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264: GD-IGA1: A Screening Test for Pediatric IgA Nephropathy?
NKF 2010 Spring Clinical Meetings Abstracts
261 HYPERCALCEMIA DUE TO GRANULOMATOUS ACTIVITY OF PNEUMOCYSTIS JIROVECI PNEUMONIA IN A RENAL TRANSPLANT PATIENT Charbel Salem, James Simon, Nephrology, Cleveland Clinic, Cleveland, OH, USA Hypercalcemia due to macrophage production of 1-alpha hydroxylase is a known complication of granulomatous processes such as sarcoidosis and tuberculosis. It is a rare complication of Pneumocystic Jiroveci Pneumonia (PJP), which does not typically form granulomas. We describe a 49 year old renal transplant recipient with stage 4 chronic kidney disease and secondary hyperparathyroidism who presented with shortness of breath, fever and pulmonary infiltrates. Ionized calcium on blood gas analysis was 1.36mmol/L. Further work-up revealed an elevated 1,25OH Vitamin D level of 90pg/mL. 25OH Vitamin D5 was 29.6ng/mL and PTH was 25pg/mL. Serum calcium rose to 12.6mg/dL. One year earlier, PTH was 215pg/mL and Vitamin D levels were normal. He developed respiratory failure with worsening bilateral pulmonary infiltrates. Cultures from broncho-alveolar lavage grew PJP. He was treated with intravenous bactrim and solumedrol with good clinical response. After one week of therapy, the 1,25OH Vitamin D level normalized. Serum calcium normalized shortly afterward. Granulomatous activity leading to hypercalcemia in PJP infection is rarely described. We found 5 cases of PJP-associated hypercalcemia in the medical literature, two occurring in renal transplant patients. All cases responded to PJP therapy. Nephrologists should be aware of this entity as appropriate antimicrobial therapy should lead to resolution of the hypercalcemia.
262 ASSOCIATION OF 25 HYDROXY VITAMIN D WITH HEALTH RELATED QUALITY OF LIFE AND PHYSICAL FUNCTION IN A HEMODIALYSIS POPULATION Wilner Samson, Farmington, CT; Sharad Sathyan, Farmington , CT; Aim: To describe the Vitamin D stores in a hemodialysis population and to explore 25 hydroxy vitamin D (25 OHD) association with physical performance and health-related quality of life, including cognitive function. Methods: Subjects provided informed consent and 25 OH vitamin D levels were assessed. Physical assessment included 6 minute walk, handgrip strength and Short Physical Performance Battery (SPPB). Health questionnaires include cognitive screen, activities and instrumental activities of daily living, SF-36 and Geriatric Depression Scale. Results: Thus far, 16 subjects (mean age 64 + 16 years; 10 men/ 6 women; 63% Caucasian) had 25 OHD levels of 23.2 + 7.3 ng/dl. Thirteen subjects (81%) had 25 OHD less than 30 ng/dl. There was no association between physical performance and 25 OHD in this early assessment. Most subjects scored perfectly on the cognitive scale. There was no association between 25 OHD and questions regarding general health in this population in which 58% described their health as fair or poor. There was an association between 25 OHD and physical or emotional problems interfering with normal social activities (p=.004). Conclusions: Our preliminary data confirms that 25 OHD insufficiency is widely prevalent in the ESRD population. While an association between 25 OHD and physical performance was not seen, it could be due to the small sample and we will continue to recruit. There is an interesting association with questions pertaining to physical and emotional problems interfering with normal activities. Further work will be required to explore whether supplementation may improve physical and emotional health-related quality of life.
