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Acute Onset of Metastatic Calcification in a Dialysis Patient–A Case Report
NKF 2012 Spring Clinical Meetings Abstracts
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RESULTS OF A ONE-YEAR ASSESSMENT OF QUALITY INDICATORS IN AN ACUTE DIALYSIS PROGRAM OPERATED BY A LARGE DIALYSIS PROVIDER (LDO) Joanne Brady, Benjamin Chen, Tom Seguine, David Stone, Robert Provenzano DaVita Inc., Denver, CO, USA The delivery of acute dialysis has traditionally operated outside the framework of formal clinical quality assessment and improvement programs. There has been scant information published about quality indicators in the provision of acute dialysis treatments. To improve quality of service, enhance communication among patient care teams, understand the nursing care given, and optimize clinical outcomes for patients, our nurses completed an Acute Clinical Outcome Indicators (ACOI) form for each dialysis treatment within an acute dialysis program for 2010. Participating facilities provided 288,885 treatments in 2010. We present key indicators of processes of care measures using the data from each treatment. Question Goal Actual Vascular access - signs and/or symptoms of 95% 97% infection present (% of No) Hypotensive episode during treatment (% of No) 90% 77% Pre-treatment report from hospital nurse (% of Yes) 100% 97% Post-treatment report to hospital nurse (% of Yes) 100% 99% Pre-weight completed (% of Yes) 95% 74% Post-weight completed (% of Yes) 95% 66% Hgb < 9.0 g/dL (% of No) 95% 79% Dialyzer and/or system clotted during treatment (% 95% 94% of No) Procedure education provided to patient and/or 85% 89% family (% of Yes) Time-Out/Safety Process per LDO P&P performed 100% 97% (% of Yes) Tracking of clinical measures using our ACOI process established baseline data in the provision of acute dialysis treatments. This data will be used as a benchmark to assure patients, payers and healthcare providers of the value of the prescribed therapy, as well as be valuable in establishing future safety and patient outcomes quality measures.
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Fig 1- CT Abdomen Fig 2- Renal Angiogram both sides In conclusion acute renal infarct is mostly due to atheroembolic disease but other causes like renal artery ectasia /aneurysm as in our patient should also be considered in the differential diagnosis. Renal artery ectasia is not well reported in literature.
208 ACUTE ONSET OF METASTATIC CALCIFICATION IN A DIALYSIS PATIENT – A CASE REPORT Ajith Puram, Naheed Ansari, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY Metastatic calcification in ESRD patients is due to alteration in calcium and phosphorus balance. Calcium phosphate deposition can occur in any soft tissues such as blood vessels, myocardium, and cardiac valves. Growing evidence suggests that increased risk of cardiac mortality in ESRD patients may be partly due to vascular calcification. Metastatic calcification usually occurs slowly in the dialysis patients. We report an unusual case of rapidly occurring metastatic calcification within few days in a critically ill dialysis patient. A 36 yr old African American female with past medical history of HTN, SLE, ESRD on hemodialysis for two months presented to the hospital with hypertensive urgency after missing 2 sessions of hemodialysis, she was intubated for respiratory failure. Hospital course was complicated with hemophilus bacteremia, DIC and septic shock. She also had loculated pleural effusions and underwent repeated CT scans during hospital stay for evaluation of pleural effusions. At time of admission CT scan chest showed no calcifications but subsequent CT scan done one week later showed acute calcification of the myocardium, pericardium and pleura which further progressed during the hospital course. CT scan findings are given in the figures below. Her calcium phosphate product remained high in range of 80-120during time of evolving metastatic calcification. Fig 1 CT scan on admission Fig 2 CT scan week after hospitalization
Abrupt development of metastatic calcification of the myocardium in ESRD patients is not reported in the literature. This case teaches clinicians to monitor calcium phosphorus daily and keep product to <55 in critically ill dialysis patient to avoid this devastating complication.
A66
RENAL INFARCTION SECONDARY TO RENAL ARTERY ANOMALY – A CASE REPORT Ajith Puram, Neshatian Leila, Naheed Ansari, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY Renal infarction is rarely seen, in one study it is 0.007% of hospital admissions. Its diagnosis is often missed or delayed due to its rarity and non specific symptoms. Most of renal infarcts are due to atheroembolic disease like atrial fibrillation, LV thrombus etc. We report a case of renal infarction secondary to renal artery ectasia. A 45 yr old male with no past medical history presented to ER with sudden onset of left flank pain for 1 day. Physical exam in ER was significant for T: 101.4F, BP: 150/105mm Hg, left upper quadrant and costovertebral angle tenderness. Laboratory tests showed leukocytosis, Creatinine 1.4mg/dl, high LDH, UA with small blood with no protein. Urine toxicology screen was negative any cocaine metabolites. CT abdomen revealed wedged hypodensities in left kidney compatible with infarction and focal nonenhancing regions within left renal artery suspicious for thrombus (Fig 1). Subsequent work-up showed negative blood and urine cultures, negative hepatitis serologies, negative hypercoagulable and vasculitis work up, normal sinus rhythm on holter, negative TEE. Renal angiogram demonstrated bilateral irregular renal arteries with multiple areas of ectasia and aneurysm(Fig 2 with arrows). A nephrogram defect of the superior pole of kidney suggested renal infarction. He was referred to vascular surgery for vascular intervention.
