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Virtual Patients to Teach Electrolyte Disorders
NKF 2012 Spring Clinical Meetings Abstracts
77
79 HYPONATREMIC HYPERTENSIVE SYNDROME Victor Fayad, Timothy Muchayi, Feras Helou, Omid Bakhtar, Irfan Omar, Gregory Berger. Sinai-Grace Hospital/DMC, Detroit, Michigan. Hyponatremic hypertensive syndrome is an uncommon syndrome where the reno-vascular system affects the blood pressure (BP) along with the sodium levels. The syndrome is important, in part, because it can lead to adverse outcomes in cases of misdiagnosis due to loss of water and sodium as well as uncontrolled hypertension. We report a case of a 51-year-old African American male with a past medical history of hypertension who presented to the emergency department with sudden onset of shortness of breath, diplopia, polydipsia, generalized weakness, and severe proximal muscle cramps. His medications included metoprolol, hydralazine and amlodipine. He was allergic to ACEIs due to prior development of angioedema. On physical examination, he was found to have a BP of 204/134. There were no focal neurological findings and fundoscopic exam did not demonstrate cotton wool exudates, hemorrhages or silver wiring. The rest of his physical exam was unremarkable. Serum sodium level was 122 mmol/l, potassium 2.2 mmol/l and an anion gap of 10. Serum renin level was 3565 ng/dl/hr and serum aldosterone level was 54.3 ng/dl. Urinary sodium was 45 mmol/l, urinary potassium 14.7 mmol/l and urine osmolality was 178 mOsm/kg. Chest X-ray was negative. A renal ultrasound showed atrophy of the right kidney. A Nuclear Medicine Captopril Renal Scan demonstrated split renal function of 87% and 13% in right and left kidney, respectively. Diuretics were subsequently stopped and the patient was placed on his home antihypertensives with the addition of spironolactone. He had marginal improvement in his BP. He was subsequently scheduled for a right nephrectomy after which his hypertension and hyponatermia significantly improved. The combination of hyponatremia and hypertension can be caused by renal artery stenosis, diuretic use, chronic renal failure, or reninsecreting tumors amongst others. Hyponatremic hypertensive syndrome is one of the rarest but frequently under recognized causes of this constellation. The treatment of choice is ACEIs. However, in the case of ACEI allergy, ARBs or Aliskerin can be used. Nephrectomy of the ischemic kidney is the ultimate definite treatment.
MANAGEMENT OF CHRONIC KIDNEY DISEASE IN PATIENTS WITH AND WITHOUT CONGESTIVE HEART FAILURE Manthodi Faisa1, Peter Burke2, Wei Zhang3, James Bowen3, Claudine Jurkovitz3, Rubeen Israni1 1 Nephrology Associates PA;2 Christiana Care Health Systems;3 Christiana Care Center for Outcomes Research; Newark, DE Chronic kidney disease (CKD) has been shown to be independently associated with worsening outcomes in patients with congestive heart failure (CHF), The prevalence of anemia, metabolic bone disease and malnutrition increases with advancing CKD, The management of CKD co-morbid conditions as well as preparation for dialysis in patients with CHF has not been studied. A retrospective cohort of patients followed in a large Nephrology practice between 2000 and 2010 was evaluated. Adult patients with CKD stage 3 and above were included. Dialysis and Transplant patients were excluded. The practice electronic health records (EHRs) were linked to the health system's hospital EHR to identify patients with CHF (hospital admission with a primary or secondary diagnosis of CHF). Anemia, malnutrition and metabolic bone disease management was compared between patients with and without CHF. A total of 15,448 patients were included in the analysis, of whom 3,650 (23.6%) had CHF; 46.0% of the CHF patients were female versus 48.3% of those without CHF (p=0.0187); 50.8% of those with CHF were white versus 55.5%; Comparing patients with CHF versus without CHF: mean age (SO) was 68.7 (12.9) versus 64.6 (14.5), p<0.0001; 63.4% had CKD stage 3 versus 77.4%, 29.6% had CKD stage 4 versus 18.1 % and 7.0% CKD had stage 5 versus 4.5% at entry in the study (overall p<0.0001); 14.1 % never had serum albumin measured versus 9.2%, p<0.0001 ; mean albumin was 3.7 (0.5) mg/dL versus 3.9 (0.5), p<0.0001; mean calcium was 9.1 (0.6) mg/dL versus 9.3 (0.6), p<0.0001; only 3.0% never had calcium measured versus 1.4%, p<0.0001 , whereas as many as 62.2% never had hydroxy Vitamin 0 measured versus 55.6%, p<0.0001; mean intact PTH was 144.6 (141.6) and 95.1 (112.8), p<0.0001 ; mean hemoglobin was 11.6 (1.4) versus 12.2 (1.7), p<0.0001. Finally the ratio of catheters to fistulas was 2.2 for CHF patients and 1.6 for non CHF patients. Overall CKD management was better in the non-CHF group compared to the CHF group. Differences in the management of these conditions in CKD patients with and without CHF may contribute to the higher mortality seen in CHF patients and point to modifiable risk factors.
