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SUSTAINED LOW EFFICIENCY HEMODIALYSIS FOR REMOVAL OF DABIGATRAN
NKF 2015 Spring Clinical Meetings Abstracts
273 ORAL VITAMIN C SUPPLEMIENTATION FOR FUNCTIONAL IRON DEFICIENCY IN DIALYSIS PATIENTS Tanjim Sultana, Max Pommier, Maria V. DeVita, Michael F. Michelis. Division of Nephrology, Lenox Hill Hospital, NY, NY. Functional iron deficiency (FID) is a major cause of erythropoietin (Epo) hyporesponsiveness and persistent anemia in ESRD patients. Vitamin C acts as a reducing agent and enhances mobilization of the ferrous form of iron to transferrin thus increasing its bioavailability. High dose intravenous vitamin C has been shown to decrease the Epo requirement and improve hemoglobin levels in previous studies. This study assessed the effect of low dose oral vitamin C on Epo dose requirements in stable hemodialysis patients. This prospective, randomized controlled study enrolled 18 anemic patients with FID defined as transferrin saturation (Tsat) <30 % and ferritin levels of >100 mcg/L from July, 2014 to October, 2014.All patients had an Epo requirement of ≥ 4000 u/HD. Eight patients were randomly assigned to the study group who received oral 250 mg vitamin C daily for three months. Hemoglobin, iron and Tsat levels were recorded monthly. Epo dose was adjusted according to unit protocol depending on the hemoglobin level. None of these participants had iron supplementation during the study period. Among the eight study patients who received vitamin C, 6 had a 33% reduction in their Epo dose requirement. The Epo dose reduction per patient in vitamin C group was 1375 ± 1768 u/HD. In the control group of ten participants mean Epo dose per patient increased to 100 ± 1100 u/HD. Seven patients in this group had unchanged Epo dose over the three months period. The change in Epo dose in the vitamin C group was significantly different from the changes in the control group (P =0.045). Daily low dose oral vitamin C supplementation helps to reduce Epo dose requirements in anemic hemodialysis patients with functional iron deficiency. Despite concerns regarding oral vitamin C absorption in dialysis patients this study indicates Vitamin C is well tolerated and effective.
274 SUSTAINED LOW EFFICIENCY HEMODIALYSIS FOR REMOVAL OF DABIGATRAN Saqib Syed, Ravi Siriki, Fredrico Teran, Arnold Alper, Tulane University Medical Center, LA, USA Dabigatran is one of the new available oral direct thrombin inhibitor approved for anticoagulation therapy to prevent strokes in patients with nonvalvular atrial fibrillation. So far no rapidacting antidote to reverse the effects of dabigatran is known. We describe a case of 58-year-old male who was involved in a motor vehicle accident resulting in multiple left lower extremity open fractures. Patient history was significant for atrial fibrillation for which he was on dabigatran regimen of 150 mg orally twice a day. Patient was hypotensive on presentation secondary to hemorrhagic shock and received transfusions of 6 units of Packed red blood cells (PRBC) and 6 units of fresh frozen plasma(FFP) in the emergency room(ER) before he was transferred for operative exploration and below knee amputation of left lower extremity and received another 10 units of PRBC's, 10 units of FFPs along with 2 units of platelets and 2 units of cryoprecipitates intra-op. Significant labs on presentation to ER Hemoglobin(Hb) of 5.4, Hematocrit(Hct) of 15.8, Prothrombin time (PT) 20.9, international normalized ratio (INR) 1.9 and activated partial thromboplastin time (aPTT) 102.6 with normal kidney function with creatinine of 0.8 and BUN 14. After copious transfusions patients Hb was still less than 7, Hct <20 with aPTT of 68.2, PT 16.4 and INR 1.5. Patient continued to have non-surgical bleeding from his left lower extremity stump and Nephrology was consulted for possible use of hemodialysis for removal of dabigatran. We used sustained low efficiency hemodialysis (SLED) for time of 12 hours to remove plasma Dabigatrin. Post dialysis patient aPTT improved to 32.1 with PT of 13.8 and hemoglobin stabilized between 8.2-8.6 afterwards with no active bleeding on clinical evaluation. We here describe a case, which potentiates sustained low efficiency hemodialysis in continued life threatning hemorrhage in a critically ill patient on Dabigatran as a possible life saving modality.
