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118: Pitfalls of Vitamin D Replacement Therapy
NKF 2010 Spring Clinical Meetings Abstracts
117 INCIDENCE OF VASCULAR ACCESS TYPE AFTER RENAL ALLOGRAFT FAILURE. Karn Gupta, Micah Chan, Henry Young, Arjang Djamali, Alexander Yevzlin, University of Wisconsin, Madison, WI, USA. Arteriovenous fistulae (AVF) are widely regarded as the preferred vascular access in hemodialysis patients due to their primary patency and survival benefits. Even though allograft survival has improved based on UNOS, chronic allograft nephropathy continues to be the most prevalent cause of late transplant graft failure. Recent literature has suggested that perhaps initiation of dialysis in chronic kidney disease-transplant (CKD-T) patients may be too late and perhaps clinical practice guidelines should also be established as in CKD. Most of the data available regarding incidence of different vascular types is for failed native kidneys. As renal transplant patients are closely followed by transplant physicians, it would be expected that they have a higher incidence of AVF/AVG compared to catheters. The purpose of this study is to determine the type of vascular access in incident hemodialysis patients after a failed renal transplant. We performed a retrospective review of all failed renal transplant patients who initiated HD between January 1991 to December 2001 at our institution. Vascular access type at one month and three months from the start of HD was recorded. A total of 104 patients were identified out of which 51.9% were male, 30.8% diabetics, 98% white and 30.8% with re-transplant. At one month, 47.2% had a central venous catheter compared to 15.3% with AVF and 13.9% with AVG. At three months, 41.4% had a central venous catheter compared to 15.7% with AVF and 18.6% with AVG. 11.4% patients were started on PD. Multinomial logit regression showed females to have a higher likelihood of having a catheter at both one and three months (p=0.03 at one month and p<0.01 at 3 months). Diabetics also had a higher likelihood of having a catheter at one month (p=0.04). Our study shows that central venous catheters are still the most prevalent access type even in failed renal transplant patients. Our results emphasize the need for earlier recognition and acceptance of a failing renal transplant and need for earlier referral for access placement.
118 PITFALLS OF VITAMIN D REPLACEMENT THERAPY Renu Gupta1, Peter Van1, Neville R Dossabhoy1,2 1.Department of Medicine, LSUHSC, Shreveport , LA, USA 2.Division of Nephrology, VA Medical Center, Shreveport, LA, USA Vitamin D plays a vital role in the metabolic functions of the body. Since it requires renal activation, many patients with chronic kidney disease (CKD) have low levels. Recent epidemiologic studies have suggested that adequate levels of vitamin D improve morbidity and mortality in patients with CKD, hence KDOQI guidelines have recommended replacement therapy. We present the case of a 47-year-old African American male nursing home resident who presented to clinic complaining of progressively worsening nausea, vomiting and sleep disturbance for an uncertain amount of time. Past history included CKD secondary to type II diabetes mellitus. He also had vitamin D deficiency, for which he was getting oral ergocalciferol 50,000 international units (IU) monthly. He was later started on IV paricalcitol for secondary hyperparathyroidism upon initiating hemodialysis, with doses titrated per his parathyroid hormone (iPTH) levels. Physical examination was within normal limits. Labs drawn that day included iPTH and both 25 and 1,25 hydroxy Vitamin D levels. Levels returned one week later, showing his 25[OH]D level was >155 ng/mL (increased from 30.9 ng/mL) and his 1,25[OH]D level was 23.9 pg/mL (decreased from 27.4 pg/mL). iPTH levels were at goal. Review of his medication administration record from the nursing home revealed that he had erroneously received oral ergocalciferol 50,000 IU daily for the previous 69 days. The patient was called back and evaluated for signs and symptoms of vitamin D toxicity. During attempted replacement with both ergocalciferol and paricalcitol, our patient developed toxic levels of 25[OH]D, but 1,25[OH]D levels remained within normal limits - in fact, decreased slightly – in spite of supratherapeutic ergocalciferol doses. This case demonstrates that there may not be much benefit in supplementing CKD patients with compounds that require renal conversion for activation and may, in fact, expose them to the risk of toxicity. This case report gives an example of the pitfalls faced in replacing vitamin D in patients with CKD.
