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15 Clinical Presentation of Infection in Catheter-Dependent Hemodialysis Patients
NKF 2011 Spring Clinical Meetings Abstracts
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15 CLINICAL PRESENTATION OF INFECTION IN CATHETERDEPENDENT HEMODIALYSIS PATIENTS Yaser Al-Solaiman, Erin Estrada, Michael Allon University Of Alabama at Birmingham, Birmingham, AL, USA We evaluated prospectively the clinical presentation, microbiology, and outcomes of all cases of suspected infection in catheter-dependent HD pts during a 1.5-year period. Of 312 cases of suspected infection, an infection was confirmed in 271 cases (87%). Among those patients with confirmed infection, 34 (12%) had a non-access-related infection (including pneumonia, UTI, skin abscess, foot infection, etc), whereas the remainder had an access-related infection. The 237 access-related infections included 19 AVG infections, 8 AVF infections, 4 with Tenckhoff-related peritonitis, 21 with HD catheter exit site infections, and 186 episodes of catheter-related bacteremia (CRB). The infecting organism in CRB was Staph aureus (29%), Staph epi (38%), Enterococcus (22%), GNR (20%). Polymicrobial CRB occurred in 8% of episodes. Only 74 of 186 pts (40%) with CRB presented with fever (temp > 38oC). The remainder presented with rigors (N=67), “low grade” fever (temp 37.5-37.9oC)(N=25), exit site infection, or altered mental status. Hospitalization was required in 34% of CRB episodes, and 66% were treated as outpatients. The likelihood of hospitalization varied by organism (51% for Staph aureus, 28% for Staph epi, 30% for Enterococcus, and 17% for GNR, p<0.001). In summary, the vast majority of catheter-dependent HD patients have some type of infection, but only 59% have CRB. The majority of patients with documented CRB present without fever. Finally, the ikelihood of hospitalization for CRB varies by infecting organism, being highest for Staph aureus, and lowest for GNR.
EFFECTIVENESS OF 25 HYDROXY VITAMIN D ON SECONDARY HYPERPARATHYROIDISM IN HEMDIALYSIS PATIENTS Tarek Alhamad, Hongling Yang, Karim Harfouche, Safa Farrag,Wassim Radwan, Babak Rajabi and Pedro Blandon. Texas Tech University HSC, Paul L. Foster SOM, El Paso, Texas. Among Hemodialysis (HD) patients, Secondary hyperparathyroidism (SHPT) is a common finding. According to KDOQI guidelines, the recommended targets for dialysis patients have been set between 150 and 300 pg/mL using intact parathyroid hormone (iPTH). However, it does not recommend any native vitamin D supplementation. It has been shown that non-renal tissue will process the 25 hydroxy Vitamin D into 1,25 hydroxy Vitamin D. Objective is to study if replacing 25 Hydroxy Vitamin D levels in HD patients with SHPT would decrease the iPTH to the desired rang according the K-DOQI guidelines. We included 43 HD patients in this study from our local dialysis facility. Inclusion criteria were: 1) 25 hydroxy Vitamin D deficiency identified as: 25 hydroxy Vitamin D was less than 30 ng per milliliter. 2) SHPT identified as: PTH intact level was more than 300 pg per milliliter. The study was open-labeled in two groups. Group one (Vitamin D group) was given Ergocalciferol, whereas, group two was the control one (no Vitamin D2 or D3 was given). 15 patients were enrolled in the Vitamin D group, and 28 were considered in the control group. A response to Vitamin D was identified as a patient who, at the end of the study period, met one of the following criteria: I PTH less or equal to 300 pg per milliliter, Phosphate less or equal 5.5 mg/dl, or corrected Calcium less or equal to 10.5 mg/dl. We found that no significant difference was noticed in the PTH level, Calcium, or phosphate in the Vitamin D group comparing to the control group. In Conclusion, replacing Vitamin D2 in HD patients with 25 hydroxy Vitamin D deficiency and secondary hyperparathyroidism does not have a significant decrease in the Intact PTH level.
