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195 Outcomes of Kidney Transplantation in HIV Alone and HIV-HCV Coinfected Recipients
NKF 2011 Spring Clinical Meetings Abstracts
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ACUTE RHEUMATIC FEVER (ARF) WITH COINCIDENT POSTSTREPTOCOCCAL GLOMERULONEPHRITIS (PSGN) IN AN ADULT: A CASE REPORT AND REVIEW OF LITERATURE Wajeed Masood, Jalaja Joseph, Sabiha Bandagi. Mount Sinai School of Medicine/Queens Hospital , Jamaica, NY,USA. ARF and PSGN, 2 non suppurative sequelae of Group A streptococcus (GAS), are known to occur together but rarely. Usually it occurs in children. The extremely low incidence of these conditions occurring together in adults in the developed nations makes it a challenging diagnosis. We report such an occurrence and review 17 similar cases. A 46-year-old woman with no medical history presented with hypertensive urgency and new onset acute decompensated heart failure. Labs showed anemia, 4+ proteinuria, 50RBC/hpf and RBC casts. Additionally, sore throat & flu like symptoms 3 weeks ago were reported. Further work up including Echocardiogram showed low EF of 40% and new onset severe MR. Elevated ESR(70) and CRP(11). Positive streptozyme (1:600). Elevated ASO titers (1420 Todd U). 24 hour urine protein was 1.4g. Low C3(14 U) with normal C4. A diagnosis of Acute Rheumatic carditis with concurrent PSGN was made. The patient was started on NSAIDs & benzathine penicillin, and significant clinical improvement was noted in next 3 days. Hematuria and proteinuria resolved requiring no renal biopsy. Patient was discharged on monthly penicillin prophylaxis. At least 17 similar cases have been reported in medical literature. Of these, 2 (11.7%) were adults and 15(88%) were children.11 (64.7%) presented with the combination of ARF with carditis along with PSGN, 3(17. %) developed PSGN during a recurrent episode of ARF and 3 (17.6%) had the unusual feature of PSGN preceding ARF. Erythema marginatum noted in only 4(23.5%) cases .Only 2(11.7%) cases had positive throat culture, but all had 100 % evidence of antecedent GAS infection. Proteinuria, hematuria, low C3 was present in all 17 cases requiring renal biopsy in only few cases. Even though there are a number of rheumatogenic strains of GAS and fewer nephritogenic strains only 2 (M1& 3) were associated with both the above discussed sequelae which might elucidate their low incidence. Recognition of this condition is critical for initiation of appropriate therapy and prophylaxis, and for prevention of further complications.
194
OUTCOMES OF KIDNEY TRANSPLANTATION IN HIV ALONE AND HIV-HCV COINFECTED RECIPIENTS D Matthew, L Levin, G Malat, A Doyle, K Ranganna Drexel University College of Medicine, Philadelphia As the outcomes of transplantation in immunosuppressed HIVinfected individuals are better understood, little is known about allograft survival in HIV and Hepatitis C (HCV) co-infected recipients. We analyzed data from renal allograft recipients who were HCV positive and had CD4+ T-cell counts of at least 200 per cubic millimeter with undetectable plasma HIV type 1 (HIV-1) RNA levels on a stable antiretroviral regimen prior to transplantation. Between 2002 and 2010, a total of 92 patients underwent kidney transplantation at our institution; over the eight (8) year period, there was no difference in the graft survival between the two groups. Comparing HIV/HCV (-) vs. HIV/HCV (+), graft survival was (983.6 days vs. 897days; p=0.59); One year graft survival was 78% vs. 66.7% (p = 0.49) respectively while at year 3 it was 38% vs. 28.6 %.( p=0.37). Delayed graft function was also similar in both groups HIV/ HCV (-) (60%) vs. HIV/HVC (+) (62%) (p=0.84). Comparing renal function of HIV/ HCV (-) vs. HIV/HCV(+) allograft recipients at 3 months, 1 year and 3 years showed no significant difference in GFR in the allografts which were functioning at that time. Rates of acute cellular rejection were HIV/HCV (-) (30%) vs. HIV/HCV (+) (26%) (p =0.65) and that of antibody mediated rejection was HIV/HCV (-) (17%) vs. HIV/HCV (+) (11%). (p= 0.57). In this study of HIV infected and HIV/HCV coinfected patients, we concluded that rates of graft survival, delayed graft function, acute cellular rejection and antibody mediated rejection were similar overall in both groups.
