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188: Health-Related Quality of Life (HRQoL) and Survival of Poor Prognosis ESRD Patients on Dialysis Versus Conservative Management
NKF 2009 Spring Clinical Meetings Abstracts 185 DIABETIC TYPE 2 NEPHROPATHY (DN), PROTEINURIA (P) & HYPERTENSION (HTN) MANAGEMENT: IM RESIDENTS (R) VS FACULTY (F) IN ACADEMIC CLINICS. Allan Schwartz, Syed Ashraf, Veeraish Chauhan, Arif Jan, Drexel UCoM, Phila, PA, USA. This 2 yr QI project audited 1614 diabetic pts’ electronic medical records: R=637,F=977 from Jan’07-Nov’08 for P; P:CR {microalb=30-299mcg/mg Creatinine(Cr)& overt P=>300mcg/mgCr, eGFR using MDRD; systolic BP (SBP)& diastolic BP (DBP); number & class of anti HTN meds. 80% of pts were AA. Female were 67% in R, 80% in F clinic. P tested by:(1) UA once/yr: R=31% vs F=61%(2) P:CR R=50% vs F=70%. In R clinic 25% had microalb, 9% overt. In F clinic 21% had microalb, 8% overt. eGFR for micro DN was 83ml/min for R & 78ml/min for F. eGFR for overt DN was 61ml/min for R & 44ml/min F. BP was the same for micro & overt P pts at R & F clinics (See Table). Anti HTN meds for micro DN= 2.78 R & 2.95 F, for overt DN= 3.24 by both R & F. Residents Faculty p-Value BP Micro132/79 Micro137/78 p=0.053 NS Overt141/80 Overt139/83 p=0.081 NS ACEI Micro 36% Micro 33.3% p=0.011 Overt 42.9% Overt 27.6% p=0.085 NS ARB Micro 20.3% Micro 38.9% p=0.011 Overt 9.5% Overt 20.7% p=0.085 NS B blocker 40.8% 32.0% p=0.004 R tested P & P:CR insufficiently. Micro/Overt P prevalence was equal in R & F clinics. R reduced P:CR greater than F. eGFR was higher for micro & overt DN in R clinic. ACEI were used > by R, ARBs were used > by F. B blockers R>F; diuretic & CCB R = F. Total anti HTN meds for R=F. Goal BP of <130/80mmHg was not achieved in micro or overt DN by R or F.
186 HYPERTROPHIC OSTEOARTHROPATHY AFTER KIDNEY TRANSPLANTATION TREATED WITH PAMIDRONATE Sein Yin See, Jennifer Fillaus, Erik Ericson, Brian Stevens, Vinaya Rao, Clifford Miles University of Nebraska Medical Center, Omaha, NE. Hypertrophic osteoarthropathy (HOA) was initially described in association with chronic lung conditions by Bamberger and Marie. HOA is most commonly seen as a paraneoplastic syndrome in patients with lung cancer, and in various autoimmune and infectious diseases. Here we present a case of HOA after renal transplantation successfully treated with pamidronate. Case: A 22 year-old Caucasian male with congenital renal dysplasia received a living-related kidney transplant in April 2008. There was no prior history of HOA, cancer, or rheumatic disease. Pulmonary histoplasmosis had been diagnosed during the pre-transplant evaluation and treated with voriconazole. He received induction with basiliximab and was maintained on a steroid-free protocol. Initial graft function was good. Several weeks after transplant, the patient developed diffuse arthralgias and myalgias. He was initially treated with corticosteroids for presumed serum sickness. The symptoms initially improved, but returned when the steroids were tapered. Serologic profile for autoimmune arthritides was unremarkable. Bone scintingraphy showed multiple foci of discrete, moderately intense activity throughout the skeleton. Biopsy of the right tibia demonstrated subperiosteal new bone formation. A diagnosis of HOA was made based on the combination of clinical, radiologic and histologic information. Pamidronate, 60mg intravenously, was administered due to refractory pain. The patient reported reduction of pain by 60% and regained full range of motion in his joints by 2 weeks post treatment. Transient neutropenia was observed, but otherwise pamidronate was well-tolerated. Conclusion: HOA is a clinical syndrome characterized by proliferation of skin and bone in the distal extremities. Recently, there have been reports in the literature of refractory pain in HOA treated with bisphosphonates. To our knowledge, this is the first report of HOA after renal transplantation treated with pamidronate.
