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215: Anthropometric Measures Associated With Visceral Adiposity in Non-Dialysis Dependent CKD
A76
NKF 2009 Spring Clinical Meetings Abstracts
213
215
SHORT AND LONG TERM OUTCOMES IN ARTERIOVENOUS FISTULAS REQUIRING INTERVENTIONS TO PROMOTE MATURATION Ahsan Ullah1, Heather Duncan1,2, Prabir Roy-Chaudhury1,2, Mahmoud El-Khatib1,2, and Timmy Lee1,2, University of Cincinnati, Division of Nephrology and Hypertension1, Cincinnati Dialysis Access Program2 The emphasis on “Fistula First” has likely resulted in more interventions to promote AVF maturation and maintain patency of previously functional AVFs. Primary failures due to thrombosis or inadequate maturation remains a significant barrier in improving prevalence of AVF use. The objective of this study is to study both short-term and long-term survival among AVFs which require interventions to promote maturation and maintain patency compared to those that did not require interventions to promote maturation. A retrospective review of University patients who received autologous AVFs from January 2002 to March 2008 was performed. In total, we identified 127 patients during this period. 74.8% were male, 69.3% blacks, 53.5% diabetics, 24.4% had peripheral vascular disease, 70.1% with upper arm accesses, and 42.5% requiring intervention before AVF maturation. There were no demographic differences between patients who had an intervention before AVF maturation and those who did not. Patients with interventions prior to AVF maturation compared to those without interventions had worse cumulative survival (mean survival 797 vs 970 days, p= 0.0044), postintervention primary patency (median survival 96 vs 605 days, p=0.004) and postintervention secondary patency (median survival 390 vs 630 days, p= 0.036) and, and longer time to first AVF use (median time 127 vs 85 days, p=0.0068). Patients with interventions prior to AVF maturation had worse short and long term outcomes, and required longer maturation time before first use. Interventions may induce endothelial injury, inflammation, and oxidative stress, resulting in worse short and long-term AVF survival. Our results emphasize the importance of being able to identify prognostic markers that determine AVF survival following an intervention to promote AV fistula maturation.
214
ANTHROPOMETRIC MEASURES ASSOCIATED WITH VISCERAL ADIPOSITY IN NON-DIALYSIS DEPENDENT CKD. Vitalie Ureche1 Donna Lawson2 Ali Iranmanesh1 Kamyar Kalantar-Zadeh3 and Csaba P Kovesdy1 1Salem, VA, 2Blacksburg, VA, and 3Torrance, CA, USA Higher body mass index (BMI) has been paradoxically associated with better outcomes in patients with non-dialysis dependent CKD (NDD-CKD), but it is unclear if higher BMI or other easily obtained anthropometric measures of obesity are representative of increased visceral adiposity in this population. We prospectively compared the ability of BMI and the waist-toheight ratio (WHtR) to predict total (TFA) and visceral fat area (VFA) measured by abdominal CT in 9 leaner patients (mean±SD BMI: 24.0±1.7 kg/m2) and 11 overweight or obese patients (36.3±4.3 kg/m2) with CKD stage 3-4 who were matched for age, race, DM and estimated GFR. The associations of BMI and WHtR with TFA and VFA were examined in linear regression models and by calculating and comparing areas under the receiver operating curves (AUC). Mean±SD TFA (676±302 cm2 vs. 397±123 cm2, p=0.03) and VFA (376±205 vs. 217±95, p=0.08) were higher in the obese vs. the lean group. In linear regression models one kg/m2 higher BMI was associated with 24 cm2 higher TFA (95%CI: 9-39, p=0.004) and with 15 cm2 higher VFA (95%CI: 4-25, p=0.008); a one unit higher WHtR was associated with 1945 cm2 higher TFA (95% CI: 747-3143, p=0.003) and with 1218 cm2 higher VFA (95% CI: 406-2031, p=0.006). AUC (95%CI) of WHtR and BMI to predict TFA above the median value was 0.82 (0.60-1.00) vs. 0.78 (0.56-0.99), p=0.3 and to predict VFA above the median value was 0.71 (0.47-0.94) vs. 0.66 (0.41-0.91), p=0.4. BMI and WHtR, two easily obtained anthropometric measures of obesity are significantly associated with CT-measured visceral adiposity in patients with NDD-CKD.