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INADEQUATE INPATIENT ESRD CARE IN TEACHING HOSPITAL Dwight Mathews, Lisa Levin, Yevgeniy Latyshev, Mailha Ahmed, Sameen Rahman, Ziauddin Ahmed. Drexel University College of medicine Philadelphia, PA, USA Dialysis therapy only can replace the filtration function of ESRD patients. But to replace endocrine, metabolic and other functions of the kidneys supplemental therapies are routinely prescribed. Dialysis patients when admitted should have continued on certain routine medications. Like Erythropoietin, Multivitamins, Phosphate binders, IV iron, and Vitamin D since the admission. A survey was done in 13 hospitalized HD patients in teaching institution 2 years ago and it was found that the routine medications and tests were inadequately performed by the house staff. Intense education was instituted to the house staff regarding appropriate management of hemodialysis patients was during bedside rounds and in noon lectures. A follow up review was done after a year in 12 hospitalized HD patients but no improvement was noted. Renal fellows were then instructed to take responsibilities and carry out orders of such parameters.10 charts were reviewed by the Nephrology Fellow after 6 months and the result was noted; Medications Before inAfter in-service After Renal service to house to house staff fellow staff Took over Erythropoietin 53.8% 58.3% 90% given Renal Vitamin given
76.92%
50%
100%
Phosphate binders Vitamin D therapy
30.4% 23.4%
58.32% 33.4%
90% 100%
Tests (Recorded) Iron studies 30.2% 26.7% 100% PTH 30.2% 26.7% 100% It seems the standard teaching method of house-staff in a teaching institution may not provide enough education for ESRD care. Alternative method may be adopted including computer based reminder to improve inpatient ESRD care in teaching institution.
Am J Kidney Dis. 2011;57(4):A1-A108
DIASTOLIC BLOOD PRESSURE MAY BE AN EARLY MODIFIABLE RISK FACTOR IN PREVENTING AORTIC STIFFNESS AMONG CHRONIC KIDNEY DISEASE PATIENTS Laura Maursetter, Lynn Jacobson, Nancy Sweitzer, Lisa Nanovic. University of Wisconsin Hospitals and Clinics, Madison, Wisconsin USA Chronic kidney disease (CKD) is estimated to affect approximately 15 million American people; the majority being greater than 60 years of age. Although aging increases the risk of cardiac complications in the general population, CKD is associated with as additional 10-20% increased risk of cardiovascular death. Discovering the factors that may increase this risk and intervening earlier in patients with CKD may improve mortality among this population. Aortic stiffness is a common finding in both the aging and the CKD populations but through different pathophysiologic mechanisms. A prospective longitudinal study was launched to investigate the hypothesis that patients over the age of 65 with moderate CKD will have increased vascular stiffness when compared to age matched controls. Enrollment was conducted at the University of Wisconsin Hospital and Clinics in Madison, Wisconsin. There were 14 subjects with moderate CKD stage 3 (defined as GFR 30-60 ml/min). The control group was comprised of 23 age-matched controls without CKD. Pulse wave velocity (PWV) was measured using tonometry, which is a noninvasive assessment used to estimate vascular stiffness. Individuals performing and interpreting the tonometry readings were blinded to the study group. Recruitment yielded demographically similar cohorts. PWV did not differ between the groups but diastolic blood pressure (DBP) was significantly higher in the CKD group (P=0.03) while SBP showed no difference. Of note, a high colinearity was seen between DBP and PWV. Patients over age 65 with moderate chronic kidney disease have higher diastolic blood pressures compared with age matched controls. This suggests that intervention targeting diastolic blood pressure at this stage has potential for cardiovascular risk factor modification. Further investigation is underway.
