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ACUTE INTERSTITIAL NEPHRITIS INDUCED BY TOBRAMYCIN-IMPREGNATED CEMENT KNEE SPACER
NKF 2014 Spring Clinical Meetings Abstracts
101 ACUTE INTERSTITIAL NEPHRITIS INDUCED BY TOBRAMYCIN-IMPREGNATED CEMENT KNEE SPACER Simit Doshi, Jose Castaneda, Tamim Naber Atlantic Care Regional Medical Center, Atlantic City NJ Antibiotic impregnated bone-cement spacers (AIBS) are successful adjuncts therapy for the treatment of infected hip or knee arthroplasty. Aminoglycosides such as tobramycin have shown undetectable blood levels while still maintaining supratherapeutic concentrations in the joint space. There have been rare reports of nephrotoxicity with use of AIBS. We present a case of biopsy-proven tobramycin-induced acute interstitial nephritis with tubular injury progressed to end stage kidney disease (ESKD). A 71-year old male with congestive heart failure, coronary artery disease, hypertension, dyslipidemia, and chronic kidney disease stage three (baseline creatinine of 1.6 mg/dl). He had a total knee arthroplasty for severe osteoarthritis. Within a month of surgery, he developed a left knee effusion that required incision, drainage and exchange of the polyethylene liner. Direct cultures from affected joint were positive for methicillin-sensitive Staphylococcus aureus. He underwent left knee prosthesis removal and implantation of AIBS. The cement spacer was impregnated with 9 grams each of tobramycin and vancomycin. A steady upward trend in serum creatinine was noted over the next few days that did not respond to fluid hydration and conservative therapy. Laboratory studies revealed creatinine level up to 3.6 mg/dl. Fractional excretion of sodium was 4%. Urinalysis showed persistent mild proteinuria, but no casts, hematuria or eosinophilurea. Eventually Tobramycin level was checked and came back markedly elevated at 2.7 ug/ml while Vancomycin level was 1.0 ug/ml. The cement spacer was removed with subsequent decline in tobramycin levels. Kidney biopsy demonstrated acute tubular injury and interstitial inflammation with numerous eosinophils. Despite initial stabilization of renal function, he developed ESKD over the subsequent few months. Our case is one of the few reported in which AIBS caused nephrotoxicity by interstitial nephritis. We recommend the routine monitoring of serum creatinine and drug levels of the aminoglycoside used. We also recognize the need for further studies to address optimal combinations and concentrations of AIBS to avoid kidney injury.
102 EFFECT OF AGE ON ASSOCIATION OF SERUM CHOLESTEROL AND MORTALITY IN HEMODIALYSIS PATIENTS: Megha Doshi1; Hamid Moradi1; Elani Streja1; Connie M. Rhee1; Csaba P. Kovesdy2; Kamyar Kalantar-Zadeh1 1Harold Simmons Center, UC Irvine Medical Center, Orange, CA; 2Division of Nephrology, University of Tennessee, Memphis, TN In contrast to the general population, studies have found an inverse or non-significant association of serum total cholesterol and mortality in chronic hemodialysis (HD) patients, also known as a “lipid paradox”. We hypothesize that the association between cholesterol and mortality in HD patients may be modified by age. Across 3 categories of age (<60, 60-<70, ≥70 yrs), we examined the associations of cholesterol with 6-yr (2001-2007) all-cause mortality among 53,041 adult HD patients. We used 7 categories of timeaveraged cholesterol via Cox models adjusted for case-mix and markers of the malnutrition-inflammation complex (MICS). Patients were 62±16 years old and included 45% women, 31% blacks, and 55% diabetics. There were 23,494 patients age <60yrs, 12,880 age 60-<70yrs, and 16,667 age 70+ yrs. Using cholesterol 140160 mg/dL as a reference, there was no significant association between lower and higher levels of cholesterol with all-cause mortality in HD patients age <60yrs or 70+yrs. However, patients in the age 60-<70 yrs showed a significant increase in all-cause mortality for cholesterol >180 mg/dL, including a 26% increased death risk for those with cholesterol >200, (HR: 1.10, 95% CI: 1.00-1.21 for 180-200, and HR:1.26, 95%CI: 1.14-1.38 for 200+). Hence, HD patients age 60-70 yrs demonstrate an exception to the lipid paradox where higher cholesterol appear associated with increased all-cause mortality.
