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NKF 2007 Spring Clinical Meetings Abstracts
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SINGLE CENTER EXPERIENCE WITH LOW-DOSE THYMOGLOBULIN AND STEROID FREE INDUCTION IMMUNOSUPPRESSION IN KIDNEY TRANSPLANT PATIENTS Chhavi Gupta, Adit Mahale, Mythili Ghanta, Brian Mceever, Gopal K Chemiti, Thomas Ahlin, Bhargav M Mistry; Department of Nephrology and Transplantation, MeritCare Medical Group, Fargo, ND, USA. Thymoglobulin is a polyclonal antibody that has been used as an induction agent in kidney transplantation. We report our single center experience in kidney transplant patients induced steroid free with low dose Thymoglobulin of 1mg/kg/dose for a total of 3-5 doses (Total dose: 3-5mg/kg). The study was designed as a retrospective, non-randomized and unblinded evaluation of 46 adult renal transplant recipients at our center. Patients were induced with Thymoglobulin (1mg/kg intravenously) on days 0, 1 and 2. Some patients received more doses depending on the discretion of the physicians. Patients received IV Methylprednisolone 250mg on the day of the surgery. This was rapidly tapered and stopped over the next 6 days. The maintenance immunosuppression included combinations of Tacrolimus, Mycophenolate mofetil, Sirolimus, and Cyclosporine. The primary end point of the study was acute rejection rate 12 months post transplant. Also studied were the patient and graft survival, serum creatinine levels, glomerular filtration rate calculated by the Modification of Diet in Renal Disease (MDRD) formula, polyoma virus nephropathy, opportunistic infections and malignancies. The dose of Thymoglobulin used was 1.03±0.17 mg/kg/dose, the total number of doses used were 3.41±0.54. The total dose used was 3.51±0.84 mg/kg. Mean serum creatinine at the end of 12 months was 1.27±0.29 mg/dL. Mean MDRD-GFR at the end of 12 months was 59.1±12.5 ml/min. Patient survival was 95.65%. Death censored graft survival was 100 %. Complications included an acute rejection rate of 4 out of 46 (8.69%), Cytomegalovirus infection 2.2 % (n =1), Diabetes mellitus 6.5% (n=3), and Histoplasmosis 2.2 % (n = 1). We conclude that low dose Thymoglobulin in kidney transplant patients is safe, cost effective treatment and is associated with a low incidence of acute rejection and very good graft survival rates in patients on steroid free protocols.
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76 FABRY DISEASE & THE KIDNEY: THE UNIVERSITY OF CONNECTICUT EXPERIENCE Lalarukh Haider, Robert M Greenstein, Nancy Day Adams. University of Connecticut Health Center, Farmington, CT, USA Purpose: to review CKD in patients with Fabry disease (FD) evaluated at UCONN. We retrospectively reviewed all patients evaluated for FD at UCONN. Many of these patients are included in the Fabry registry. A total of 41 patients (20 M and 21 F) were evaluated. One patient was found not to have FD. Thirteen (11 F and 2 M) were lost to follow up and had minimal or no data. These young patients (range 447 yrs) were referred to UCONN to establish the diagnosis/carrier status of FD. Thus 27 patients (18 M and 9 F) were evaluated. Nine F were assessed. None had a renal biopsy. All had an estimated GFR (eGFR) of >60ml/min/1.73m2 [range S creat 0.6-0.8 mg/dl]. Four/9 had symptom onset at a median age of 13 years. The median 24hr urinary protein excretion was 196 mg [range: 88-1240 mg/d]. Four/9 had hypertension. One patient was treated with an ACE inhibitor (ace-i) while 2 were intolerant of ace-i/ARB. Three patients were on enzyme replacement therapy (ERT). Three with only minor symptoms declined ERT and 2 had no compelling indications. Eighteen M patients were assessed. All 18 received ERT, some starting ERT in trials prior to FDA approval of agalsidase-beta. One died of a cardiac arrest weeks after ERT onset. Two/18 had no symptoms prior to initiating ERT. The median age of symptom onset was 17.5 years. The median age at presentation was 27.5 years. Seven/18 patients had renal biopsies for proteinuria and CKD. Median 24-hr urinary protein excretion was 770 mg [range: 124-3440 mg/d]. Median eGFR was 61 ml/min/1.73 m2, range: 14-128, excluding 1 each HD and PD but including 1 renal transplant. One patient progressed to ESRD 25 months after onset ERT, receiving an LRD renal graft. Nine/18 had hypertension at presentation, with 1 developing it over follow-up. Thirteen patients were treated with acei/ARBs. As anticipated, M Fabry patients had more proteinuria and progressive CKD than F carriers. Ace-i/ARBs were used and tolerated in many male patients treated with ERT.