216 ®
THYMOGLOBULIN RELATED DELAYED CARDIOPULMONARY REACTION IN A KIDNEY TRANSPLANT RECIPIENT 1 1 Ahsan Ullah,MD , Prabir Roy-Chaudhury, MD , Gautham 1 2 1 Mogilishetty, MD , E. Steve Woodle, MD , Amit Govil, MD 1 2 Division of Nephrology and Hypertension and Transplant Surgery, University of Cincinnati Med. Ctr., Cincinnati, OH Thymoglobulin is a polyclonal antibody generated in rabbits following immunization with human T-cells and thymocytes. This case report describes an unusually delayed reaction after thymoglobulin administration. A 47 year old Afro-American male underwent deceased kidney transplant for lupus nephritis associated ESRD. His induction therapy included thymoglobulin, steroid and MMF. Patient got his 3rd dose of thymoglobulin on post-operative day 5 without any immediate adverse effect. About 22 hours later he developed acute cardiopulmonary symptoms manifested as acute bronchospasm with hypoxia, tachypnea, elevated BP, tachycardia, and fever. He was immediately treated with IV steroid, epinephrine, antihistamine and breathing treatment and he responded quickly. He was monitored in the ICU for a day and all work up for other possible etiology was negative and he was discharged home after 48 hours. The usual acute adverse reactions to thymoglobulin are related to cytokine release syndrome and include fever, tachycardia, respiratory distress, myalgia, headache etc and usually occur immediately after first dose. This was an unusually delayed and acute onset reaction. Since it is not uncommon to administer thymoglobulin on an outpatient basis post transplant for induction and for acute rejection treatment, it is prudent to keep in mind the possibility of delayed thymoglobulin reaction.
INFECTIOUS ENDOCARDITIS WITH ANTINEUTROPHIL CYTOPLASMIC AUTOANTIBODIES AND PAUCI IMMUNE CRESCENTIC GLOMERULONEPHRITIS, A CASE REPORT Kris Vanderkooy, Lakshmi Raman, Syed Hussain. Milwaukee, WI. Circulating antineutrophil cytoplasmic autoantibodies (ANCA) accompanied by pauci immune crescentic glomerulonephritis on renal biopsy typically implies a differential of three small vessel vasculitides. Conversely, infective endocarditis (IE) associated glomerulonephritis involves immune complex deposition and generally is ANCA negative. We present a case of IE accompanied by ANCA positive pauci immune crescentic glomerulonephritis. A 58-year-old gentleman hospitalized four months previously with IE presented with a three-month history of copper-colored urine. Examination revealed a poor dentition and a grade III/VI holosystolic murmur heard over the apex. Serum creatinine was initially 3.6 mg/dL, increased from a baseline of 1.0 mg/dL. Fractional excretion of sodium was 3.98%, and urine protein to creatinine ratio was 2940 mg/g. Urinalysis included red cell casts along with many RBCs and WBCs. Echocardiogram showed mitral valve vegetations with regurgitation. Blood cultures grew Streptococcus constellatus and Enterococcus faecalis. Serum ANCA was strongly positive with specificity for antiproteinase 3. Renal biopsy revealed necrotizing crescentic glomerulonephritis and electron microscopy showed no electron dense deposits. Six weeks of intravenous vancomycin and streptomycin yielded resolution of his bacteremia, clearance of vegetations, and a decrease in creatinine to 2.5 mg/dL. He never required hemodialysis and was discharged home free of complaints. The proper treatment for ANCA positive IE is not known. It is obvious that antibiotics are essential; however, the role of steroids is not fully understood. In this case, immunosuppressants were avoided out of concerns for potential exacerbation of ongoing bacterial infection. There are no controlled studies that assess the role of immunosuppresion such as cyclophosphamide in the treatment of acute kidney injury due to IE. In addition, in a patient with ANCA associated acute kidney injury and febrile illness, the possibility of IE should be entertained. We show in this case that the treatment of IE actually has a significant impact on the resolution of acute kidney injury.