A97
263 EFFECT OF LOW SERUM CREATININE ON MORTALITY/ MORBIDITY IN HOSPITALIZED ELDERLY POPULATION Suresh Samson, J. Krishnakurup, Vivian Argento, Yaw Adjepong, Yale University Bridgeport Hospital,Bridgeport,CT. USA Malnourished elderly patients tend to have lower levels of serum creatinine. A recent retrospective analyses on critically ill patient found independent association between low baseline serum creatinine (LBSC) levels and increased hospital mortality. We hypothesized that LBSC would predict similarly poor outcome in hospitalized elderly population admitted to a regular medical floor. Retrospective medical record review of all hospitalized elderly (age 65 years or over) patients admitted from June 2008 to June 2009. Abstracted data included baseline serum creatinine, weight, height, body mass index, serum albumin, ICU transfer, in-hospital mortality, disposition, and recurrent admissions to the hospital within that year. Low serum creatinine group (LBSCG) was defined as patients with baseline serum creatinine <0.8mg/dl. Patients with normal baseline serum creatinine {NBSCG} (0.8-1.2mg/dl) served as the comparison group. Patients with serum creatinine ≥1.2mg/dl and patients on dialysis were excluded from the study. The study is ongoing. Preliminary analyses based on 90 patients, 53% of whom had low serum creatinine. The median age for the whole group was 79 years, 66.7% were women and 72.9% were white. 79.2% of the LBSCG were women compared to 52.4% of the NBSCG (p=0.007). There was no statistically significant difference in age (LBSCG 80.2 vrs 78.2, p=0.3), race (LBSCG 72.9% white vrs 59.5%, p=0.1), serum albumin (LBSCG 3.1vrs 3.2, p=0.4) or BMI (LBSCG 24.1 vrs 26.2, p=0.1) between the two groups. The in-hospital mortality rates was 6.3% for the LBSCG and 11.9% for the NBSCG (p=0.3). 18.4% of the LBSCG required ICU transfer compared to 11.5% for the NBSCG (p=0.3). For those discharged alive, 46.7% of the LBSCG were sent to an ECF rather than home compared to 43.2% for the NBSCG. Our preliminary analysis fails to find statistically significant association between low serum creatinine and hospital outcomes among non-critically ill patients. This is probably related to the small sample size used for the preliminary analyses. The full analyses, based on all 6000 eligible patients, will clarify these findings.
264 GD-IGA1: A SCREENING TEST FOR PEDIATRIC IgA Nephropathy? John Sanders1, Zina Moldoveanu2, Grant Sommes3, M. Colleen Hastings1, Wen-Qiang Huang2, Sherry Walker4, Olivia Hancox4, Jan Novak2 and Robert Wyatt1 1 Pediatrics, Univ. of Tenn. Health Science Center, Memphis, TN; 2 Microbiology, Univ. of Alabama at Birmingham, Birmingham, AL; 3 Epidemiology, Univ. of Tenn. Health Science Center, Mem-phis, TN, 4Le Bonheur Children’s Medical Center, Memphis, TN As diagnosis of IgA nephropathy (IgAN) requires renal biopsy, development of accurate screening laboratory tests would aid in evaluating patients with persistent hematuria. Increased levels of galactose deficient IgA1 (Gd-IgA1) is a principal pathogenic feature of IgAN. Studies in adults using a highly reproducible ELISA for GdIgA1 demonstrate significantly elevated serum Gd-IgA1 levels in patients with IgAN compared to healthy controls. Our objective was to determine whether the levels of Gd-IgA1 could be considered a marker to differentiate the pediatric IgAN patients from the pediatric disease and health controls. Levels of Gd-IgA1 in sera from pediatric subjects (2-18 years; 16 patients with biopsy-proven IgAN, 83 healthy controls, and 17 patients with non-IgAN glomerular disease were measured. Statistical significance was determined using linear mixed modeling. Group demographics: healthy controls (mean age 12.5±3.3 yrs; M:F 1.3:1; Black:non-Black 1.3:1), IgAN (mean age 12.7±3.9 yrs; M:F 0.5:1; Black:non-Black 0.3:1), and disease controls (mean age 10.7±3.4 yrs; M:F 0.9:1; Black:non-Black 1.8:1). Median Gd-IgA1 median value of 654 U/dL (241-1517 U/dL) for IgAN patients was significantly greater (p=0.003) than that for health controls (289.2 U/dL; 81-1009 U/dL) and for disease controls (351 U/dL; 80-716 U/dL). A Gd-IgA1 level of 446 U/dL (90th%tile for Controls), gives a sensitivity of 75% and a speci-ficity of 90% with a positive predictive value of 60% and a nega-tive predictive value of 95%. Repeat GdIgA1 measurement at about 6 months after entry demonstrated no significant changed levels in all of the groups. In summary, serum Gd-IgA1 levels can be used as a reason-able screening test for IgAN in pediatric patients.