CLINICAL PREDICTORS OF SEVERITY OF PROTEINURIA IN A COHORT OF PATIENTS WITH HEPATITIS C AND PROTEINURIA. Susan M. Hailpern, Robin Arora, Salman Waheed, Belinda Jim, Anjali Acharya; Jacobi Medical Center and Albert Einstein College of Medicine; Bronx, NY USA Glomerular disease with proteinuria and renal failure is seen in patients with hepatitis C infection (Hep-C). Hep-C has also been independently associated with microalbuminuria in the absence of diabetes. The purpose of this study was to examine the association of clinical and laboratory factors as well as co-morbid conditions on the degree of proteinuria in a cohort of Hep-C patients. We performed a retrospective chart review of 239 patients with a primary diagnosis of Hep-C who may have also had other co-morbid conditions. Charts were reviewed for clinical and demographic characteristics. Proteinuria was dichotomized ≥100 mg. Continuous variables were compared between proteinuria groups using Student’s ttests; categorical variables were compared between proteinuria groups using chi-square tests. A multivariable logistic regression was used to examine the association between proteinuria ≥100 mg and clinical and demographic characteristics of the Hep-C patients. The cohort was 38% male, mean age 51.2 years ± 8.9, with 44.4% having proteinuia ≥100mg. The proteinuria ≥100 mg group had a significantly lower hemoglobin, albumin, and total protein (p=0.01, 0.01, and 0.03, respectively). This group was less likely to have a prior diagnosis of hypertension (p=0.01). There were no statistically significant differences in the prevalence of diabetes (p=0.29), age (p=0.99), or sex (p=0.29) between the two groups. In multivariable logistic regression, albumin was significantly and inversely associated with proteinuria ≥100 mg (OR: 0.53; 95% CI: 0.36, 0.76), as was PT (OR: 0.87; 95% CI: 0.79, 0.95) and a prior diagnosis of hypertension (OR: 0.32; 95% CI: 0.13, 0.79). In summary, among patients with Hep-C proteinuria ≥100 mg was independently and inversely associated with a history of hypertension albumin, and prothrombin time. This study found no association between proteinuria ≥100 mg and a history of diabetes or age. Further research is needed to explore the implications of these observations.
MODERATE CHRONIC KIDNEY DISEASE AND COGNITIVE FUNCTION IN ADULTS 20-59 YEARS OF AGE (NHANES III) Susan M. Hailpern, Michal Melamed, Hillel W. Cohen, Thomas H. Hostetter; Albert Einstein College of Medicine; Bronx, NY USA Previous studies among elderly suggest an association between chronic kidney disease (CKD) and cognitive impairment. The purpose of this study was to determine whether moderate CKD is associated with cognitive performance among young, healthy, ethnically diverse adults. Three computerized cognitive function tests of visual-motor reaction time (Simple Reaction Time), visual attention (Symbol Digit Substitution), and learning/concentration (Serial Digit Learning) were administered to a random sample of participants, aged 20-59 years, who completed initial interviews and medical examination in the National Health and Nutrition Examination Survey III. Participants for this study (n=4,849) completed at least one cognitive function test. Glomerular filtration rate (GFR) was estimated using the Modification of Diet in Renal Disease equation. Moderate CKD was defined as estimated GFR (eGFR) 30-59 mL/min/1.73m2. Unadjusted, residualadjusted, and multivariate-adjusted logistic regression models were used. The cohort was 49.0% male, 11.6% Black, and mean ± SE age was 37.2 ± 0.23 years and eGFR 105.5 ± 0.73 mL/min/1.73m2. There were 31 prevalent cases of moderate CKD (0.8%). Models were adjusted for residual effects of age, sex, race, diabetes, and other known potential confounders. In multivariate models, moderate CKD was not significantly associated with reaction time, but was significantly associated with learning/concentration (OR: 2.41; 95% CI: 1.30, 5.63) and impairment in visual attention (OR: 2.74; 95% CI: 1.01, 7.40). In summary, among those in a large nationally representative sample of healthy, ethnically diverse 20-59 year-old adults, moderate CKD, reflected by eGFR 30-59 ml/min/1.73m2, was significantly associated with poorer performance in visual attention and learning/concentration.