Am J Kidney Dis. 2015;65(4):A1-A93
275 TELENEPHROLOGY FOR THE REMOTE MANAGEMENT OF CHRONIC KIDNEY DISEASE: A RETROSPECTIVE COHORT STUDY Tan Judy1, Mehrotra Anita1, Rohatgi Rajeev1,2 1Mount Sinai Hospital, New York, NY 2 James J. Peters VAMC, Bronx, NY Background: Chronic kidney disease (CKD) is a common lifethreatening medical condition, affecting ~26 million adults in the U.S. In Veterans Integrated Service Network (VISN) 3, veterans with CKD who live in the Hudson Valley Veterans Affair Medical Center (VAMC) catchment area travel to the James J. Peters VAMC in the Bronx for nephrology care. The no-show and cancellation rates for these renal evaluations exceeded 50%, so we surmised that the distance between the Hudson Valley and James J. Peters VAMC (60 miles) discouraged travel for nephrology care. Hypothesis: We hypothesized patients cared through a Telenephrology service, where patients visit the local VA and are evaluated remotely by a Bronx VA nephrologist, would exhibit comparable clinical outcomes and visit compliance as conventional in-person renal care, in part, related to the convenience of attending their local clinic. Results: Provisional analysis of the subjects followed in the Telenephrology service showed 117 unique patients were evaluated. The mean age was 71±11years old with 98.3% males. 70% of the patients were white and 26.5% African American. The predominant etiology of CKD was diabetic nephropathy (31.6%) followed by hypertensive nephrosclerosis (26.5%). In the 87 patients who had 1year follow up data, eGFR was well-preserved over the year (33 mL/min vs. 32 mL/min; p=0.04). Systolic blood pressure (BP) was reduced from 138±20 to 133±16 mm Hg (p=0.03), but no difference was observed in diastolic BP. Urine protein-creatinine ratio fell from 0.58 to 0.25 (p=0.07). 94% of patients had parathyroid levels checked and 70.9% were on ACE inhibitors during the first year of follow up. Conclusion: After 1 year of follow-up, patients with CKD who were remotely followed via Telenephrology had well-preserved eGFR and a reduced systolic BP. Proteinuria was likewise reduced, but did not reach statistical significance. Future analysis of this cohort will focus on the whether the clinical outcomes (change in eGFR, proteinuria, BP) and compliance with visits is similar to that in the conventional care group.
276 REDUCTION IN REPEAT HOSPITALIZATIONS IN A PATIENT WITH LOIN PAIN HEMATURIA SYNDROME USING OUTPATIENT HYDRATION: Bhargavi Tangirala, Erdal Sarac, The Renal Group, Boardman, OH Loin pain-hematuria syndrome (LPHS) is a rare disorder, characterized by recurrent flank pain and hematuria. Patients with LPHS present with hematuria, incapacitating flank pain leading to recurrent hospitalization, multiple imaging studies, urological procedures, absence from work and narcotic addiction. LPHS is a diagnosis of exclusion, and the treatment options are limited and include conservative management with intravenous fluids, and pain medication, surgical therapies like renal auto transplantation and renal denervation. Our patient is a 37 year old white male initially diagnosed with IgA nephropathy. He started having relapsing and remitting episodes of flank pain, gross hematuria followed by acute elevation in creatinine which resulted in recurrent hospitalizations for IV hydration therapy. These episodes increased in frequency and severity (average 1.7 admissions per month) and escalating doses of narcotics for pain. There was no evidence of nephrolithiasis. Urological evaluation revealed no structural urinary tract abnormalities. Imaging showed normal renal vasculature, Platelet count, liver function tests and Prothrombin time were within normal limits. He was diagnosed with secondary LPHS. In view of his debilitating symptoms and frequent admissions he was referred for renal auto transplantation which he refused. Then we offered an experimental therapy to place a port and start scheduled outpatient (OP) IV hydration therapy (3-4 L of IV normal saline per week) to reduce the frequency of hospitalization, to which he agreed. With this, he started showing remarkable improvement with his symptoms, reduction in hospitalization rates (average 0.9 admissions per month) and use of IV narcotics for pain control reduced significantly. He did not experience any major adverse events. LPHS remains a therapeutic challenge. With scheduled OP IV hydration therapy we were successfully able to reduce his hospitalization rates and IV narcotic use for pain control and this approach may be considered in carefully selected patients with LPHS.