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16 RHABDOMYOLYSIS CAUSED BY UNUSUAL INTERACTION BETWEEN SIMVASTATIN AND AZITHROMYCIN Gaurav Alreja, Sadiq Inayatullah, Saurabh Goel, Gregory Braden Baystate Medical Center, Tufts University, Springfield, Massachusetts. Rhabdomyolysis (rhabdo) is an uncommon but life-threatening adverse effect of statin therapy. We report a rare case of rhabdo caused by potential drug interaction between simvastatin and azithromycin. A 73 yr Caucasian male with history of chronic kidney disease stage 3 due to idiopathic interstitial nephritis (baseline Cr 1.7 mg/dl), diabetes mellitus, hypertension, hyperlipidemia presented with weakness of lower extremities for 1 week. His medications included allopurinol prednisone, labetalol, bumetanide and simvastatin 80 mg/d (for 2 yrs). He received Azithromycin (AZI) 500 mg followed by 250 mg daily for next 4 days, 1 wk ago for acute bronchitis. He was found to have rhabdo with CPK of 11,240 U/L and Cr of 3.8 mg/dl. Discontinuation of simvastatin with IV hydration and bicarbonate resulted in resolution of rhabdo. Simvastatin was reintroduced at 40 mg/d after 2 months and later increased to 80 mg/d without any subsequent recurrence of myalgia or weakness. Rhabdo related deaths have been reported with all statins except fluvastatin. Important variables affecting its occurrence include statin dose, patient characteristics and concurrent use of other medications that may alter the pharmacokinetics of the statins. Simvastatin and lovastatin are metabolized by CYP3A4, AZI by both CYP3A3 & 3A4 and fluvastatin by CYC2C9 enzyme system. Macrolides inhibit CYP3A4, thus elevating the statin levels. However, AZI (an azalide, subclass of macrolide) interferes poorly with CYP3A4 & after hepatic metabolism gets excreted in the bile. Although, rhabdo with AZI & lovastatin has been previously reported, this is a rare reported case of rhabdo caused by co-administration of AZI and simvastatin. Polymorphism of CYP3A4 might explain such rare cases despite insignificant inhibition by AZT in studies. Interference in biliary excretion of statins by AZT (through P-glycoprotein and multi drug resistance protein) might be another mechanism. His advanced age, underlying CKD and high dose of simvastatin might also have contributed to this rare complication. In conclusion, AZI might be coadministered with statins, with caution as there is risk of rhabdo.
A20
EFFECT OF INSULIN THERAPY OR ORAL HYPOGLYCEMIC THERAPY ON THE ARTERIAL BLOOD PRESSURE AND CARDIOVASCULAR EVENTS IN PROTEINURIC NEPHROPATHY PATIENTS Jamal Al Wakeel1, Durdana Hammad1, Youssef MK Farag1 1 King Saud University-King Khalid University Hospital, Riyadh, Saudi Arabia Diabetic patients have significantly increased cardiovascular and renal events. We evaluated the possible effect of insulin treatment alone or oral hypoglycemic agents (OHG) treatment alone on the blood pressure and cardiovascular outcome in type 2 diabetes patients with nephropathy. We recruited 508 proteinuric diabetic nephropathy patients, 53.3% males were included. One hundred and ninety two patients were on oral hypoglycemic treatment while 28 patients were on insulin alone, while the remaining patients were on combined insulin-and oral hypoglycemic therapy. Duration of diabetes was 13.7±8 vs. 13.82±7 years. The initial serum creatinine was 109±95 vs. 94±71.2 µmol/L. The eGFR at initial visit was 96.6±56.5 vs. 85.3±37.7 mL/min per 1. 73 m2eGFR at last visit was 69.19±37 vs. 55.4±34 mL/min per 1. 73 m2. Patients treated with insulin had improvement in their systolic blood pressure and diastolic blood pressure, further they were at lower risk of having cardiovascular and renal events. SBP was reduced in insulin treated group significantly as compared to OH treated group 24.9±19.5 vs. 135.9±24.5 mmHg (p=0.02). DBP was significantly lower in insulin treated group 74.8±10 vs. 79.5±9.9 mmHg (p=0.02). There was no significant effect of insulin on renal or cardiovascular outcome, and that what we concluded our study. Treatment uncntl’d Stroke MI Angina Choice HTN On Insulin