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ACUTE RHEUMATIC FEVER (ARF) WITH COINCIDENT POSTSTREPTOCOCCAL GLOMERULONEPHRITIS (PSGN) IN AN ADULT: A CASE REPORT AND REVIEW OF LITERATURE Wajeed Masood, Jalaja Joseph, Sabiha Bandagi. Mount Sinai School of Medicine/Queens Hospital , Jamaica, NY,USA. ARF and PSGN, 2 non suppurative sequelae of Group A streptococcus (GAS), are known to occur together but rarely. Usually it occurs in children. The extremely low incidence of these conditions occurring together in adults in the developed nations makes it a challenging diagnosis. We report such an occurrence and review 17 similar cases. A 46-year-old woman with no medical history presented with hypertensive urgency and new onset acute decompensated heart failure. Labs showed anemia, 4+ proteinuria, 50RBC/hpf and RBC casts. Additionally, sore throat & flu like symptoms 3 weeks ago were reported. Further work up including Echocardiogram showed low EF of 40% and new onset severe MR. Elevated ESR(70) and CRP(11). Positive streptozyme (1:600). Elevated ASO titers (1420 Todd U). 24 hour urine protein was 1.4g. Low C3(14 U) with normal C4. A diagnosis of Acute Rheumatic carditis with concurrent PSGN was made. The patient was started on NSAIDs & benzathine penicillin, and significant clinical improvement was noted in next 3 days. Hematuria and proteinuria resolved requiring no renal biopsy. Patient was discharged on monthly penicillin prophylaxis. At least 17 similar cases have been reported in medical literature. Of these, 2 (11.7%) were adults and 15(88%) were children.11 (64.7%) presented with the combination of ARF with carditis along with PSGN, 3(17. %) developed PSGN during a recurrent episode of ARF and 3 (17.6%) had the unusual feature of PSGN preceding ARF. Erythema marginatum noted in only 4(23.5%) cases .Only 2(11.7%) cases had positive throat culture, but all had 100 % evidence of antecedent GAS infection. Proteinuria, hematuria, low C3 was present in all 17 cases requiring renal biopsy in only few cases. Even though there are a number of rheumatogenic strains of GAS and fewer nephritogenic strains only 2 (M1& 3) were associated with both the above discussed sequelae which might elucidate their low incidence. Recognition of this condition is critical for initiation of appropriate therapy and prophylaxis, and for prevention of further complications.
194
OUTCOMES OF KIDNEY TRANSPLANTATION IN HIV ALONE AND HIV-HCV COINFECTED RECIPIENTS D Matthew, L Levin, G Malat, A Doyle, K Ranganna Drexel University College of Medicine, Philadelphia As the outcomes of transplantation in immunosuppressed HIVinfected individuals are better understood, little is known about allograft survival in HIV and Hepatitis C (HCV) co-infected recipients. We analyzed data from renal allograft recipients who were HCV positive and had CD4+ T-cell counts of at least 200 per cubic millimeter with undetectable plasma HIV type 1 (HIV-1) RNA levels on a stable antiretroviral regimen prior to transplantation. Between 2002 and 2010, a total of 92 patients underwent kidney transplantation at our institution; over the eight (8) year period, there was no difference in the graft survival between the two groups. Comparing HIV/HCV (-) vs. HIV/HCV (+), graft survival was (983.6 days vs. 897days; p=0.59); One year graft survival was 78% vs. 66.7% (p = 0.49) respectively while at year 3 it was 38% vs. 28.6 %.( p=0.37). Delayed graft function was also similar in both groups HIV/ HCV (-) (60%) vs. HIV/HVC (+) (62%) (p=0.84). Comparing renal function of HIV/ HCV (-) vs. HIV/HCV(+) allograft recipients at 3 months, 1 year and 3 years showed no significant difference in GFR in the allografts which were functioning at that time. Rates of acute cellular rejection were HIV/HCV (-) (30%) vs. HIV/HCV (+) (26%) (p =0.65) and that of antibody mediated rejection was HIV/HCV (-) (17%) vs. HIV/HCV (+) (11%). (p= 0.57). In this study of HIV infected and HIV/HCV coinfected patients, we concluded that rates of graft survival, delayed graft function, acute cellular rejection and antibody mediated rejection were similar overall in both groups.