A61
119 STAPHYLOCOCCUS LUGDUNENSIS MITRAL VALVE ENDOCARDITIS IN A PATIENT ON CHRONIC HEMODIALYSIS Renu Gupta1, Fereidoon Shafiei1, V. K Rao1 1. Department of Medicine, LSUHSC, Shreveport, LA, USA Staphylococcus species is increasingly recognized as a cause of virulent infections including endocarditis. We describe a case in which coagulasenegative staphylococcus in blood was anything but a contaminant. A 47-year-old African American male presented to the emergency room with complaints of shortness of breath, fever and pleuritic chest pain of one day duration. He had end stage renal disease on chronic hemodialysis, Type II diabetes mellitus and anemia. He was febrile (102.4°F), tachycardic, hypertensive and had bilateral pulmonary crackles and pedal edema. He had been hospitalized 5 weeks prior with Staphylococcus lugdunensis bacteremia and an infected 2-week-old arterio-venous graft which had purulent discharge. At that point, the graft and his tunneled catheter were removed and he was treated with a 4 week course of vancomycin. A temporary dialysis catheter was placed. Echocardiogram during the current visit revealed large mitral valve vegetations and severe mitral regurgitation. He underwent a mitral valve replacement and was initiated on intravenous antibiotics. He also developed right brachial artery emboli that required embolectomy. He was subsequently discharged in a stable condition. S. lugdunensis is a coagulase-negative staphylococcus (CNS). It is unique among CNS because of its propensity for causing aggressive native valve infective endocarditis. A proteinaceous biofilm formation is believed to play a major role in the pathogenesis, especially in the setting of catheters. The mortality rate of S. lugdunensis endocarditis rivals that of Staphylococcus aureus. S. lugdunensis is generally susceptible to betalactam agents. If speciation is not performed, these bacteria might be mistaken for Staphylococcus epidermidis, a relatively avirulent bacterium that is a common contaminant of cultures. Endocarditis due to this organism is characterized by high mortality, rapid tissue destruction, and a predilection for native valves. Because the clinical outcome is much more favorable with valvular replacement, speciation of the organism assumes great importance in defining the therapeutic approach and resultant outcomes.
120 UTILITY OF SCUF IN HYPOTENSIVE ICU PATIENTS Mohit Gupta , Rouzbeh Afsari, Stephanie Tzarnas, Neha Bansal, Simi Shahabdeen, Nauman Shahid, Prasanna Srinagesh,, Ziauddin Ahmed Drexel University College of Medicine, Philadelphia, PA, USA Despite severe volume overload sometimes it is difficult to remove fluid by Continuous VenoVenous Hemofiltration (CVVH) in some ICU patients. Different methods have been tried to maintain hemodynamic stability such as use of vasopressors (VP), decreasing ultra filtration (UF) rate, isovolemic CVVH etc. Slow continuous UF (SCUF) was performed in two patients who needed volume removal but could not tolerate even isovolemic CVVH due to hypotension. Data was collected on 2 such patients in the ICU which included the mode of therapy (CVVH vs SCUF), use of VP, volume removed per day, blood pressure (BP), blood flow rate and dialysate flow rate. The first patient a 64 year old female with ESRD (end stage renal disease) on Hemodialysis was admitted to the ICU due to sepsis. The CVVH was started due to hypotension. After 2 days, despite being on isovolemic CVVH, patient exhibited hypotension, increase in VP and oxygen requirement. CVVH was switched to SCUF and in next 24 hours 6.3 liters of fluid was removed, VP requirement decreased with improvement of BP. CVVH was reintroduced due to hyperkalemia after 2 days of SCUF and the patient again became hypotensive. The modality was then switched to SCUF with successful removal of 3.9 to 4.2 liter of fluid per day. During this time the antibiotic regimen was re-adjusted, the patient became alert and was extubated. CVVH was resumed for hyperkalemia and the patient at this time tolerated the CVVH. The second patient a 58 year old female presented with septic shock and was placed on CVVH and antibiotics. Patient had significant volume overload, however she became hypotensive, requiring increased VP despite being on isovolemic CVVH. SCUF was utilized twice and both the times 3.4 and 5.2 liters volume per day was removed with subsequent improvement in BP and decreased need for VP. This patient also subsequently tolerated CVVH. From the above observation it appears that there can be an interim role of SCUF in critically ill patients when CVVH is not tolerated. A larger study is needed to confirm this finding.