HYPOCITRATURIA IN MAGNESIUM AMMONIUM PHOSPHATE (STRUVITE) STONE FORMERS Cindy Pynadath, Grace Snyder-Garza, Xiaobo Liu, Phillip Hall, Surafel Gebreselassie. Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH Kidney stone occurrences are increasing in the United States with a lifetime prevalence of 10% in men and 5% in women. Calcium stones predominate, followed by magnesium ammonium phosphate (struvite) stones and uric acid stones. The purpose of this study was to evaluate metabolic abnormalities in struvite stone formers. Our retrospective analysis included 1466 adult subjects seen in the Cleveland Clinic between January 2006 and December 2010 who had kidney stone analysis and corresponding 24 hour urine analysis including urine volume, creatinine, citrate, calcium, sodium, oxalate, uric acid and pH. Of the cohort, 54 were excluded because of insufficient data. Ninety-one percent of our patients were Caucasians, 58% were males, and the mean age was 53.6 years. Similar to other reports, calcium oxalate and calcium phosphate predominated (71.7%) followed by calcium and uric acid mixed stones (17.9%), pure uric acid stones (6.4%), struvite (3.8%) and cysteine stones (0.35%). Struvite stones were more common in females (p<0.001), and were associated with urinary tract infection ( p<.001). A two sample T test to compare metabolic abnormalities between struvite and non-struvite stone formers found no statistically significant difference between the two groups in BMI, serum bicarbonate, serum calcium, serum uric acid, and serum PTH. As expected, urine pH was significantly higher in the struvite group (p< 0.001). There was no statistically significant difference between the two groups for urine volume, calcium, sodium, oxalate but 24 hour urine citrate was lower in the struvite group ( p <0.001). Urine citrate level was also significantly lower with struvite stones (p<0.001) compared with calcium stones. Forty percent of struvite stone formers had urinary citrate level <320 mg/day as well as significantly lower urine sodium, urine oxalate and urine uric acid but higher urine pH. In conclusion our study shows that hypocitraturia is prevalent in struvite stone formers. Our cohort had a small number of struvite stone formers (3.8%), making definite conclusions difficult. Further study is needed to evaluate if hypocitraturia is a risk factor for struvite stone formation.
Am J Kidney Dis. 2012;59(4):A1-A92
205
207
RESULTS OF A ONE-YEAR ASSESSMENT OF QUALITY INDICATORS IN AN ACUTE DIALYSIS PROGRAM OPERATED BY A LARGE DIALYSIS PROVIDER (LDO) Joanne Brady, Benjamin Chen, Tom Seguine, David Stone, Robert Provenzano DaVita Inc., Denver, CO, USA The delivery of acute dialysis has traditionally operated outside the framework of formal clinical quality assessment and improvement programs. There has been scant information published about quality indicators in the provision of acute dialysis treatments. To improve quality of service, enhance communication among patient care teams, understand the nursing care given, and optimize clinical outcomes for patients, our nurses completed an Acute Clinical Outcome Indicators (ACOI) form for each dialysis treatment within an acute dialysis program for 2010. Participating facilities provided 288,885 treatments in 2010. We present key indicators of processes of care measures using the data from each treatment. Question Goal Actual Vascular access - signs and/or symptoms of 95% 97% infection present (% of No) Hypotensive episode during treatment (% of No) 90% 77% Pre-treatment report from hospital nurse (% of Yes) 100% 97% Post-treatment report to hospital nurse (% of Yes) 100% 99% Pre-weight completed (% of Yes) 95% 74% Post-weight completed (% of Yes) 95% 66% Hgb < 9.0 g/dL (% of No) 95% 79% Dialyzer and/or system clotted during treatment (% 95% 94% of No) Procedure education provided to patient and/or 85% 89% family (% of Yes) Time-Out/Safety Process per LDO P&P performed 100% 97% (% of Yes) Tracking of clinical measures using our ACOI process established baseline data in the provision of acute dialysis treatments. This data will be used as a benchmark to assure patients, payers and healthcare providers of the value of the prescribed therapy, as well as be valuable in establishing future safety and patient outcomes quality measures.
206
Fig 1- CT Abdomen Fig 2- Renal Angiogram both sides In conclusion acute renal infarct is mostly due to atheroembolic disease but other causes like renal artery ectasia /aneurysm as in our patient should also be considered in the differential diagnosis. Renal artery ectasia is not well reported in literature.