17.9%
14.3%
21.4%
25%
On OHG
31.8%
14.1%
25%
36.5%
p value
< 0.001
0.97
0.7
0.2
Am J Kidney Dis. 2011;57(4):A1-A108
13
15 CLINICAL PRESENTATION OF INFECTION IN CATHETERDEPENDENT HEMODIALYSIS PATIENTS Yaser Al-Solaiman, Erin Estrada, Michael Allon University Of Alabama at Birmingham, Birmingham, AL, USA We evaluated prospectively the clinical presentation, microbiology, and outcomes of all cases of suspected infection in catheter-dependent HD pts during a 1.5-year period. Of 312 cases of suspected infection, an infection was confirmed in 271 cases (87%). Among those patients with confirmed infection, 34 (12%) had a non-access-related infection (including pneumonia, UTI, skin abscess, foot infection, etc), whereas the remainder had an access-related infection. The 237 access-related infections included 19 AVG infections, 8 AVF infections, 4 with Tenckhoff-related peritonitis, 21 with HD catheter exit site infections, and 186 episodes of catheter-related bacteremia (CRB). The infecting organism in CRB was Staph aureus (29%), Staph epi (38%), Enterococcus (22%), GNR (20%). Polymicrobial CRB occurred in 8% of episodes. Only 74 of 186 pts (40%) with CRB presented with fever (temp > 38oC). The remainder presented with rigors (N=67), “low grade” fever (temp 37.5-37.9oC)(N=25), exit site infection, or altered mental status. Hospitalization was required in 34% of CRB episodes, and 66% were treated as outpatients. The likelihood of hospitalization varied by organism (51% for Staph aureus, 28% for Staph epi, 30% for Enterococcus, and 17% for GNR, p<0.001). In summary, the vast majority of catheter-dependent HD patients have some type of infection, but only 59% have CRB. The majority of patients with documented CRB present without fever. Finally, the ikelihood of hospitalization for CRB varies by infecting organism, being highest for Staph aureus, and lowest for GNR.
EFFECTIVENESS OF 25 HYDROXY VITAMIN D ON SECONDARY HYPERPARATHYROIDISM IN HEMDIALYSIS PATIENTS Tarek Alhamad, Hongling Yang, Karim Harfouche, Safa Farrag,Wassim Radwan, Babak Rajabi and Pedro Blandon. Texas Tech University HSC, Paul L. Foster SOM, El Paso, Texas. Among Hemodialysis (HD) patients, Secondary hyperparathyroidism (SHPT) is a common finding. According to KDOQI guidelines, the recommended targets for dialysis patients have been set between 150 and 300 pg/mL using intact parathyroid hormone (iPTH). However, it does not recommend any native vitamin D supplementation. It has been shown that non-renal tissue will process the 25 hydroxy Vitamin D into 1,25 hydroxy Vitamin D. Objective is to study if replacing 25 Hydroxy Vitamin D levels in HD patients with SHPT would decrease the iPTH to the desired rang according the K-DOQI guidelines. We included 43 HD patients in this study from our local dialysis facility. Inclusion criteria were: 1) 25 hydroxy Vitamin D deficiency identified as: 25 hydroxy Vitamin D was less than 30 ng per milliliter. 2) SHPT identified as: PTH intact level was more than 300 pg per milliliter. The study was open-labeled in two groups. Group one (Vitamin D group) was given Ergocalciferol, whereas, group two was the control one (no Vitamin D2 or D3 was given). 15 patients were enrolled in the Vitamin D group, and 28 were considered in the control group. A response to Vitamin D was identified as a patient who, at the end of the study period, met one of the following criteria: I PTH less or equal to 300 pg per milliliter, Phosphate less or equal 5.5 mg/dl, or corrected Calcium less or equal to 10.5 mg/dl. We found that no significant difference was noticed in the PTH level, Calcium, or phosphate in the Vitamin D group comparing to the control group. In Conclusion, replacing Vitamin D2 in HD patients with 25 hydroxy Vitamin D deficiency and secondary hyperparathyroidism does not have a significant decrease in the Intact PTH level.