78
80 ASSOCIATION OF SERUM SODIUM LEVELS WITH MORTALITY IN NON-DIALYSIS DEPENDENT CHRONIC KIDNEY DISEASE Vince Faridani1,4, Jun L Lu2, Kamyar KalantarZadeh3, Csaba P Kovesdy1,4, 1Virginia Tech Carilion School of Medicine, Roanoke, VA. 2Salem Research Institute, Salem VA. 3 Harbor-UCLA, Torrance, CA. 4Salem VA Medical Center, Salem VA. The outcomes associated with hyponatremia in patients with nondialysis dependent CKD (NDD-CKD) are unclear. We examined the association between serum sodium and all-cause mortality in 1,236 males (age 68 11) with CKD stage 1-5 (eGFR 37 17). Associations of time-varying outpatient serum sodium with mortality were examined in Cox models with adjustment for socio-demographics, comorbidities, labs and medication use. Nonlinear associations were explored by using cubic splines. Lower serum sodium was linearly associated with increased mortality (figure 1). A 10 mEq/L lower serum sodium was associated with a multivariable adjusted hazard ratio of all cause mortality (95% CI) of 1.60 (1.11-2.29), p=0.01. Hyponatremia is associated with increased mortality in patients with moderate and advanced NDD-CKD. Interventional trials are needed to determine if correction of hyponatremia can result in improved outcomes in this population.
A34
VIRTUAL PATIENTS TO TEACH ELECTROLYTE DISORDERS Laura Ferreira Provenzano, Kristine Schonder, Hoda Kaldas. University of Pittsburgh, School of Medicine and School of Pharmacy, Pittsburgh, PA, USA Electrolyte abnormalities are common. Accurate patient assessment and lab interpretation are critical in their management. Medical and pharmacy students are taught physiology of electrolyte disorders in the didactic portion of the curriculum. Cases are reviewed through lectures or bedside discussion during clinical rotations. The complexity of these disorders makes students unable to achieve competency unless exposed to many cases. Previous studies showed most students lack electrolyte management competency. Those with the opportunity to practice problem solving score better on tests than those who depend on standard teaching methods. We propose an innovative approach to teach electrolyte disorders using VpSim, an online virtual patient player, authoring and administration application for medical education. Virtual patients are computer simulations of clinical encounters where learners interact with an on-screen patient. Course objectives were established with the aid of experts in the field. The first phase involved development of four cases to teach water disorders (hypo and hypernatremia). Cases included a clinical scenario and questions covering key aspects of the pathophysiology and treatment of the disorder. Questions were followed by pertinent feedback and combined with a tutorial integrating the physiology learned in the curriculum with clinical aspects of the virtual patient. Cases also allowed experiencing possible harms associated with mismanagement. They were reviewed by 3 senior nephrologists for content and level of difficulty. Cases will be validated to assess effectiveness in improving knowledge by comparing scores of pre and posttests and the feasibility to integrate the module in the current medical and pharmacy curricula. If proven effective, virtual patients can be used by other specialties to integrate basic science with common clinical conditions and provide more cases to teach complex disorders and topics that require repeated practice to promote competency.