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103 EXAMINING THE ROBUSTNESS OF CARDIOVASCULAR MORTALITY IN THE OBESITY PARADOX: A MARGINAL STRUCTURAL MODEL ANALYSIS: Megha Doshi1; Elani Streja1; Connie M. Rhee1; Wei-Ling Lau1; Csaba P. Kovesdy2; Steven Brunelli,3 Kamyar Kalantar-Zadeh1 1Harold Simmons Center, UC Irvine, Orange, CA; 2Nephrology, Univ. of Tennessee, Memphis, TN; 3 DaVita Clinical Research, Denver, CO Previous studies have found an inverse association between body mass index (BMI) and cardiovascular (CV) death in chronic hemodialysis (HD) patients, also known as the “reverse epidemiology”. It is not clear whether these observations result from residual confounding. We investigated this association accounting for time-dependent confounders using marginal structural modeling (MSM) and hypothesized that even after applying MSM, the inverse association of BMI with CV death in HD patients remains robust. We examined the associations of BMI with CV mortality among 127,324 adult HD patients during 2001-2006 period using 11 BMI categories using baseline, time-averaged, and time-varying BMI via adjusted Cox models, and an MSM to adjust for time-dependent confounders. Patients were 62±15 years old and included 45% women, 32% blacks, and 57% diabetics. In all four models, BMI showed a linear incremental and inverse association with CV death. In MSM analyses, compared to a BMI of 25-27.5, BMI of <18 was associated with a 64% higher death risk (HR 1.64, 95% CI 1.46-1.85), whereas the CV mortality risks were significantly lower with higher BMI with the greatest survival advantage for BMI 40-<45 (HR: 0.79, 95% CI 0.68-0.92). Hence, the CV survival advantages of high BMI is robust across all models including MSM analyses.
104 MULTILOCULAR CYSTIC RENAL CELL CARCINOMA: A PRETRANSPLANT MALIGNANCY WITH NO TUMOR-FREE WAITING PERIOD: 1April Elam, 2Ekamol Tantisattamo, 2Jason Cobb, 1Department of Medicine, Morehouse School of Medicine 2 Renal Division, Department of Medicine, Emory University, Atlanta, Georgia, USA Most pre-transplant malignancies require a tumor-free waiting period before transplantation. We report an ESRD patient with an incidental left renal mass who subsequently underwent nephrectomy. Pathology showed multilocular cystic renal cell carcinoma (MCRCC) with clear margins. Kidney transplant was planned after no evidence of tumor recurrence in 6 months. A 50-year-old African American male with history of ESRD from FSGS on chronic hemodialysis. One and a half years earlier, he presented with flu-like symptoms and acute dyspnea. His serum creatinine was elevated to 18 mg/dL from a normal baseline serum creatinine 2 months prior. He underwent emergent HD. A renal biopsy was performed and revealed collapsing FSGS. Three months later, he transitioned to PD for 4 months when dialysis was successfully discontinued. However, 8 months later, he required re-initiation of HD. Abdominal MRI for pre-kidney transplant evaluation revealed a 4.7 cm cystic lesion in the interpolar left kidney with a thick septation and mild mural nodularity; no definite enhancing soft tissue elements. Concerning for renal cancer, he underwent left laparoscopic radical nephrectomy. Pathology revealed 3.0 x 2.3 x 2.2 cm MCRCC, clear cell type, grade 1, T1A NX with negative surgical margins. He returned to follow up as an outpatient and will be listed for kidney transplant if repeated images show no evidence of residual, recurrent or metastatic disease. MCRCC is a rare low grade RCC. There is no report of recurrence or metastases. Although the recommended minimum tumor-free waiting period before transplantation for RCC is 2–5 years, MCRCC may not delay kidney transplantation in recipients with such a low malignant potential. However, cancer surveillance in the post-transplantation period is warranted, as immunosuppressive medications may alter the benign clinical course of MCRCC.
