163: Potentially Avoidable Fluid Overload Treatment in Hemodialysis Patients

NKF 2009 Spring Clinical Meetings Abstracts 161 DIALYSIS DURING HURRICANE IKE. NEED FOR IMPROVED EMERGENCY PREPAREDNESS. Amber S. Podoll, Ramdas Kumar, James J. McCarthy, Kevin W. Finkel, University of Texas Health Science Center, Houston, Texas As Hurricane Ike approached Houston in September 2008, residents within the storm surge were evacuated based on projected flood zones. Unfortunately, many patients with chronic medical needs failed to consider the potential impact of the 150 mile zone of power outage. More than four million people in the Houston metropolitan area were without electricity for an average of 7.5 days, leaving >9000 dialysis patients without adequate access to treatment. The majority of patients presented to the emergency department (ED) of one of the two hospitals in the area which had full power and a safe water supply, requesting routine dialysis. Within 36 hrs, 12% of evaluations in the ED were for dialysis-related issues, representing a 4.7-fold increase compared to usual volume. Of those presenting, 38% required emergent hemodialysis. In an attempt to preserve inpatient capacity within a federal disaster area, the hospital declared a state of emergency and patients who were stable after dialysis were discharged. The majority (50%) of ED patients were treated medically for mild hyperkalemia and discharged. On presentation, average values were as follows: SBP 173.6 mmHg, DBP 90.2 mmHg and serum potassium 5.1 mg/dL. 4 patients were admitted with vascular access failure, of which 3 required temporary catheter placement because of the unavailability of non-emergent vascular access services. Several patients on home hemodialysis and peritoneal dialysis (PD) were unable to perform their treatments due to lack of electricity or unsterile environments. In the three weeks following the storm, there were 6 cases of peritonitis in PD patients. Our experience shows that projected power outages need to be carefully considered when planning evacuation zones. Dialysis patients should be evacuated before predictable natural disasters for their physical safety as well as in anticipation of their medical needs.

162 DIETARY INTAKE IN HEMODIALYSIS PATIENTS Mohammad Qamar* , Beth Piraino*, Linda Snetselaar**,Susan Stark*,Mary A. Sevick*. * University of Pittsburgh, Pittsburgh PA, USA. **University of Iowa, Iowa City, Iowa, USA. Nutrition correlates with mortality and morbidity in HD patients (pts). A RCT of a behavioral approach to enhancing adherence to the renal diet vs attention control group is underway. Baseline dietary information was collected and is presented here. Detailed dietary information was collected with unscheduled phone calls by a dietitian on one weekend day, one non-dialysis weekday and one dialysis weekday at baseline of the RCT. Calorie and protein intake were estimated using adjusted edema-free body weight. Statistics used were Student’s test and Friedman test. Participants included 22 HD patients, mean age 52 years (SD=16.6), 82% minorities, 59% male, mean duration dialysis 30 mo (SD=42.3). Intake and Non- HD HD Non HD recommended per day weekday weekday weekend Calcium(g) 1g 0.7+/- 0.6 0.6+/-0.4 0.8+/-0.6 Phosphorous(g) 1g 0.9+/-0.3 0.8+/-0.4 1.0+/-0.6 Mg (mg) 200-300mg 200+/-80 170+/-100 200+/-100 Zinc(mg) 15mg 11+/-6 9+/-5 10+/-7 Sodium(g) 0.75-2g* 2.6+/-1.0 2.1+/-1.0 2.6+/-1.4 Potassium(g)<2.0g 2.0+/-0.9 1.6+/-1.0 1.8+/-0.9 Protein(gm/kg) 1.2 0.9+/-0.3 0.8+/-0.4 0.9+/-0.5 Calories(kcal/kg) 30-35 21+/-7 19+/-9 22+/-11 %Protein/Calories 18+/-5 17+/-5 16+/-3 *p=0.091 HD vs non HD day The results of this dietary recall indicate that HD pts take in higher than recommended sodium and have marginal protein and caloric intake, with minor variations based on the day of the week. Research is needed to evaluate alternative interventions for improving dietary intake in this patient population. This study was supported by Paul Teschan Research Fund and NIH-R01-NR010135.