196
INADEQUATE INPATIENT ESRD CARE IN TEACHING HOSPITAL Dwight Mathews, Lisa Levin, Yevgeniy Latyshev, Mailha Ahmed, Sameen Rahman, Ziauddin Ahmed. Drexel University College of medicine Philadelphia, PA, USA Dialysis therapy only can replace the filtration function of ESRD patients. But to replace endocrine, metabolic and other functions of the kidneys supplemental therapies are routinely prescribed. Dialysis patients when admitted should have continued on certain routine medications. Like Erythropoietin, Multivitamins, Phosphate binders, IV iron, and Vitamin D since the admission. A survey was done in 13 hospitalized HD patients in teaching institution 2 years ago and it was found that the routine medications and tests were inadequately performed by the house staff. Intense education was instituted to the house staff regarding appropriate management of hemodialysis patients was during bedside rounds and in noon lectures. A follow up review was done after a year in 12 hospitalized HD patients but no improvement was noted. Renal fellows were then instructed to take responsibilities and carry out orders of such parameters.10 charts were reviewed by the Nephrology Fellow after 6 months and the result was noted; Medications Before inAfter in-service After Renal service to house to house staff fellow staff Took over Erythropoietin 53.8% 58.3% 90% given Renal Vitamin given
76.92%
50%
100%
Phosphate binders Vitamin D therapy
30.4% 23.4%
58.32% 33.4%
90% 100%
Tests (Recorded) Iron studies 30.2% 26.7% 100% PTH 30.2% 26.7% 100% It seems the standard teaching method of house-staff in a teaching institution may not provide enough education for ESRD care. Alternative method may be adopted including computer based reminder to improve inpatient ESRD care in teaching institution.
Am J Kidney Dis. 2011;57(4):A1-A108
DIASTOLIC BLOOD PRESSURE MAY BE AN EARLY MODIFIABLE RISK FACTOR IN PREVENTING AORTIC STIFFNESS AMONG CHRONIC KIDNEY DISEASE PATIENTS Laura Maursetter, Lynn Jacobson, Nancy Sweitzer, Lisa Nanovic. University of Wisconsin Hospitals and Clinics, Madison, Wisconsin USA Chronic kidney disease (CKD) is estimated to affect approximately 15 million American people; the majority being greater than 60 years of age. Although aging increases the risk of cardiac complications in the general population, CKD is associated with as additional 10-20% increased risk of cardiovascular death. Discovering the factors that may increase this risk and intervening earlier in patients with CKD may improve mortality among this population. Aortic stiffness is a common finding in both the aging and the CKD populations but through different pathophysiologic mechanisms. A prospective longitudinal study was launched to investigate the hypothesis that patients over the age of 65 with moderate CKD will have increased vascular stiffness when compared to age matched controls. Enrollment was conducted at the University of Wisconsin Hospital and Clinics in Madison, Wisconsin. There were 14 subjects with moderate CKD stage 3 (defined as GFR 30-60 ml/min). The control group was comprised of 23 age-matched controls without CKD. Pulse wave velocity (PWV) was measured using tonometry, which is a noninvasive assessment used to estimate vascular stiffness. Individuals performing and interpreting the tonometry readings were blinded to the study group. Recruitment yielded demographically similar cohorts. PWV did not differ between the groups but diastolic blood pressure (DBP) was significantly higher in the CKD group (P=0.03) while SBP showed no difference. Of note, a high colinearity was seen between DBP and PWV. Patients over age 65 with moderate chronic kidney disease have higher diastolic blood pressures compared with age matched controls. This suggests that intervention targeting diastolic blood pressure at this stage has potential for cardiovascular risk factor modification. Further investigation is underway.
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