117 INCIDENCE OF VASCULAR ACCESS TYPE AFTER RENAL ALLOGRAFT FAILURE. Karn Gupta, Micah Chan, Henry Young, Arjang Djamali, Alexander Yevzlin, University of Wisconsin, Madison, WI, USA. Arteriovenous fistulae (AVF) are widely regarded as the preferred vascular access in hemodialysis patients due to their primary patency and survival benefits. Even though allograft survival has improved based on UNOS, chronic allograft nephropathy continues to be the most prevalent cause of late transplant graft failure. Recent literature has suggested that perhaps initiation of dialysis in chronic kidney disease-transplant (CKD-T) patients may be too late and perhaps clinical practice guidelines should also be established as in CKD. Most of the data available regarding incidence of different vascular types is for failed native kidneys. As renal transplant patients are closely followed by transplant physicians, it would be expected that they have a higher incidence of AVF/AVG compared to catheters. The purpose of this study is to determine the type of vascular access in incident hemodialysis patients after a failed renal transplant. We performed a retrospective review of all failed renal transplant patients who initiated HD between January 1991 to December 2001 at our institution. Vascular access type at one month and three months from the start of HD was recorded. A total of 104 patients were identified out of which 51.9% were male, 30.8% diabetics, 98% white and 30.8% with re-transplant. At one month, 47.2% had a central venous catheter compared to 15.3% with AVF and 13.9% with AVG. At three months, 41.4% had a central venous catheter compared to 15.7% with AVF and 18.6% with AVG. 11.4% patients were started on PD. Multinomial logit regression showed females to have a higher likelihood of having a catheter at both one and three months (p=0.03 at one month and p<0.01 at 3 months). Diabetics also had a higher likelihood of having a catheter at one month (p=0.04). Our study shows that central venous catheters are still the most prevalent access type even in failed renal transplant patients. Our results emphasize the need for earlier recognition and acceptance of a failing renal transplant and need for earlier referral for access placement.
118 PITFALLS OF VITAMIN D REPLACEMENT THERAPY Renu Gupta1, Peter Van1, Neville R Dossabhoy1,2 1.Department of Medicine, LSUHSC, Shreveport , LA, USA 2.Division of Nephrology, VA Medical Center, Shreveport, LA, USA Vitamin D plays a vital role in the metabolic functions of the body. Since it requires renal activation, many patients with chronic kidney disease (CKD) have low levels. Recent epidemiologic studies have suggested that adequate levels of vitamin D improve morbidity and mortality in patients with CKD, hence KDOQI guidelines have recommended replacement therapy. We present the case of a 47-year-old African American male nursing home resident who presented to clinic complaining of progressively worsening nausea, vomiting and sleep disturbance for an uncertain amount of time. Past history included CKD secondary to type II diabetes mellitus. He also had vitamin D deficiency, for which he was getting oral ergocalciferol 50,000 international units (IU) monthly. He was later started on IV paricalcitol for secondary hyperparathyroidism upon initiating hemodialysis, with doses titrated per his parathyroid hormone (iPTH) levels. Physical examination was within normal limits. Labs drawn that day included iPTH and both 25 and 1,25 hydroxy Vitamin D levels. Levels returned one week later, showing his 25[OH]D level was >155 ng/mL (increased from 30.9 ng/mL) and his 1,25[OH]D level was 23.9 pg/mL (decreased from 27.4 pg/mL). iPTH levels were at goal. Review of his medication administration record from the nursing home revealed that he had erroneously received oral ergocalciferol 50,000 IU daily for the previous 69 days. The patient was called back and evaluated for signs and symptoms of vitamin D toxicity. During attempted replacement with both ergocalciferol and paricalcitol, our patient developed toxic levels of 25[OH]D, but 1,25[OH]D levels remained within normal limits - in fact, decreased slightly – in spite of supratherapeutic ergocalciferol doses. This case demonstrates that there may not be much benefit in supplementing CKD patients with compounds that require renal conversion for activation and may, in fact, expose them to the risk of toxicity. This case report gives an example of the pitfalls faced in replacing vitamin D in patients with CKD.
