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ACUTE PERITONITIS IN A PATIENT ON PERITONEAL DIALYSIS FOLLOWING COLONOSCOPY
NKF 2015 Spring Clinical Meetings Abstracts
181 DIALYSIS DEPENDENT RENAL FAILURE DUE TO GEMCETABINE INDUCED TTP Arani Nanavati, Shrey Velani. Western Michigan University School of Medicine, Kalamazoo, MI, USA Introduction- TTP is commonly refractory to steroids and is a medical emergency requiring plasmapheresis. We present a case in which TTP was thought to be secondary to a chemotherapeutic drug and was refractory to steroids. The renal failure progressed and ultimately needed renal replacement therapy. Case scenario- 30 yo female diagnosed with ovarian cancer and treated with surgery, presented 3 years later with recurrent tumor and increased tumor burden in her peritoneum and bowels. She underwent debulking surgery and was started on chemotherapeutic regimen consisting of Carboplatin and Gemcitabine. After initiation of these medicines she developed AKI, thrombocytopenia. She was eventually diagnosed with TTP. Her AKI was stage 1 at the time of diagnoses and patient was treated with steroids initially but her platelet count and renal failure were refractory to steroid therapy so she was started on plasmapheresis and hemodialysis. Patient was also started on Eculizumab therapy and after completion of plasmapheresis treatment she was discharged on Eculizumab and outpatient dialysis treatment. Patient’s platelet count improved gradually and her dialysis requirement decreased being off dialysis currently. Discussion- Thrombotic thrombocytopenic purpura (TTP) is an uncommon hematologic disorder characterized by microangiopathic hemolytic anemia (MHA) and thrombocytopenia with or without fever, renal failure, and neurologic manifestations. Etiology of which may be uncertain in majority of cases. Gemcitabine was believed to be the precipitating factor in our patient. Our patient had a normal baseline renal function. TTP induced renal failure required hemodialysis but was eventually reversible. The reversibility is attributed to the combination of initiation of early plasmapheresis, Eculizumab, discontinuation of Gemcitabine.
182 ACUTE PERITONITIS IN A PATIENT ON PERITONEAL DIALYSIS FOLLOWING COLONOSCOPY Aarti Narayan, Pooja Kumari, Jiwan Thapa , Marshfield Clinic , Wisconsin, USA Acute peritonitis has been reported in patients undergoing peritoneal dialysis (PD) after colonoscopy. The proposed theory is translocation of bacteria from the colon into the peritoneal cavity. Despite recommendation to use prophylactic antibiotics by International Society of Peritoneal Dialysis (ISPD), practice pattern varies widely amongst gastroenterologists. CASE 48 year old female with type 2 diabetes mellitus and end stage renal disease on continuous cycler PD underwent colonoscopy and polypectomy for suspected lower gastrointestinal bleed. She had been given polyethylene glycol orally and several free water enemas for bowel preparation. She did not receive any prophylactic antibiotic. Following day she presented with abdominal pain and grossly bloody peritoneal fluid. Fluid analysis showed 8783 total nucleated cells/μL (89% neutrophils) and culture grew Vancomycin resistant Enterococcus faecium species. Exit site looked normal. CT abdomen was negative for perforation. She was treated with intraperitoneal Ceftazidime and oral Linezolid and showed dramatic improvement. DISCUSSION Infectious peritonitis can be a potentially serious and modality threatening complication after colonoscopy in patients undergoing PD with a reported incidence of 6.3% in retrospective studies. In 2005, the ISPD recommended use of prophylactic antibiotics and keeping peritoneal cavity dry in these patients prior to undergoing colonoscopy. Due to paucity of good quality evidence, practice pattern regarding prophylactic antibiotics varies widely amongst gastroenterologists. The American Society of Gastrointestinal Endoscopy recently recognized this problem and issued guidelines in favor of using antibiotics prior to endoscopy in patients on PD. Given potential dire complications including termination of PD modality, we agree with these recommendations and favor routine use of prophylactic antibiotics on all PD patients undergoing colonoscopy. Furthermore, we suggest repeated enemas be avoided in such patients to decrease risk of bacterial translocation.
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183 ASSOCIATION OF HEALTH LITERACY WITH MEDICATION SELF-MANAGEMENT: Jessica Nelson,1 Christina Yule,1 Andrea Berger,1 Steven Weisbord,2 Jamie Green1; 1Geisinger Medical Center, Danville, PA; 2VA Pittsburgh Healthcare System, Pittsburgh, PA; USA. Medication management capacity (MMC) is the ability to selfadminister a medication regimen as it has been prescribed. MMC provides information about the accuracy of medication use, whereas measures of medication adherence typically focus on how often medications are taken or refilled. We sought to explore the association of health literacy with MMC and medication adherence in patients with chronic kidney disease (CKD). We performed a cross-sectional study of patients with non-dialysis dependent CKD stages 3B-5 with established nephrology care in a single clinic in rural Pennsylvania. Health literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine (REALM), categorized as limited (score <60) versus adequate (score >60). MMC was measured with the Drug Regimen Unassisted Grading Scale (DRUGS), which requires subjects to perform the following 4 tasks with each of their medications: identify the appropriate medication, open the container, select the correct dose, and report the appropriate timing of doses. Scores on the DRUGS range from 0 to 100. Selfreported medication adherence was assessed using the Morisky 8-Item Medication Adherence Scale (MMAS). A total of 208 patients completed the study. Mean age was 72, 56% were male, 99% white, 53% had a less than or equal to high school level of education, and 23% had limited health literacy. Of 208 patients, 175 (84%) brought their medications on the day of enrollment and completed the DRUGS measure. While total DRUGS scores were high (median 100, IQR 95-100), patients with limited health literacy had significantly lower median scores than those with adequate health literacy (97 vs. 100, p<0.001). There was no association between health literacy and MMAS (p=0.73). Patients with limited health literacy may have difficulty taking their medications accurately despite reporting good adherence. These findings should be considered when providing education about medication use.