Am J Kidney Dis. 2012;59(4):A1-A92
77
79 HYPONATREMIC HYPERTENSIVE SYNDROME Victor Fayad, Timothy Muchayi, Feras Helou, Omid Bakhtar, Irfan Omar, Gregory Berger. Sinai-Grace Hospital/DMC, Detroit, Michigan. Hyponatremic hypertensive syndrome is an uncommon syndrome where the reno-vascular system affects the blood pressure (BP) along with the sodium levels. The syndrome is important, in part, because it can lead to adverse outcomes in cases of misdiagnosis due to loss of water and sodium as well as uncontrolled hypertension. We report a case of a 51-year-old African American male with a past medical history of hypertension who presented to the emergency department with sudden onset of shortness of breath, diplopia, polydipsia, generalized weakness, and severe proximal muscle cramps. His medications included metoprolol, hydralazine and amlodipine. He was allergic to ACEIs due to prior development of angioedema. On physical examination, he was found to have a BP of 204/134. There were no focal neurological findings and fundoscopic exam did not demonstrate cotton wool exudates, hemorrhages or silver wiring. The rest of his physical exam was unremarkable. Serum sodium level was 122 mmol/l, potassium 2.2 mmol/l and an anion gap of 10. Serum renin level was 3565 ng/dl/hr and serum aldosterone level was 54.3 ng/dl. Urinary sodium was 45 mmol/l, urinary potassium 14.7 mmol/l and urine osmolality was 178 mOsm/kg. Chest X-ray was negative. A renal ultrasound showed atrophy of the right kidney. A Nuclear Medicine Captopril Renal Scan demonstrated split renal function of 87% and 13% in right and left kidney, respectively. Diuretics were subsequently stopped and the patient was placed on his home antihypertensives with the addition of spironolactone. He had marginal improvement in his BP. He was subsequently scheduled for a right nephrectomy after which his hypertension and hyponatermia significantly improved. The combination of hyponatremia and hypertension can be caused by renal artery stenosis, diuretic use, chronic renal failure, or reninsecreting tumors amongst others. Hyponatremic hypertensive syndrome is one of the rarest but frequently under recognized causes of this constellation. The treatment of choice is ACEIs. However, in the case of ACEI allergy, ARBs or Aliskerin can be used. Nephrectomy of the ischemic kidney is the ultimate definite treatment.
MANAGEMENT OF CHRONIC KIDNEY DISEASE IN PATIENTS WITH AND WITHOUT CONGESTIVE HEART FAILURE Manthodi Faisa1, Peter Burke2, Wei Zhang3, James Bowen3, Claudine Jurkovitz3, Rubeen Israni1 1 Nephrology Associates PA;2 Christiana Care Health Systems;3 Christiana Care Center for Outcomes Research; Newark, DE Chronic kidney disease (CKD) has been shown to be independently associated with worsening outcomes in patients with congestive heart failure (CHF), The prevalence of anemia, metabolic bone disease and malnutrition increases with advancing CKD, The management of CKD co-morbid conditions as well as preparation for dialysis in patients with CHF has not been studied. A retrospective cohort of patients followed in a large Nephrology practice between 2000 and 2010 was evaluated. Adult patients with CKD stage 3 and above were included. Dialysis and Transplant patients were excluded. The practice electronic health records (EHRs) were linked to the health system's hospital EHR to identify patients with CHF (hospital admission with a primary or secondary diagnosis of CHF). Anemia, malnutrition and metabolic bone disease management was compared between patients with and without CHF. A total of 15,448 patients were included in the analysis, of whom 3,650 (23.6%) had CHF; 46.0% of the CHF patients were female versus 48.3% of those without CHF (p=0.0187); 50.8% of those with CHF were white versus 55.5%; Comparing patients with CHF versus without CHF: mean age (SO) was 68.7 (12.9) versus 64.6 (14.5), p<0.0001; 63.4% had CKD stage 3 versus 77.4%, 29.6% had CKD stage 4 versus 18.1 % and 7.0% CKD had stage 5 versus 4.5% at entry in the study (overall p<0.0001); 14.1 % never had serum albumin measured versus 9.2%, p<0.0001 ; mean albumin was 3.7 (0.5) mg/dL versus 3.9 (0.5), p<0.0001; mean calcium was 9.1 (0.6) mg/dL versus 9.3 (0.6), p<0.0001; only 3.0% never had calcium measured versus 1.4%, p<0.0001 , whereas as many as 62.2% never had hydroxy Vitamin 0 measured versus 55.6%, p<0.0001; mean intact PTH was 144.6 (141.6) and 95.1 (112.8), p<0.0001 ; mean hemoglobin was 11.6 (1.4) versus 12.2 (1.7), p<0.0001. Finally the ratio of catheters to fistulas was 2.2 for CHF patients and 1.6 for non CHF patients. Overall CKD management was better in the non-CHF group compared to the CHF group. Differences in the management of these conditions in CKD patients with and without CHF may contribute to the higher mortality seen in CHF patients and point to modifiable risk factors.
