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Associations of Dietary Protein Intake With Serum Albumin Level in Hemodialysis Patients
NKF 2016 Spring Clinical Meetings Abstracts
Case Report 101 ASSOCIATIONS OF DIETARY PROTEIN INTAKE WITH SERUM ALBUMIN LEVEL IN HEMODIALYSIS PATIENTS. Rieko Eriguchi1; Yoshitsugu Obi1; Connie M. Rhee1; Tae Hee Kim1; Melissa Soohoo1; Elani Streja1; Kamyar Kalantar-Zadeh1. 1 Harold Simmons Center, UC Irvine, Orange, CA Lower serum albumin levels, an important marker of nutrition and inflammation, are associated with higher mortality in hemodialysis (HD) patients. However, it is unclear if dietary protein intake evaluated by normalized protein catabolic rate (nPCR) can predict serum albumin levels in HD patients. We hypothesize that an increase in nPCR is associated with an increase in serum albumin. We examined calculated nPCR, taking into account residual renal function in an US cohort of 36,713 incident HD patients who initiated dialysis between 2007-2011. The association of change in calculated nPCR level (n=13,900) and change in serum albumin level during the first 6 months of dialysis was examined using logistic regression models with multivariable adjustment for case-mix covariates and markers of the malnutrition and inflammation complex syndrome (MICS). Patients were 62±15 years; 37% female, 28% African-American, and 47% diabetic. An increase in the change in calculated nPCR was linearly associated with a higher odds of a rise in serum albumin (≥0.20g/dL/6month) [Figure].
A rise or drop in dietary protein intake, represented by nPCR changes over time, was associated with parallel changes in serum albumin level in HD patients. These data suggest potential impact of dietary protein intake on serum albumin.
102 ASSOCIATION BETWEEN HEMODIALYSIS TREATMENT TIME AND LOSS OF RESIDUAL RENAL FUNCTION: Richard J Fatzinger, Sophia Rosen, Yue Jiao, Sheetal Chaudhuri, John Larkin, Stephan Thijssen, Len Usvyat, Peter Kotanko, Franklin W Maddux, Fresenius Medical Care North America, Waltham, MA, USA, Renal Research Institute, New York, NY, USA Hemodialysis (HD) patients with preserved residual renal function (RRF) are known to have improved survival rates compared to patients with minimal to no RRF, yet the factors related to loss of RRF are not well understood. We aimed to investigate whether HD treatment time is associated with time to complete loss of RRF. This study utilized data for all incident HD patients treated at Fresenius Medical Care North America clinics during 2014 who exhibited a presence of initial RRF (>0 mL/min urine urea clearance average during the first 90 days of HD) and survived 1 year after initiation of chronic HD. Patients were divided into quartiles of initial RRF (≥0.1 to <2.6, ≥2.6 to <3.6, ≥3.6 to <5.3, >5.3 to 15.0 mL/min). Time to the complete loss of RRF (=0 mL/min) was estimated for 3 months after the last RRF measurement performed. A Cox model adjusted by age, sex, race, mean body mass index (BMI), and mean ultrafiltration volume (UFV) was constructed to assess the associations of HD treatment time and time to loss of RRF across the quartiles of initial RRF. Mean treatment time, BMI, and UFV were calculated from values during the first 90 days of HD. Overall, data from 141,700 patients with the presence of RRF during the incident period of HD were analyzed. Longer treatment times were observed to be significantly associated with a shortened time to complete loss of RRF in patients in the highest quartile of RRF (hazard ratio =1.28, p =0.0002), but not in the three lower RRF quartiles. The results indicate that patients with longer treatment times and higher RRF at the initiation of chronic HD have a faster loss of RRF. Despite this, treatment time is not related to loss of RRF in patients with lower levels of RRF starting HD. However, this observation could be biased due to patients with higher initial levels of RRF being prescribed longer treatment times based on physicians’ practice patterns. Additional analyses are needed to address this issue.