Am J Kidney Dis. 2014;63(5):A1-A121
101 ACUTE INTERSTITIAL NEPHRITIS INDUCED BY TOBRAMYCIN-IMPREGNATED CEMENT KNEE SPACER Simit Doshi, Jose Castaneda, Tamim Naber Atlantic Care Regional Medical Center, Atlantic City NJ Antibiotic impregnated bone-cement spacers (AIBS) are successful adjuncts therapy for the treatment of infected hip or knee arthroplasty. Aminoglycosides such as tobramycin have shown undetectable blood levels while still maintaining supratherapeutic concentrations in the joint space. There have been rare reports of nephrotoxicity with use of AIBS. We present a case of biopsy-proven tobramycin-induced acute interstitial nephritis with tubular injury progressed to end stage kidney disease (ESKD). A 71-year old male with congestive heart failure, coronary artery disease, hypertension, dyslipidemia, and chronic kidney disease stage three (baseline creatinine of 1.6 mg/dl). He had a total knee arthroplasty for severe osteoarthritis. Within a month of surgery, he developed a left knee effusion that required incision, drainage and exchange of the polyethylene liner. Direct cultures from affected joint were positive for methicillin-sensitive Staphylococcus aureus. He underwent left knee prosthesis removal and implantation of AIBS. The cement spacer was impregnated with 9 grams each of tobramycin and vancomycin. A steady upward trend in serum creatinine was noted over the next few days that did not respond to fluid hydration and conservative therapy. Laboratory studies revealed creatinine level up to 3.6 mg/dl. Fractional excretion of sodium was 4%. Urinalysis showed persistent mild proteinuria, but no casts, hematuria or eosinophilurea. Eventually Tobramycin level was checked and came back markedly elevated at 2.7 ug/ml while Vancomycin level was 1.0 ug/ml. The cement spacer was removed with subsequent decline in tobramycin levels. Kidney biopsy demonstrated acute tubular injury and interstitial inflammation with numerous eosinophils. Despite initial stabilization of renal function, he developed ESKD over the subsequent few months. Our case is one of the few reported in which AIBS caused nephrotoxicity by interstitial nephritis. We recommend the routine monitoring of serum creatinine and drug levels of the aminoglycoside used. We also recognize the need for further studies to address optimal combinations and concentrations of AIBS to avoid kidney injury.
102 EFFECT OF AGE ON ASSOCIATION OF SERUM CHOLESTEROL AND MORTALITY IN HEMODIALYSIS PATIENTS: Megha Doshi1; Hamid Moradi1; Elani Streja1; Connie M. Rhee1; Csaba P. Kovesdy2; Kamyar Kalantar-Zadeh1 1Harold Simmons Center, UC Irvine Medical Center, Orange, CA; 2Division of Nephrology, University of Tennessee, Memphis, TN In contrast to the general population, studies have found an inverse or non-significant association of serum total cholesterol and mortality in chronic hemodialysis (HD) patients, also known as a “lipid paradox”. We hypothesize that the association between cholesterol and mortality in HD patients may be modified by age. Across 3 categories of age (<60, 60-<70, ≥70 yrs), we examined the associations of cholesterol with 6-yr (2001-2007) all-cause mortality among 53,041 adult HD patients. We used 7 categories of timeaveraged cholesterol via Cox models adjusted for case-mix and markers of the malnutrition-inflammation complex (MICS). Patients were 62±16 years old and included 45% women, 31% blacks, and 55% diabetics. There were 23,494 patients age <60yrs, 12,880 age 60-<70yrs, and 16,667 age 70+ yrs. Using cholesterol 140160 mg/dL as a reference, there was no significant association between lower and higher levels of cholesterol with all-cause mortality in HD patients age <60yrs or 70+yrs. However, patients in the age 60-<70 yrs showed a significant increase in all-cause mortality for cholesterol >180 mg/dL, including a 26% increased death risk for those with cholesterol >200, (HR: 1.10, 95% CI: 1.00-1.21 for 180-200, and HR:1.26, 95%CI: 1.14-1.38 for 200+). Hence, HD patients age 60-70 yrs demonstrate an exception to the lipid paradox where higher cholesterol appear associated with increased all-cause mortality.
