- Email: [email protected]
Silica Nephrolithiasis Associated With Excessive Use of Common Dietary and Vitamin Supplements
NKF 2016 Spring Clinical Meetings Abstracts
Case Report 73
75
TRENDS IN HOSPITALIZATION AND MORTALITY IN CANDIDEMIA IN A HEMODIALYSIS PATIENT: SAVE THE ACCESS PREVALENT HEMODIALYSIS PATIENTS: Allan J. Collins, Peer OR SAVE THE PATIENT? Kidney Care Initiative Investigators. Nanette Chua, Stephen Migdal, Zeinab Tamam, Danna Brock, 2 Progress in reducing hospitalization events and overall mortality are Yahya Osman-Malik, Zeenat Yousuf Bhat. central Wayne State University, Detroit, Michigan, USA 1, 1 objectives of improving care for the dialysis population. 1 Laith Al-Rabadi, MBBS, * Rivka Ayalon, MD, Ramon G. Bonegio, MD,were PhD, Historically, US dialysis patients on average hospitalized twice Vascular access associated blood stream infection is a known 2,y 3 4 per year for anM. average of 13-14 days per year.PhD, Recent changes in complication inJennifer hemodialysis patients.MD, Catheters have M. the Fujii, MD, E.(HD) Ballard, Alan Joel Henderson, MD, practice related to using more fistulas and 1 1 reducing the use of catheters, highest risk and arteriovenous fistulas the least risk. Candidemia David J. Salant, MD, and Laurence H. Beck Jr, MD, PhD as well as incentives to reduce readmissions, may have changed event is the 4th most common cause of healthcare-associated blood rates. stream infection, with mortality as high as 25%. Usual treatment Using data obtained from the Centers for Medicare & Medicaid of Candidemia consists of a 14 day course of antifungals (based Serviceswith End-Stage Disease database for 2004-2012, we There is little information aboutremoval. pregnancy outcomes in patients activeRenal membranous nephropathy (MN), on species and susceptibilities) and catheter unadjustedAhospitalization and mortality rates. especially those with circulating autoantibodies phospholipase A 53 year old lady with End-stage renal disease, on HD via AV to M-typecomputed 2 receptor (PLA2R), the major Hospitalizations declined to 16.5 per 100 patient years in 2013 Graft (AVG), hepatitis C, drug was admitted autoantigen in intravenous primary MN. Weuse, present what wetobelieve to parallel be the with first aknown case of successful pregnancy in fall in mortality rates. 2011-2013 showed reductions in hospital after developing fever during dialysis. Blood cultures year prior tobeyond pregnancy, patient developed a 39-year-old woman with PLA2R-associated MN. In thehospitalizations prior yearthe patterns. The mortality rate has parapsilosis . AVG was normal on physical exam grew Candida anasarca, hypoalbuminemia (albumin, 1.3-2.2 g/dL), and proteinuria excretion, Kidney bi- last 25 declined 24%(protein from 2004 to 2013 to a29.2 new g/d). all-time low in the and on duplex study. Transthoracic echocardiogram showed no the patientyears. was seropositive for anti-PLA2R autoantibodies. opsy revealed MN with staining for PLA2R, and vegetations. Endophthalmitis was ruled out on funduscopy. She did not respond conservative therapy and was treated with intravenous rituximab (2 doses of 1 g each). was givenShe a loading dose of oralto fluconazole, followed by 200mg Several weeks afterlater, presentation, she wasShe found daily for for 14 days. A week her fever recurred. wasto be 6 weeks pregnant and was closely followed up without switched further to IV micafungin. Vascular surgery did not recommend immunosuppressive treatment. Proteinuria remained with protein excretion in the 8- to 12-g/d range. any surgical intervention. Transesophageal echocardiogram was Circulating anti-PLA 2R levels declined but were still detectable. At 38 weeks, a healthy baby girl was born, negative. She was discharged on oral flucanozole 400mg daily without proteinuria at birth or at her subsequent 6-month postnatal visit. At the time of delivery, the mother still for 6 weeks. Blood cultures were negative initially. However, immunoglobulin G1 (IgG1), IgG3, and IgG4 subclasses, although at had detectable 2R ofstill and 16th dayanti-PLA of treatment grew C. repeat cultures on the 14th