261 HYPERCALCEMIA DUE TO GRANULOMATOUS ACTIVITY OF PNEUMOCYSTIS JIROVECI PNEUMONIA IN A RENAL TRANSPLANT PATIENT Charbel Salem, James Simon, Nephrology, Cleveland Clinic, Cleveland, OH, USA Hypercalcemia due to macrophage production of 1-alpha hydroxylase is a known complication of granulomatous processes such as sarcoidosis and tuberculosis. It is a rare complication of Pneumocystic Jiroveci Pneumonia (PJP), which does not typically form granulomas. We describe a 49 year old renal transplant recipient with stage 4 chronic kidney disease and secondary hyperparathyroidism who presented with shortness of breath, fever and pulmonary infiltrates. Ionized calcium on blood gas analysis was 1.36mmol/L. Further work-up revealed an elevated 1,25OH Vitamin D level of 90pg/mL. 25OH Vitamin D5 was 29.6ng/mL and PTH was 25pg/mL. Serum calcium rose to 12.6mg/dL. One year earlier, PTH was 215pg/mL and Vitamin D levels were normal. He developed respiratory failure with worsening bilateral pulmonary infiltrates. Cultures from broncho-alveolar lavage grew PJP. He was treated with intravenous bactrim and solumedrol with good clinical response. After one week of therapy, the 1,25OH Vitamin D level normalized. Serum calcium normalized shortly afterward. Granulomatous activity leading to hypercalcemia in PJP infection is rarely described. We found 5 cases of PJP-associated hypercalcemia in the medical literature, two occurring in renal transplant patients. All cases responded to PJP therapy. Nephrologists should be aware of this entity as appropriate antimicrobial therapy should lead to resolution of the hypercalcemia.
262 ASSOCIATION OF 25 HYDROXY VITAMIN D WITH HEALTH RELATED QUALITY OF LIFE AND PHYSICAL FUNCTION IN A HEMODIALYSIS POPULATION Wilner Samson, Farmington, CT; Sharad Sathyan, Farmington , CT; Aim: To describe the Vitamin D stores in a hemodialysis population and to explore 25 hydroxy vitamin D (25 OHD) association with physical performance and health-related quality of life, including cognitive function. Methods: Subjects provided informed consent and 25 OH vitamin D levels were assessed. Physical assessment included 6 minute walk, handgrip strength and Short Physical Performance Battery (SPPB). Health questionnaires include cognitive screen, activities and instrumental activities of daily living, SF-36 and Geriatric Depression Scale. Results: Thus far, 16 subjects (mean age 64 + 16 years; 10 men/ 6 women; 63% Caucasian) had 25 OHD levels of 23.2 + 7.3 ng/dl. Thirteen subjects (81%) had 25 OHD less than 30 ng/dl. There was no association between physical performance and 25 OHD in this early assessment. Most subjects scored perfectly on the cognitive scale. There was no association between 25 OHD and questions regarding general health in this population in which 58% described their health as fair or poor. There was an association between 25 OHD and physical or emotional problems interfering with normal social activities (p=.004). Conclusions: Our preliminary data confirms that 25 OHD insufficiency is widely prevalent in the ESRD population. While an association between 25 OHD and physical performance was not seen, it could be due to the small sample and we will continue to recruit. There is an interesting association with questions pertaining to physical and emotional problems interfering with normal activities. Further work will be required to explore whether supplementation may improve physical and emotional health-related quality of life.