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LIGHTS OUT: A CASE OF MPGN CAUSED BY MONOCLONAL GAMMOPATHY OF RENAL SIGNIFICANCE (MGRS): Nilson Feliz, Manuel Fernandez, Lisa Sebastian, Roberto Collazo-Maldonado. Methodist Dallas Health System, Dallas, TX, USA. A 60 year old ex-convict African American man was referred to the Al-Rabadi, MBBS,1,* Rivka office for evaluation of nephrotic syndrome. HisLaith past medical history was positive for HTN, DM, Hepatitis C successfully treated with Jennifer E. Ballard, MD,2,y Alan ombitasvir/periteprevir/dasabuvir for 3 months. His hepatitis C viral David J. Salant, MD,1 load was undetectable. On physical exam, he was hypertensive and fluid overload with anasarca. Labs showed an elevated creatinine of 2.2 mg/dL (from a baseline of 1.3 mg/dL), serum albumin 1.9 mg/dL, ESR There is little information about pregnancy o 78 mm/hr, and proteinuria of 11.8 g/day, urine sediment showed 3+ with protein with no hematuria or casts, UPIEPespecially showed 35 %those M-spike withcirculating autoantibod monoclonal IgG lambda chain and SPIEP autoantigen showed IgG lambda spike, MN. We present what in primary the rest of serology work up was normal, including cryoglobulins. a 39-year-old woman with PLA2R-associate He was admitted for IV diuresis, blood pressure control and work up anasarca, hypoalbuminemia (albumin, 1.3-2. of his nephrotic syndrome. Skeletal survey was negative. Kidney opsy revealed MN with staining for PLA2R, a biopsy showed MPGN with negative cryoglobulins, moderate tubular She did not respond to conservative therapy a atrophy and interstitial fibrosis with mild arteriosclerosis. No crescents were seen. EM showed effacement of footSeveral process and no immune weeks after presentation, she was fou deposits. . Bone marrow flow cytometry studies revealed 1% lambda further immunosuppressive treatment. Protei light chain-restricted plasma cells. After discussing the case with R levels declined but w Circulating anti-PLA 2 hematologist, we concluded that his MPGN was secondary to MGRS. without proteinuria at birth or at her subseque He was treated with dexamethasone and bortezomib which detectable circulating immediately caused a drop in creatinine tohad 1.5 mg/dL, improvement in anti-PLA2R of imm low titers. trace amounts of IgG4 ant serum albumin to 3.6 mg/dL, and normalization of ESROnly to 18 mm/hr. MGRS is a rare cause of membranoproliferative glomerulonephritis discrepancy between anti-PLA2R levels in th (MPGN) due to deposition of monoclonal Am immunoglobulin complexes J Kidney Dis. 67(5):775-778. ª 2016 by in the kidney without the characteristic systemic manifestations of paraproteinemia. Nephrologists should be aware of this entity and WORDS: Membranous nephropathy ( consider it in the differential diagnosis forINDEX any patient presenting with receptor (PLA2SPIEP/ R); autoantibody; placenta; ritu elevated creatinine and nephrotic syndrome, and abnormal UPIEP with no other explanation for renal findings. Collaboration with hematologist is crucial for diagnosis that can lead to early recognition and treatment.
Pregnancy in a Patient Wit and Circulating Anti-P
P
regnant patients with autoimmune disease deliver newborns with a spectrum of cl manifestations due to the transplacental passa 104 circulating autoantibodies. Pregnant patients USING DIGITAL MEDIA TO DECREASE PERITONEAL or myasthenia gravis can deliver babies DIAYLSIS RELATED lupus INFECTIONS: Simone Fertel, Mihran 1,2 corresponding disease in the Neo Naljayan, Louisiana State University School of Medicine, New neonate. Orleans, LA, USA membranous nephropathy (MN) not associated Peritonitis remains a major cause of morbidity and mortality congenital infection was first described in 199 for peritoneal dialysis (PD) patients. Studies have shown that attributed to the passive transfer of maternal peritonitis leads to increase in mortality, as well as increase in 3 bodies to putative renal antigens. ultrafiltration failure which eventually leads to PD failure. At More than a d this time, there is no later, formal Debiec and standardized handwashing et al4 identified the first antigen inv education in PD units nationwide. We have developed a 14 step in such cases as neutral endopeptidase (NE handwashing sheet which includes written and visual cues to metalloprotease present on the surface of the pod describe each step, based on World Health Organization handwashing guidelines and as well as a 4 minute to review regulation of va involved in thevideo proteolytic proper handwashing technique. tive peptides. Debiec et al described a mother w Under IRB approval, we randomized 9 patients to two groups. mutation preventing NEP expression who had fo Both groups reviewed the 14 step handwashing sheet, and all anti-NEP antibodies to fetomaternal alloi patients were tested to have a baseline score usingdue a checklist with all 14 steps. Then, patients in Group A watched the nization from a previous miscarriage; these antib handwashing video every month draw visit, were to during cross their the lab placenta and cause subepit while Group B had no further review of the technique. All deposits in the fetal kidney of a subsequent patients were tested at month 3. nancy. M-type At baseline, Group A had an average score phospholipase of 83.25 and GroupA2 receptor (PL B had an average score of 82.20. 3 months,asGroup A had autoantigen fo was laterAfter identified the major 5 an average score of 90.25 and Group an average score of mary MN Binhadadults. Little literature exists 94.8. There were no cases of peritonitis in Group A and one exit pregnancy outcomes in patients site infection in Group A. There was one case of peritonitis in with nephrotic due to primary Group B and no cases of drome exit site infections in Group B.MN, with no data ava Our study showed thatabout using digital media to in promote pregnancy PLAefficient 2R-associated disease handwashing was just present as effective as we the believe control and could what to be the first known ca possibly be used as a tool for patients who do PD at home. For pregnancy in a patient with PLA the patient who does not have to come into the clinic daily, 2R-associated wasproper seropositive for anti-PLA2R autoantib digital media allows one who to review hygiene remotely. throughout the course of her pregnancy. Am J Kidney Dis. 2016;67(5):A1-A118
Case Report 101 ASSOCIATIONS OF DIETARY PROTEIN INTAKE WITH SERUM ALBUMIN LEVEL IN HEMODIALYSIS PATIENTS. Rieko Eriguchi1; Yoshitsugu Obi1; Connie M. Rhee1; Tae Hee Kim1; Melissa Soohoo1; Elani Streja1; Kamyar Kalantar-Zadeh1. 1 Harold Simmons Center, UC Irvine, Orange, CA Lower serum albumin levels, an important marker of nutrition and inflammation, are associated with higher mortality in hemodialysis (HD) patients. However, it is unclear if dietary protein intake evaluated by normalized protein catabolic rate (nPCR) can predict serum albumin levels in HD patients. We hypothesize that an increase in nPCR is associated with an increase in serum albumin. We examined calculated nPCR, taking into account residual renal function in an US cohort of 36,713 incident HD patients who initiated dialysis between 2007-2011. The association of change in calculated nPCR level (n=13,900) and change in serum albumin level during the first 6 months of dialysis was examined using logistic regression models with multivariable adjustment for case-mix covariates and markers of the malnutrition and inflammation complex syndrome (MICS). Patients were 62±15 years; 37% female, 28% African-American, and 47% diabetic. An increase in the change in calculated nPCR was linearly associated with a higher odds of a rise in serum albumin (≥0.20g/dL/6month) [Figure].
