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285 Hyponatremia; A Risk Factor for In-Hospital Falls
NKF 2011 Spring Clinical Meetings Abstracts
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HYPONATREMIA; A RISK FACTOR FOR IN-HOSPITAL FALLS Nijal Sheth, Alan Dubrow, Maria Kassab, Eliot Charen, James F. Winchester, Beth Israel Medical Center, New York, New York. Others have recently reported that hyponatremia (serum sodium < 138 meq/L) is associated with out-patient falls as well as in-hospital and long term mortality. We hypothesized that hyponatremia would be a risk factor for in-hospital falls as well, a finding which would significantly impact morbidity as well as cost of care. We investigated all patients who fell at our hospital from 01/01/10 to 07/21/10 for serum sodium, medications with possibility of affecting serum sodium concentration and can cause fall, and co morbidities (cancer, CHF, DM, cirrhosis, HIV, ESRD). Fall data was obtained from incident reports. The data regarding patients with hyponatremia was gathered through ICD 9 discharge coding. From a total of 24,494 admissions (excluding pediatrics, Obstetrics-Gynecology, and intensive care units admissions) there were 73 hyponatremic patients (serum sodium <135) who fell. Odds Ratio of in-hospital fall if hyponatremic was 24.97(18.74 – 33.27, 95% confidence interval) and the P value using chi-square with Yates correction was < 0.0001. Among the hyponatremics mean serum sodium was 131.87meq/L and, mean age was 67.09 years. Additionally from all hyponatremics who fell there were twice as many men as women. There was no significant difference in terms of medications or co morbidities between hyponatremics and normonatremics who fell. Hyponatremics Normonatremics Total Fall 73 313 386 No Fall 223 23,882 24,105 Total 296 24,195 24,494 In conclusion, mild hyponatremia which might be unrecognized in the elderly significantly increases the incidence of in-hospital falls. We plan to initiate a prospective investigation to determine impact of hyponatremia correction in reducing the incidence of in-hospital falls.
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ASSOCIATION OF PLATELET COUNTS WITH SURROGATES OF DIETARY PROTEIN INTAKE AND MUSCLE MASS IN HEMODIALYSIS PATIENTS Christian S Shinaberger1, Miklos Z Molnar1, Elani Streja1, Csaba P Kovesdy2, Joel Kopple1, Kamyar Kalantar-Zadeh1; 1Harold Simmons Center, Harbor-UCLA Medical Center, Torrance, CA; 2Nephrology, Salem VA MC, Salem, VA Better nutritional status, as indicated by higher dietary protein intake and/or higher muscle mass, is associated with greater survival in maintenance hemodialysis (MHD) patients. We examined the hypothesis that higher normalized protein nitrogen appearance (nPNA, nPCR) and serum creatinine, measures of protein intake and/or muscle mass, respectively, are associated with favorable platelet activity profile in MHD patients. We separately examined associations of 13week averaged platelet count with 13-week averaged nPNA (g/kg/day) and serum creatinine (mg/dL) over 6 months in 40,697 MHD patients from DaVita clinics in the USA. Models were also adjusted for casemix. Patients were 61±15 years old and included 47%women, 46% diabetics and 34% African Americans. The 13-week averaged platelet count was 229±78x103. In both unadjusted and case-mix adjusted models, incrementally higher serum creatinine and higher nPNA levels were associated with lower platelet count (see Figures). 270
270
P la t e le t C o u n t ( x 1 ,0 0 0 /f l) .
250
unadjusted case-mix
260
P la te le t C o u n t (x 1 ,0 0 0 /fl) .
unadjusted case-mix
260
250
240
240
230
230
220
220
210
210
200
200 < 0.8
0.8- <0
.9
.0 0.9- <1
1.0- <1
.1
.2 1.1- <1
>= 1.2
Normalized Protein Nirogen Apperance [nPNA, nPCR] (g/kg/day)
<4
4 -<6
6 - <8
8 - <10
10 - <1
2
12 - <1
4
>=14
Serum Creatinine (mg/dL)
Based on these findings we advance the hypothesis that the relationship between malnutrition, inflammation, cardiovascular events and mortality may be mediated in part by thrombocytosis.