circulating low titers. trace on amounts of IgG4 AVG anti-PLA . She wasOnly restarted IV micafungin. was 2R were found in cord blood. Potential reasons for the parapsilosis in thewas maternal and fetal circulation are discussed. between removed discrepancy and a tunneled catheteranti-PLA was placed. The patient 2R levels discharged flucanozole 400mg daily for 6 weeks afterNational Kidney Foundation, Inc. AmonJ oral Kidney Dis. 67(5):775-778. ª 2016 by the first negative blood culture. Succeeding cultures were negative. Candidemia in HD patients warrants early treatment using INDEX WORDS: Membranous nephropathy (MN); nephrotic Major syndrome; pregnancy; M-type phospholipase reductions have occurred in hospitalization eventsAand 2 effective antifungal therapy. Access removal is associated with mortality in the These trends are consistent with Healthy receptor (PLA2R); autoantibody; immunoglobulin G last (Ig 10 G)years. subclass. faster, more successful irradication of the placenta; fungi and rituximab; better People 2020 objectives. Metrics which employ trends over time, rather treatment outcomes. Failure to do so may result in treatment than alternative measures such as standardized mortality or failure, relapse or increased morbidity and mortality. Save the hospitalization ratios, may be a superior way to assess progress in the patient and not the access! care of dialysis patients.
Pregnancy in a Patient With Primary Membranous Nephropathy and Circulating Anti-PLA R Antibodies: A Case Report
P
regnant patients with autoimmune disease may deliver newborns with a spectrum of clinical manifestations due to the transplacental passage of 74 circulating autoantibodies. Pregnant patients with EVALUATION OF VANCOMYCIN DOSING IN PATIENTS ON lupus or myasthenia gravis can deliver babies with CONTINUOUS RENAL REPLACEMENT THERAPY 1,2 Hazel Yiting Chia, disease Shen Hui Chuang, Department of Pharmacy, Tan Tock corresponding in the neonate. Neonatal Seng Hospital, Singapore membranous nephropathy (MN) not associated with The objective of the study was to evaluate the effectiveness of congenital infection was first described in 1990 and institutional vancomycin dosing guidelines (loading dose of vancomycin 25mg/kg followed a maintenance dose of 10-15mg/kg every 24h for attributed to theby passive transfer of maternal anti3 those on CVVH or CVVHD or 7.5-10mg/kg every 12h for those on bodies to putative renal antigens. More than a decade CVVHDF) in patients receiving continuous renal replacement therapy later, Debiec et al4objective identified firsttheantigen involved (CRRT). The primary was tothe describe percentage of patients CRRT cases who attained levels (15-20mg/L). in on such as therapeutic neutralvancomycin endopeptidase (NEP), a This retrospective review was conducted in Tan Tock Seng Hospital, metalloprotease present on the surface of the podocyte Singapore intensive care units (ICUs) from 1 June 2013 to 28 February and2014. involved in proteolytic regulation vasoacPatients whothe received ≥24h of CRRT, received of ≥2 vancomycin and had Debiec ≥1 vancomycin measured were included.with Patients’ tivedoses, peptides. et allevels described a mother a demographics, microbiological investigations, CRRT characteristics, mutation preventing NEP expression who had formed vancomycin therapy and drug levels, and urine output were collected. anti-NEP fetomaternal alloimmuDescriptiveantibodies statistics were due used totodetermine the percentage of patients who attained vancomycin levels at five these 12 hourlyantibodies time intervals nization fromtherapeutic a previous miscarriage; (T) from the start of therapy (T1 = 0-12h, T2 = 13-24h, T3 = 25-36h, T4 = were to and cross the from placenta and cause subepithelial 37-48h T5 = 49-60h the start of therapy). deposits thepatients fetal (75%) kidney ofCVVHDF, a subsequent pregMajorityinof the were on with a median dose intensityM-type of 32ml/kg/h. No patients received recommended(PLA vancomycin nancy. phospholipase Athe receptor 2 2R) 25mg/kg loading dose. Five out of twenty (25%) of the patients received wasmaintenance later identified as the