184 PREVALENCE AND CORRELATES OF MEDICATION ADHERENCE IN PATIENTS WITH CHRONIC KIDNEY DISEASE Jessica Nelson,1 Christina Yule,1 Andrea Berger,1 Steven Weisbord,2 Jamie Green1; 1Geisinger Medical Center, Danville, PA; 2VA Pittsburgh Healthcare System, Pittsburgh, PA; USA. Medication adherence is an important aspect of chronic kidney disease (CKD) self-management. We sought to explore factors associated with medication adherence in patients with CKD. We performed a cross-sectional study of patients with nondialysis dependent CKD stages 3B-5 with established nephrology care in a single clinic in rural Pennsylvania. Selfreported medication adherence was assessed using the Morisky 8-Item Medication Adherence Scale (MMAS) and categorized as low (score 3-8), medium (score 1-2), or high (score=0). Additional surveys included patient demographics, kidney disease knowledge (KiKS), self-efficacy (Perceived Kidney SelfManagement Scale), and social support (Multidimensional Scale of Perceived Social Support). A total of 205 patients completed the study. Mean age was 72, 56% were male, 99% white, 53% had a less than or equal to high school level of education, and 23% had low health literacy. The prevalence of low, medium, and high medication adherence was 21%, 47%, and 32%, respectively. Factors associated with medication adherence included race (p=0.01), level of social support (p=0.03), and self-efficacy (p<0.01). There was no association of medication adherence with age, gender, educational level, health literacy, or kidney disease knowledge. A significant number of patients with CKD have less than optimal medication adherence. Social support and self-efficacy may be important targets for interventions designed to improve medication adherence in CKD patients.
Am J Kidney Dis. 2015;65(4):A1-A93
181 DIALYSIS DEPENDENT RENAL FAILURE DUE TO GEMCETABINE INDUCED TTP Arani Nanavati, Shrey Velani. Western Michigan University School of Medicine, Kalamazoo, MI, USA Introduction- TTP is commonly refractory to steroids and is a medical emergency requiring plasmapheresis. We present a case in which TTP was thought to be secondary to a chemotherapeutic drug and was refractory to steroids. The renal failure progressed and ultimately needed renal replacement therapy. Case scenario- 30 yo female diagnosed with ovarian cancer and treated with surgery, presented 3 years later with recurrent tumor and increased tumor burden in her peritoneum and bowels. She underwent debulking surgery and was started on chemotherapeutic regimen consisting of Carboplatin and Gemcitabine. After initiation of these medicines she developed AKI, thrombocytopenia. She was eventually diagnosed with TTP. Her AKI was stage 1 at the time of diagnoses and patient was treated with steroids initially but her platelet count and renal failure were refractory to steroid therapy so she was started on plasmapheresis and hemodialysis. Patient was also started on Eculizumab therapy and after completion of plasmapheresis treatment she was discharged on Eculizumab and outpatient dialysis treatment. Patient’s platelet count improved gradually and her dialysis requirement decreased being off dialysis currently. Discussion- Thrombotic thrombocytopenic purpura (TTP) is an uncommon hematologic disorder characterized by microangiopathic hemolytic anemia (MHA) and thrombocytopenia with or without fever, renal failure, and neurologic manifestations. Etiology of which may be uncertain in majority of cases. Gemcitabine was believed to be the precipitating factor in our patient. Our patient had a normal baseline renal function. TTP induced renal failure required hemodialysis but was eventually reversible. The reversibility is attributed to the combination of initiation of early plasmapheresis, Eculizumab, discontinuation of Gemcitabine.
