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189: Dietary Sodium and Appetite in Hemodialysis
A70 189 DIETARY SODIUM AND APPETITE IN HEMODIALYSIS Hall, Beth*, Stark, Susan*, Snetselaar, Linda**, Piraino, Beth*, Qamar, Mohammad*, Sevick, Mary Ann* *University of Pittsburgh, Pittsburgh PA,USA. **University of Iowa, Iowa City ,Iowa, USA. Sodium (Na+) intake is difficult to control because many foods are naturally high in Na+, and most prepared/prepackaged foods have significant amounts of Na+ added to enhance taste and prolong shelflife. The purpose of this report is to describe the concentration of Na+ in foods consumed on nondialysis and dialysis days. 24-hour dietary recalls were obtained with unscheduled telephone calls on 1 weekend day, 1 nondialysis weekday and 1dialysis weekday and analyzed using NDS-R. Participants included 22 hemodialysis patients, mean age 52 years (SD=17), 82% minorities, 59% male, mean duration dialysis 30 mos (SD=42). Participants consumed 1,379 total gms (SD=545) of food on dialysis weekdays compared to 1,614 gms (SD=592) on nondialysis weekdays and 1,560 gms (SD=586) on weekends (p=0.38). The ratio of Na+ to total weight of food consumed per day was highest on nondialysis weekdays (1.7mgs/gm/day; SD=0.71) and lowest on dialysis weekdays (1.6mgs/gm/day; SD=0.54; p=0.66). The amount of food consumed was compared for participants consuming >1.5mgs/gm/day of Na+ and <1.5mgs/gm/day. Those consuming >1.5mgs/gm/day Na+ consumed fewer total grams of food compared to those consuming <1.5mgs/gm/day (1,373 versus 2,037gms; p<0.001) on nondialysis weekdays. On weekend days, the same pattern was seen, but was only marginally significant (1,210 versus 1,564 gms; p=0.08). On dialysis weekdays, participants consuming >1.5mgs/gm/day of Na+ consumed 1,665 total gms of food compared to 1,482 gms in those consuming <1.5mgs/gm/day (p=0.99). Those consuming higher concentrations of Na+ on nondialysis days appear to have poorer appetite on those days. The findings of this pilot study highlight the importance of simultaneously addressing dietary restrictions and dietary adequacy with nutritional counseling. This study was supported through grants from the Paul Teschan Research Fund and NIH-R01-NR010135.
190 ASSOCIATION OF SERUM ALKALINE PHOSPHATASE AND CORONARY ARTERY CALCIFICATION IN HEMODIALYSIS PATIENTS Ronney Shantouf, Mehdi Rambod, Csaba P Kovesdy, Naser Ahmadi; Allen R Nissenson, Matthew J Budoff , and Kamyar Kalantar-Zadeh. Harold Simmons Center & Cardiology, LABioMed at Harbor-UCLA, Torrance, CA; Salem VA, Salem, VA; DaVita Inc, El Segundo, CA. Background: Coronary artery calcification is associated with cardiovascular morbidity & mortality in hemodialysis (HD) patients (pts). We hypothesized that serum alkaline phosphatase (AlkPhos) is a predictor of CAC score (CACS) in HD pts. Methods: We studied the association between AlkPhos and CACS in HD pts. Results: CACS>0 was present in 136 (out of 151) pts who underwent EBCT (56±13 yrs old, 38% women, 46% Blacks, 61% diabetics); median AlkPhos was 101 mg/dl; 51% (n=69) had CACS ≥400, 34% (n=46) AlkPhos ≥120 mg/dl. The odds of having CACS ≥400 was increased by increasing AlkPhos (Figure). In unadjusted logistic model, HD pts with AlkPhos
NKF 2009 Spring Clinical Meetings Abstracts 191 METABOLIC ACIDOSIS, HYPEROSMOLAITY, AND ACUTE KIDNEY INJURY ASSOCIATED WITH PROPYLENE GLYCOL TOXICITY SECONDARY TO LORAZEPAM INFUSION Shahzad Shafique, The University of Kansas Medical Center, Kansas City, Kansas. A 54-year-old white male with a history of multiple admissions for alcohol intoxication was admitted with right flank pain. A CT scan revealed a small right psoas hematoma which was managed conservatively. He developed alcohol withdrawl seizures after 2 days and started on high dose infusion of lorazepam (LZ) and transferred to