A88
NANOPARTICLE ENCAPSULATED MYCOPHENOLIC ACID DELAYS MURINE SKIN ALLOGRAFT REJECTION WITHOUT TOXIC DRUG EFFECTS Anushree C. Shirali, 1, Michael Look2, Tarek M. Fahmy,2 and Daniel R. Goldstein.1 Immunosuppressive agents are necessary for preventing acute allograft rejection but their dose-dependent side effects can induce morbidity and reduce long term allograft survival. Using a MHC mismatched murine skin graft model, we tested whether poly [lactideco-glycolide] nanoparticles (NP), a novel drug delivery platform, can efficaciously deliver mycophenolic acid (MPA) and improve transplant outcomes without the toxicity of soluble (unencapsulated) MPA. We transplanted C57BL/6 mice with BM12 skin grafts and treated them between 0-14d post-transplant with daily dosed 5mg soluble MPA (dMPA), or intermittently dosed 5 mg soluble MPA (sMPA) or 5 mg NP loaded with 1-10 µg MPA per mg NP (NP-MPA). Control groups received 5 mg empty NP or no treatment. We assessed the impact of NP-MPA treatment on graft survival, RBC indices, and dendritic cell (DC) function. Compared to mice that received no treatment (MST=19.5d) or mice that received empty NP (MST=20d), mice that received NP-MPA exhibited significantly prolonged allograft survival (MST = 33 days, p=0.0002 and p=0.02, respectively). sMPA provided marginal survival benefit compared to untreated mice (MST=22d, p=0.01) without further benefit with daily dosing (MST=22 d). Significantly, dMPA treatment induced a profound anemia (Fig. 2) which persisted until withdrawal of drug. We found that DCs endocytosed NP and DCs treated with NPMPA were defective in priming alloimmune T cells. NP-MPA delay acute allograft rejection with increased efficacy and without toxicity compared to soluble MPA. Despite containing 1000 fold lower total drug burden, NP-MPA achieves maximal graft prolongation via modulation of innate immune function and avoids dose-dependent anemia. Nanoparticles may be a novel delivery system for post-transplant immunosuppressive agents to improve solid organ transplant outcomes and minimize drug toxicities.
STAGE OF CKD AND ASSOCIATED COSTS IN A TYPE 2 DIABETES MANAGED CARE POPULATION Zita Shiue,1 Courtney Rees, 1 Wayne Katon, 3 Paul Ciechanowski, 3 Michael Von Korff, 3 Evette Ludman, 3 Do Peterson3, Elizabeth Lin, 3 Bessie Young1,2; 1University of Washington, Seattle, WA; 2Veterans Affairs Puget Sound Health System, Seattle, WA; 3Group Health Research Inst., Seattle WA The prevalence of chronic kidney disease (CKD) is significant and continues to rise in the United States. Costs for CKD patients are double their age-matched controls and diabetes remains one of the largest cost modifiers; however, less is known about specific CKD costs within a primary care diabetes population treated in a managed care setting. We sought to characterize the total costs of care at all stages of CKD among a primary care population with Type 2 diabetes. The Pathways Study is a prospective longitudinal cohort study of diabetic patients within a large managed care system. Stage of CKD was defined by the National Kidney Foundation guidelines. Costs were examined at 6 months from baseline and included: primary and specialty care, pharmacy, laboratory, emergency room, inpatient costs, and a total sum across all cost categories. Cuzick non-parametric testing was used to assess for trend with all CKD categories compared to CKD stage 0. Of the 3754 patients included in the study, 3283 individuals met one of the definitions of CKD. The mean absolute total costs for CKD stages 0-5 at six months were: $2076, $3508, $3292, $4867, $7905, $14233, respectively. Absolute percentage of total outpatient costs at each stage was: 66%, 48%, 53%, 49%, 48%, and 37%. Compared to stage 0, patients in stages 2 to 5 demonstrated significantly increased costs within each cost category and overall. Those in stage 1 also had increased total costs compared to stage 0, but this did not reach statistical significance (p=0.051). Cuzick nonparametric tests showed a significant, increasing cost trend by CKD stage in all cost categories (p<0.0001), as well as for total costs (p<0.0001). Total costs of care increase significantly with increasing stages of CKD. Much of this economic burden of disease may be attributable to a larger percentage of inpatient costs at the later stages of CKD. Stage of CKD is an important predictor of health care costs in a managed care organization for patients with Type 2 diabetes.
