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334 Prevalence of Recurrent Intradialytic Hypertension
NKF 2011 Spring Clinical Meetings Abstracts
333 AUTOIMMUNE HEMOLYTIC ANEMIA AS A FIRST MANIFESTATION OF HIV NEPHROPATHY. Kalyan Uppaluri1, Hilana Hatoum1, Sundar Ramanathan1, Fadi Rzouq2, Aileen May Arguelles1, Daniel Gutteridge1, Kesari1. :Internal Medicine Department, Michigan State University/MRMC, Flint, MI. 2: Internal Medicine Department, Michigan State University/Covenant Health Care, Saginaw, MI, USA. Background: Anemia is the most common hematologic abnormality associated with Human immunodeficiency Virus (HIV) infection; affecting in late stage disease and usually multifactorial. Autoimmune Hemolytic Anemia (AIHA) is pretty uncommon presentation in HIV. AIHA is an uncommon but potentially lethal disorder requiring prompt diagnosis and treatment. Aim: To report a case of HIV nephropathy first manifested as AIHA. Clinical Vignette: A 44 y/o white man admitted to the hospital with one-month history of fatigue and weight loss. Other associated symptoms included generalized weakness, loose stools (2-3 times/ day), and no intentional weight loss. There was no significant medical history except than being a smoker. Physical exam was normal. Laboratory work-up was relevant for pancytopenia, Acute Kidney Injury (Creatinine= 2.19 mg/dL), high Lactate dehydronase (LDH), and positive direct Coombs test. An extensive work-up of AIHA, AKI, and pancytopenia ruled out other possible etiologies except for positive HIV serology. Renal biopsy revealed Focal Segmental Glomerulosclerosis (FSGS). HIV induced AKI and AIHA was considered as final diagnosis and the patient was started on HAART and steroid therapy. Conclusion: Although anemia is common in HIV, AIHA is rare and barely presents as the first manifestation of this infection. The mechanism is still unclear as well as the prognosis. It is really important to check for HIV in any patient with AKI and anemia of unknown etiology.
334 PREVALENCE OF RECURRENT INTRADIALYTIC HYPERTENSION Peter Van Buren, Catherine Kim, Robert Toto, Jula Inrig University of Texas Southwestern Medical Center-Dallas, Division of Nephrology Dallas, TX United States Intradialytic hypertension (IH), defined as an increase in systolic blood pressure (SBP) from pre to post hemodialysis (HD), is associated with increased mortality. The prevalence of IH is estimated to be 15% in the HD population based on brief study periods lasting less than 2 weeks, but its prevalence over longer time periods and how consistently individual patients have IH remain unknown. The purpose of this study is to determine the prevalence of IH over 6 months and assess the accuracy of the criteria used to define recurrent IH. We analyzed pre and post-HD SBP measurements obtained by automated sphygmomanometers for every HD session among all prevalent HD patients in our academic practice from January 25 to August 10, 2010. We defined IH as an SBP increase ≥ 10 mmHg from pre to post-HD, and defined recurrent IH as IH occurring in ≥4 out of any 6 consecutive treatments at on at least 2 separate occasions. We identified the prevalence of single and recurrent episodes of IH, and determined the sensitivity and specificity of our diagnostic criteria. Of 363 subjects, the mean age was 54.2 years (±12.3), 60% were male, 59% African American, and 34% Hispanic. IH occurred in 21.3% of 22,865 treatments and occurred at least once in 98.1% of subjects during 6 months. Subjects had IH in 0-89.9% of their treatments (median 17.7%, 25th-75th percentile 8.9-31.4%). Recurrent IH occurred in 104 subjects (28.9%). The sensitivity, specificity, and likelihood ratio in identifying subjects with IH in at least 50% of treatments was 100%, 77.6%, and 4.47 for the recurrent IH criteria. Intradialytic hypertension intermittently occurs in most HD patients, and is a recurrent event in almost 30% of patients. Our criteria for recurrent IH has high diagnostic accuracy for identifying subjects with this BP pattern in more than 50% of their treatments over 6 months. Differences in clinical outcomes between patients with different frequencies of IH remain to be determined.
A100
335 ADHERENCE TO STABLE HEMOGLOBIN ANEMIA PROTOCOL INCREASES ACHIEVEMENT OF TARGET HEMOGLOBIN LEVELS David Van Wyck1; Irina Goykhman1; Steve Wilson1; Joe Weldon1; Mahesh Krishnan1 1 DaVita Inc., Denver, CO, USA SHAPE (Stable Hemoglobin Anemia Program Effort) is a 4-year quality improvement program at a large dialysis organization (LDO) to optimize anemia management. The goals are to provide a protocol that, with greater than 95% adherence to protocol orders, achieves a high percentage of hemodialysis patients with Hb in the 10-12 g/dL target range, and minimizes percentage of patients below and above-target. To assess potential design elements, we evaluated 6 new protocols in over 7,000 patients undergoing treatment in over 100 in-center hemodialysis facilities at the LDO. We accumulated over 3,000 patient-years experience by September, 2010, when patients in the 6th and final pilot, which incorporated the most successful elements of previous pilots, had accumulated up to 4 months of experience. At that time, we compared Month 1 results in patients who were enrolled in the final SHAPE pilot protocol for at least 3 months based on adherence rate. All performance goals were met (Table). Cohort Rate of Mean Hb <10 Hb 10Hb >12 Adherence Hb g/dL 12 g/dL g/dL (g/dL) (%) (%) (%) All > 60% 11.1 11.0 71.3 17.7 participating pilot facilities Highest> 95% 11.1 8.8 77.7 13.5 adherence pilot facilities Anemia management using the newest version of SHAPE produces excellent Hb outcomes. High levels of adherence to the new protocol further improve outcomes and ensure successful anemia management performance under the proposed CMS Quality Improvement Program.