78
80 ASSOCIATION OF SERUM SODIUM LEVELS WITH MORTALITY IN NON-DIALYSIS DEPENDENT CHRONIC KIDNEY DISEASE Vince Faridani1,4, Jun L Lu2, Kamyar KalantarZadeh3, Csaba P Kovesdy1,4, 1Virginia Tech Carilion School of Medicine, Roanoke, VA. 2Salem Research Institute, Salem VA. 3 Harbor-UCLA, Torrance, CA. 4Salem VA Medical Center, Salem VA. The outcomes associated with hyponatremia in patients with nondialysis dependent CKD (NDD-CKD) are unclear. We examined the association between serum sodium and all-cause mortality in 1,236 males (age 68 11) with CKD stage 1-5 (eGFR 37 17). Associations of time-varying outpatient serum sodium with mortality were examined in Cox models with adjustment for socio-demographics, comorbidities, labs and medication use. Nonlinear associations were explored by using cubic splines. Lower serum sodium was linearly associated with increased mortality (figure 1). A 10 mEq/L lower serum sodium was associated with a multivariable adjusted hazard ratio of all cause mortality (95% CI) of 1.60 (1.11-2.29), p=0.01. Hyponatremia is associated with increased mortality in patients with moderate and advanced NDD-CKD. Interventional trials are needed to determine if correction of hyponatremia can result in improved outcomes in this population.
A34
VIRTUAL PATIENTS TO TEACH ELECTROLYTE DISORDERS Laura Ferreira Provenzano, Kristine Schonder, Hoda Kaldas. University of Pittsburgh, School of Medicine and School of Pharmacy, Pittsburgh, PA, USA Electrolyte abnormalities are common. Accurate patient assessment and lab interpretation are critical in their management. Medical and pharmacy students are taught physiology of electrolyte disorders in the didactic portion of the curriculum. Cases are reviewed through lectures or bedside discussion during clinical rotations. The complexity of these disorders makes students unable to achieve competency unless exposed to many cases. Previous studies showed most students lack electrolyte management competency. Those with the opportunity to practice problem solving score better on tests than those who depend on standard teaching methods. We propose an innovative approach to teach electrolyte disorders using VpSim, an online virtual patient player, authoring and administration application for medical education. Virtual patients are computer simulations of clinical encounters where learners interact with an on-screen patient. Course objectives were established with the aid of experts in the field. The first phase involved development of four cases to teach water disorders (hypo and hypernatremia). Cases included a clinical scenario and questions covering key aspects of the pathophysiology and treatment of the disorder. Questions were followed by pertinent feedback and combined with a tutorial integrating the physiology learned in the curriculum with clinical aspects of the virtual patient. Cases also allowed experiencing possible harms associated with mismanagement. They were reviewed by 3 senior nephrologists for content and level of difficulty. Cases will be validated to assess effectiveness in improving knowledge by comparing scores of pre and posttests and the feasibility to integrate the module in the current medical and pharmacy curricula. If proven effective, virtual patients can be used by other specialties to integrate basic science with common clinical conditions and provide more cases to teach complex disorders and topics that require repeated practice to promote competency.
Am J Kidney Dis. 2012;59(4):A1-A92