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74: Renal Involvement With Normal Kidney Size in a Patient With Mantle Cell Lymphoma
NKF 2009 Spring Clinical Meetings Abstracts 73 CROSS-SECTIONAL ASSOCIATION OF SERUM CYSTATIN C AND PERIPHERAL ARTERIAL DISEASE Susan M. Hailpern, Meda E. Pavkov, Ann. M. O’Hare, Desmond E. Williams. Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA. USA. Recent evidence suggests that cystatin C may be an alternative to creatinine and creatinine-based estimates of renal function for measuring glomerular filtration rate (GFR). Cystatin C is also an independent predictor of cardiovascular events and mortality. The aim of the present study was to measure the association between serum cystatin C and peripheral arterial disease (PAD). Data from participants aged ≥40 years from the 1999-2002 National Health and Nutrition Examination Survey were analyzed to evaluate the associations between PAD, defined as ankle-brachial index <0.9, and elevated cystatin C (dichotomized at highest tertile: ≥1.05 mg/L). We used multivariable logistic regression analysis, weighted to account for the survey design and adjusted for selected potential confounders. Among the 2972 study participants, mean age (± SD) 56.3 ± 13.3 years, 46.7% male, 77.3% non-Hispanic white, 9.6% non-Hispanic black, 4.5% Mexican American, and 8.6% other. Prevalence of PAD was 5.2% (n=309). Participants with PAD were significantly older, more likely to have diabetes, a history of cardiovascular disease, more likely to be taking lipid-lowering medication, and to be physically inactive than those without. Levels of cystatin C, homocysteine, serum creatinine, and albuminuria were all higher in patients with PAD. Multivariable logistic regression models adjusted for potential confounders of PAD found a significant association between PAD and elevated cystatin C (odds ratio [OR]: 2.94; 95% confidence interval [CI]: 1.59, 5.43; p<0.001). The association persisted excluding those at higher risk for PAD with eGFR<60 ml/min/1.73 m2 (OR: 2.98; 95% CI: 1.61, 5.54; p<0.001). Elevated cystatin C is independently associated with peripheral arterial disease.
74 RENAL INVOLVEMENT WITH NORMAL KIDNEY SIZE IN A PATIENT WITH MANTLE CELL LYMPHOMA Hooman Hajian, Pritkia Shrivastava, W Brian Reeves. Penn State Hershey Medical Center, Hershey, PA, USA Mantle cell lymphoma (MCL) is a mature B-cell non-Hodgkin's Lymphoma (NHL) which has a variable, but often aggressive, course. Approximately 7% of adult NHLs are MCL, with a median age at diagnosis of 68 years old. It affects men almost 3 times more than women and Caucasians almost 2 times more than African Americans. The majority of cases present with advanced disease, most commonly involving the lymph nodes, spleen, Waldeyer's ring, bone marrow, and blood, while, in almost 25% of cases, the presentation is that of extra-nodal disease. Infiltration of the kidneys with tumor cells, particularly without significant enlargement in size, is uncommon. We present an unusual case of a 68-year-old Caucasian male with previously normal kidney function who presented with a one month history of progressive abdominal pain, weakness, dyspnea on exertion and hot flashes. His serum creatinine at the time of presentation was 2 mg/dl and continued to progressively worsen, reaching a peak of 4.4 mg/dl. Imaging studies during his hospitalization revealed mediastinal and bilateral hilar and upper abdominal lymphadenopathy and splenomegaly on CT scans, with normal kidney size both by Ultrasound and MRI. Further workup did not yield any clues as to the cause of his acute kidney injury. Ultimately, a kidney biopsy showed diffuse infiltration by tumor cells throughout the renal parenchyma, surrounding the renal tubules, extending into the tubular epithelium, and destroying many of the tubules. The patient was started on appropriate chemotherapy protocol, which resulted in rapid resolution of the kidney dysfunction back to normal. Infiltration of the kidneys by malignant cells is usually accompanied by an increase in their size. However, it is important to consider the possibility of infiltrative disease despite normal kidney size, particularly in cases of renal failure with inconclusive workup and no clear explanation for the acute kidney injury.
