- Email: [email protected]
143 Staphylococcus Schleiferi Subsp. Coagulans Bacteremia in a Immunocompromised Hemodialysis Patient
NKF 2011 Spring Clinical Meetings Abstracts
141 BASELINE CHARACTERISTICS OF SUBJECTS IN IMPACTSHPT: A STUDY TO EVALUATE THE EFFICACY AND SAFETY OF PARICALCITOL AND CINACALCET IN HEMODIALYSIS PATIENTS WITH SECONDARY HYPERPARATHYROIDISM Markus Ketteler1, Kevin Martin2, Mario Cozzolino3, David Goldsmith4, Amit Sharma5, Myles Wolf 6, Samina Khan7, Michael Amdahl7, Emily Dumas7, and Paul Audhya7 1 Klinikum Coburg, Germany; 2Saint Louis University, USA; 3Paolo Hospital, Italy; 4Guy’s Hospital, UK; 5Boise Kidney and Hypertension Institute, USA; 6Univ. of Miami, USA; 7 Abbott Laboratories, USA Paricalcitol and the combination therapy of cinacalcet with low-dose vitamin D are used to treat SHPT in dialysis patients. IMPACT SHPT is an ongoing, randomized, 28 week open-label trial that compares the efficacy and safety of paricalcitol vs. cinacalcet-centered therapies in hemodialysis patients. The primary endpoint is the proportion of subjects achieving a mean iPTH between 150-300 pg/mL during weeks 21 to 28. Baseline characteristics (Table 1) were similar in both groups except for calcium (p=0.036), phosphorus (p=0.043) and diastolic BP (0.031). Results will allow evaluation of the effectiveness and safety of paricalcitol vs. cinacalcet and low-dose vitamin D therapies in treatment of SHPT.
142 CAST NEPHROPATHY AS A HARBINGER OF HISTOLOGIC TRANSFORMATION OF WALDENSTROM MACROGLOBULINEMIA Binaya Khanal, Anjali Parajuli, Sylvia Betcher SUNY Upstate Medical University, Syracuse, New York We report a 71 year old male who was diagnosed with Waldenstrom macroglobulinemia 9 years ago with urine Ig M paraprotein and retroperitoneal lymphadenopathy. Of note, he was treated with four cycles of Rituximab infusion in the past. He presented suddenly with non-oliguric acute kidney injury with serum creatinine of 4.6. He was asymptomatic and hemodynamically stable. Random urine protein creatinine ratio was 4 although urine dipstick showed only 30 protein. Renal biopsy showed myeloma cast nephropathy with Ig G lambda paraprotein. Glomeruli did not show mesangial matrix increase, hypercellularity or amyloid. Of note, serum immunofixation electrophoresis showed Ig G kappa and Ig M lambda paraproteins quantitatively increased compared to 9 years ago. Similarly, urine immunofixation electrophoresis also showed much higher quantitative free kappa and lambda light chains. The patient underwent series of plasmapheresis and his renal function improved. Bone marrow biopsy was suggestive of Ig G lambda plasma cell myeloma with 60% plasma cell infiltration. Of note, bone marrow biopsy 9 years ago was negative for myeloma. He was then treated with Bortezomib and Dexamethasone. Unfortunately, he gradually worsened kidney function and was started on hemodialysis. Waldenstrom macroglulinemia is a rare disorder characterized by circulating monoclonal Ig M and lymphoplasmocytic lymphoma in bone marrow. Although our patient was asymptomatic, patients present with symptoms due to infiltration of hematopoitic tissues or the effect of circulating Ig M. Renal failure is unusual and especially cast nephropathy doesnot occur due to very less urinary light chains compared with myeloma. Acute kidney injury in this setting deserves renal biopsy because of rare possibility of cryoglobulinemia, tumor cell infiltration or immune mediated glomerulonephritis. The cast nephropathy on renal biopsy in our case suggested the histologic transformation of bone marrow to plasma cell myeloma.
