a low C4 level. A renal biopsy was consistent with an immune complex mediated glomemlonephritis. With his history of rheumatic heart disease endocarditis was investigated. All blood cultures were negative and echocardiogram showed valvular deformation, but no evidence of vegetations. Although a firm diagnosis of endocarditis was never made, over a period of 9 months the patient continued to deteriorate. H e developed an ischemic stroke, worsening renal ftmction requiring dialysis, septic shock related to central line infection and subsequently died. Endocardids was finally diagnosed by echocardiogram (TEE) but only after he had been on dialysis with a central line related infection. At autopsy Bartonella henselae endocarditis was suspected histologically and confn'med using polymerase chain reaction and southern bl0t techniques, This appears to be the first case of Bartonella eudocarditis in the literature in which renal manifestations preceded any cardiac evidence of involvement. No other etiology of immune complex glomemlonephritis was identified.
18 REDUCING HYPERPARATHYROIDISM IN AFRICANAMERICAN HEMODIALYSIS PATIENTS USING PARICALCITOL, P. Crawford, M. Sobrero, S. Shott, A. Deering, T. Young. FMC Neomedica, Evergreen Park, Illinois, USA. Secondary prevention of renal bone disease in a 9 0 % African-American hemodialysis population was the goal of this prospective study. Reduction of high parathyroid hormone (PTH) levels (> 200 pg/ml) without raising patients' calcium or phosPhorus levels was sought by using paricalcitol, a vitamin D analog. Gender and weight differences were also analyzed. One hundred ten patients from two urban hemodialysis units participated. Patients with PTH levels > 200 pg/ml and calcium X phosphorus products < 72mg/dl were selected. PTH levels were monitored monthly; calcium and phosphorus levels were measured twicepar mont h. Initial paricalcitol dose was based on each patient's PTH level and estimated dry weight (EDW). Data analysis revealed that paricalcitol was -very effective in reducing high PTHlevels in African-American patients (p < .0005). Patients with higher EDWs had more rapid reduction of PTH than those with lower EDWs. No age or gender differences were noted. There was a transient increase in calciumlevels (p .= .006) and no change in phosphorus levels (p = .51). Areas for further study should include: patients with mildly elevated PTH who may respond better to calcitriol; dosingparica!citol more aggressively early to reduce very high PTH levels: bone tests and cost-effectiveness studies to compare calcitriol to paricalcitol in preventing renal osteodystrophy.
A15
19 DIFFICULTIES 1N ANEMIA MANAGEMENT OF ESRD DIALYSIS PATIENTS. ILUMINADO CRUZ, LENA CAUTON, AND ADRIAN HOSTEN. HOWARD UN/VERSITY HOSPITAL. WASHINTON, DC. The availability of Epo and IV Fe has significantly improved the management of anemia of ESRD dialysis patients(pts). It is reoommended that HbFrlct be maintained at 11-12/33%-36% level. This study deals with our experience in the management ofanemla in our dialysis unit. Method: CBC was monitored monthly and Fe, ~ransferrin, and ferritin quarterly. Epo was given IV or SQ every dialysis and doses adjusted to maintain target level. IV Fe was given prn to maintain h-ansferrin saturation(Tsar) > 20%. Resuks: There were 164 pts followed for a 9 month(mo) period of which 104 pts failed to maintain the target Hct [16 pts(10%) for 1 too, 39(23%) for 2 too, 50(31%) for 3 or >]. Monthly, the # of pts who were trouble to maintain the target Hot ranged from 27% to 46%.Low Hct was seen in 34(83%) of 41 new ESRD pts. Low Tsat was present in 34 l~S mad high Tsar(> 50%) in 8 pts. Epo dose ranged from 18 -676 U/kg/D with a mean dose of 101 U/kg. Co-morbid eonditons include: malignancies, bleeding, sickle cell, CHF, severe angina, recent surgery, high PTH and recurrent hospitalization. Conclusions: 1. Majority of pts failed to consistently maintain the targe~ Hot. 2. Multiple causes are responsible for this failure; major ones are Pe deficiency, co-morbid factors and Epo dosing. 3. A significant number of new ESRD pts are anemic with associated Fe deficiency.
2O SUCCESSFUL REDUCTION OF ANTI-HYPERTENSIVES USING BIOIMPEDANCE SPECTROSCOPY TO DETERMINE "DRY WEIGHT" IN CHRONIC DIALYSIS PATIENTS.
