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92: Hypertension in Early-Stage Kidney Disease: An Update From the Kidney Early Evaluation Program
NKF 2009 Spring Clinical Meetings Abstracts 89 IMMUNOTACTOID GLOMERULOPATHY IN AN HIVPOSITIVE AND HEPATITIS B AND C NEGATIVE AFRICANAMERICAN WOMAN: A CASE REPORT AND REVIEW OF LITERATURE K. Jhaveri1, C. Chen3, C. Hartono1 , S. V. Seshan2 Division of Nephrology and Hypertension1 and the Department of Pathology2, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, USA. The George Washington University School of Medicine3, Washington, DC, USA. Renal disease is not uncommon in those infected with HIV. The African American population presents frequently with HIV-associated nephropathy (HIVAN). Immunotactoid glomerulonephritis (ITG) is a rare disorder found in less than 1% of renal biopsies characterized by organized tubular immune complex deposits, observed more often in Caucasians. ITG tends to occur in an older age group and in some patients has been associated with a hemopoietic malignancy. There has only been one other reported adult case of ITG in a HIV positive, HCV and HBV negative African-American male. A 68 year old AAW, diagnosed 5 years ago with well controlled HIV infection, HTN, hyperlipidemia and diastolic heart failure presented with costo-chondritic chest pain. Incidentally, microscopic hematuria and proteinuria of 2.87gms/24hrs was discovered. Her physical examination and renal function were unremarkable. Serologic tests for ASO, antiDNAase, HBV, HCV were all negative with normal complement levels. An initial malignancy workup was negative. MRI/MRA of the pelvis revealed normal renal vessels. A percutaneous renal biopsy showed diffuse membranous glomerulopathy, with mild mesangial proliferation and segmental sclerosing lesions on light microscopy. IF revealed mainly IgM, kappa and C3 positive deposits. Electron microscopy confirmed organized subepithelial tubular deposits diagnostic of ITG. There was no evidence of HIVAN. Out of five reported HIV positive cases and ITG in the literature, 3 were HCV+, 2 were Caucasian and 3 were African American (AA) without detectable hematologic malignancy. Although HIVAN is the most common kidney disease in AA adults, a systematic examination of renal biopsies in these patients may yield other forms of HIV associated immune complex glomerular lesions.
90 THE EFECT OF ERYTHROPOIESIS STIMULATING AGENTS ON MEASURES OF PHYSICAL FUNCTIONING AND EXERCISE TOLERANCE IN CHRONIC RENAL FAILURE PATIENTS ON DIALYSIS: A SYSTEMATIC REVIEW 1 Kirsten Johansen, 2Fred Finkelstein, 3Dennis Revicki, 4Matthew Gitlin, 5 Chris Evans, 4Tracy J Mayne. 1University of California, San Francisco, CA, 2Yale University, New Haven, CT, 3UBC, Bethesda, MD, 4Amgen, Thousand Oaks, Ca, 5Mapi Values, Boston, MA. The purpose of this study was to review the available evidence on the effect of erythropoiesis stimulating agents (ESA) on physical functioning (PF) and exercise capacity (ET), using VO2 peak, maximum workload and exercise duration in patients with chronic renal failure who received dialysis. A systematic search was conducted using MEDLINE, and EMBASE. The literature search was limited to papers published in the English language between 1988 and 2008, included all ESA agents, included both randomized clinical trials and observational studies, as long as pre- and post-treatment scores were reported after ESA treatment. Citation-searching of relevant articles also was conducted. 381 potential PF and 213 ET articles were identified. After review of the article abstracts, a total of 80 PF and 46 ET articles were reviewed. Based on this more in-depth evaluation, a total of 12 PF articles [5 studies as with Karnofsky Performance Scale (KPS), 4 studies with Kidney Disease Questionnaire (KDQ), and 3 studies with the Sickness Impact Profile (SIP)] and 29 ET articles [19 studies with VO2, 16 studies with maximal workload, and 5 studies with exercise duration] were included. PF improved in all 5 studies as measured by the KPS (range: 3.7%-25.8%); in 4 studies as measured by the KDQ Physical Symptoms Score (range: 6.3%-44.4%); and in 3 studies as measured by the SIP Physical Scores (range: 14.3%-61.9%). VO2 peak increased significantly in all but one of the studies, with a non-significant reduction reported in one study. The average change in VO2 peak across all studies was 28%. The average change in maximal workload was similar in magnitude to the average change in VO2peak (26.5%), the average change in exercise duration was 40.7%. In conclusion, the studies and instruments examined above show improvement in scores evaluating PF and ET after the treatment with ESAs.