336 SULFA-RESISTANT NOCARDIA PERITONITIS WITH PULMONARY INVOLVEMENT – A CASE REPORT Rejeesh Vasudev, Bethany Pellegrino, Rebecca Schmidt West Virginia University, Morgantown, West Virginia Rare causes of peritonitis in patients on peritoneal dialysis (PD) require a heightened awareness as these may imitate routine processes. Failure of early diagnosis and appropriate treatment could reduce the chance of favorable return to PD. We report a case of 79 year old male on PD for 3 years with one episode of peritonitis in the remote past who presented with abdominal discomfort and nausea. Patient was discharged 2 weeks prior with a diagnosis of community-acquired pneumonia. On physical exam he was afebrile with abdominal tenderness. Lab tests revealed no leukocytosis, but PD fluid WBC count was 9000/UL. Chest CT showed a right upper lobe mass with central cavity and PD fluid cultured out Nocardia pseudobrasiliensis. Blood cultures were negative. After 8 days of intravenous trimethoprim-sulfamethoxazole (TMP-SMX), PD fluid WBC was 3200/UL, prompting removal of the PD catheter. When the sensitivity report revealed Nocardia resistant to TMPSMX, he was switched to ciprofloxacin with swift and sustained clinical improvement. Nocardia (gram-positive rod-shaped branching bacteria) is a rare cause of peritonitis. Cultures require 2-4 weeks to grow. Sulfa drugs are first-line and have been used successfully in most reported cases, though pulmonary involvement was not evident as in our patient. Clinicians should consider the possibility of nocardia peritonitis when the diagnosis is unclear or the response to empiric antibiotics is suboptimal. Interestingly, the pathogen most likely responsible for our patient's recurrent pneumonia was identified only from peritoneal fluid.
Am J Kidney Dis. 2011;57(4):A1-A108
333 AUTOIMMUNE HEMOLYTIC ANEMIA AS A FIRST MANIFESTATION OF HIV NEPHROPATHY. Kalyan Uppaluri1, Hilana Hatoum1, Sundar Ramanathan1, Fadi Rzouq2, Aileen May Arguelles1, Daniel Gutteridge1, Kesari1. :Internal Medicine Department, Michigan State University/MRMC, Flint, MI. 2: Internal Medicine Department, Michigan State University/Covenant Health Care, Saginaw, MI, USA. Background: Anemia is the most common hematologic abnormality associated with Human immunodeficiency Virus (HIV) infection; affecting in late stage disease and usually multifactorial. Autoimmune Hemolytic Anemia (AIHA) is pretty uncommon presentation in HIV. AIHA is an uncommon but potentially lethal disorder requiring prompt diagnosis and treatment. Aim: To report a case of HIV nephropathy first manifested as AIHA. Clinical Vignette: A 44 y/o white man admitted to the hospital with one-month history of fatigue and weight loss. Other associated symptoms included generalized weakness, loose stools (2-3 times/ day), and no intentional weight loss. There was no significant medical history except than being a smoker. Physical exam was normal. Laboratory work-up was relevant for pancytopenia, Acute Kidney Injury (Creatinine= 2.19 mg/dL), high Lactate dehydronase (LDH), and positive direct Coombs test. An extensive work-up of AIHA, AKI, and pancytopenia ruled out other possible etiologies except for positive HIV serology. Renal biopsy revealed Focal Segmental Glomerulosclerosis (FSGS). HIV induced AKI and AIHA was considered as final diagnosis and the patient was started on HAART and steroid therapy. Conclusion: Although anemia is common in HIV, AIHA is rare and barely presents as the first manifestation of this infection. The mechanism is still unclear as well as the prognosis. It is really important to check for HIV in any patient with AKI and anemia of unknown etiology.