Douglass T. Domoto, and Marilyn E. Weindel. St. Louis, MO. Control of blood pressure in hemodialysis patients still requires the use of multiple anti-hypertensives. Reducing dry weight can also reduce mean blood pressure. However, determining dry weight has been a clinical judgment at best. Bioimpedance spectroscopy was used to determine total body water, and the intracellular and extracellular distribution of water, in 2i chronic hemodialysis patients. Patients were studied at least two times between 3 and 12 months. Efforts were made to reduce post dialysis dry weight by increased ultrafiltratiom The dose and number of anti-hypertensive medications were reduced in most patients as dry weight was reduced. Blood pressures were measured for 24 hours after dialysis with an ambulatory blood pressure monitor. Of the 21 patients wh o completed the study, 11 were mate and t0 females. Post dialysis weights were reduced in i0 patients, remained unchanged within one kilogram in 4, apA increased in 6 patients. Anti-hypertensives were reduced or stopped in 16 patients and remained unchanged in 3. Blood pressure classifications remained stable or improved in the 24 hours post dialysis as determined by ambulatory blood pressure monitoring in all patient~. Total body water and/or extracellnlar water decreased in 12 of t6 patients with reduced medications. Intraeellular fluid varied presumably reflecting body mass. However, when extracellniar fluid vohmle was factored by body mass index, n o correlation to blood pressure or number of antihypertensives was noted. We conclude that t) Fluid removal is important in control of bIood pressure and reduction of anti-hypertensives. 2) Bioimpedance is helpfnl in determining fluid distribution. 3) However, excess fluid alone is not the only mechanism f o r hypertension in hemodiaiysis patients.
17 IMMUNE COMPLEX GLOMERULONEPHRITIS 1N A PATIENT WITH BARTONELLA HENSELAE ENDOCARDITIS. Gerardo A Chica IlI, Patrick D Walker2, Margie A Scott2, Mary Jo Shaver 1. 1Division of Nephrology, 2Division of Pathology University of Arkansas for Medical Sciences and Central Arkansas Veterans Healthcare System, Little Rock, AR. Bartonetla species chronic infections including those associated with endocarditis is a well-known entity due to a fastidious gram-negative bacillus that often eludes cnimre isolation. The clinical manifestations of this disorder are varied with insidious onset ofnonspecific symptoms to a more serious illness. Bartonella henselae is known to be associated with cat-scratch disease, bacillary angiomntosis and peliosis hepatis in patients who are itnmtmocompromised, especially those with human immunodeficiency virus disease. Cases of Bartonella endocarditJs are most frequently due to chronic B. quintana infection, occurring primarily in homeless persons. Here we report eu a 65-year-old Caucasian male patient who was referred to the renal service for evaluation of persistent hematuria and an elevated creatinine of 2.0 mg/dL. He had a past history of rheumatic heart disease and on serological evaluation was noted to have a low C4 level. A renal biopsy was consistent with an immune complex mediated glomemlonephritis. With his history of rheumatic heart disease endocarditis was investigated. All blood cultures were negative and echocardiogram showed valvular deformation, but no evidence of vegetations. Although a firm diagnosis of endocarditis was never made, over a period of 9 months the patient continued to deteriorate. H e developed an ischemic stroke, worsening renal ftmction requiring dialysis, septic shock related to central line infection and subsequently died. Endocardids was finally diagnosed by echocardiogram (TEE) but only after he had been on dialysis with a central line related infection. At autopsy Bartonella henselae endocarditis was suspected histologically and confn'med using polymerase chain reaction and southern bl0t techniques, This appears to be the first case of Bartonella eudocarditis in the literature in which renal manifestations preceded any cardiac evidence of involvement. No other etiology of immune complex glomemlonephritis was identified.