A41 75 HYPOTONIC FLUID THERAPY INDUCED HYPONATREMIA IN HOSPITALIZED CHILDREN WITH GASTROENTERITS AND DEHYDRATION mina hanna, mohammad s. saberi. Department of Pediatrics, Saint John Hospital and Medical Center, Detroit, MI. Hypotonic saline solutions have been used for over 5 decades to treat children with diarrheal dehydration. Recently, concern has been raised about the potential risk for iatrogenic hyponatremia as a result of this therapy. The purpose of this study was to look at the incidence and severity of acquired hyponatremia in children admitted to the hospital with acute gastroenteritis and dehydration and treated with hypotonic saline solutions. We reviewed the medical records of 124 previously healthy children aged 1 month to 12 years (mean age 3.3 + 3.1 years), admitted to the hospital with acute gastroenteritis and isotonic dehydration (serum Na 130-150 mEq/l) between January 2000 and December of 2005 that had at least 2 serum Na measurement, one on admission and another after 4-24 hours (mean 13.2 + 5.2 hrs) of IV hypotonic fluid (5% dextrose in 0.2%, in 0.3% or in 0.45% saline) therapy. There was significant increase in weight (12.6 + 9.9 kg to 12.8 + 9.8 kg), increase in CO2 (17.7 + 5.1 to 20.0 + 4.1mmol/l), decrease in Na (139.3 + 4.2 to 137.6 + 3.2mEq/l), decrease in BUN (16.8 + 6.6 to 8.9 + 4.0 mg/dl) and decrease in creatinine (0.42 + 0.15 to 0.37 + 0.14 mg/dl) with hydration (paired t-test p <0.01 for all). Of 97 patients with isonatremia (Na 135-145 mEq/l, mean 140.1 + 2.7) on admission, 79 remained isonatremic (Na 138.3 + 2.7) and 18 (18%) became hyponatremic (Na 133.4 + 0.9) with hydration. The drop in serum Na (5.7 + 3.1 mEq/l) was significantly (p < 0.002) higher in patients who became hyponatremic than in those who remained normonatremic (-1.8 + 3.4 mEq/l). None of the patients developed symptoms of hyponatremia. Of 19 patients who had serum Na of 130-134 mEq/l (mean 132.8 + 1.3) on admission, 14 (73%) became isonatremic (mean Na 136.7 + 2.6 mEq/l, and a rise of 3.9 + 2.5 mEq/l) despite hypotonic fluid therapy but 5 remained hyponatremic. Isonatremic patients who became hyponatremic with fluid therapy were older than those who remained isonatremic (5.8 + 2.7 vs. 2.8 + 3.1 years; p < .0005) but the rate of initial saline bolus (26.1 + 10.4 vs. 20.2 + 8.6 ml /kg) and the rate of subsequent IV fluid (4.3 + 1.6 vs. 4.8 + 1.6 ml / kg / hour) did not vary. Eighty two percent of patients were on D5-0.3% saline, 15% on D5-0.45% saline and 3% D5-0.2% saline. It is concluded that although in healthy subjects the ratio of water to Na in serum (6.89-7.40 ml / mEq) is tightly controlled by ADH-kidney axis, mild hyponatremia is common in hypotonic fluid treated children with gastroenteritis and dehydration.
76 POST TRANSPLANT BONE DISEASE. ARE WE MISSING ANYTHING? Haque, Ammar; Siddiqui, Khadija; Saleh, Mohammad; Alberti, Barbara; Hussain, Syed. Cement J-Zablocki VAMC and Medical College of Wisconsin, Milwaukee, WI, USA. Background: One major adverse effect of kidney transplantation is osteoporosis. However, the relationship of PTH, serum Ca, vitamin D levels, and duration of dialysis prior to transplantation remains largely unexplored. This study aims to assess the relationship of PTH, serum Ca., vitamin D, bone mineral density (BMD) exams, and duration of dialysis prior to receiving kidney transplant. Methods: We retrospectively reviewed medical records of 43 patients who received a renal transplant. Patients were excluded (16) if they did not have the appropriate labs (PTH, serum Ca., vitamin D levels) and the BMD exam as needed for the study. Patients were further classified by their chronic kidney disease (CKD) stage based on their eGFR(MDRD): group A (CKD stage II), group B (CKD stage III), and group C (CKD stage IV). Results: All but one of patients were male (total n=27). Group A consisted of 5 patients (mean age 59.6±16, mean eGFR 70.22±5.66, n=5); group B, 18 patients (mean age 51±4.55, mean eGFR 47.2±7.69, n=18); and group C, 4 patients (mean age 62.8±7.63, mean eGFR 24.45±5.17, n=4). 40%, 5%, and 0% of the patient(s) in group A, group B, and group C (respectively) were found to have osteoporosis. 60%, 55%, and 75% of the patient(s) in group A, group B, and group C had osteopenia. 85.2% of all the patients in our study have bone mineralization disease. The mean PTH levels were 155 pg/ml (±170.12), 128 pg/ml (±71.53), and 159 pg/ml (±144.86) in group A, group B, and group C, respectively. 25 hydroxy vitamin D levels were 28.2 (±9.23), 39.2 (±12.4), and 24 (±5.5) in group A, group B, and group C, respectively. T scores were -2.32 (±0.6), -1.56 (±0.73), and -1.05 (±0.173) in group A, group B, and group C, respectively. Patients had 40.5 months, 22.41 months, and 24.75 months of pretransplant hemodialysis in group A, group B, and group C (respectively). Conclusion: Longer duration of pre-transplant hemodialysis was associated with a lower T-score. Defective bone mineralization did not seem to be dependent on different stages of kidney disease. A prospective trial is needed to assess the requirement of possible interventions regarding bone disease in post transplant patients as in non-transplant CKD patients.