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SINGLE CENTER EXPERIENCE WITH LOW-DOSE THYMOGLOBULIN AND STEROID FREE INDUCTION IMMUNOSUPPRESSION IN KIDNEY TRANSPLANT PATIENTS Chhavi Gupta, Adit Mahale, Mythili Ghanta, Brian Mceever, Gopal K Chemiti, Thomas Ahlin, Bhargav M Mistry; Department of Nephrology and Transplantation, MeritCare Medical Group, Fargo, ND, USA. Thymoglobulin is a polyclonal antibody that has been used as an induction agent in kidney transplantation. We report our single center experience in kidney transplant patients induced steroid free with low dose Thymoglobulin of 1mg/kg/dose for a total of 3-5 doses (Total dose: 3-5mg/kg). The study was designed as a retrospective, non-randomized and unblinded evaluation of 46 adult renal transplant recipients at our center. Patients were induced with Thymoglobulin (1mg/kg intravenously) on days 0, 1 and 2. Some patients received more doses depending on the discretion of the physicians. Patients received IV Methylprednisolone 250mg on the day of the surgery. This was rapidly tapered and stopped over the next 6 days. The maintenance immunosuppression included combinations of Tacrolimus, Mycophenolate mofetil, Sirolimus, and Cyclosporine. The primary end point of the study was acute rejection rate 12 months post transplant. Also studied were the patient and graft survival, serum creatinine levels, glomerular filtration rate calculated by the Modification of Diet in Renal Disease (MDRD) formula, polyoma virus nephropathy, opportunistic infections and malignancies. The dose of Thymoglobulin used was 1.03±0.17 mg/kg/dose, the total number of doses used were 3.41±0.54. The total dose used was 3.51±0.84 mg/kg. Mean serum creatinine at the end of 12 months was 1.27±0.29 mg/dL. Mean MDRD-GFR at the end of 12 months was 59.1±12.5 ml/min. Patient survival was 95.65%. Death censored graft survival was 100 %. Complications included an acute rejection rate of 4 out of 46 (8.69%), Cytomegalovirus infection 2.2 % (n =1), Diabetes mellitus 6.5% (n=3), and Histoplasmosis 2.2 % (n = 1). We conclude that low dose Thymoglobulin in kidney transplant patients is safe, cost effective treatment and is associated with a low incidence of acute rejection and very good graft survival rates in patients on steroid free protocols.
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76 FABRY DISEASE & THE KIDNEY: THE UNIVERSITY OF CONNECTICUT EXPERIENCE Lalarukh Haider, Robert M Greenstein, Nancy Day Adams. University of Connecticut Health Center, Farmington, CT, USA Purpose: to review CKD in patients with Fabry disease (FD) evaluated at UCONN. We retrospectively reviewed all patients evaluated for FD at UCONN. Many of these patients are included in the Fabry registry. A total of 41 patients (20 M and 21 F) were evaluated. One patient was found not to have FD. Thirteen (11 F and 2 M) were lost to follow up and had minimal or no data. These young patients (range 447 yrs) were referred to UCONN to establish the diagnosis/carrier status of FD. Thus 27 patients (18 M and 9 F) were evaluated. Nine F were assessed. None had a renal biopsy. All had an estimated GFR (eGFR) of >60ml/min/1.73m2 [range S creat 0.6-0.8 mg/dl]. Four/9 had symptom onset at a median age of 13 years. The median 24hr urinary protein excretion was 196 mg [range: 88-1240 mg/d]. Four/9 had hypertension. One patient was treated with an ACE inhibitor (ace-i) while 2 were intolerant of ace-i/ARB. Three patients were on enzyme replacement therapy (ERT). Three with only minor symptoms declined ERT and 2 had no compelling indications. Eighteen M patients were assessed. All 18 received ERT, some starting ERT in trials prior to FDA approval of agalsidase-beta. One died of a cardiac arrest weeks after ERT onset. Two/18 had no symptoms prior to initiating ERT. The median age of symptom onset was 17.5 years. The median age at presentation was 27.5 years. Seven/18 patients had renal biopsies for proteinuria and CKD. Median 24-hr urinary protein excretion was 770 mg [range: 124-3440 mg/d]. Median eGFR was 61 ml/min/1.73 m2, range: 14-128, excluding 1 each HD and PD but including 1 renal transplant. One patient progressed to ESRD 25 months after onset ERT, receiving an LRD renal graft. Nine/18 had hypertension at presentation, with 1 developing it over follow-up. Thirteen patients were treated with acei/ARBs. As anticipated, M Fabry patients had more proteinuria and progressive CKD than F carriers. Ace-i/ARBs were used and tolerated in many male patients treated with ERT.