18 REDUCING HYPERPARATHYROIDISM IN AFRICANAMERICAN HEMODIALYSIS PATIENTS USING PARICALCITOL, P. Crawford, M. Sobrero, S. Shott, A. Deering, T. Young. FMC Neomedica, Evergreen Park, Illinois, USA. Secondary prevention of renal bone disease in a 9 0 % African-American hemodialysis population was the goal of this prospective study. Reduction of high parathyroid hormone (PTH) levels (> 200 pg/ml) without raising patients' calcium or phosPhorus levels was sought by using paricalcitol, a vitamin D analog. Gender and weight differences were also analyzed. One hundred ten patients from two urban hemodialysis units participated. Patients with PTH levels > 200 pg/ml and calcium X phosphorus products < 72mg/dl were selected. PTH levels were monitored monthly; calcium and phosphorus levels were measured twicepar mont h. Initial paricalcitol dose was based on each patient's PTH level and estimated dry weight (EDW). Data analysis revealed that paricalcitol was -very effective in reducing high PTHlevels in African-American patients (p < .0005). Patients with higher EDWs had more rapid reduction of PTH than those with lower EDWs. No age or gender differences were noted. There was a transient increase in calciumlevels (p .= .006) and no change in phosphorus levels (p = .51). Areas for further study should include: patients with mildly elevated PTH who may respond better to calcitriol; dosingparica!citol more aggressively early to reduce very high PTH levels: bone tests and cost-effectiveness studies to compare calcitriol to paricalcitol in preventing renal osteodystrophy.
A15
19 DIFFICULTIES 1N ANEMIA MANAGEMENT OF ESRD DIALYSIS PATIENTS. ILUMINADO CRUZ, LENA CAUTON, AND ADRIAN HOSTEN. HOWARD UN/VERSITY HOSPITAL. WASHINTON, DC. The availability of Epo and IV Fe has significantly improved the management of anemia of ESRD dialysis patients(pts). It is reoommended that HbFrlct be maintained at 11-12/33%-36% level. This study deals with our experience in the management ofanemla in our dialysis unit. Method: CBC was monitored monthly and Fe, ~ransferrin, and ferritin quarterly. Epo was given IV or SQ every dialysis and doses adjusted to maintain target level. IV Fe was given prn to maintain h-ansferrin saturation(Tsar) > 20%. Resuks: There were 164 pts followed for a 9 month(mo) period of which 104 pts failed to maintain the target Hct [16 pts(10%) for 1 too, 39(23%) for 2 too, 50(31%) for 3 or >]. Monthly, the # of pts who were trouble to maintain the target Hot ranged from 27% to 46%.Low Hct was seen in 34(83%) of 41 new ESRD pts. Low Tsat was present in 34 l~S mad high Tsar(> 50%) in 8 pts. Epo dose ranged from 18 -676 U/kg/D with a mean dose of 101 U/kg. Co-morbid eonditons include: malignancies, bleeding, sickle cell, CHF, severe angina, recent surgery, high PTH and recurrent hospitalization. Conclusions: 1. Majority of pts failed to consistently maintain the targe~ Hot. 2. Multiple causes are responsible for this failure; major ones are Pe deficiency, co-morbid factors and Epo dosing. 3. A significant number of new ESRD pts are anemic with associated Fe deficiency.
2O SUCCESSFUL REDUCTION OF ANTI-HYPERTENSIVES USING BIOIMPEDANCE SPECTROSCOPY TO DETERMINE "DRY WEIGHT" IN CHRONIC DIALYSIS PATIENTS.
Douglass T. Domoto, and Marilyn E. Weindel. St. Louis, MO. Control of blood pressure in hemodialysis patients still requires the use of multiple anti-hypertensives. Reducing dry weight can also reduce mean blood pressure. However, determining dry weight has been a clinical judgment at best. Bioimpedance spectroscopy was used to determine total body water, and the intracellular and extracellular distribution of water, in 2i chronic hemodialysis patients. Patients were studied at least two times between 3 and 12 months. Efforts were made to reduce post dialysis dry weight by increased ultrafiltratiom The dose and number of anti-hypertensive medications were reduced in most patients as dry weight was reduced. Blood pressures were measured for 24 hours after dialysis with an ambulatory blood pressure monitor. Of the 21 patients wh o completed the study, 11 were mate and t0 females. Post dialysis weights were reduced in i0 patients, remained unchanged within one kilogram in 4, apA increased in 6 patients. Anti-hypertensives were reduced or stopped in 16 patients and remained unchanged in 3. Blood pressure classifications remained stable or improved in the 24 hours post dialysis as determined by ambulatory blood pressure monitoring in all patient~. Total body water and/or extracellnlar water decreased in 12 of t6 patients with reduced medications. Intraeellular fluid varied presumably reflecting body mass. However, when extracellniar fluid vohmle was factored by body mass index, n o correlation to blood pressure or number of antihypertensives was noted. We conclude that t) Fluid removal is important in control of bIood pressure and reduction of anti-hypertensives. 2) Bioimpedance is helpfnl in determining fluid distribution. 3) However, excess fluid alone is not the only mechanism f o r hypertension in hemodiaiysis patients.