A97
263 EFFECT OF LOW SERUM CREATININE ON MORTALITY/ MORBIDITY IN HOSPITALIZED ELDERLY POPULATION Suresh Samson, J. Krishnakurup, Vivian Argento, Yaw Adjepong, Yale University Bridgeport Hospital,Bridgeport,CT. USA Malnourished elderly patients tend to have lower levels of serum creatinine. A recent retrospective analyses on critically ill patient found independent association between low baseline serum creatinine (LBSC) levels and increased hospital mortality. We hypothesized that LBSC would predict similarly poor outcome in hospitalized elderly population admitted to a regular medical floor. Retrospective medical record review of all hospitalized elderly (age 65 years or over) patients admitted from June 2008 to June 2009. Abstracted data included baseline serum creatinine, weight, height, body mass index, serum albumin, ICU transfer, in-hospital mortality, disposition, and recurrent admissions to the hospital within that year. Low serum creatinine group (LBSCG) was defined as patients with baseline serum creatinine <0.8mg/dl. Patients with normal baseline serum creatinine {NBSCG} (0.8-1.2mg/dl) served as the comparison group. Patients with serum creatinine ≥1.2mg/dl and patients on dialysis were excluded from the study. The study is ongoing. Preliminary analyses based on 90 patients, 53% of whom had low serum creatinine. The median age for the whole group was 79 years, 66.7% were women and 72.9% were white. 79.2% of the LBSCG were women compared to 52.4% of the NBSCG (p=0.007). There was no statistically significant difference in age (LBSCG 80.2 vrs 78.2, p=0.3), race (LBSCG 72.9% white vrs 59.5%, p=0.1), serum albumin (LBSCG 3.1vrs 3.2, p=0.4) or BMI (LBSCG 24.1 vrs 26.2, p=0.1) between the two groups. The in-hospital mortality rates was 6.3% for the LBSCG and 11.9% for the NBSCG (p=0.3). 18.4% of the LBSCG required ICU transfer compared to 11.5% for the NBSCG (p=0.3). For those discharged alive, 46.7% of the LBSCG were sent to an ECF rather than home compared to 43.2% for the NBSCG. Our preliminary analysis fails to find statistically significant association between low serum creatinine and hospital outcomes among non-critically ill patients. This is probably related to the small sample size used for the preliminary analyses. The full analyses, based on all 6000 eligible patients, will clarify these findings.
264 GD-IGA1: A SCREENING TEST FOR PEDIATRIC IgA Nephropathy? John Sanders1, Zina Moldoveanu2, Grant Sommes3, M. Colleen Hastings1, Wen-Qiang Huang2, Sherry Walker4, Olivia Hancox4, Jan Novak2 and Robert Wyatt1 1 Pediatrics, Univ. of Tenn. Health Science Center, Memphis, TN; 2 Microbiology, Univ. of Alabama at Birmingham, Birmingham, AL; 3 Epidemiology, Univ. of Tenn. Health Science Center, Mem-phis, TN, 4Le Bonheur Children’s Medical Center, Memphis, TN As diagnosis of IgA nephropathy (IgAN) requires renal biopsy, development of accurate screening laboratory tests would aid in evaluating patients with persistent hematuria. Increased levels of galactose deficient IgA1 (Gd-IgA1) is a principal pathogenic feature of IgAN. Studies in adults using a highly reproducible ELISA for GdIgA1 demonstrate significantly elevated serum Gd-IgA1 levels in patients with IgAN compared to healthy controls. Our objective was to determine whether the levels of Gd-IgA1 could be considered a marker to differentiate the pediatric IgAN patients from the pediatric disease and health controls. Levels of Gd-IgA1 in sera from pediatric subjects (2-18 years; 16 patients with biopsy-proven IgAN, 83 healthy controls, and 17 patients with non-IgAN glomerular disease were measured. Statistical significance was determined using linear mixed modeling. Group demographics: healthy controls (mean age 12.5±3.3 yrs; M:F 1.3:1; Black:non-Black 1.3:1), IgAN (mean age 12.7±3.9 yrs; M:F 0.5:1; Black:non-Black 0.3:1), and disease controls (mean age 10.7±3.4 yrs; M:F 0.9:1; Black:non-Black 1.8:1). Median Gd-IgA1 median value of 654 U/dL (241-1517 U/dL) for IgAN patients was significantly greater (p=0.003) than that for health controls (289.2 U/dL; 81-1009 U/dL) and for disease controls (351 U/dL; 80-716 U/dL). A Gd-IgA1 level of 446 U/dL (90th%tile for Controls), gives a sensitivity of 75% and a speci-ficity of 90% with a positive predictive value of 60% and a nega-tive predictive value of 95%. Repeat GdIgA1 measurement at about 6 months after entry demonstrated no significant changed levels in all of the groups. In summary, serum Gd-IgA1 levels can be used as a reason-able screening test for IgAN in pediatric patients.