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PAGE KIDNEY - A RARE CAUSE OF ACCELERATED HYPERTENSION
NKF 2015 Spring Clinical Meetings Abstracts
145 BIO-IMPEDANCE IN PERITONEAL DIALYSIS: CONTROL OVER HYPER HYDRATION AND BLOOD PRESSURE Koraichi Zakariae, Gonzalez F., Soria J.J, Clavijo F. C.H. Torrecardenas, Almeria. Spain BACKGROUND: Spectroscopic multifrequency bioimpedance (BIS) is a noninvasive, inexpensive and easy to use technique to analyze body composition and hydration status accurately and objectively, complementing clinical evaluation for better control of comorbidities own patients on renal replacement therapy are as overhydration and hypertension. DESIGN: A retrospective descriptive study was conducted. 55 patients on peritoneal dialysis (PD) were included with 10 months follow up. Using BIS Monitor (BCM Fresenius) was determined every two months: state of hydration, fluid overload in liters (OHL) considered OHL>1.5L, body mass index (BMI), fat mass index (FTI) and adipose tissue mass (ATM). Furthermore measures blood pressure (BP) and the number of prescribed antihypertensive drugs. 72% were male and 28% female. The mean age was 56 years. 89% had a history of hypertension, 70.9% showed BP at the beginning of study above 140/80 mmHg. The mean average BP was 147/ 87 mmHg, The mean BMI was 27 ± 3.6 kg/m2 and 38.2% had OHL> 1.5 L. RESULTS: Patients with BP> 140/80 mmHg had higher ATM (37.1 ± 13 kg; p=0.039). A positive correlation between SBP values and OHL(p=0.004,R=0.387) was observed. The differences between the SBP of overhydrated patients (OHL>1.5L; SBP=157 ±23.8 mmHg) and normohydrated, SBP=141±19.5 mmHg). (p=0.010). At 10 months follow-up using BIS, a drop in the blood pressure (of 5 mmHg) and the percentage of patients overhydrated (17%), was observed. Reduction in the number of antihypertensive drugs (2.5 to 2 (p=0.013)). The correlation between TAS and OHL figures stood at 10 months follow-up (R=0.387; p=0.038). CONCLUSIONS - Using BIS allowed us to more accurately estimate the state of hydration in comparison with classical clinical markers, getting reduce fluid overload - Give individualized dietary advice and distinguish patients with volume-dependent hypertension - Reduce the number of antihypertensive drugs used. - Fluid overload was associated with higher SBP. - Patients with hypertension had greater FTI.
146 PAGE KIDNEY-A RARE CAUSE OF ACCELERATED HYPERTENSION: A Hayas Haseer Koya, Roshni Radhakrishna, Dona Varghese, Dinesh John, Tanya George. SUNY Upstate Medical University, Syracuse, NY, USA Accelerated hypertension is a medical emergency requiring immediate management. We describe a rare cause of accelerated hypertension secondary to extra renal compression, otherwise known as page kidney. 73 year old male with no significant past medical history presented with 3 day history of left flank pain. On evaluation he had acute anemia and accelerated hypertension with blood pressures over 200/100. Treatment was initiated with intravenous antihypertensives for immediate blood pressure control and blood transfusions for anemia. Renal artery stenosis was ruled out by ultrasound Doppler. Abdominal CT revealed a large left renal subcapsular hematoma with retroperitoneal extension. In the absence of any identifiable traumatic or non-traumatic causes, a diagnosis of page kidney due to spontaneous subcapsular hematoma was made. Patient was started on oral ACE inhibitor to control hypertension. He underwent renal angioembolization with subsequent reduction in size of hematoma and improvement in blood pressures within 48 to 72 hours. Page kidney (first described by Page in 1939) is a rare cause of hypertension caused by activation of renin angiotensin axis due to renal hypoperfusion and microvascular ischemia, resulting from extrinsic compression of kidneys. Subcapsular or perinephric hematoma due to various etiologies including blunt trauma, tumor, cystic lesions and renal biopsies can lead to page kidney. Diagnostic studies include CT, MRA, or US Doppler. Initial treatment is medical-ACE inhibitors or ARB to control blood pressure. In resistant cases surgical options include angioembolization (preferred in cases due to hematoma), percutaneous drainage or laparoscopic decortication. We reiterate the need for a high index of suspicion for Page kidney in patients presenting with resistant hypertension with associated abdominal symptoms and anemia.