14
16 RHABDOMYOLYSIS CAUSED BY UNUSUAL INTERACTION BETWEEN SIMVASTATIN AND AZITHROMYCIN Gaurav Alreja, Sadiq Inayatullah, Saurabh Goel, Gregory Braden Baystate Medical Center, Tufts University, Springfield, Massachusetts. Rhabdomyolysis (rhabdo) is an uncommon but life-threatening adverse effect of statin therapy. We report a rare case of rhabdo caused by potential drug interaction between simvastatin and azithromycin. A 73 yr Caucasian male with history of chronic kidney disease stage 3 due to idiopathic interstitial nephritis (baseline Cr 1.7 mg/dl), diabetes mellitus, hypertension, hyperlipidemia presented with weakness of lower extremities for 1 week. His medications included allopurinol prednisone, labetalol, bumetanide and simvastatin 80 mg/d (for 2 yrs). He received Azithromycin (AZI) 500 mg followed by 250 mg daily for next 4 days, 1 wk ago for acute bronchitis. He was found to have rhabdo with CPK of 11,240 U/L and Cr of 3.8 mg/dl. Discontinuation of simvastatin with IV hydration and bicarbonate resulted in resolution of rhabdo. Simvastatin was reintroduced at 40 mg/d after 2 months and later increased to 80 mg/d without any subsequent recurrence of myalgia or weakness. Rhabdo related deaths have been reported with all statins except fluvastatin. Important variables affecting its occurrence include statin dose, patient characteristics and concurrent use of other medications that may alter the pharmacokinetics of the statins. Simvastatin and lovastatin are metabolized by CYP3A4, AZI by both CYP3A3 & 3A4 and fluvastatin by CYC2C9 enzyme system. Macrolides inhibit CYP3A4, thus elevating the statin levels. However, AZI (an azalide, subclass of macrolide) interferes poorly with CYP3A4 & after hepatic metabolism gets excreted in the bile. Although, rhabdo with AZI & lovastatin has been previously reported, this is a rare reported case of rhabdo caused by co-administration of AZI and simvastatin. Polymorphism of CYP3A4 might explain such rare cases despite insignificant inhibition by AZT in studies. Interference in biliary excretion of statins by AZT (through P-glycoprotein and multi drug resistance protein) might be another mechanism. His advanced age, underlying CKD and high dose of simvastatin might also have contributed to this rare complication. In conclusion, AZI might be coadministered with statins, with caution as there is risk of rhabdo.
A20
EFFECT OF INSULIN THERAPY OR ORAL HYPOGLYCEMIC THERAPY ON THE ARTERIAL BLOOD PRESSURE AND CARDIOVASCULAR EVENTS IN PROTEINURIC NEPHROPATHY PATIENTS Jamal Al Wakeel1, Durdana Hammad1, Youssef MK Farag1 1 King Saud University-King Khalid University Hospital, Riyadh, Saudi Arabia Diabetic patients have significantly increased cardiovascular and renal events. We evaluated the possible effect of insulin treatment alone or oral hypoglycemic agents (OHG) treatment alone on the blood pressure and cardiovascular outcome in type 2 diabetes patients with nephropathy. We recruited 508 proteinuric diabetic nephropathy patients, 53.3% males were included. One hundred and ninety two patients were on oral hypoglycemic treatment while 28 patients were on insulin alone, while the remaining patients were on combined insulin-and oral hypoglycemic therapy. Duration of diabetes was 13.7±8 vs. 13.82±7 years. The initial serum creatinine was 109±95 vs. 94±71.2 µmol/L. The eGFR at initial visit was 96.6±56.5 vs. 85.3±37.7 mL/min per 1. 73 m2eGFR at last visit was 69.19±37 vs. 55.4±34 mL/min per 1. 73 m2. Patients treated with insulin had improvement in their systolic blood pressure and diastolic blood pressure, further they were at lower risk of having cardiovascular and renal events. SBP was reduced in insulin treated group significantly as compared to OH treated group 24.9±19.5 vs. 135.9±24.5 mmHg (p=0.02). DBP was significantly lower in insulin treated group 74.8±10 vs. 79.5±9.9 mmHg (p=0.02). There was no significant effect of insulin on renal or cardiovascular outcome, and that what we concluded our study. Treatment uncntl’d Stroke MI Angina Choice HTN On Insulin
17.9%
14.3%
21.4%
25%
On OHG
31.8%
14.1%
25%
36.5%
p value
< 0.001
0.97
0.7
0.2
Am J Kidney Dis. 2011;57(4):A1-A108