A52
143 STAPHYLOCOCCUS SCHLEIFERI SUBSP. COAGULANS BACTEREMIA IN A IMMUNOCOMPROMISED HEMODIALYSIS PATIENT Binaya Khanal, Sandra Bird, Anjali Parajuli SUNY Upstate Medical University, Syracuse, New York We report a 54 year old male with end stage renal disease due to hypertensive nephrosclerosis on maintainence hemodialysis. He also had liver transplant 6 years ago for end stage alcoholic liver disease. Of note, the patient was on Tacrolimus 2 mg twice a day orally. Internal jugular cuffed tunneled catheter was used for dialysis access because his left forearm fistula clotted 3 months ago. He presented with fever of 39 degree centigrade and chills without localizing symptoms. Blood cultures (2 out of 2) were positive for Staphylococcus intermedius. He was treated with intravenous Cefazolin for 3 weeks and the catheter was salvaged. Three months later, the patient developed high fever and chills again. Peripheral blood cultures grew Staphylococcous schleiferi subsp. coagulans in 2 out of 2 cultures. The organism was resistant to oxacillin and ampicillin but susceptible to clindamycin, tertracycline and linezolid. The hemodialysis catheter was removed and replaced. He was started on intravenous Linezolid for 2 weeks. Repeat blood cultures 2 weeks later showed no growth. Staphylococcus schleiferi sp coagulans has been described very rarely with human pathogenicity. Case reports on infection with this organism are usually described in dogs causing otitis externa. Our patient did not have pet at home, however he often visited his daughter who has a pet dog. To our knowledge, staphylococcus schleiferi subsp. coagulans bacteremia in hemodialysis patients has hardly ever been described. Of note, these organisms are closely related phenotypically to S. intermedius than other staphylococcus. Similarities in phenotypic and microbiological characteristics between S. schleiferi subsp. coagulans and S. aureus have resulted in frequent misidentification. It is also possible that we confused with S. intermedius in our case for the first episode of bacteremia.
144 ASSOCIATION OF EDUCATION LEVEL WITH DIALYSIS OUTCOME Muhammad Khattak, Gurprataap S. Sandhu, Ranil Desilva, Jalaj Garg, Alexander Goldfarb-Rumyantzev, Beth Israel Deaconess Medical Center. The impact of education on health care outcome has been studied in the past but its role in the dialysis population is unclear. The objective of this retrospective study was to evaluate the association of the education level with dialysis outcome. We analyzed USRDS data of patients with ESRD aged ≥18 years. Education level at the time of ESRD onset was the primary variable of interest. The outcome of the study was patient mortality. We used four categories of education level: 0 = less than 12 years of education; 1 = high school graduate; 2 =some college; 3 = college graduate. Subgroups based on age, race, sex, donor type and diabetic status were also analyzed. After adjustments for covariates in Cox model, using individuals with less than 12 years of education as a reference, patients with college education showed decreased mortality with HR of 0.81, p = 0.010. Hazard Ratio (95% CI) p Education less than 12 years
Reference
Education: High school graduate
0.99 (0.88-1.11)
0.861
Education: Some college
0.90 (0.78-1.05)
0.193
Education: College graduate
0.81 (0.69-0.95)
0.010
We showed that higher education level is associated with improved survival of patients on dialysis.
Am J Kidney Dis. 2011;57(4):A1-A108
141 BASELINE CHARACTERISTICS OF SUBJECTS IN IMPACTSHPT: A STUDY TO EVALUATE THE EFFICACY AND SAFETY OF PARICALCITOL AND CINACALCET IN HEMODIALYSIS PATIENTS WITH SECONDARY HYPERPARATHYROIDISM Markus Ketteler1, Kevin Martin2, Mario Cozzolino3, David Goldsmith4, Amit Sharma5, Myles Wolf 6, Samina Khan7, Michael Amdahl7, Emily Dumas7, and Paul Audhya7 1 Klinikum Coburg, Germany; 2Saint Louis University, USA; 3Paolo Hospital, Italy; 4Guy’s Hospital, UK; 5Boise Kidney and Hypertension Institute, USA; 6Univ. of Miami, USA; 7 Abbott Laboratories, USA Paricalcitol and the combination therapy of cinacalcet with low-dose vitamin D are used to treat SHPT in dialysis patients. IMPACT SHPT is an ongoing, randomized, 28 week open-label trial that compares the efficacy and safety of paricalcitol vs. cinacalcet-centered therapies in hemodialysis patients. The primary endpoint is the proportion of subjects achieving a mean iPTH between 150-300 pg/mL during weeks 21 to 28. Baseline characteristics (Table 1) were similar in both groups except for calcium (p=0.036), phosphorus (p=0.043) and diastolic BP (0.031). Results will allow evaluation of the effectiveness and safety of paricalcitol vs. cinacalcet and low-dose vitamin D therapies in treatment of SHPT.