Am J Kidney Dis. 2015;65(4):A1-A93
147 GEMCITABINE INDUCED THROMBOTIC MICROANGIOPATHY: ROLE OF ECULIZUMAB Abhishek Kumar, Yogesh Sanghvi, Sarika Deshmukh, Satyarth Kulshrestha, Sarat Kuppachi, University of Iowa, Iowa City, IA, USA Thrombotic microangiopathy (TMA) syndromes are a group of disorders characterized by microangiopathic hemolytic anemia, thrombocytopenia and organ injury. Gemcitabine (Gem) associated TMA is reported in 0.03-1.3% of patients, but mechanism is not known. Response to plasmapheresis (PP) is disappointing. We describe successful treatment of gemcitabine associated TMA with eculizumab in this case report. Patient Age Cancer Gem TMA Response to (yr) dose criteria Rx #1 68 Pancreas 23 g/m2 Hapto <10 PP x0 Schisto 3+ EculizumabPlt 44k/m3 9 doses- cr Hb 6.5 g/dl at 2.5 Cr 5.4from 0.8 #2
49
Cholangiocarcinoma
16.9g/m2
Hapto <10 Schisto 3+ Plt 79k/m3 Hb 5.1g/dl Cr 3.1 from 0.7
PPx3 -no response Eculizumab1 dose- Plt upto 300k, Cr at 2.7,Hb 8.5
Conclusions: Disappointing response to PP has been described, suggesting no role of a circulating factor. Response to eculizumab suggests underlying complement dysregulation in patients who get TMA with Gem. Gem may be a second-hit. This explains risks of <1% in exposed patients. Reference: Leal F, Macedo LT, Carvalheira JB, Gemcitabine-related thrombotic microangiopathy: a single-centre retrospective series. J Chemother 2014 Jun;26(3):169-72.
148 A RARE CASE OF PERITONITIS: Pooja Kumari, Aarti Narayan, Jiwan Thapa, Marshfield Clinic, WI, USA Infectious peritonitis carries significant morbidity and mortality and frequently leads to discontinuation of peritoneal dialysis (PD). We report a case of PD associated peritonitis caused by rare bacteria Achromobacter xyloxidans that required removal of PD catheter. CASE A 65 year old man with ESRD due to membranoproliferative glomerulonephritis on continuous cycler PD for one year presented with abdominal pain. Culture of cloudy peritoneal fluid with a high cell count of 3400/ml grew A.xyloxidans sensitive to ceftazidime. 2weeks IP ceftazidime resulted in improvement but discontinuation was followed by abdominal pain, fever and cloudy peritoneal fluid within 4days. Exit site appeared normal and PD fluid showed total nucleated cells of 5431/ml with 86% neutrophils. Culture again grew A.xyloxidans, still sensitive to ceftazidime and quinolones. Blood culture was negative. He was retreated with IP ceftazidime but did not respond over next 4 days. The PD catheter was removed and patient was switched to hemodialysis. Antibiotic was switched to intravenous ciprofloxacin with dramatic improvement. DISSCUSSION Achromobacter is a gram negative rod that inhabits aquatic environments and is rarely isolated from the human gastrointestinal tract and ear canal. It rarely causes infections, except in immunocompromised hosts. It is an exceedinlgy rare cause of PD peritonitis and there are no clear guidelines in the literature about treatment or catheter care. Review of the literature, mostly limited to case reports, suggests frequent antibiotic resistance and often necessitating removal of catheter and switch of dialysis modality. Our patient was not on immunosuppressants. Despite apparent sensitivity in vitro, the infection did not respond to antibiotic treatment ultimately leading to catheter removal and termination of PD. Our knowledge regarding the evolution, treatment, and catheter care and host risk factors for Achromobacter peritonitis remains very limited. Our own experience and documented reports suggest that Achromobacter peritonitis is extremely resistant to usual treatment despite apparent in vitro sensitivity and early catheter removal is usually warranted to adequately treat the infection.