A45 91 WIDE FLUCTUATION OF PTH LEVELS DESPITE UNCHANGED DOSE OF CINCACALCET IN HEMODIALYSIS PATIENTS Amir Jundi, Aniruddha Palya, Bhargavi Degapudi, Karthik Ranganna, Ziauddin Ahmed. Division of Nephrology.Drexel University College of Medicine Purpose: The goals in treatment of secondary hyperparathyroidism are to lower levels of PTH, calcium, and phosphorus in the blood to prevent progressive bone disease and the systemic consequences of disordered mineral metabolism. Hemodialysis patients with uncontrolled secondary Hyperparathyroidism have a favorable impact on bone-specific alkaline phosphatase, bone turnover and bone fibrosis with reductions in PTH. The calcium-sensing receptor on the surface of the chief cell of the parathyroid gland is the principal regulator of PTH secretion. Cinacalcet directly lowers PTH levels by increasing the sensitivity of the calcium-sensing receptor to extracellular calcium. Introduction of Cinacalcet and its increase use in the dialysis units allow clinical observation of its sustained effects on the PTH measurement. Methods: We have reviewed the records of 17 stable dialysis patients who were receiving Cinacalcet over last 12 months period. Non compliant patients and those with history of hospitalization were excluded. 8/17 (47%) patients had improved PTH with unchanged or increasing doses of Cinacalcet therapy. 3/17 (17.6%) patients didn’t respond to increase Cinacalcet dose. PTH fluctuated (150-800) significantly despite an unchanged dose of Cinacalcet therapy in 6/17 (35.2%) patients. Serum calcium and phosphate levels didn’t have any consistent relationship with the fluctuation of PTH levels. The patients did not receive any drugs like erythromycin or ketoconazole that could interact with Cinacalcet. Conclusion: Wide fluctuation of PTH levels observed in one third of dialysis patients despite unchanged dose of Cinacalcet therapy.
92 HYPERTENSION IN EARLY-STAGE KIDNEY DISEASE: AN UPDATE FROM THE KIDNEY EARLY EVALUATION PROGRAM Rigas Kalaitzidis1 Suying Li2 Changchun Wang2 Shu-Cheng Chen, 2 Peter A. McCullough3George Bakris1 1Department of Medicine University of Chicago, Pritzker School of Medicine, Chicago, Illinois; 2Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota;3Department of Medicine, William Beaumont Hospital, Royal Oak, Michigan Chronic kidney disease (CKD) is a worldwide public health problem. Systolic blood pressure level over time as an associated feature of CKD has not been fully explored in community volunteer and nationally representative samples of the US population. This cross-sectional analysis evaluated hypertension and early-stage CKD in participants in the Kidney Early Evaluation Program (KEEP), a voluntary community-based health screening program administered by the National Kidney Foundation, and the National Health and Nutrition Examination Survey (NHANES) data to assess similarities and differences between these populations. Participants in both databases were aged 18 years. The KEEP database included 88,559 participants and the NHANES 20,095. Hypertension prevalence was higher in KEEP (69.6%) than NHANES (38.1%); P < 0.001. Compared with NHANES, KEEP participants had higher rates of obesity (79.5% versus 51.5%, P < 0.001) and diabetes (28.0 versus 8.9%, P < 0.001). Among diabetic participants, KEEP had slightly higher rates of prevalent hypertension (88.5% versus 85.7, P = 0.03). Among hypertensive participants, CKD stages 3 and 4 were more prevalent in KEEP than NHANES (79.1% versus 69.3%, P < 0.001). Rates of CKD stages 3 and 4 were higher in KEEP than NHANES for the following subgroups: African Americans (72.4% versus 57.4%, P < 0.001), smokers (69.1% versus 55.6%, P = 0.002), and those with hypercholesterolemia (80.2% versus 71.9%, P < 0.001). In the volunteer KEEP population, rates of hypertension and CKD were higher than in NHANES, most prominently in African Americans and participants with increased cardiovascular risk.
90 THE EFECT OF ERYTHROPOIESIS STIMULATING AGENTS ON MEASURES OF PHYSICAL FUNCTIONING AND EXERCISE TOLERANCE IN CHRONIC RENAL FAILURE PATIENTS ON DIALYSIS: A SYSTEMATIC REVIEW 1 Kirsten Johansen, 2Fred Finkelstein, 3Dennis Revicki, 4Matthew Gitlin, 5 Chris Evans, 4Tracy J Mayne. 1University of California, San Francisco, CA, 2Yale University, New Haven, CT, 3UBC, Bethesda, MD, 4Amgen, Thousand Oaks, Ca, 5Mapi Values, Boston, MA. The purpose of this study was to review the available evidence on the effect of erythropoiesis stimulating agents (ESA) on physical functioning (PF) and exercise capacity (ET), using VO2 peak, maximum workload and exercise duration in patients with chronic renal failure who received dialysis. A systematic search was conducted using MEDLINE, and EMBASE. The literature search was limited to papers published in the English language between 1988 and 2008, included all ESA agents, included both randomized clinical trials and observational studies, as long as pre- and post-treatment scores were reported after ESA treatment. Citation-searching of relevant articles also was conducted. 381 potential PF and 213 ET articles were identified. After review of the article abstracts, a total of 80 PF and 46 ET articles were reviewed. Based on this more in-depth evaluation, a total of 12 PF articles [5 studies as with Karnofsky Performance Scale (KPS), 4 studies with Kidney Disease Questionnaire (KDQ), and 3 studies with the Sickness Impact Profile (SIP)] and 29 ET articles [19 studies with VO2, 16 studies with maximal workload, and 5 studies with exercise duration] were included. PF improved in all 5 studies as measured by the KPS (range: 3.7%-25.8%); in 4 studies as measured by the KDQ Physical Symptoms Score (range: 6.3%-44.4%); and in 3 studies as measured by the SIP Physical Scores (range: 14.3%-61.9%). VO2 peak increased significantly in all but one of the studies, with a non-significant reduction reported in one study. The average change in VO2 peak across all studies was 28%. The average change in maximal workload was similar in magnitude to the average change in VO2peak (26.5%), the average change in exercise duration was 40.7%. In conclusion, the studies and instruments examined above show improvement in scores evaluating PF and ET after the treatment with ESAs.