A83
273 ORAL VITAMIN C SUPPLEMIENTATION FOR FUNCTIONAL IRON DEFICIENCY IN DIALYSIS PATIENTS Tanjim Sultana, Max Pommier, Maria V. DeVita, Michael F. Michelis. Division of Nephrology, Lenox Hill Hospital, NY, NY. Functional iron deficiency (FID) is a major cause of erythropoietin (Epo) hyporesponsiveness and persistent anemia in ESRD patients. Vitamin C acts as a reducing agent and enhances mobilization of the ferrous form of iron to transferrin thus increasing its bioavailability. High dose intravenous vitamin C has been shown to decrease the Epo requirement and improve hemoglobin levels in previous studies. This study assessed the effect of low dose oral vitamin C on Epo dose requirements in stable hemodialysis patients. This prospective, randomized controlled study enrolled 18 anemic patients with FID defined as transferrin saturation (Tsat) <30 % and ferritin levels of >100 mcg/L from July, 2014 to October, 2014.All patients had an Epo requirement of ≥ 4000 u/HD. Eight patients were randomly assigned to the study group who received oral 250 mg vitamin C daily for three months. Hemoglobin, iron and Tsat levels were recorded monthly. Epo dose was adjusted according to unit protocol depending on the hemoglobin level. None of these participants had iron supplementation during the study period. Among the eight study patients who received vitamin C, 6 had a 33% reduction in their Epo dose requirement. The Epo dose reduction per patient in vitamin C group was 1375 ± 1768 u/HD. In the control group of ten participants mean Epo dose per patient increased to 100 ± 1100 u/HD. Seven patients in this group had unchanged Epo dose over the three months period. The change in Epo dose in the vitamin C group was significantly different from the changes in the control group (P =0.045). Daily low dose oral vitamin C supplementation helps to reduce Epo dose requirements in anemic hemodialysis patients with functional iron deficiency. Despite concerns regarding oral vitamin C absorption in dialysis patients this study indicates Vitamin C is well tolerated and effective.
274 SUSTAINED LOW EFFICIENCY HEMODIALYSIS FOR REMOVAL OF DABIGATRAN Saqib Syed, Ravi Siriki, Fredrico Teran, Arnold Alper, Tulane University Medical Center, LA, USA Dabigatran is one of the new available oral direct thrombin inhibitor approved for anticoagulation therapy to prevent strokes in patients with nonvalvular atrial fibrillation. So far no rapidacting antidote to reverse the effects of dabigatran is known. We describe a case of 58-year-old male who was involved in a motor vehicle accident resulting in multiple left lower extremity open fractures. Patient history was significant for atrial fibrillation for which he was on dabigatran regimen of 150 mg orally twice a day. Patient was hypotensive on presentation secondary to hemorrhagic shock and received transfusions of 6 units of Packed red blood cells (PRBC) and 6 units of fresh frozen plasma(FFP) in the emergency room(ER) before he was transferred for operative exploration and below knee amputation of left lower extremity and received another 10 units of PRBC's, 10 units of FFPs along with 2 units of platelets and 2 units of cryoprecipitates intra-op. Significant labs on presentation to ER Hemoglobin(Hb) of 5.4, Hematocrit(Hct) of 15.8, Prothrombin time (PT) 20.9, international normalized ratio (INR) 1.9 and activated partial thromboplastin time (aPTT) 102.6 with normal kidney function with creatinine of 0.8 and BUN 14. After copious transfusions patients Hb was still less than 7, Hct <20 with aPTT of 68.2, PT 16.4 and INR 1.5. Patient continued to have non-surgical bleeding from his left lower extremity stump and Nephrology was consulted for possible use of hemodialysis for removal of dabigatran. We used sustained low efficiency hemodialysis (SLED) for time of 12 hours to remove plasma Dabigatrin. Post dialysis patient aPTT improved to 32.1 with PT of 13.8 and hemoglobin stabilized between 8.2-8.6 afterwards with no active bleeding on clinical evaluation. We here describe a case, which potentiates sustained low efficiency hemodialysis in continued life threatning hemorrhage in a critically ill patient on Dabigatran as a possible life saving modality.