major autoantigen for privancomycin 5doses as per institutional guidelines. The mary MN ofinpatients adults. Littletherapeutic literature existslevels about proportion who attained vancomycin was greater in patients who did not to dosing guidelines (55% vs 43%). pregnancy outcomes inadhere patients with nephrotic synThe compliance to institutional vancomycin CRRT dosing guideline was drome due topoorprimary withdosing no and data available poor. Despite adherence MN, to guideline no loading doses about in PLA R-associated disease. We were pregnancy given, the majority of patients were able to attain therapeutic 2 vancomycin the different time first intervals. Efforts case should of be present whatlevels we across believe to be the known made to improve compliance to dosing protocol for a meaningful analysis in pregnancy the future. in a patient with PLA2R-associated MN who was seropositive for anti-PLA2R autoantibodies throughout the course of her pregnancy. Am J Kidney Dis. 2016;67(5):A1-A118
CASE REPORT
A 39-year-old multiparous woman with morbid obesity presented for workup of severe nephrotic syndrome several months 76 before her current pregnancy. She had been treated for resistant SILICA NEPHROLITHIASIS ASSOCIATED WITH hypertension and lower-extremity edema during the past year, EXCESSIVE USE OF COMMON DIETARY AND VITAMIN but her proteinuria had been overlooked. At presentation, serum SUPPLEMENTS: Matthew Corvo, Raymond Raut, Winston creatinine level was 1.52 mg/dL (corresponding to estimated Shih, Panupong Lisawat, Danbury Hospital, CT, USA glomerular filtration rate of 46 mL/min/1.73 m2 as calculated by Silica and its related isomeric forms are common additives in themany isotope-dilution mass supplements, spectrometryprimarily –traceable vitamin and dietary used4-variable for its MDRD [Modification of Diet in Renal Disease] equahygroscopic properties. Organic silica compound isStudy absorbed in tion); serum 1.5main g/dL; andof24-hour urine protein the GI tract.albumin Kidneyslevel, are the route excretion of silica. excretion, g. intake The kidney biopsy specimen revealed features Excessive29.2 silica may lead to silica nephrolithiasis. We typical MN containing with additional for the presentofa primary case of silica kidneystrong stone staining due to excessive PLA within immune deposits (Fig S1). Many of the 2R antigen dietary supplement. subepithelial deposits completely surrounded new This is an 85-year-oldwere female with medical history of by atrial basement materialwho(Fig and for 35% of the fibrillationmembrane and hypertension was S2), consulted metabolic stone work up after a prolonged history of passing ‘sand-like’ sediment in her urine. Cystoscopy was negative for any From the 1pathology. Department Medicine, Section, and Deanatomical CTofscan showedRenal a 4 mm non-obstructing 2 3 partments of mid Obstetrics andcalculus Gynecology, and 4Paradiopaque right renal withoutPediatrics, hydronephrosis. thology and Medicine, passed Bostonfragments University Medical Later on theLaboratory patient spontaneously of stones Center, Boston,silica MA.compound on analysis. Interestingly, patient that showed * Currenttoaffiliation: of Internal Medicine, Division admitted be takingDepartment over 40 different supplements daily. All ofcontained Nephrology, University Utah additives. School of The Medicine, Lake various forms of silica patientSalt refused City, UT.taking those supplements despite the findings. to stop y Current affiliation:this Department Obstetrics and Gynecology, We are reporting interestingofcase that illustrates the Medstar Washington Washington, DC. correlation betweenHospital excessiveCenter, silica-containing supplements Received 2015. Accepted revised form October 27, intake andJune silica29, nephrolithiasis thatinmay not be an uncommon 2015. online December 2015. content entityOriginally and but ispublished under-recognized given the29, ubiquitous Address to Laurence H. Beck Jr, MD, PhD, of silica incorrespondence many supplements. Renal Section, X-504, 650 Albany St, Boston, MA 02118. E-mail: [email protected] � 2016 by the National Kidney Foundation, Inc. 0272-6386 http://dx.doi.org/10.1053/j.ajkd.2015.10.031 775 A37