74 RENAL INVOLVEMENT WITH NORMAL KIDNEY SIZE IN A PATIENT WITH MANTLE CELL LYMPHOMA Hooman Hajian, Pritkia Shrivastava, W Brian Reeves. Penn State Hershey Medical Center, Hershey, PA, USA Mantle cell lymphoma (MCL) is a mature B-cell non-Hodgkin's Lymphoma (NHL) which has a variable, but often aggressive, course. Approximately 7% of adult NHLs are MCL, with a median age at diagnosis of 68 years old. It affects men almost 3 times more than women and Caucasians almost 2 times more than African Americans. The majority of cases present with advanced disease, most commonly involving the lymph nodes, spleen, Waldeyer's ring, bone marrow, and blood, while, in almost 25% of cases, the presentation is that of extra-nodal disease. Infiltration of the kidneys with tumor cells, particularly without significant enlargement in size, is uncommon. We present an unusual case of a 68-year-old Caucasian male with previously normal kidney function who presented with a one month history of progressive abdominal pain, weakness, dyspnea on exertion and hot flashes. His serum creatinine at the time of presentation was 2 mg/dl and continued to progressively worsen, reaching a peak of 4.4 mg/dl. Imaging studies during his hospitalization revealed mediastinal and bilateral hilar and upper abdominal lymphadenopathy and splenomegaly on CT scans, with normal kidney size both by Ultrasound and MRI. Further workup did not yield any clues as to the cause of his acute kidney injury. Ultimately, a kidney biopsy showed diffuse infiltration by tumor cells throughout the renal parenchyma, surrounding the renal tubules, extending into the tubular epithelium, and destroying many of the tubules. The patient was started on appropriate chemotherapy protocol, which resulted in rapid resolution of the kidney dysfunction back to normal. Infiltration of the kidneys by malignant cells is usually accompanied by an increase in their size. However, it is important to consider the possibility of infiltrative disease despite normal kidney size, particularly in cases of renal failure with inconclusive workup and no clear explanation for the acute kidney injury.
A41 75 HYPOTONIC FLUID THERAPY INDUCED HYPONATREMIA IN HOSPITALIZED CHILDREN WITH GASTROENTERITS AND DEHYDRATION mina hanna, mohammad s. saberi. Department of Pediatrics, Saint John Hospital and Medical Center, Detroit, MI. Hypotonic saline solutions have been used for over 5 decades to treat children with diarrheal dehydration. Recently, concern has been raised about the potential risk for iatrogenic hyponatremia as a result of this therapy. The purpose of this study was to look at the incidence and severity of acquired hyponatremia in children admitted to the hospital with acute gastroenteritis and dehydration and treated with hypotonic saline solutions. We reviewed the medical records of 124 previously healthy children aged 1 month to 12 years (mean age 3.3 + 3.1 years), admitted to the hospital with acute gastroenteritis and isotonic dehydration (serum Na 130-150 mEq/l) between January 2000 and December of 2005 that had at least 2 serum Na measurement, one on admission and another after 4-24 hours (mean 13.2 + 5.2 hrs) of IV hypotonic fluid (5% dextrose in 0.2%, in 0.3% or in 0.45% saline) therapy. There was significant increase in weight (12.6 + 9.9 kg to 12.8 + 9.8 kg), increase in CO2 (17.7 + 5.1 to 20.0 + 4.1mmol/l), decrease in Na (139.3 + 4.2 to 137.6 + 3.2mEq/l), decrease in BUN (16.8 + 6.6 to 8.9 + 4.0 mg/dl) and decrease in creatinine (0.42 + 0.15 to 0.37 + 0.14 mg/dl) with hydration (paired t-test p <0.01 for all). Of 97 patients with isonatremia (Na 135-145 mEq/l, mean 140.1 + 2.7) on admission, 79 