208 ACUTE ONSET OF METASTATIC CALCIFICATION IN A DIALYSIS PATIENT – A CASE REPORT Ajith Puram, Naheed Ansari, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY Metastatic calcification in ESRD patients is due to alteration in calcium and phosphorus balance. Calcium phosphate deposition can occur in any soft tissues such as blood vessels, myocardium, and cardiac valves. Growing evidence suggests that increased risk of cardiac mortality in ESRD patients may be partly due to vascular calcification. Metastatic calcification usually occurs slowly in the dialysis patients. We report an unusual case of rapidly occurring metastatic calcification within few days in a critically ill dialysis patient. A 36 yr old African American female with past medical history of HTN, SLE, ESRD on hemodialysis for two months presented to the hospital with hypertensive urgency after missing 2 sessions of hemodialysis, she was intubated for respiratory failure. Hospital course was complicated with hemophilus bacteremia, DIC and septic shock. She also had loculated pleural effusions and underwent repeated CT scans during hospital stay for evaluation of pleural effusions. At time of admission CT scan chest showed no calcifications but subsequent CT scan done one week later showed acute calcification of the myocardium, pericardium and pleura which further progressed during the hospital course. CT scan findings are given in the figures below. Her calcium phosphate product remained high in range of 80-120during time of evolving metastatic calcification. Fig 1 CT scan on admission Fig 2 CT scan week after hospitalization
Abrupt development of metastatic calcification of the myocardium in ESRD patients is not reported in the literature. This case teaches clinicians to monitor calcium phosphorus daily and keep product to <55 in critically ill dialysis patient to avoid this devastating complication.
A66
RENAL INFARCTION SECONDARY TO RENAL ARTERY ANOMALY – A CASE REPORT Ajith Puram, Neshatian Leila, Naheed Ansari, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY Renal infarction is rarely seen, in one study it is 0.007% of hospital admissions. Its diagnosis is often missed or delayed due to its rarity and non specific symptoms. Most of renal infarcts are due to atheroembolic disease like atrial fibrillation, LV thrombus etc. We report a case of renal infarction secondary to renal artery ectasia. A 45 yr old male with no past medical history presented to ER with sudden onset of left flank pain for 1 day. Physical exam in ER was significant for T: 101.4F, BP: 150/105mm Hg, left upper quadrant and costovertebral angle tenderness. Laboratory tests showed leukocytosis, Creatinine 1.4mg/dl, high LDH, UA with small blood with no protein. Urine toxicology screen was negative any cocaine metabolites. CT abdomen revealed wedged hypodensities in left kidney compatible with infarction and focal nonenhancing regions within left renal artery suspicious for thrombus (Fig 1). Subsequent work-up showed negative blood and urine cultures, negative hepatitis serologies, negative hypercoagulable and vasculitis work up, normal sinus rhythm on holter, negative TEE. Renal angiogram demonstrated bilateral irregular renal arteries with multiple areas of ectasia and aneurysm(Fig 2 with arrows). A nephrogram defect of the superior pole of kidney suggested renal infarction. He was referred to vascular surgery for vascular intervention.
HYPOCITRATURIA IN MAGNESIUM AMMONIUM PHOSPHATE (STRUVITE) STONE FORMERS Cindy Pynadath, Grace Snyder-Garza, Xiaobo Liu, Phillip Hall, Surafel Gebreselassie. Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH Kidney stone occurrences are increasing in the United States with a lifetime prevalence of 10% in men and 5% in women. Calcium stones predominate, followed by magnesium ammonium phosphate (struvite) stones and uric acid stones. The purpose of this study was to evaluate metabolic abnormalities in struvite stone formers. Our retrospective analysis included 1466 adult subjects seen in the Cleveland Clinic between January 2006 and December 2010 who had kidney stone analysis and corresponding 24 hour urine analysis including urine volume, creatinine, citrate, calcium, sodium, oxalate, uric acid and pH. Of the cohort, 54 were excluded because of insufficient data. Ninety-one percent of our patients were Caucasians, 58% were males, and the mean age was 53.6 years. Similar to other reports, calcium oxalate and calcium phosphate predominated (71.7%) followed by calcium and uric acid mixed stones (17.9%), pure uric acid stones (6.4%), struvite (3.8%) and cysteine stones (0.35%). Struvite stones were more common in females (p<0.001), and were associated with urinary tract infection ( p<.001). A two sample T test to compare metabolic abnormalities between struvite and non-struvite stone formers found no statistically significant difference between the two groups in BMI, serum bicarbonate, serum calcium, serum uric acid, and serum PTH. As expected, urine pH was significantly higher in the struvite group (p< 0.001). There was no statistically significant difference between the two groups for urine volume, calcium, sodium, oxalate but 24 hour urine citrate was lower in the struvite group ( p <0.001). Urine citrate level was also significantly lower with struvite stones (p<0.001) compared with calcium stones. Forty percent of struvite stone formers had urinary citrate level <320 mg/day as well as significantly lower urine sodium, urine oxalate and urine uric acid but higher urine pH. In conclusion our study shows that hypocitraturia is prevalent in struvite stone formers. Our cohort had a small number of struvite stone formers (3.8%), making definite conclusions difficult. Further study is needed to evaluate if hypocitraturia is a risk factor for struvite stone formation.
Am J Kidney Dis. 2012;59(4):A1-A92