A51
145 BIO-IMPEDANCE IN PERITONEAL DIALYSIS: CONTROL OVER HYPER HYDRATION AND BLOOD PRESSURE Koraichi Zakariae, Gonzalez F., Soria J.J, Clavijo F. C.H. Torrecardenas, Almeria. Spain BACKGROUND: Spectroscopic multifrequency bioimpedance (BIS) is a noninvasive, inexpensive and easy to use technique to analyze body composition and hydration status accurately and objectively, complementing clinical evaluation for better control of comorbidities own patients on renal replacement therapy are as overhydration and hypertension. DESIGN: A retrospective descriptive study was conducted. 55 patients on peritoneal dialysis (PD) were included with 10 months follow up. Using BIS Monitor (BCM Fresenius) was determined every two months: state of hydration, fluid overload in liters (OHL) considered OHL>1.5L, body mass index (BMI), fat mass index (FTI) and adipose tissue mass (ATM). Furthermore measures blood pressure (BP) and the number of prescribed antihypertensive drugs. 72% were male and 28% female. The mean age was 56 years. 89% had a history of hypertension, 70.9% showed BP at the beginning of study above 140/80 mmHg. The mean average BP was 147/ 87 mmHg, The mean BMI was 27 ± 3.6 kg/m2 and 38.2% had OHL> 1.5 L. RESULTS: Patients with BP> 140/80 mmHg had higher ATM (37.1 ± 13 kg; p=0.039). A positive correlation between SBP values and OHL(p=0.004,R=0.387) was observed. The differences between the SBP of overhydrated patients (OHL>1.5L; SBP=157 ±23.8 mmHg) and normohydrated, SBP=141±19.5 mmHg). (p=0.010). At 10 months follow-up using BIS, a drop in the blood pressure (of 5 mmHg) and the percentage of patients overhydrated (17%), was observed. Reduction in the number of antihypertensive drugs (2.5 to 2 (p=0.013)). The correlation between TAS and OHL figures stood at 10 months follow-up (R=0.387; p=0.038). CONCLUSIONS - Using BIS allowed us to more accurately estimate the state of hydration in comparison with classical clinical markers, getting reduce fluid overload - Give individualized dietary advice and distinguish patients with volume-dependent hypertension - Reduce the number of antihypertensive drugs used. - Fluid overload was associated with higher SBP. - Patients with hypertension had greater FTI.
146 PAGE KIDNEY-A RARE CAUSE OF ACCELERATED HYPERTENSION: A Hayas Haseer Koya, Roshni Radhakrishna, Dona Varghese, Dinesh John, Tanya George. SUNY Upstate Medical University, Syracuse, NY, USA Accelerated hypertension is a medical emergency requiring immediate management. We describe a rare cause of accelerated hypertension secondary to extra renal compression, otherwise known as page kidney. 73 year old male with no significant past medical history presented with 3 day history of left flank pain. On evaluation he had acute anemia and accelerated hypertension with blood pressures over 200/100. Treatment was initiated with intravenous antihypertensives for immediate blood pressure control and blood transfusions for anemia. Renal artery stenosis was ruled out by ultrasound Doppler. Abdominal CT revealed a large left renal subcapsular hematoma with retroperitoneal extension. In the absence of any identifiable traumatic or non-traumatic causes, a diagnosis of page kidney due to spontaneous subcapsular hematoma was made. Patient was started on oral ACE inhibitor to control hypertension. He underwent renal angioembolization with subsequent reduction in size of hematoma and improvement in blood pressures within 48 to 72 hours. Page kidney (first described by Page in 1939) is a rare cause of hypertension caused by activation of renin angiotensin axis due to renal hypoperfusion and microvascular ischemia, resulting from extrinsic compression of kidneys. Subcapsular or perinephric hematoma due to various etiologies including blunt trauma, tumor, cystic lesions and renal biopsies can lead to page kidney. Diagnostic studies include CT, MRA, or US Doppler. Initial treatment is medical-ACE inhibitors or ARB to control blood pressure. In resistant cases surgical options include angioembolization (preferred in cases due to hematoma), percutaneous drainage or laparoscopic decortication. We reiterate the need for a high index of suspicion for Page kidney in patients presenting with resistant hypertension with associated abdominal symptoms and anemia.