334 PREVALENCE OF RECURRENT INTRADIALYTIC HYPERTENSION Peter Van Buren, Catherine Kim, Robert Toto, Jula Inrig University of Texas Southwestern Medical Center-Dallas, Division of Nephrology Dallas, TX United States Intradialytic hypertension (IH), defined as an increase in systolic blood pressure (SBP) from pre to post hemodialysis (HD), is associated with increased mortality. The prevalence of IH is estimated to be 15% in the HD population based on brief study periods lasting less than 2 weeks, but its prevalence over longer time periods and how consistently individual patients have IH remain unknown. The purpose of this study is to determine the prevalence of IH over 6 months and assess the accuracy of the criteria used to define recurrent IH. We analyzed pre and post-HD SBP measurements obtained by automated sphygmomanometers for every HD session among all prevalent HD patients in our academic practice from January 25 to August 10, 2010. We defined IH as an SBP increase ≥ 10 mmHg from pre to post-HD, and defined recurrent IH as IH occurring in ≥4 out of any 6 consecutive treatments at on at least 2 separate occasions. We identified the prevalence of single and recurrent episodes of IH, and determined the sensitivity and specificity of our diagnostic criteria. Of 363 subjects, the mean age was 54.2 years (±12.3), 60% were male, 59% African American, and 34% Hispanic. IH occurred in 21.3% of 22,865 treatments and occurred at least once in 98.1% of subjects during 6 months. Subjects had IH in 0-89.9% of their treatments (median 17.7%, 25th-75th percentile 8.9-31.4%). Recurrent IH occurred in 104 subjects (28.9%). The sensitivity, specificity, and likelihood ratio in identifying subjects with IH in at least 50% of treatments was 100%, 77.6%, and 4.47 for the recurrent IH criteria. Intradialytic hypertension intermittently occurs in most HD patients, and is a recurrent event in almost 30% of patients. Our criteria for recurrent IH has high diagnostic accuracy for identifying subjects with this BP pattern in more than 50% of their treatments over 6 months. Differences in clinical outcomes between patients with different frequencies of IH remain to be determined.
A100
335 ADHERENCE TO STABLE HEMOGLOBIN ANEMIA PROTOCOL INCREASES ACHIEVEMENT OF TARGET HEMOGLOBIN LEVELS David Van Wyck1; Irina Goykhman1; Steve Wilson1; Joe Weldon1; Mahesh Krishnan1 1 DaVita Inc., Denver, CO, USA SHAPE (Stable Hemoglobin Anemia Program Effort) is a 4-year quality improvement program at a large dialysis organization (LDO) to optimize anemia management. The goals are to provide a protocol that, with greater than 95% adherence to protocol orders, achieves a high percentage of hemodialysis patients with Hb in the 10-12 g/dL target range, and minimizes percentage of patients below and above-target. To assess potential design elements, we evaluated 6 new protocols in over 7,000 patients undergoing treatment in over 100 in-center hemodialysis facilities at the LDO. We accumulated over 3,000 patient-years experience by September, 2010, when patients in the 6th and final pilot, which incorporated the most successful elements of previous pilots, had accumulated up to 4 months of experience. At that time, we compared Month 1 results in patients who were enrolled in the final SHAPE pilot protocol for at least 3 months based on adherence rate. All performance goals were met (Table). Cohort Rate of Mean Hb <10 Hb 10Hb >12 Adherence Hb g/dL 12 g/dL g/dL (g/dL) (%) (%) (%) All > 60% 11.1 11.0 71.3 17.7 participating pilot facilities Highest> 95% 11.1 8.8 77.7 13.5 adherence pilot facilities Anemia management using the newest version of SHAPE produces excellent Hb outcomes. High levels of adherence to the new protocol further improve outcomes and ensure successful anemia management performance under the proposed CMS Quality Improvement Program.
336 SULFA-RESISTANT NOCARDIA PERITONITIS WITH PULMONARY INVOLVEMENT – A CASE REPORT Rejeesh Vasudev, Bethany Pellegrino, Rebecca Schmidt West Virginia University, Morgantown, West Virginia Rare causes of peritonitis in patients on peritoneal dialysis (PD) require a heightened awareness as these may imitate routine processes. Failure of early diagnosis and appropriate treatment could reduce the chance of favorable return to PD. We report a case of 79 year old male on PD for 3 years with one episode of peritonitis in the remote past who presented with abdominal discomfort and nausea. Patient was discharged 2 weeks prior with a diagnosis of community-acquired pneumonia. On physical exam he was afebrile with abdominal tenderness. Lab tests revealed no leukocytosis, but PD fluid WBC count was 9000/UL. Chest CT showed a right upper lobe mass with central cavity and PD fluid cultured out Nocardia pseudobrasiliensis. Blood cultures were negative. After 8 days of intravenous trimethoprim-sulfamethoxazole (TMP-SMX), PD fluid WBC was 3200/UL, prompting removal of the PD catheter. When the sensitivity report revealed Nocardia resistant to TMPSMX, he was switched to ciprofloxacin with swift and sustained clinical improvement. Nocardia (gram-positive rod-shaped branching bacteria) is a rare cause of peritonitis. Cultures require 2-4 weeks to grow. Sulfa drugs are first-line and have been used successfully in most reported cases, though pulmonary involvement was not evident as in our patient. Clinicians should consider the possibility of nocardia peritonitis when the diagnosis is unclear or the response to empiric antibiotics is suboptimal. Interestingly, the pathogen most likely responsible for our patient's recurrent pneumonia was identified only from peritoneal fluid.
Am J Kidney Dis. 2011;57(4):A1-A108