ICU. On hospital day 8, he developed severe metabolic acidosis (pH 7.11), hyperosmolality (Osmolal gap of 145mmol/Kg) and acute kidney injury followed by intubation and mechanical ventilation. The patient was suspected of having propylene glycol (PG) toxicity secondary to prolonged infusion of LZ (11 mg/hour averaged over 6 days), which got stopped immediately. PG is commonly used as a solvent in many drugs including LZ. Hyperosmolality, metabolic acidosis and AKI are classic signs of PG toxicity. The agent is generally safe in low doses, but large doses can be toxic, particularly if they are given over a short period of time. The treatment of choice in PG toxicity is HD. The patient underwent emergency HD once PG toxicity is suspected. The diagnosis was confirmed by a high serum PG level (790 mg/dl) before the first dialysis session . Daily HD was continued for the next 4 days. As osmolal gap correlates closely with serum PG level, the patient's daily osmolal gap was monitored in order to estimate PG decay. After the second dialysis session, his osmolal gap had improved to 39 mmol/kg. Patient gradually showed clinical and metabolic recovery and got discharged after a week. Lab Data Day 7 Day 8a Day 9 Day 10 Day 11 BUN (mg/dl) 6 12 11 13 11 S. Cr (mg/dl) 0.9 2.2 1.5 0.9 0.8 Anion Gap 10 14 10 6 5 Osmolal Gap NA 145 39 25 12 S. bicarb(mg/dl) 23 13 22 26 27 a - patient started on hemodialysis
192 DETERMINANTS OF VASCULAR ACCESS – PATIENT CHARACTERISTICS OR PHYSICIAN PREFERENCE? Megha Shah 1, Vijay Jain 1, Lori Spalding 2, Wajid Choudhry 1 (1-Unity Health System, 2- East View Dialysis Unit) Rochester, NY, USA As part of the Fistula First Initiative the goal for 2009 for the percentage of patients using arteriovenous fistula (AVF) for dialysis has been increased to 66%. However most facilities fall short of this target. The objective of this study is to determine the main factor influencing the choice of vascular access in patients. This is a retrospective study on all 176 patients who received a new vascular access for hemodialysis over 18 months in a group of 3 hospital based dialysis units (120 patients), compared with a private dialysis unit (56 patients) which has been recognized for having one of the best fistula rate by New York State ESRD Network. Nephrologists and Surgeons in both the groups were separate. A significantly higher number of patients received AVF as their primary vascular access at the private dialysis unit, despite no significant difference in co-morbidities, i.e. diabetes, coronary artery disease and peripheral vascular disease, in both the groups. There was no statistically significant difference in the two groups in primary and secondary fistula failure rates, i.e. failure of fistula to mature and failure after use. AVF rate (%)
≥120 mg/dl compared to those with AlkPhos <120 mg/dl, had an odds ratio (OR and 95% CI) of 2.5 (1.2-5.2) for having CACS ≥400. In the model that was adjusted for age, sex, diabetes, vintage and interleukin6, AlkPhos ≥120 mg/dl was robustly associated with CACS ≥400 (OR=3.6, 95% CI 1.3-9.6). Conclusion: Serum AlkPhos, mainly levels grater than 120 mg/dl, may be a predictor of coronary calcification in MHD pts, independent of case-mix and inflammation.
DM (%)
CAD (%)
PVD (%)
Private unit 59.0 63.3 48.4 57.6 Hospital based units 28.8 51.6 70.9 70.9 p value <0.001 >0.5 >0.5 >0.1 Our study shows that prevalence of AVF varies in different dialysis units, involving different providers. Although the co-morbidities in the studied groups of patients were similar, yet the private unit had a higher prevalence of working AVF. This implies the presence of bias amongst providers in Hospital based dialysis units when selecting a patient for type of access. Thus a higher rate of AVF placement, closer to the target rate, can be achieved by removing this bias.