NKF 2009 Spring Clinical Meetings Abstracts
213
215
SHORT AND LONG TERM OUTCOMES IN ARTERIOVENOUS FISTULAS REQUIRING INTERVENTIONS TO PROMOTE MATURATION Ahsan Ullah1, Heather Duncan1,2, Prabir Roy-Chaudhury1,2, Mahmoud El-Khatib1,2, and Timmy Lee1,2, University of Cincinnati, Division of Nephrology and Hypertension1, Cincinnati Dialysis Access Program2 The emphasis on “Fistula First” has likely resulted in more interventions to promote AVF maturation and maintain patency of previously functional AVFs. Primary failures due to thrombosis or inadequate maturation remains a significant barrier in improving prevalence of AVF use. The objective of this study is to study both short-term and long-term survival among AVFs which require interventions to promote maturation and maintain patency compared to those that did not require interventions to promote maturation. A retrospective review of University patients who received autologous AVFs from January 2002 to March 2008 was performed. In total, we identified 127 patients during this period. 74.8% were male, 69.3% blacks, 53.5% diabetics, 24.4% had peripheral vascular disease, 70.1% with upper arm accesses, and 42.5% requiring intervention before AVF maturation. There were no demographic differences between patients who had an intervention before AVF maturation and those who did not. Patients with interventions prior to AVF maturation compared to those without interventions had worse cumulative survival (mean survival 797 vs 970 days, p= 0.0044), postintervention primary patency (median survival 96 vs 605 days, p=0.004) and postintervention secondary patency (median survival 390 vs 630 days, p= 0.036) and, and longer time to first AVF use (median time 127 vs 85 days, p=0.0068). Patients with interventions prior to AVF maturation had worse short and long term outcomes, and required longer maturation time before first use. Interventions may induce endothelial injury, inflammation, and oxidative stress, resulting in worse short and long-term AVF survival. Our results emphasize the importance of being able to identify prognostic markers that determine AVF survival following an intervention to promote AV fistula maturation.
214
ANTHROPOMETRIC MEASURES ASSOCIATED WITH VISCERAL ADIPOSITY IN NON-DIALYSIS DEPENDENT CKD. Vitalie Ureche1 Donna Lawson2 Ali Iranmanesh1 Kamyar Kalantar-Zadeh3 and Csaba P Kovesdy1 1Salem, VA, 2Blacksburg, VA, and 3Torrance, CA, USA Higher body mass index (BMI) has been paradoxically associated with better outcomes in patients with non-dialysis dependent CKD (NDD-CKD), but it is unclear if higher BMI or other easily obtained anthropometric measures of obesity are representative of increased visceral adiposity in this population. We prospectively compared the ability of BMI and the waist-toheight ratio (WHtR) to predict total (TFA) and visceral fat area (VFA) measured by abdominal CT in 9 leaner patients (mean±SD BMI: 24.0±1.7 kg/m2) and 11 overweight or obese patients (36.3±4.3 kg/m2) with CKD stage 3-4 who were matched for age, race, DM and estimated GFR. The associations of BMI and WHtR with TFA and VFA were examined in linear regression models and by calculating and comparing areas under the receiver operating curves (AUC). Mean±SD TFA (676±302 cm2 vs. 397±123 cm2, p=0.03) and VFA (376±205 vs. 217±95, p=0.08) were higher in the obese vs. the lean group. In linear regression models one kg/m2 higher BMI was associated with 24 cm2 higher TFA (95%CI: 9-39, p=0.004) and with 15 cm2 higher VFA (95%CI: 4-25, p=0.008); a one unit higher WHtR was associated with 1945 cm2 higher TFA (95% CI: 747-3143, p=0.003) and with 1218 cm2 higher VFA (95% CI: 406-2031, p=0.006). AUC (95%CI) of WHtR and BMI to predict TFA above the median value was 0.82 (0.60-1.00) vs. 0.78 (0.56-0.99), p=0.3 and to predict VFA above the median value was 0.71 (0.47-0.94) vs. 0.66 (0.41-0.91), p=0.4. BMI and WHtR, two easily obtained anthropometric measures of obesity are significantly associated with CT-measured visceral adiposity in patients with NDD-CKD.