Case Report 73
75
TRENDS IN HOSPITALIZATION AND MORTALITY IN CANDIDEMIA IN A HEMODIALYSIS PATIENT: SAVE THE ACCESS PREVALENT HEMODIALYSIS PATIENTS: Allan J. Collins, Peer OR SAVE THE PATIENT? Kidney Care Initiative Investigators. Nanette Chua, Stephen Migdal, Zeinab Tamam, Danna Brock, 2 Progress in reducing hospitalization events and overall mortality are Yahya Osman-Malik, Zeenat Yousuf Bhat. central Wayne State University, Detroit, Michigan, USA 1, 1 objectives of improving care for the dialysis population. 1 Laith Al-Rabadi, MBBS, * Rivka Ayalon, MD, Ramon G. Bonegio, MD,were PhD, Historically, US dialysis patients on average hospitalized twice Vascular access associated blood stream infection is a known 2,y 3 4 per year for anM. average of 13-14 days per year.PhD, Recent changes in complication inJennifer hemodialysis patients.MD, Catheters have M. the Fujii, MD, E.(HD) Ballard, Alan Joel Henderson, MD, practice related to using more fistulas and 1 1 reducing the use of catheters, highest risk and arteriovenous fistulas the least risk. Candidemia David J. Salant, MD, and Laurence H. Beck Jr, MD, PhD as well as incentives to reduce readmissions, may have changed event is the 4th most common cause of healthcare-associated blood rates. stream infection, with mortality as high as 25%. Usual treatment Using data obtained from the Centers for Medicare & Medicaid of Candidemia consists of a 14 day course of antifungals (based Serviceswith End-Stage Disease database for 2004-2012, we There is little information aboutremoval. pregnancy outcomes in patients activeRenal membranous nephropathy (MN), on species and susceptibilities) and catheter unadjustedAhospitalization and mortality rates. especially those with circulating autoantibodies phospholipase A 53 year old lady with End-stage renal disease, on HD via AV to M-typecomputed 2 receptor (PLA2R), the major Hospitalizations declined to 16.5 per 100 patient years in 2013 Graft (AVG), hepatitis C, drug was admitted autoantigen in intravenous primary MN. Weuse, present what wetobelieve to parallel be the with first aknown case of successful pregnancy in fall in mortality rates. 2011-2013 showed reductions in hospital after developing fever during dialysis. Blood cultures year prior tobeyond pregnancy, patient developed a 39-year-old woman with PLA2R-associated MN. In thehospitalizations prior yearthe patterns. The mortality rate has parapsilosis . AVG was normal on physical exam grew Candida anasarca, hypoalbuminemia (albumin, 1.3-2.2 g/dL), and proteinuria excretion, Kidney bi- last 25 declined 24%(protein from 2004 to 2013 to a29.2 new g/d). all-time low in the and on duplex study. Transthoracic echocardiogram showed no the patientyears. was seropositive for anti-PLA2R autoantibodies. opsy revealed MN with staining for PLA2R, and vegetations. Endophthalmitis was ruled out on funduscopy. She did not respond conservative therapy and was treated with intravenous rituximab (2 doses of 1 g each). was givenShe a loading dose of oralto fluconazole, followed by 200mg Several weeks afterlater, presentation, she wasShe found daily for for 14 days. A week her fever recurred. wasto be 6 weeks pregnant and was closely followed up without switched further to IV micafungin. Vascular surgery did not recommend immunosuppressive treatment. Proteinuria remained with protein excretion in the 8- to 12-g/d range. any surgical intervention. Transesophageal echocardiogram was Circulating anti-PLA 2R levels declined but were still detectable. At 38 weeks, a healthy baby girl was born, negative. She was discharged on oral flucanozole 400mg daily without proteinuria at birth or at her subsequent 6-month postnatal visit. At the time of delivery, the mother still for 6 weeks. Blood cultures were negative initially. However, immunoglobulin G1 (IgG1), IgG3, and IgG4 subclasses, although at had detectable 2R ofstill and 16th dayanti-PLA of treatment grew C. repeat cultures on the 14th circulating low titers. trace on amounts of IgG4 AVG anti-PLA . She wasOnly restarted