CLINICAL PREDICTORS OF SEVERITY OF PROTEINURIA IN A COHORT OF PATIENTS WITH HEPATITIS C AND PROTEINURIA. Susan M. Hailpern, Robin Arora, Salman Waheed, Belinda Jim, Anjali Acharya; Jacobi Medical Center and Albert Einstein College of Medicine; Bronx, NY USA Glomerular disease with proteinuria and renal failure is seen in patients with hepatitis C infection (Hep-C). Hep-C has also been independently associated with microalbuminuria in the absence of diabetes. The purpose of this study was to examine the association of clinical and laboratory factors as well as co-morbid conditions on the degree of proteinuria in a cohort of Hep-C patients. We performed a retrospective chart review of 239 patients with a primary diagnosis of Hep-C who may have also had other co-morbid conditions. Charts were reviewed for clinical and demographic characteristics. Proteinuria was dichotomized ≥100 mg. Continuous variables were compared between proteinuria groups using Student’s ttests; categorical variables were compared between proteinuria groups using chi-square tests. A multivariable logistic regression was used to examine the association between proteinuria ≥100 mg and clinical and demographic characteristics of the Hep-C patients. The cohort was 38% male, mean age 51.2 years ± 8.9, with 44.4% having proteinuia ≥100mg. The proteinuria ≥100 mg group had a significantly lower hemoglobin, albumin, and total protein (p=0.01, 0.01, and 0.03, respectively). This group was less likely to have a prior diagnosis of hypertension (p=0.01). There were no statistically significant differences in the prevalence of diabetes (p=0.29), age (p=0.99), or sex (p=0.29) between the two groups. In multivariable logistic regression, albumin was significantly and inversely associated with proteinuria ≥100 mg (OR: 0.53; 95% CI: 0.36, 0.76), as was PT (OR: 0.87; 95% CI: 0.79, 0.95) and a prior diagnosis of hypertension (OR: 0.32; 95% CI: 0.13, 0.79). In summary, among patients with Hep-C proteinuria ≥100 mg was independently and inversely associated with a history of hypertension albumin, and prothrombin time. This study found no association between proteinuria ≥100 mg and a history of diabetes or age. Further research is needed to explore the implications of these observations.
MODERATE CHRONIC KIDNEY DISEASE AND COGNITIVE FUNCTION IN ADULTS 20-59 YEARS OF AGE (NHANES III) Susan M. Hailpern, Michal Melamed, Hillel W. Cohen, Thomas H. Hostetter; Albert Einstein College of Medicine; Bronx, NY USA Previous studies among elderly suggest an association between chronic kidney disease (CKD) and cognitive impairment. The purpose of this study was to determine whether moderate CKD is associated with cognitive performance among young, healthy, ethnically diverse adults. Three computerized cognitive function tests of visual-motor reaction time (Simple Reaction Time), visual attention (Symbol Digit Substitution), and learning/concentration (Serial Digit Learning) were administered to a random sample of participants, aged 20-59 years, who completed initial interviews and medical examination in the National Health and Nutrition Examination Survey III. Participants for this study (n=4,849) completed at least one cognitive function test. Glomerular filtration rate (GFR) was estimated using the Modification of Diet in Renal Disease equation. Moderate CKD was defined as estimated GFR (eGFR) 30-59 mL/min/1.73m2. Unadjusted, residualadjusted, and multivariate-adjusted logistic regression models were used. The cohort was 49.0% male, 11.6% Black, and mean ± SE age was 37.2 ± 0.23 years and eGFR 105.5 ± 0.73 mL/min/1.73m2. There were 31 prevalent cases of moderate CKD (0.8%). Models were adjusted for residual effects of age, sex, race, diabetes, and other known potential confounders. In multivariate models, moderate CKD was not significantly associated with reaction time, but was significantly associated with learning/concentration (OR: 2.41; 95% CI: 1.30, 5.63) and impairment in visual attention (OR: 2.74; 95% CI: 1.01, 7.40). In summary, among those in a large nationally representative sample of healthy, ethnically diverse 20-59 year-old adults, moderate CKD, reflected by eGFR 30-59 ml/min/1.73m2, was significantly associated with poorer performance in visual attention and learning/concentration.