Am J Kidney Dis. 2015;65(4):A1-A93
275 TELENEPHROLOGY FOR THE REMOTE MANAGEMENT OF CHRONIC KIDNEY DISEASE: A RETROSPECTIVE COHORT STUDY Tan Judy1, Mehrotra Anita1, Rohatgi Rajeev1,2 1Mount Sinai Hospital, New York, NY 2 James J. Peters VAMC, Bronx, NY Background: Chronic kidney disease (CKD) is a common lifethreatening medical condition, affecting ~26 million adults in the U.S. In Veterans Integrated Service Network (VISN) 3, veterans with CKD who live in the Hudson Valley Veterans Affair Medical Center (VAMC) catchment area travel to the James J. Peters VAMC in the Bronx for nephrology care. The no-show and cancellation rates for these renal evaluations exceeded 50%, so we surmised that the distance between the Hudson Valley and James J. Peters VAMC (60 miles) discouraged travel for nephrology care. Hypothesis: We hypothesized patients cared through a Telenephrology service, where patients visit the local VA and are evaluated remotely by a Bronx VA nephrologist, would exhibit comparable clinical outcomes and visit compliance as conventional in-person renal care, in part, related to the convenience of attending their local clinic. Results: Provisional analysis of the subjects followed in the Telenephrology service showed 117 unique patients were evaluated. The mean age was 71±11years old with 98.3% males. 70% of the patients were white and 26.5% African American. The predominant etiology of CKD was diabetic nephropathy (31.6%) followed by hypertensive nephrosclerosis (26.5%). In the 87 patients who had 1year follow up data, eGFR was well-preserved over the year (33 mL/min vs. 32 mL/min; p=0.04). Systolic blood pressure (BP) was reduced from 138±20 to 133±16 mm Hg (p=0.03), but no difference was observed in diastolic BP. Urine protein-creatinine ratio fell from 0.58 to 0.25 (p=0.07). 94% of patients had parathyroid levels checked and 70.9% were on ACE inhibitors during the first year of follow up. Conclusion: After 1 year of follow-up, patients with CKD who were remotely followed via Telenephrology had well-preserved eGFR and a reduced systolic BP. Proteinuria was likewise reduced, but did not reach statistical significance. Future analysis of this cohort will focus on the whether the clinical outcomes (change in eGFR, proteinuria, BP) and compliance with visits is similar to that in the conventional care group.
276 REDUCTION IN REPEAT HOSPITALIZATIONS IN A PATIENT WITH LOIN PAIN HEMATURIA SYNDROME USING OUTPATIENT HYDRATION: Bhargavi Tangirala, Erdal Sarac, The Renal Group, Boardman, OH Loin pain-hematuria syndrome (LPHS) is a rare disorder, characterized by recurrent flank pain and hematuria. Patients with LPHS present with hematuria, incapacitating flank pain leading to recurrent hospitalization, multiple imaging studies, urological procedures, absence from work and narcotic addiction. LPHS is a diagnosis of exclusion, and the treatment options are limited and include conservative management with intravenous fluids, and pain medication, surgical therapies like renal auto transplantation and renal denervation. Our patient is a 37 year old white male initially diagnosed with IgA nephropathy. He started having relapsing and remitting episodes of flank pain, gross hematuria followed by acute elevation in creatinine which resulted in recurrent hospitalizations for IV hydration therapy. These episodes increased in frequency and severity (average 1.7 admissions per month) and escalating doses of narcotics for pain. There was no evidence of nephrolithiasis. Urological evaluation revealed no structural urinary tract abnormalities. Imaging showed normal renal vasculature, Platelet count, liver function tests and Prothrombin time were within normal limits. He was diagnosed with secondary LPHS. In view of his debilitating symptoms and frequent admissions he was referred for renal auto transplantation which he refused. Then we offered an experimental therapy to place a port and start scheduled outpatient (OP) IV hydration therapy (3-4 L of IV normal saline per week) to reduce the frequency of hospitalization, to which he agreed. With this, he started showing remarkable improvement with his symptoms, reduction in hospitalization rates (average 0.9 admissions per month) and use of IV narcotics for pain control reduced significantly. He did not experience any major adverse events. LPHS remains a therapeutic challenge. With scheduled OP IV hydration therapy we were successfully able to reduce his hospitalization rates and IV narcotic use for pain control and this approach may be considered in carefully selected patients with LPHS.
A83