A61
119 STAPHYLOCOCCUS LUGDUNENSIS MITRAL VALVE ENDOCARDITIS IN A PATIENT ON CHRONIC HEMODIALYSIS Renu Gupta1, Fereidoon Shafiei1, V. K Rao1 1. Department of Medicine, LSUHSC, Shreveport, LA, USA Staphylococcus species is increasingly recognized as a cause of virulent infections including endocarditis. We describe a case in which coagulasenegative staphylococcus in blood was anything but a contaminant. A 47-year-old African American male presented to the emergency room with complaints of shortness of breath, fever and pleuritic chest pain of one day duration. He had end stage renal disease on chronic hemodialysis, Type II diabetes mellitus and anemia. He was febrile (102.4°F), tachycardic, hypertensive and had bilateral pulmonary crackles and pedal edema. He had been hospitalized 5 weeks prior with Staphylococcus lugdunensis bacteremia and an infected 2-week-old arterio-venous graft which had purulent discharge. At that point, the graft and his tunneled catheter were removed and he was treated with a 4 week course of vancomycin. A temporary dialysis catheter was placed. Echocardiogram during the current visit revealed large mitral valve vegetations and severe mitral regurgitation. He underwent a mitral valve replacement and was initiated on intravenous antibiotics. He also developed right brachial artery emboli that required embolectomy. He was subsequently discharged in a stable condition. S. lugdunensis is a coagulase-negative staphylococcus (CNS). It is unique among CNS because of its propensity for causing aggressive native valve infective endocarditis. A proteinaceous biofilm formation is believed to play a major role in the pathogenesis, especially in the setting of catheters. The mortality rate of S. lugdunensis endocarditis rivals that of Staphylococcus aureus. S. lugdunensis is generally susceptible to betalactam agents. If speciation is not performed, these bacteria might be mistaken for Staphylococcus epidermidis, a relatively avirulent bacterium that is a common contaminant of cultures. Endocarditis due to this organism is characterized by high mortality, rapid tissue destruction, and a predilection for native valves. Because the clinical outcome is much more favorable with valvular replacement, speciation of the organism assumes great importance in defining the therapeutic approach and resultant outcomes.
120 UTILITY OF SCUF IN HYPOTENSIVE ICU PATIENTS Mohit Gupta , Rouzbeh Afsari, Stephanie Tzarnas, Neha Bansal, Simi Shahabdeen, Nauman Shahid, Prasanna Srinagesh,, Ziauddin Ahmed Drexel University College of Medicine, Philadelphia, PA, USA Despite severe volume overload sometimes it is difficult to remove fluid by Continuous VenoVenous Hemofiltration (CVVH) in some ICU patients. Different methods have been tried to maintain hemodynamic stability such as use of vasopressors (VP), decreasing ultra filtration (UF) rate, isovolemic CVVH etc. Slow continuous UF (SCUF) was performed in two patients who needed volume removal but could not tolerate even isovolemic CVVH due to hypotension. Data was collected on 2 such patients in the ICU which included the mode of therapy (CVVH vs SCUF), use of VP, volume removed per day, blood pressure (BP), blood flow rate and dialysate flow rate. The first patient a 64 year old female with ESRD (end stage renal disease) on Hemodialysis was admitted to the ICU due to sepsis. The CVVH was started due to hypotension. After 2 days, despite being on isovolemic CVVH, patient exhibited hypotension, increase in VP and oxygen requirement. CVVH was switched to SCUF and in next 24 hours 6.3 liters of fluid was removed, VP requirement decreased with improvement of BP. CVVH was reintroduced due to hyperkalemia after 2 days of SCUF and the patient again became hypotensive. The modality was then switched to SCUF with successful removal of 3.9 to 4.2 liter of fluid per day. During this time the antibiotic regimen was re-adjusted, the patient became alert and was extubated. CVVH was resumed for hyperkalemia and the patient at this time tolerated the CVVH. The second patient a 58 year old female presented with septic shock and was placed on CVVH and antibiotics. Patient had significant volume overload, however she became hypotensive, requiring increased VP despite being on isovolemic CVVH. SCUF was utilized twice and both the times 3.4 and 5.2 liters volume per day was removed with subsequent improvement in BP and decreased need for VP. This patient also subsequently tolerated CVVH. From the above observation it appears that there can be an interim role of SCUF in critically ill patients when CVVH is not tolerated. A larger study is needed to confirm this finding.