A44
103 EXAMINING THE ROBUSTNESS OF CARDIOVASCULAR MORTALITY IN THE OBESITY PARADOX: A MARGINAL STRUCTURAL MODEL ANALYSIS: Megha Doshi1; Elani Streja1; Connie M. Rhee1; Wei-Ling Lau1; Csaba P. Kovesdy2; Steven Brunelli,3 Kamyar Kalantar-Zadeh1 1Harold Simmons Center, UC Irvine, Orange, CA; 2Nephrology, Univ. of Tennessee, Memphis, TN; 3 DaVita Clinical Research, Denver, CO Previous studies have found an inverse association between body mass index (BMI) and cardiovascular (CV) death in chronic hemodialysis (HD) patients, also known as the “reverse epidemiology”. It is not clear whether these observations result from residual confounding. We investigated this association accounting for time-dependent confounders using marginal structural modeling (MSM) and hypothesized that even after applying MSM, the inverse association of BMI with CV death in HD patients remains robust. We examined the associations of BMI with CV mortality among 127,324 adult HD patients during 2001-2006 period using 11 BMI categories using baseline, time-averaged, and time-varying BMI via adjusted Cox models, and an MSM to adjust for time-dependent confounders. Patients were 62±15 years old and included 45% women, 32% blacks, and 57% diabetics. In all four models, BMI showed a linear incremental and inverse association with CV death. In MSM analyses, compared to a BMI of 25-27.5, BMI of <18 was associated with a 64% higher death risk (HR 1.64, 95% CI 1.46-1.85), whereas the CV mortality risks were significantly lower with higher BMI with the greatest survival advantage for BMI 40-<45 (HR: 0.79, 95% CI 0.68-0.92). Hence, the CV survival advantages of high BMI is robust across all models including MSM analyses.
104 MULTILOCULAR CYSTIC RENAL CELL CARCINOMA: A PRETRANSPLANT MALIGNANCY WITH NO TUMOR-FREE WAITING PERIOD: 1April Elam, 2Ekamol Tantisattamo, 2Jason Cobb, 1Department of Medicine, Morehouse School of Medicine 2 Renal Division, Department of Medicine, Emory University, Atlanta, Georgia, USA Most pre-transplant malignancies require a tumor-free waiting period before transplantation. We report an ESRD patient with an incidental left renal mass who subsequently underwent nephrectomy. Pathology showed multilocular cystic renal cell carcinoma (MCRCC) with clear margins. Kidney transplant was planned after no evidence of tumor recurrence in 6 months. A 50-year-old African American male with history of ESRD from FSGS on chronic hemodialysis. One and a half years earlier, he presented with flu-like symptoms and acute dyspnea. His serum creatinine was elevated to 18 mg/dL from a normal baseline serum creatinine 2 months prior. He underwent emergent HD. A renal biopsy was performed and revealed collapsing FSGS. Three months later, he transitioned to PD for 4 months when dialysis was successfully discontinued. However, 8 months later, he required re-initiation of HD. Abdominal MRI for pre-kidney transplant evaluation revealed a 4.7 cm cystic lesion in the interpolar left kidney with a thick septation and mild mural nodularity; no definite enhancing soft tissue elements. Concerning for renal cancer, he underwent left laparoscopic radical nephrectomy. Pathology revealed 3.0 x 2.3 x 2.2 cm MCRCC, clear cell type, grade 1, T1A NX with negative surgical margins. He returned to follow up as an outpatient and will be listed for kidney transplant if repeated images show no evidence of residual, recurrent or metastatic disease. MCRCC is a rare low grade RCC. There is no report of recurrence or metastases. Although the recommended minimum tumor-free waiting period before transplantation for RCC is 2–5 years, MCRCC may not delay kidney transplantation in recipients with such a low malignant potential. However, cancer surveillance in the post-transplantation period is warranted, as immunosuppressive medications may alter the benign clinical course of MCRCC.
Am J Kidney Dis. 2014;63(5):A1-A121