190 ASSOCIATION OF SERUM ALKALINE PHOSPHATASE AND CORONARY ARTERY CALCIFICATION IN HEMODIALYSIS PATIENTS Ronney Shantouf, Mehdi Rambod, Csaba P Kovesdy, Naser Ahmadi; Allen R Nissenson, Matthew J Budoff , and Kamyar Kalantar-Zadeh. Harold Simmons Center & Cardiology, LABioMed at Harbor-UCLA, Torrance, CA; Salem VA, Salem, VA; DaVita Inc, El Segundo, CA. Background: Coronary artery calcification is associated with cardiovascular morbidity & mortality in hemodialysis (HD) patients (pts). We hypothesized that serum alkaline phosphatase (AlkPhos) is a predictor of CAC score (CACS) in HD pts. Methods: We studied the association between AlkPhos and CACS in HD pts. Results: CACS>0 was present in 136 (out of 151) pts who underwent EBCT (56±13 yrs old, 38% women, 46% Blacks, 61% diabetics); median AlkPhos was 101 mg/dl; 51% (n=69) had CACS ≥400, 34% (n=46) AlkPhos ≥120 mg/dl. The odds of having CACS ≥400 was increased by increasing AlkPhos (Figure). In unadjusted logistic model, HD pts with AlkPhos
NKF 2009 Spring Clinical Meetings Abstracts 191 METABOLIC ACIDOSIS, HYPEROSMOLAITY, AND ACUTE KIDNEY INJURY ASSOCIATED WITH PROPYLENE GLYCOL TOXICITY SECONDARY TO LORAZEPAM INFUSION Shahzad Shafique, The University of Kansas Medical Center, Kansas City, Kansas. A 54-year-old white male with a history of multiple admissions for alcohol intoxication was admitted with right flank pain. A CT scan revealed a small right psoas hematoma which was managed conservatively. He developed alcohol withdrawl seizures after 2 days and started on high dose infusion of lorazepam (LZ) and transferred to ICU. On hospital day 8, he developed severe metabolic acidosis (pH 7.11), hyperosmolality (Osmolal gap of 145mmol/Kg) and acute kidney injury followed by intubation and mechanical ventilation. The patient was suspected of having propylene glycol (PG) toxicity secondary to prolonged infusion of LZ (11 mg/hour averaged over 6 days), which got stopped immediately. PG is commonly used as a solvent in many drugs including LZ. Hyperosmolality, metabolic acidosis and AKI are classic signs of PG toxicity. The agent is generally safe in low doses, but large doses can be toxic, particularly if they are given over a short period of time. The treatment of choice in PG toxicity is HD. The patient underwent emergency HD once PG toxicity is suspected. The diagnosis was confirmed by a high serum PG level (790 mg/dl) before the first dialysis session . Daily HD was continued for the next 4 days. As osmolal gap correlates closely with serum PG level, the patient's daily osmolal gap was monitored in order to estimate PG decay. After the second dialysis session, his osmolal gap had improved to 39 mmol/kg. Patient gradually showed clinical and metabolic recovery and got discharged after a week. Lab Data Day 7 Day 8a Day 9 Day 10 Day 11 BUN (mg/dl) 6 12 11 13 11 S. Cr (mg/dl) 0.9 2.2 1.5 0.9 0.8 Anion Gap 10 14 10 6 5 Osmolal Gap NA 145 39 25 12 S. bicarb(mg/dl) 23 13 22 26 27 a - patient started on hemodialysis
192 DETERMINANTS OF VASCULAR ACCESS – PATIENT CHARACTERISTICS OR PHYSICIAN PREFERENCE? Megha Shah 1, Vijay Jain 1, Lori Spalding 2, Wajid Choudhry 1 (1-Unity Health System, 2- East View Dialysis Unit) Rochester, NY, USA As part of the Fistula First Initiative the goal for 2009 for the percentage of patients using arteriovenous fistula (AVF) for dialysis has been increased to 66%. However most facilities fall short of this target. The objective of this study is to determine the main factor influencing the choice of vascular access in patients. This is a retrospective study on all 176 patients who received a new vascular access for hemodialysis over 18 months in a group of 3 hospital based dialysis units (120 patients), compared with a private dialysis unit (56 patients) which has been recognized for having one of the best fistula rate by New York State ESRD Network. Nephrologists and Surgeons in both the groups were separate. A significantly higher number of patients received AVF as their primary vascular access at the private dialysis unit, despite no significant difference in co-morbidities, i.e. diabetes, coronary artery disease and peripheral vascular disease, in both the groups. There was no statistically significant difference in the two groups in primary and secondary fistula failure rates, i.e. failure of fistula to mature and failure after use. AVF rate (%)
≥120 mg/dl compared to those with AlkPhos <120 mg/dl, had an odds ratio (OR and 95% CI) of 2.5 (1.2-5.2) for having CACS ≥400. In the model that was adjusted for age, sex, diabetes, vintage and interleukin6, AlkPhos ≥120 mg/dl was robustly associated with CACS ≥400 (OR=3.6, 95% CI 1.3-9.6). Conclusion: Serum AlkPhos, mainly levels grater than 120 mg/dl, may be a predictor of coronary calcification in MHD pts, independent of case-mix and inflammation.
DM (%)
CAD (%)
PVD (%)
Private unit 59.0 63.3 48.4 57.6 Hospital based units 28.8 51.6 70.9 70.9 p value <0.001 >0.5 >0.5 >0.1 Our study shows that prevalence of AVF varies in different dialysis units, involving different providers. Although the co-morbidities in the studied groups of patients were similar, yet the private unit had a higher prevalence of working AVF. This implies the presence of bias amongst providers in Hospital based dialysis units when selecting a patient for type of access. Thus a higher rate of AVF placement, closer to the target rate, can be achieved by removing this bias.