142 CAST NEPHROPATHY AS A HARBINGER OF HISTOLOGIC TRANSFORMATION OF WALDENSTROM MACROGLOBULINEMIA Binaya Khanal, Anjali Parajuli, Sylvia Betcher SUNY Upstate Medical University, Syracuse, New York We report a 71 year old male who was diagnosed with Waldenstrom macroglobulinemia 9 years ago with urine Ig M paraprotein and retroperitoneal lymphadenopathy. Of note, he was treated with four cycles of Rituximab infusion in the past. He presented suddenly with non-oliguric acute kidney injury with serum creatinine of 4.6. He was asymptomatic and hemodynamically stable. Random urine protein creatinine ratio was 4 although urine dipstick showed only 30 protein. Renal biopsy showed myeloma cast nephropathy with Ig G lambda paraprotein. Glomeruli did not show mesangial matrix increase, hypercellularity or amyloid. Of note, serum immunofixation electrophoresis showed Ig G kappa and Ig M lambda paraproteins quantitatively increased compared to 9 years ago. Similarly, urine immunofixation electrophoresis also showed much higher quantitative free kappa and lambda light chains. The patient underwent series of plasmapheresis and his renal function improved. Bone marrow biopsy was suggestive of Ig G lambda plasma cell myeloma with 60% plasma cell infiltration. Of note, bone marrow biopsy 9 years ago was negative for myeloma. He was then treated with Bortezomib and Dexamethasone. Unfortunately, he gradually worsened kidney function and was started on hemodialysis. Waldenstrom macroglulinemia is a rare disorder characterized by circulating monoclonal Ig M and lymphoplasmocytic lymphoma in bone marrow. Although our patient was asymptomatic, patients present with symptoms due to infiltration of hematopoitic tissues or the effect of circulating Ig M. Renal failure is unusual and especially cast nephropathy doesnot occur due to very less urinary light chains compared with myeloma. Acute kidney injury in this setting deserves renal biopsy because of rare possibility of cryoglobulinemia, tumor cell infiltration or immune mediated glomerulonephritis. The cast nephropathy on renal biopsy in our case suggested the histologic transformation of bone marrow to plasma cell myeloma.
A52
143 STAPHYLOCOCCUS SCHLEIFERI SUBSP. COAGULANS BACTEREMIA IN A IMMUNOCOMPROMISED HEMODIALYSIS PATIENT Binaya Khanal, Sandra Bird, Anjali Parajuli SUNY Upstate Medical University, Syracuse, New York We report a 54 year old male with end stage renal disease due to hypertensive nephrosclerosis on maintainence hemodialysis. He also had liver transplant 6 years ago for end stage alcoholic liver disease. Of note, the patient was on Tacrolimus 2 mg twice a day orally. Internal jugular cuffed tunneled catheter was used for dialysis access because his left forearm fistula clotted 3 months ago. He presented with fever of 39 degree centigrade and chills without localizing symptoms. Blood cultures (2 out of 2) were positive for Staphylococcus intermedius. He was treated with intravenous Cefazolin for 3 weeks and the catheter was salvaged. Three months later, the patient developed high fever and chills again. Peripheral blood cultures grew Staphylococcous schleiferi subsp. coagulans in 2 out of 2 cultures. The organism was resistant to oxacillin and ampicillin but susceptible to clindamycin, tertracycline and linezolid. The hemodialysis catheter was removed and replaced. He was started on intravenous Linezolid for 2 weeks. Repeat blood cultures 2 weeks later showed no growth. Staphylococcus schleiferi sp coagulans has been described very rarely with human pathogenicity. Case reports on infection with this organism are usually described in dogs causing otitis externa. Our patient did not have pet at home, however he often visited his daughter who has a pet dog. To our knowledge, staphylococcus schleiferi subsp. coagulans bacteremia in hemodialysis patients has hardly ever been described. Of note, these organisms are closely related phenotypically to S. intermedius than other staphylococcus. Similarities in phenotypic and microbiological characteristics between S. schleiferi subsp. coagulans and S. aureus have resulted in frequent misidentification. It is also possible that we confused with S. intermedius in our case for the first episode of bacteremia.
144 ASSOCIATION OF EDUCATION LEVEL WITH DIALYSIS OUTCOME Muhammad Khattak, Gurprataap S. Sandhu, Ranil Desilva, Jalaj Garg, Alexander Goldfarb-Rumyantzev, Beth Israel Deaconess Medical Center. The impact of education on health care outcome has been studied in the past but its role in the dialysis population is unclear. The objective of this retrospective study was to evaluate the association of the education level with dialysis outcome. We analyzed USRDS data of patients with ESRD aged ≥18 years. Education level at the time of ESRD onset was the primary variable of interest. The outcome of the study was patient mortality. We used four categories of education level: 0 = less than 12 years of education; 1 = high school graduate; 2 =some college; 3 = college graduate. Subgroups based on age, race, sex, donor type and diabetic status were also analyzed. After adjustments for covariates in Cox model, using individuals with less than 12 years of education as a reference, patients with college education showed decreased mortality with HR of 0.81, p = 0.010. Hazard Ratio (95% CI) p Education less than 12 years
Reference
Education: High school graduate
0.99 (0.88-1.11)
0.861
Education: Some college
0.90 (0.78-1.05)
0.193
Education: College graduate
0.81 (0.69-0.95)
0.010
We showed that higher education level is associated with improved survival of patients on dialysis.
Am J Kidney Dis. 2011;57(4):A1-A108