Am J Kidney Dis. 2011;57(4):A1-A108
285
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HYPONATREMIA; A RISK FACTOR FOR IN-HOSPITAL FALLS Nijal Sheth, Alan Dubrow, Maria Kassab, Eliot Charen, James F. Winchester, Beth Israel Medical Center, New York, New York. Others have recently reported that hyponatremia (serum sodium < 138 meq/L) is associated with out-patient falls as well as in-hospital and long term mortality. We hypothesized that hyponatremia would be a risk factor for in-hospital falls as well, a finding which would significantly impact morbidity as well as cost of care. We investigated all patients who fell at our hospital from 01/01/10 to 07/21/10 for serum sodium, medications with possibility of affecting serum sodium concentration and can cause fall, and co morbidities (cancer, CHF, DM, cirrhosis, HIV, ESRD). Fall data was obtained from incident reports. The data regarding patients with hyponatremia was gathered through ICD 9 discharge coding. From a total of 24,494 admissions (excluding pediatrics, Obstetrics-Gynecology, and intensive care units admissions) there were 73 hyponatremic patients (serum sodium <135) who fell. Odds Ratio of in-hospital fall if hyponatremic was 24.97(18.74 – 33.27, 95% confidence interval) and the P value using chi-square with Yates correction was < 0.0001. Among the hyponatremics mean serum sodium was 131.87meq/L and, mean age was 67.09 years. Additionally from all hyponatremics who fell there were twice as many men as women. There was no significant difference in terms of medications or co morbidities between hyponatremics and normonatremics who fell. Hyponatremics Normonatremics Total Fall 73 313 386 No Fall 223 23,882 24,105 Total 296 24,195 24,494 In conclusion, mild hyponatremia which might be unrecognized in the elderly significantly increases the incidence of in-hospital falls. We plan to initiate a prospective investigation to determine impact of hyponatremia correction in reducing the incidence of in-hospital falls.
286
288
ASSOCIATION OF PLATELET COUNTS WITH SURROGATES OF DIETARY PROTEIN INTAKE AND MUSCLE MASS IN HEMODIALYSIS PATIENTS Christian S Shinaberger1, Miklos Z Molnar1, Elani Streja1, Csaba P Kovesdy2, Joel Kopple1, Kamyar Kalantar-Zadeh1; 1Harold Simmons Center, Harbor-UCLA Medical Center, Torrance, CA; 2Nephrology, Salem VA MC, Salem, VA Better nutritional status, as indicated by higher dietary protein intake and/or higher muscle mass, is associated with greater survival in maintenance hemodialysis (MHD) patients. We examined the hypothesis that higher normalized protein nitrogen appearance (nPNA, nPCR) and serum creatinine, measures of protein intake and/or muscle mass, respectively, are associated with favorable platelet activity profile in MHD patients. We separately examined associations of 13week averaged platelet count with 13-week averaged nPNA (g/kg/day) and serum creatinine (mg/dL) over 6 months in 40,697 MHD patients from DaVita clinics in the USA. Models were also adjusted for casemix. Patients were 61±15 years old and included 47%women, 46% diabetics and 34% African Americans. The 13-week averaged platelet count was 229±78x103. In both unadjusted and case-mix adjusted models, incrementally higher serum creatinine and higher nPNA levels were associated with lower platelet count (see Figures). 270
270
P la t e le t C o u n t ( x 1 ,0 0 0 /f l) .
250
unadjusted case-mix
260
P la te le t C o u n t (x 1 ,0 0 0 /fl) .
unadjusted case-mix
260
250
240
240
230
230
220
220
210
210
200
200 < 0.8
0.8- <0
.9
.0 0.9- <1
1.0- <1
.1
.2 1.1- <1
>= 1.2
Normalized Protein Nirogen Apperance [nPNA, nPCR] (g/kg/day)
<4
4 -<6
6 - <8
8 - <10
10 - <1
2
12 - <1
4
>=14
Serum Creatinine (mg/dL)
Based on these findings we advance the hypothesis that the relationship between malnutrition, inflammation, cardiovascular events and mortality may be mediated in part by thrombocytosis.