IV micafungin. was 2R were found in cord blood. Potential reasons for the parapsilosis in thewas maternal and fetal circulation are discussed. between removed discrepancy and a tunneled catheteranti-PLA was placed. The patient 2R levels discharged flucanozole 400mg daily for 6 weeks afterNational Kidney Foundation, Inc. AmonJ oral Kidney Dis. 67(5):775-778. ª 2016 by the first negative blood culture. Succeeding cultures were negative. Candidemia in HD patients warrants early treatment using INDEX WORDS: Membranous nephropathy (MN); nephrotic Major syndrome; pregnancy; M-type phospholipase reductions have occurred in hospitalization eventsAand 2 effective antifungal therapy. Access removal is associated with mortality in the These trends are consistent with Healthy receptor (PLA2R); autoantibody; immunoglobulin G last (Ig 10 G)years. subclass. faster, more successful irradication of the placenta; fungi and rituximab; better People 2020 objectives. Metrics which employ trends over time, rather treatment outcomes. Failure to do so may result in treatment than alternative measures such as standardized mortality or failure, relapse or increased morbidity and mortality. Save the hospitalization ratios, may be a superior way to assess progress in the patient and not the access! care of dialysis patients.
Pregnancy in a Patient With Primary Membranous Nephropathy and Circulating Anti-PLA R Antibodies: A Case Report
P
regnant patients with autoimmune disease may deliver newborns with a spectrum of clinical manifestations due to the transplacental passage of 74 circulating autoantibodies. Pregnant patients with EVALUATION OF VANCOMYCIN DOSING IN PATIENTS ON lupus or myasthenia gravis can deliver babies with CONTINUOUS RENAL REPLACEMENT THERAPY 1,2 Hazel Yiting Chia, disease Shen Hui Chuang, Department of Pharmacy, Tan Tock corresponding in the neonate. Neonatal Seng Hospital, Singapore membranous nephropathy (MN) not associated with The objective of the study was to evaluate the effectiveness of congenital infection was first described in 1990 and institutional vancomycin dosing guidelines (loading dose of vancomycin 25mg/kg followed a maintenance dose of 10-15mg/kg every 24h for attributed to theby passive transfer of maternal anti3 those on CVVH or CVVHD or 7.5-10mg/kg every 12h for those on bodies to putative renal antigens. More than a decade CVVHDF) in patients receiving continuous renal replacement therapy later, Debiec et al4objective identified firsttheantigen involved (CRRT). The primary was tothe describe percentage of patients CRRT cases who attained levels (15-20mg/L). in on such as therapeutic neutralvancomycin endopeptidase (NEP), a This retrospective review was conducted in Tan Tock Seng Hospital, metalloprotease present on the surface of the podocyte Singapore intensive care units (ICUs) from 1 June 2013 to 28 February and2014. involved in proteolytic regulation vasoacPatients whothe received ≥24h of CRRT, received of ≥2 vancomycin and had Debiec ≥1 vancomycin measured were included.with Patients’ tivedoses, peptides. et allevels described a mother a demographics, microbiological investigations, CRRT characteristics, mutation preventing NEP expression who had formed vancomycin therapy and drug levels, and urine output were collected. anti-NEP fetomaternal alloimmuDescriptiveantibodies statistics were due used totodetermine the percentage of patients who attained vancomycin levels at five these 12 hourlyantibodies time intervals nization fromtherapeutic a previous miscarriage; (T) from the start of therapy (T1 = 0-12h, T2 = 13-24h, T3 = 25-36h, T4 = were to and cross the from placenta and cause subepithelial 37-48h T5 = 49-60h the start of therapy). deposits thepatients fetal (75%) kidney ofCVVHDF, a subsequent pregMajorityinof the were on with a median dose intensityM-type of 32ml/kg/h. No patients received recommended(PLA vancomycin nancy. phospholipase Athe receptor 2 2R) 25mg/kg loading dose. Five out of twenty (25%) of the patients received wasmaintenance later identified as the major autoantigen for privancomycin 5doses as per institutional guidelines. The