remained isonatremic (Na 138.3 + 2.7) and 18 (18%) became hyponatremic (Na 133.4 + 0.9) with hydration. The drop in serum Na (5.7 + 3.1 mEq/l) was significantly (p < 0.002) higher in patients who became hyponatremic than in those who remained normonatremic (-1.8 + 3.4 mEq/l). None of the patients developed symptoms of hyponatremia. Of 19 patients who had serum Na of 130-134 mEq/l (mean 132.8 + 1.3) on admission, 14 (73%) became isonatremic (mean Na 136.7 + 2.6 mEq/l, and a rise of 3.9 + 2.5 mEq/l) despite hypotonic fluid therapy but 5 remained hyponatremic. Isonatremic patients who became hyponatremic with fluid therapy were older than those who remained isonatremic (5.8 + 2.7 vs. 2.8 + 3.1 years; p < .0005) but the rate of initial saline bolus (26.1 + 10.4 vs. 20.2 + 8.6 ml /kg) and the rate of subsequent IV fluid (4.3 + 1.6 vs. 4.8 + 1.6 ml / kg / hour) did not vary. Eighty two percent of patients were on D5-0.3% saline, 15% on D5-0.45% saline and 3% D5-0.2% saline. It is concluded that although in healthy subjects the ratio of water to Na in serum (6.89-7.40 ml / mEq) is tightly controlled by ADH-kidney axis, mild hyponatremia is common in hypotonic fluid treated children with gastroenteritis and dehydration.
76 POST TRANSPLANT BONE DISEASE. ARE WE MISSING ANYTHING? Haque, Ammar; Siddiqui, Khadija; Saleh, Mohammad; Alberti, Barbara; Hussain, Syed. Cement J-Zablocki VAMC and Medical College of Wisconsin, Milwaukee, WI, USA. Background: One major adverse effect of kidney transplantation is osteoporosis. However, the relationship of PTH, serum Ca, vitamin D levels, and duration of dialysis prior to transplantation remains largely unexplored. This study aims to assess the relationship of PTH, serum Ca., vitamin D, bone mineral density (BMD) exams, and duration of dialysis prior to receiving kidney transplant. Methods: We retrospectively reviewed medical records of 43 patients who received a renal transplant. Patients were excluded (16) if they did not have the appropriate labs (PTH, serum Ca., vitamin D levels) and the BMD exam as needed for the study. Patients were further classified by their chronic kidney disease (CKD) stage based on their eGFR(MDRD): group A (CKD stage II), group B (CKD stage III), and group C (CKD stage IV). Results: All but one of patients were male (total n=27). Group A consisted of 5 patients (mean age 59.6±16, mean eGFR 70.22±5.66, n=5); group B, 18 patients (mean age 51±4.55, mean eGFR 47.2±7.69, n=18); and group C, 4 patients (mean age 62.8±7.63, mean eGFR 24.45±5.17, n=4). 40%, 5%, and 0% of the patient(s) in group A, group B, and group C (respectively) were found to have osteoporosis. 60%, 55%, and 75% of the patient(s) in group A, group B, and group C had osteopenia. 85.2% of all the patients in our study have bone mineralization disease. The mean PTH levels were 155 pg/ml (±170.12), 128 pg/ml (±71.53), and 159 pg/ml (±144.86) in group A, group B, and group C, respectively. 25 hydroxy vitamin D levels were 28.2 (±9.23), 39.2 (±12.4), and 24 (±5.5) in group A, group B, and group C, respectively. T scores were -2.32 (±0.6), -1.56 (±0.73), and -1.05 (±0.173) in group A, group B, and group C, respectively. Patients had 40.5 months, 22.41 months, and 24.75 months of pretransplant hemodialysis in group A, group B, and group C (respectively). Conclusion: Longer duration of pre-transplant hemodialysis was associated with a lower T-score. Defective bone mineralization did not seem to be dependent on different stages of kidney disease. A prospective trial is needed to assess the requirement of possible interventions regarding bone disease in post transplant patients as in non-transplant CKD patients.