182 ACUTE PERITONITIS IN A PATIENT ON PERITONEAL DIALYSIS FOLLOWING COLONOSCOPY Aarti Narayan, Pooja Kumari, Jiwan Thapa , Marshfield Clinic , Wisconsin, USA Acute peritonitis has been reported in patients undergoing peritoneal dialysis (PD) after colonoscopy. The proposed theory is translocation of bacteria from the colon into the peritoneal cavity. Despite recommendation to use prophylactic antibiotics by International Society of Peritoneal Dialysis (ISPD), practice pattern varies widely amongst gastroenterologists. CASE 48 year old female with type 2 diabetes mellitus and end stage renal disease on continuous cycler PD underwent colonoscopy and polypectomy for suspected lower gastrointestinal bleed. She had been given polyethylene glycol orally and several free water enemas for bowel preparation. She did not receive any prophylactic antibiotic. Following day she presented with abdominal pain and grossly bloody peritoneal fluid. Fluid analysis showed 8783 total nucleated cells/μL (89% neutrophils) and culture grew Vancomycin resistant Enterococcus faecium species. Exit site looked normal. CT abdomen was negative for perforation. She was treated with intraperitoneal Ceftazidime and oral Linezolid and showed dramatic improvement. DISCUSSION Infectious peritonitis can be a potentially serious and modality threatening complication after colonoscopy in patients undergoing PD with a reported incidence of 6.3% in retrospective studies. In 2005, the ISPD recommended use of prophylactic antibiotics and keeping peritoneal cavity dry in these patients prior to undergoing colonoscopy. Due to paucity of good quality evidence, practice pattern regarding prophylactic antibiotics varies widely amongst gastroenterologists. The American Society of Gastrointestinal Endoscopy recently recognized this problem and issued guidelines in favor of using antibiotics prior to endoscopy in patients on PD. Given potential dire complications including termination of PD modality, we agree with these recommendations and favor routine use of prophylactic antibiotics on all PD patients undergoing colonoscopy. Furthermore, we suggest repeated enemas be avoided in such patients to decrease risk of bacterial translocation.
A60
183 ASSOCIATION OF HEALTH LITERACY WITH MEDICATION SELF-MANAGEMENT: Jessica Nelson,1 Christina Yule,1 Andrea Berger,1 Steven Weisbord,2 Jamie Green1; 1Geisinger Medical Center, Danville, PA; 2VA Pittsburgh Healthcare System, Pittsburgh, PA; USA. Medication management capacity (MMC) is the ability to selfadminister a medication regimen as it has been prescribed. MMC provides information about the accuracy of medication use, whereas measures of medication adherence typically focus on how often medications are taken or refilled. We sought to explore the association of health literacy with MMC and medication adherence in patients with chronic kidney disease (CKD). We performed a cross-sectional study of patients with non-dialysis dependent CKD stages 3B-5 with established nephrology care in a single clinic in rural Pennsylvania. Health literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine (REALM), categorized as limited (score <60) versus adequate (score >60). MMC was measured with the Drug Regimen Unassisted Grading Scale (DRUGS), which requires subjects to perform the following 4 tasks with each of their medications: identify the appropriate medication, open the container, select the correct dose, and report the appropriate timing of doses. Scores on the DRUGS range from 0 to 100. Selfreported medication adherence was assessed using the Morisky 8-Item Medication Adherence Scale (MMAS). A total of 208 patients completed the study. Mean age was 72, 56% were male, 99% white, 53% had a less than or equal to high school level of education, and 23% had limited health literacy. Of 208 patients, 175 (84%) brought their medications on the day of enrollment and completed the DRUGS measure. While total DRUGS scores were high (median 100, IQR 95-100), patients with limited health literacy had significantly lower median scores than those with adequate health literacy (97 vs. 100, p<0.001). There was no association between health literacy and MMAS (p=0.73). Patients with limited health literacy may have difficulty taking their medications accurately despite reporting good adherence. These findings should be considered when providing education about medication use.
184 PREVALENCE AND CORRELATES OF MEDICATION ADHERENCE IN PATIENTS WITH CHRONIC KIDNEY DISEASE Jessica Nelson,1 Christina Yule,1 Andrea Berger,1 Steven Weisbord,2 Jamie Green1; 1Geisinger Medical Center, Danville, PA; 2VA Pittsburgh Healthcare System, Pittsburgh, PA; USA. Medication adherence is an important aspect of chronic kidney disease (CKD) self-management. We sought to explore factors associated with medication adherence in patients with CKD. We performed a cross-sectional study of patients with nondialysis dependent CKD stages 3B-5 with established nephrology care in a single clinic in rural Pennsylvania. Selfreported medication adherence was assessed using the Morisky 8-Item Medication Adherence Scale (MMAS) and categorized as low (score 3-8), medium (score 1-2), or high (score=0). Additional surveys included patient demographics, kidney disease knowledge (KiKS), self-efficacy (Perceived Kidney SelfManagement Scale), and social support (Multidimensional Scale of Perceived Social Support). A total of 205 patients completed the study. Mean age was 72, 56% were male, 99% white, 53% had a less than or equal to high school level of education, and 23% had low health literacy. The prevalence of low, medium, and high medication adherence was 21%, 47%, and 32%, respectively. Factors associated with medication adherence included race (p=0.01), level of social support (p=0.03), and self-efficacy (p<0.01). There was no association of medication adherence with age, gender, educational level, health literacy, or kidney disease knowledge. A significant number of patients with CKD have less than optimal medication adherence. Social support and self-efficacy may be important targets for interventions designed to improve medication adherence in CKD patients.
Am J Kidney Dis. 2015;65(4):A1-A93