A69 187 SEXUAL DYSFUNCTION IN FEMALE DIALYSIS PATIENTS Srikanth Seethala, Mark L. Unruh, Rachel Hess, Steven D. Weisbord There has been considerable research on erectile dysfunction in patients on dialysis, however considerably less is known about sexual dysfunction in women receiving maintenance dialysis. We sought to assess sexual dysfunction in female patients receiving chronic peritoneal dialysis (PD) or hemodialysis (HD). We approached all female patients at 6 HD and 1 PD units in western Pennsylvania and asked them to complete the Female Sexual Function Index (FSFI), a 19-item index that assesses 6 domains of sexual function (desire, arousal, lubrication, orgasm, pain and satisfaction). Total FSFI scores < 26.5 are consistent with the presence of sexual dysfunction. We also asked patients whether they had discussed their sexual dysfunction with a gynecologist, renal provider or PCP and whether they had received any treatment. Of 122 patients approached, 66 were eligible and enrolled. 22 (33%) reported not being sexually active and were not included in our analysis of sexual dysfunction. Of the remaining 44 patients, the mean age was 59, 50% were diabetic and 52% were residing with a significant other. Overall, 33 patients (75%) had FSFI scores < 26.5, while 70% of patients residing with a significant other had FSFI scores < 26.5. Mean scores for each of the 6 individual domains were consistent with significant impairment (Table). Only 21% of patients with sexual dysfunction discussed this issue with a gynecologist and none had spoken with a renal provider or PCP. None of the patients reported receiving any treatment for Mean sexual dysfunction. Domain (N) scores Range Sexual dysfunction is highly Desire (44) 2.45 1.2-6 prevalent in women on dialysis. Arousal (42) 2.28 0-6 Multiple domains of sexual Orgasm (39) 2.13 0-6 function are impaired in this Lubrication (40) 2.22 0-6 patient population. Very few Satisfaction(36) 3.03 0.8-6 patients appear to discuss this Pain(34) 3.23 0-6 problem with healthcare providers or receive treatment. Future efforts should focus on improving the assessment of and implementation of therapy for sexual dysfunction in women on dialysis.
188 HEALTH-RELATED QUALITY OF LIFE (HRQoL) AND SURVIVAL OF POOR PROGNOSIS ESRD PATIENTS ON DIALYSIS VERSUS CONSERVATIVE MANAGEMENT. YY Seowa, LM Qua, SH Tanc,KS Wonga, CM Chana,CR Gohb, A Yeeb, a Dept of Renal Medicine, Singapore General Hospital, Singapore. b Dept of Palliative Medicine, National Cancer Centre, Singapore. C Dept of Clinical Trials and Epidemiological Sciences, NCC, S’pore. There is increasing acceptance of poor prognosis endstage renal disease (ESRD) patients for renal replacement therapy (RRT). For those who opt for conservative measures, an increasing number are referred to palliative care services. Our primary objective is to assess HRQoL and survival in poor prognosis ESRD patients whether they embark on RRT or not. We conducted a prospective observational study of 54 incident ESRD (cGFR9-11ml/min) patients who fulfill our criteria of poor prognosis (age ≥75 or Charlson Comorbidity Index (CCI)≥8). KDQoL scores, Karnofsky Performance scores (KPS), biochemical and socioeconomic parameters were collected at baseline and 6months. Follow up period was 6months. Nine patients died. Median time to death was 2.69months (2.173.78). Comparing baseline parameters, those who died had lower KPS scores (p=0.03) and the KDQoL physical functioning scores (p=0.02). Hb(p=0.03) and Hct (p=0.04) were also lower despite same frequency of usage of epo. Fourteen patients embarked on RRT while 29 had not. Median time to RRT was 2.83 months (IQR 2.30 - 5.55). We considered intraindividual change in KDQoL and KPS scores at 6months versus baseline for each group. Out of 9 of the kidney disease specific scales, those on RRT had improvement in their symptom/problem list (p=0.005) and overall health (p=0.05). There was no difference in the change in SF-12 physical and mental composite scores nor KPS between the groups. We conclude that for this group of poor prognosis ESRD patients, poor KPS and physical functioning plus lower Hb/Hct at baseline predict 6month mortality and while embarking on RRT appears to improve symptoms and General Health, RRT didn’t make a difference to their physical or mental functioning.
186 HYPERTROPHIC OSTEOARTHROPATHY AFTER KIDNEY TRANSPLANTATION TREATED WITH PAMIDRONATE Sein Yin See, Jennifer Fillaus, Erik Ericson, Brian Stevens, Vinaya Rao, Clifford Miles University of Nebraska Medical Center, Omaha, NE. Hypertrophic osteoarthropathy (HOA) was initially described in association with chronic lung conditions by Bamberger and Marie. HOA is most commonly seen as a paraneoplastic syndrome in patients with lung cancer, and in various autoimmune and infectious diseases. Here we present a case of HOA after renal transplantation successfully treated with pamidronate. Case: A 22 year-old Caucasian male with congenital renal dysplasia received a living-related kidney transplant in April 2008. There was no prior history of HOA, cancer, or rheumatic disease. Pulmonary histoplasmosis had been diagnosed during the pre-transplant evaluation and treated with voriconazole. He received induction with basiliximab and was maintained on a steroid-free protocol. Initial graft function was good. Several weeks after transplant, the patient developed diffuse arthralgias and myalgias. He was initially treated with corticosteroids for presumed serum sickness. The symptoms initially improved, but returned when the steroids were tapered. Serologic profile for autoimmune arthritides was unremarkable. Bone scintingraphy showed multiple foci of discrete, moderately intense activity throughout the skeleton. Biopsy of the right tibia demonstrated subperiosteal new bone formation. A diagnosis of HOA was made based on the combination of clinical, radiologic and histologic information. Pamidronate, 60mg intravenously, was administered due to refractory pain. The patient reported reduction of pain by 60% and regained full range of motion in his joints by 2 weeks post treatment. Transient neutropenia was observed, but otherwise pamidronate was well-tolerated. Conclusion: HOA is a clinical syndrome characterized by proliferation of skin and bone in the distal extremities. Recently, there have been reports in the literature of refractory pain in HOA treated with bisphosphonates. To our knowledge, this is the first report of HOA after renal transplantation treated with pamidronate.