A63 163 POTENTIALLY AVOIDABLE FLUID OVERLOAD TREATMENT IN HEMODIALYSIS PATIENTS Yang Qiu, Jiannong Liu, Thomas J. Arneson, David T. Gilbertson, Allan J. Collins. Chronic Disease Research Group, Minneapolis Fluid overload (FO) is a common complication in Hemodialysis (HD) patients. Emergency treatment for FO can be expensive, and some of these episodes of treatments could be potentially avoidable. Patterns of emergency treatment for FO have received little study. We developed a claims-based definition of potentially avoidable FO treatment to describe the frequency and cost of these treatments in the inpatient, emergency department (ED), and hospital outpatient observation settings, using the Medicare End-Stage Renal Disease database. The study population included Medicare patients receiving HD on January 1, 2004, excluding those who died, changed to peritoneal dialysis (PD), underwent kidney transplant, lost Medicare primary payer status, recovered renal function or were lost-to-follow up in the first 6 months of 2004. Patients were followed from July 1, 2004 to the earliest date of death, change to PD, transplant, payer change, lost-tofollow-up, recovery of renal function or the end of 2006. A potentially avoidable FO treatment episode was defined as follows: inpatient, hospital observation, or ED stay with principal diagnosis code for FO, heart failure, or pulmonary edema; HD done on day of admission or following day; length of stay <= 3 days; no vascular access procedures or complications; no cardiovascular procedures or AMI diagnosis; not a surgical DRG. Among the 176,790 patient study population, 17,457 (10%) experienced at least one potentially avoidable FO episode, with an event rate of 0.79 per patient year. Most (78%) of the episodes were treated in the inpatient setting. Average cost per treatment episode was $5657 with notably higher costs for patients treated in the inpatient setting ($6826). The total FO-related Medicare cost was about $150 million in the two and half years follow up period. FO episodes requiring emergent treatment are relatively common and quite expensive. We believe the definition used for potentially avoidable FO treatment episodes is conservative. Additional analysis could identify associations between FO treatment episodes and patient characteristics and may suggest actions to prevent them.

164 ASSOCIATION OF SOLUBLE ENDOTOXIN RECEPTOR CD14 AND MORTALITY IN HEMODIALYSIS (HD) PATIENTS (PTS) Dominic Raj, Mehdi Rambod, Vallab Shah, Kamyar Kalantar-Zadeh. Division Nephrology, Univ. of New Mexico, NM; and Harold Simmons Center, Harbor-UCLA, Torrance, CA CD14 is involved in innate immunity mediating cell activation & signaling in response to endotoxin. We hypothesized that elevated sCD14 in HD pts is associated inflammatory cytokine activation & increased mortality. We measured sCD14 level in a cohort of 310 HD pts. The mean sCD14 was 7.24±2.45 µg/ml. Tumor necrosis factor(TNF- ) was the strongest correlate of sCD14 (r=0.24, p<0.001) followed by interleukin (IL)-6 (r=0.18, p=0.002), ferritin (r=0.21, p=<0.001), transferrin (r=-0.19, p=<0.001). Over the 33 months followup, 71 pts died. Multivariable Cox analysis adjusted for case-mix & other nutritional/inflammatory confounders including serum TNF- , CReactive protein, & IL-6 showed that compared to lowest sCD14 tertile, sCD14 levels in the third tertile (>7.8 µg/ml) were associated with higher death risk (hazard ratio 1.94; 95% CI 1.01-3.75, p=0.04).

Thus, elevated sCD14 is positively related to markers of inflammation, negatively to nutritional status & an independent predictor of mortality. Further studies are needed to examine the usefulness of sCD14 in risk stratification & clinical decision-making process in HD pts.