216 ®
THYMOGLOBULIN RELATED DELAYED CARDIOPULMONARY REACTION IN A KIDNEY TRANSPLANT RECIPIENT 1 1 Ahsan Ullah,MD , Prabir Roy-Chaudhury, MD , Gautham 1 2 1 Mogilishetty, MD , E. Steve Woodle, MD , Amit Govil, MD 1 2 Division of Nephrology and Hypertension and Transplant Surgery, University of Cincinnati Med. Ctr., Cincinnati, OH Thymoglobulin is a polyclonal antibody generated in rabbits following immunization with human T-cells and thymocytes. This case report describes an unusually delayed reaction after thymoglobulin administration. A 47 year old Afro-American male underwent deceased kidney transplant for lupus nephritis associated ESRD. His induction therapy included thymoglobulin, steroid and MMF. Patient got his 3rd dose of thymoglobulin on post-operative day 5 without any immediate adverse effect. About 22 hours later he developed acute cardiopulmonary symptoms manifested as acute bronchospasm with hypoxia, tachypnea, elevated BP, tachycardia, and fever. He was immediately treated with IV steroid, epinephrine, antihistamine and breathing treatment and he responded quickly. He was monitored in the ICU for a day and all work up for other possible etiology was negative and he was discharged home after 48 hours. The usual acute adverse reactions to thymoglobulin are related to cytokine release syndrome and include fever, tachycardia, respiratory distress, myalgia, headache etc and usually occur immediately after first dose. This was an unusually delayed and acute onset reaction. Since it is not uncommon to administer thymoglobulin on an outpatient basis post transplant for induction and for acute rejection treatment, it is prudent to keep in mind the possibility of delayed thymoglobulin reaction.
INFECTIOUS ENDOCARDITIS WITH ANTINEUTROPHIL CYTOPLASMIC AUTOANTIBODIES AND PAUCI IMMUNE CRESCENTIC GLOMERULONEPHRITIS, A CASE REPORT Kris Vanderkooy, Lakshmi Raman, Syed Hussain. Milwaukee, WI. Circulating antineutrophil cytoplasmic autoantibodies (ANCA) accompanied by pauci immune crescentic glomerulonephritis on renal biopsy typically implies a differential of three small vessel vasculitides. Conversely, infective endocarditis (IE) associated glomerulonephritis involves immune complex deposition and generally is ANCA negative. We present a case of IE accompanied by ANCA positive pauci immune crescentic glomerulonephritis. A 58-year-old gentleman hospitalized four months previously with IE presented with a three-month history of copper-colored urine. Examination revealed a poor dentition and a grade III/VI holosystolic murmur heard over the apex. Serum creatinine was initially 3.6 mg/dL, increased from a baseline of 1.0 mg/dL. Fractional excretion of sodium was 3.98%, and urine protein to creatinine ratio was 2940 mg/g. Urinalysis included red cell casts along with many RBCs and WBCs. Echocardiogram showed mitral valve vegetations with regurgitation. Blood cultures grew Streptococcus constellatus and Enterococcus faecalis. Serum ANCA was strongly positive with specificity for antiproteinase 3. Renal biopsy revealed necrotizing crescentic glomerulonephritis and electron microscopy showed no electron dense deposits. Six weeks of intravenous vancomycin and streptomycin yielded resolution of his bacteremia, clearance of vegetations, and a decrease in creatinine to 2.5 mg/dL. He never required hemodialysis and was discharged home free of complaints. The proper treatment for ANCA positive IE is not known. It is obvious that antibiotics are essential; however, the role of steroids is not fully understood. In this case, immunosuppressants were avoided out of concerns for potential exacerbation of ongoing bacterial infection. There are no controlled studies that assess the role of immunosuppresion such as cyclophosphamide in the treatment of acute kidney injury due to IE. In addition, in a patient with ANCA associated acute kidney injury and febrile illness, the possibility of IE should be entertained. We show in this case that the treatment of IE actually has a significant impact on the resolution of acute kidney injury.