A69 187 SEXUAL DYSFUNCTION IN FEMALE DIALYSIS PATIENTS Srikanth Seethala, Mark L. Unruh, Rachel Hess, Steven D. Weisbord There has been considerable research on erectile dysfunction in patients on dialysis, however considerably less is known about sexual dysfunction in women receiving maintenance dialysis. We sought to assess sexual dysfunction in female patients receiving chronic peritoneal dialysis (PD) or hemodialysis (HD). We approached all female patients at 6 HD and 1 PD units in western Pennsylvania and asked them to complete the Female Sexual Function Index (FSFI), a 19-item index that assesses 6 domains of sexual function (desire, arousal, lubrication, orgasm, pain and satisfaction). Total FSFI scores < 26.5 are consistent with the presence of sexual dysfunction. We also asked patients whether they had discussed their sexual dysfunction with a gynecologist, renal provider or PCP and whether they had received any treatment. Of 122 patients approached, 66 were eligible and enrolled. 22 (33%) reported not being sexually active and were not included in our analysis of sexual dysfunction. Of the remaining 44 patients, the mean age was 59, 50% were diabetic and 52% were residing with a significant other. Overall, 33 patients (75%) had FSFI scores < 26.5, while 70% of patients residing with a significant other had FSFI scores < 26.5. Mean scores for each of the 6 individual domains were consistent with significant impairment (Table). Only 21% of patients with sexual dysfunction discussed this issue with a gynecologist and none had spoken with a renal provider or PCP. None of the patients reported receiving any treatment for Mean sexual dysfunction. Domain (N) scores Range Sexual dysfunction is highly Desire (44) 2.45 1.2-6 prevalent in women on dialysis. Arousal (42) 2.28 0-6 Multiple domains of sexual Orgasm (39) 2.13 0-6 function are impaired in this Lubrication (40) 2.22 0-6 patient population. Very few Satisfaction(36) 3.03 0.8-6 patients appear to discuss this Pain(34) 3.23 0-6 problem with healthcare providers or receive treatment. Future efforts should focus on improving the assessment of and implementation of therapy for sexual dysfunction in women on dialysis.
188 HEALTH-RELATED QUALITY OF LIFE (HRQoL) AND SURVIVAL OF POOR PROGNOSIS ESRD PATIENTS ON DIALYSIS VERSUS CONSERVATIVE MANAGEMENT. YY Seowa, LM Qua, SH Tanc,KS Wonga, CM Chana,CR Gohb, A Yeeb, a Dept of Renal Medicine, Singapore General Hospital, Singapore. b Dept of Palliative Medicine, National Cancer Centre, Singapore. C Dept of Clinical Trials and Epidemiological Sciences, NCC, S’pore. There is increasing acceptance of poor prognosis endstage renal disease (ESRD) patients for renal replacement therapy (RRT). For those who opt for conservative measures, an increasing number are referred to palliative care services. Our primary objective is to assess HRQoL and survival in poor prognosis ESRD patients whether they embark on RRT or not. We conducted a prospective observational study of 54 incident ESRD (cGFR9-11ml/min) patients who fulfill our criteria of poor prognosis (age ≥75 or Charlson Comorbidity Index (CCI)≥8). KDQoL scores, Karnofsky Performance scores (KPS), biochemical and socioeconomic parameters were collected at baseline and 6months. Follow up period was 6months. Nine patients died. Median time to death was 2.69months (2.173.78). Comparing baseline parameters, those who died had lower KPS scores (p=0.03) and the KDQoL physical functioning scores (p=0.02). Hb(p=0.03) and Hct (p=0.04) were also lower despite same frequency of usage of epo. Fourteen patients embarked on RRT while 29 had not. Median time to RRT was 2.83 months (IQR 2.30 - 5.55). We considered intraindividual change in KDQoL and KPS scores at 6months versus baseline for each group. Out of 9 of the kidney disease specific scales, those on RRT had improvement in their symptom/problem list (p=0.005) and overall health (p=0.05). There was no difference in the change in SF-12 physical and mental composite scores nor KPS between the groups. We conclude that for this group of poor prognosis ESRD patients, poor KPS and physical functioning plus lower Hb/Hct at baseline predict 6month mortality and while embarking on RRT appears to improve symptoms and General Health, RRT didn’t make a difference to their physical or mental functioning.