mary MN ofinpatients adults. Littletherapeutic literature existslevels about proportion who attained vancomycin was greater in patients who did not to dosing guidelines (55% vs 43%). pregnancy outcomes inadhere patients with nephrotic synThe compliance to institutional vancomycin CRRT dosing guideline was drome due topoorprimary withdosing no and data available poor. Despite adherence MN, to guideline no loading doses about in PLA R-associated disease. We were pregnancy given, the majority of patients were able to attain therapeutic 2 vancomycin the different time first intervals. Efforts case should of be present whatlevels we across believe to be the known made to improve compliance to dosing protocol for a meaningful analysis in pregnancy the future. in a patient with PLA2R-associated MN who was seropositive for anti-PLA2R autoantibodies throughout the course of her pregnancy. Am J Kidney Dis. 2016;67(5):A1-A118
CASE REPORT
A 39-year-old multiparous woman with morbid obesity presented for workup of severe nephrotic syndrome several months 76 before her current pregnancy. She had been treated for resistant SILICA NEPHROLITHIASIS ASSOCIATED WITH hypertension and lower-extremity edema during the past year, EXCESSIVE USE OF COMMON DIETARY AND VITAMIN but her proteinuria had been overlooked. At presentation, serum SUPPLEMENTS: Matthew Corvo, Raymond Raut, Winston creatinine level was 1.52 mg/dL (corresponding to estimated Shih, Panupong Lisawat, Danbury Hospital, CT, USA glomerular filtration rate of 46 mL/min/1.73 m2 as calculated by Silica and its related isomeric forms are common additives in themany isotope-dilution mass supplements, spectrometryprimarily –traceable vitamin and dietary used4-variable for its MDRD [Modification of Diet in Renal Disease] equahygroscopic properties. Organic silica compound isStudy absorbed in tion); serum 1.5main g/dL; andof24-hour urine protein the GI tract.albumin Kidneyslevel, are the route excretion of silica. excretion, g. intake The kidney biopsy specimen revealed features Excessive29.2 silica may lead to silica nephrolithiasis. We typical MN containing with additional for the presentofa primary case of silica kidneystrong stone staining due to excessive PLA within immune deposits (Fig S1). Many of the 2R antigen dietary supplement. subepithelial deposits completely surrounded new This is an 85-year-oldwere female with medical history of by atrial basement materialwho(Fig and for 35% of the fibrillationmembrane and hypertension was S2), consulted metabolic stone work up after a prolonged history of passing ‘sand-like’ sediment in her urine. Cystoscopy was negative for any From the 1pathology. Department Medicine, Section, and Deanatomical CTofscan showedRenal a 4 mm non-obstructing 2 3 partments of mid Obstetrics andcalculus Gynecology, and 4Paradiopaque right renal withoutPediatrics, hydronephrosis. thology and Medicine, passed Bostonfragments University Medical Later on theLaboratory patient spontaneously of stones Center, Boston,silica MA.compound on analysis. Interestingly, patient that showed * Currenttoaffiliation: of Internal Medicine, Division admitted be takingDepartment over 40 different supplements daily. All ofcontained Nephrology, University Utah additives. School of The Medicine, Lake various forms of silica patientSalt refused City, UT.taking those supplements despite the findings. to stop y Current affiliation:this Department Obstetrics and Gynecology, We are reporting interestingofcase that illustrates the Medstar Washington Washington, DC. correlation betweenHospital excessiveCenter, silica-containing supplements Received 2015. Accepted revised form October 27, intake andJune silica29, nephrolithiasis thatinmay not be an uncommon 2015. online December 2015. content entityOriginally and but ispublished under-recognized given the29, ubiquitous Address to Laurence H. Beck Jr, MD, PhD, of silica incorrespondence many supplements. Renal Section, X-504, 650 Albany St, Boston, MA 02118. E-mail: [email protected] � 2016 by the National Kidney Foundation, Inc. 0272-6386 http://dx.doi.org/10.1053/j.ajkd.2015.10.031 775 A37