A45 91 WIDE FLUCTUATION OF PTH LEVELS DESPITE UNCHANGED DOSE OF CINCACALCET IN HEMODIALYSIS PATIENTS Amir Jundi, Aniruddha Palya, Bhargavi Degapudi, Karthik Ranganna, Ziauddin Ahmed. Division of Nephrology.Drexel University College of Medicine Purpose: The goals in treatment of secondary hyperparathyroidism are to lower levels of PTH, calcium, and phosphorus in the blood to prevent progressive bone disease and the systemic consequences of disordered mineral metabolism. Hemodialysis patients with uncontrolled secondary Hyperparathyroidism have a favorable impact on bone-specific alkaline phosphatase, bone turnover and bone fibrosis with reductions in PTH. The calcium-sensing receptor on the surface of the chief cell of the parathyroid gland is the principal regulator of PTH secretion. Cinacalcet directly lowers PTH levels by increasing the sensitivity of the calcium-sensing receptor to extracellular calcium. Introduction of Cinacalcet and its increase use in the dialysis units allow clinical observation of its sustained effects on the PTH measurement. Methods: We have reviewed the records of 17 stable dialysis patients who were receiving Cinacalcet over last 12 months period. Non compliant patients and those with history of hospitalization were excluded. 8/17 (47%) patients had improved PTH with unchanged or increasing doses of Cinacalcet therapy. 3/17 (17.6%) patients didn’t respond to increase Cinacalcet dose. PTH fluctuated (150-800) significantly despite an unchanged dose of Cinacalcet therapy in 6/17 (35.2%) patients. Serum calcium and phosphate levels didn’t have any consistent relationship with the fluctuation of PTH levels. The patients did not receive any drugs like erythromycin or ketoconazole that could interact with Cinacalcet. Conclusion: Wide fluctuation of PTH levels observed in one third of dialysis patients despite unchanged dose of Cinacalcet therapy.
92 HYPERTENSION IN EARLY-STAGE KIDNEY DISEASE: AN UPDATE FROM THE KIDNEY EARLY EVALUATION PROGRAM Rigas Kalaitzidis1 Suying Li2 Changchun Wang2 Shu-Cheng Chen, 2 Peter A. McCullough3George Bakris1 1Department of Medicine University of Chicago, Pritzker School of Medicine, Chicago, Illinois; 2Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota;3Department of Medicine, William Beaumont Hospital, Royal Oak, Michigan Chronic kidney disease (CKD) is a worldwide public health problem. Systolic blood pressure level over time as an associated feature of CKD has not been fully explored in community volunteer and nationally representative samples of the US population. This cross-sectional analysis evaluated hypertension and early-stage CKD in participants in the Kidney Early Evaluation Program (KEEP), a voluntary community-based health screening program administered by the National Kidney Foundation, and the National Health and Nutrition Examination Survey (NHANES) data to assess similarities and differences between these populations. Participants in both databases were aged 18 years. The KEEP database included 88,559 participants and the NHANES 20,095. Hypertension prevalence was higher in KEEP (69.6%) than NHANES (38.1%); P < 0.001. Compared with NHANES, KEEP participants had higher rates of obesity (79.5% versus 51.5%, P < 0.001) and diabetes (28.0 versus 8.9%, P < 0.001). Among diabetic participants, KEEP had slightly higher rates of prevalent hypertension (88.5% versus 85.7, P = 0.03). Among hypertensive participants, CKD stages 3 and 4 were more prevalent in KEEP than NHANES (79.1% versus 69.3%, P < 0.001). Rates of CKD stages 3 and 4 were higher in KEEP than NHANES for the following subgroups: African Americans (72.4% versus 57.4%, P < 0.001), smokers (69.1% versus 55.6%, P = 0.002), and those with hypercholesterolemia (80.2% versus 71.9%, P < 0.001). In the volunteer KEEP population, rates of hypertension and CKD were higher than in NHANES, most prominently in African Americans and participants with increased cardiovascular risk.