Am J Kidney Dis. 2015;65(4):A1-A93
147 GEMCITABINE INDUCED THROMBOTIC MICROANGIOPATHY: ROLE OF ECULIZUMAB Abhishek Kumar, Yogesh Sanghvi, Sarika Deshmukh, Satyarth Kulshrestha, Sarat Kuppachi, University of Iowa, Iowa City, IA, USA Thrombotic microangiopathy (TMA) syndromes are a group of disorders characterized by microangiopathic hemolytic anemia, thrombocytopenia and organ injury. Gemcitabine (Gem) associated TMA is reported in 0.03-1.3% of patients, but mechanism is not known. Response to plasmapheresis (PP) is disappointing. We describe successful treatment of gemcitabine associated TMA with eculizumab in this case report. Patient Age Cancer Gem TMA Response to (yr) dose criteria Rx #1 68 Pancreas 23 g/m2 Hapto <10 PP x0 Schisto 3+ EculizumabPlt 44k/m3 9 doses- cr Hb 6.5 g/dl at 2.5 Cr 5.4from 0.8 #2
49
Cholangiocarcinoma
16.9g/m2
Hapto <10 Schisto 3+ Plt 79k/m3 Hb 5.1g/dl Cr 3.1 from 0.7
PPx3 -no response Eculizumab1 dose- Plt upto 300k, Cr at 2.7,Hb 8.5
Conclusions: Disappointing response to PP has been described, suggesting no role of a circulating factor. Response to eculizumab suggests underlying complement dysregulation in patients who get TMA with Gem. Gem may be a second-hit. This explains risks of <1% in exposed patients. Reference: Leal F, Macedo LT, Carvalheira JB, Gemcitabine-related thrombotic microangiopathy: a single-centre retrospective series. J Chemother 2014 Jun;26(3):169-72.
148 A RARE CASE OF PERITONITIS: Pooja Kumari, Aarti Narayan, Jiwan Thapa, Marshfield Clinic, WI, USA Infectious peritonitis carries significant morbidity and mortality and frequently leads to discontinuation of peritoneal dialysis (PD). We report a case of PD associated peritonitis caused by rare bacteria Achromobacter xyloxidans that required removal of PD catheter. CASE A 65 year old man with ESRD due to membranoproliferative glomerulonephritis on continuous cycler PD for one year presented with abdominal pain. Culture of cloudy peritoneal fluid with a high cell count of 3400/ml grew A.xyloxidans sensitive to ceftazidime. 2weeks IP ceftazidime resulted in improvement but discontinuation was followed by abdominal pain, fever and cloudy peritoneal fluid within 4days. Exit site appeared normal and PD fluid showed total nucleated cells of 5431/ml with 86% neutrophils. Culture again grew A.xyloxidans, still sensitive to ceftazidime and quinolones. Blood culture was negative. He was retreated with IP ceftazidime but did not respond over next 4 days. The PD catheter was removed and patient was switched to hemodialysis. Antibiotic was switched to intravenous ciprofloxacin with dramatic improvement. DISSCUSSION Achromobacter is a gram negative rod that inhabits aquatic environments and is rarely isolated from the human gastrointestinal tract and ear canal. It rarely causes infections, except in immunocompromised hosts. It is an exceedinlgy rare cause of PD peritonitis and there are no clear guidelines in the literature about treatment or catheter care. Review of the literature, mostly limited to case reports, suggests frequent antibiotic resistance and often necessitating removal of catheter and switch of dialysis modality. Our patient was not on immunosuppressants. Despite apparent sensitivity in vitro, the infection did not respond to antibiotic treatment ultimately leading to catheter removal and termination of PD. Our knowledge regarding the evolution, treatment, and catheter care and host risk factors for Achromobacter peritonitis remains very limited. Our own experience and documented reports suggest that Achromobacter peritonitis is extremely resistant to usual treatment despite apparent in vitro sensitivity and early catheter removal is usually warranted to adequately treat the infection.
A51