A88
NANOPARTICLE ENCAPSULATED MYCOPHENOLIC ACID DELAYS MURINE SKIN ALLOGRAFT REJECTION WITHOUT TOXIC DRUG EFFECTS Anushree C. Shirali, 1, Michael Look2, Tarek M. Fahmy,2 and Daniel R. Goldstein.1 Immunosuppressive agents are necessary for preventing acute allograft rejection but their dose-dependent side effects can induce morbidity and reduce long term allograft survival. Using a MHC mismatched murine skin graft model, we tested whether poly [lactideco-glycolide] nanoparticles (NP), a novel drug delivery platform, can efficaciously deliver mycophenolic acid (MPA) and improve transplant outcomes without the toxicity of soluble (unencapsulated) MPA. We transplanted C57BL/6 mice with BM12 skin grafts and treated them between 0-14d post-transplant with daily dosed 5mg soluble MPA (dMPA), or intermittently dosed 5 mg soluble MPA (sMPA) or 5 mg NP loaded with 1-10 µg MPA per mg NP (NP-MPA). Control groups received 5 mg empty NP or no treatment. We assessed the impact of NP-MPA treatment on graft survival, RBC indices, and dendritic cell (DC) function. Compared to mice that received no treatment (MST=19.5d) or mice that received empty NP (MST=20d), mice that received NP-MPA exhibited significantly prolonged allograft survival (MST = 33 days, p=0.0002 and p=0.02, respectively). sMPA provided marginal survival benefit compared to untreated mice (MST=22d, p=0.01) without further benefit with daily dosing (MST=22 d). Significantly, dMPA treatment induced a profound anemia (Fig. 2) which persisted until withdrawal of drug. We found that DCs endocytosed NP and DCs treated with NPMPA were defective in priming alloimmune T cells. NP-MPA delay acute allograft rejection with increased efficacy and without toxicity compared to soluble MPA. Despite containing 1000 fold lower total drug burden, NP-MPA achieves maximal graft prolongation via modulation of innate immune function and avoids dose-dependent anemia. Nanoparticles may be a novel delivery system for post-transplant immunosuppressive agents to improve solid organ transplant outcomes and minimize drug toxicities.
STAGE OF CKD AND ASSOCIATED COSTS IN A TYPE 2 DIABETES MANAGED CARE POPULATION Zita Shiue,1 Courtney Rees, 1 Wayne Katon, 3 Paul Ciechanowski, 3 Michael Von Korff, 3 Evette Ludman, 3 Do Peterson3, Elizabeth Lin, 3 Bessie Young1,2; 1University of Washington, Seattle, WA; 2Veterans Affairs Puget Sound Health System, Seattle, WA; 3Group Health Research Inst., Seattle WA The prevalence of chronic kidney disease (CKD) is significant and continues to rise in the United States. Costs for CKD patients are double their age-matched controls and diabetes remains one of the largest cost modifiers; however, less is known about specific CKD costs within a primary care diabetes population treated in a managed care setting. We sought to characterize the total costs of care at all stages of CKD among a primary care population with Type 2 diabetes. The Pathways Study is a prospective longitudinal cohort study of diabetic patients within a large managed care system. Stage of CKD was defined by the National Kidney Foundation guidelines. Costs were examined at 6 months from baseline and included: primary and specialty care, pharmacy, laboratory, emergency room, inpatient costs, and a total sum across all cost categories. Cuzick non-parametric testing was used to assess for trend with all CKD categories compared to CKD stage 0. Of the 3754 patients included in the study, 3283 individuals met one of the definitions of CKD. The mean absolute total costs for CKD stages 0-5 at six months were: $2076, $3508, $3292, $4867, $7905, $14233, respectively. Absolute percentage of total outpatient costs at each stage was: 66%, 48%, 53%, 49%, 48%, and 37%. Compared to stage 0, patients in stages 2 to 5 demonstrated significantly increased costs within each cost category and overall. Those in stage 1 also had increased total costs compared to stage 0, but this did not reach statistical significance (p=0.051). Cuzick nonparametric tests showed a significant, increasing cost trend by CKD stage in all cost categories (p<0.0001), as well as for total costs (p<0.0001). Total costs of care increase significantly with increasing stages of CKD. Much of this economic burden of disease may be attributable to a larger percentage of inpatient costs at the later stages of CKD. Stage of CKD is an important predictor of health care costs in a managed care organization for patients with Type 2 diabetes.
Am J Kidney Dis. 2011;57(4):A1-A108