A rise or drop in dietary protein intake, represented by nPCR changes over time, was associated with parallel changes in serum albumin level in HD patients. These data suggest potential impact of dietary protein intake on serum albumin.
102 ASSOCIATION BETWEEN HEMODIALYSIS TREATMENT TIME AND LOSS OF RESIDUAL RENAL FUNCTION: Richard J Fatzinger, Sophia Rosen, Yue Jiao, Sheetal Chaudhuri, John Larkin, Stephan Thijssen, Len Usvyat, Peter Kotanko, Franklin W Maddux, Fresenius Medical Care North America, Waltham, MA, USA, Renal Research Institute, New York, NY, USA Hemodialysis (HD) patients with preserved residual renal function (RRF) are known to have improved survival rates compared to patients with minimal to no RRF, yet the factors related to loss of RRF are not well understood. We aimed to investigate whether HD treatment time is associated with time to complete loss of RRF. This study utilized data for all incident HD patients treated at Fresenius Medical Care North America clinics during 2014 who exhibited a presence of initial RRF (>0 mL/min urine urea clearance average during the first 90 days of HD) and survived 1 year after initiation of chronic HD. Patients were divided into quartiles of initial RRF (≥0.1 to <2.6, ≥2.6 to <3.6, ≥3.6 to <5.3, >5.3 to 15.0 mL/min). Time to the complete loss of RRF (=0 mL/min) was estimated for 3 months after the last RRF measurement performed. A Cox model adjusted by age, sex, race, mean body mass index (BMI), and mean ultrafiltration volume (UFV) was constructed to assess the associations of HD treatment time and time to loss of RRF across the quartiles of initial RRF. Mean treatment time, BMI, and UFV were calculated from values during the first 90 days of HD. Overall, data from 141,700 patients with the presence of RRF during the incident period of HD were analyzed. Longer treatment times were observed to be significantly associated with a shortened time to complete loss of RRF in patients in the highest quartile of RRF (hazard ratio =1.28, p =0.0002), but not in the three lower RRF quartiles. The results indicate that patients with longer treatment times and higher RRF at the initiation of chronic HD have a faster loss of RRF. Despite this, treatment time is not related to loss of RRF in patients with lower levels of RRF starting HD. However, this observation could be biased due to patients with higher initial levels of RRF being prescribed longer treatment times based on physicians’ practice patterns. Additional analyses are needed to address this issue.
A44
103
LIGHTS OUT: A CASE OF MPGN CAUSED BY MONOCLONAL GAMMOPATHY OF RENAL SIGNIFICANCE (MGRS): Nilson Feliz, Manuel Fernandez, Lisa Sebastian, Roberto Collazo-Maldonado. Methodist Dallas Health System, Dallas, TX, USA. A 60 year old ex-convict African American man was referred to the Al-Rabadi, MBBS,1,* Rivka office for evaluation of nephrotic syndrome. HisLaith past medical history was positive for HTN, DM, Hepatitis C successfully treated with Jennifer E. Ballard, MD,2,y Alan ombitasvir/periteprevir/dasabuvir for 3 months. His hepatitis C viral David J. Salant, MD,1 load was undetectable. On physical exam, he was hypertensive and fluid overload with anasarca. Labs showed an elevated creatinine of 2.2 mg/dL (from a baseline of 1.3 mg/dL), serum albumin 1.9 mg/dL, ESR There is little information about pregnancy o 78 mm/hr, and proteinuria of 11.8 g/day, urine sediment showed 3+ with protein with no hematuria or casts, UPIEPespecially showed 35 %those M-spike withcirculating autoantibod monoclonal IgG lambda chain and SPIEP autoantigen showed IgG lambda spike, MN. We present what in primary the rest of serology work up was normal, including cryoglobulins. a 39-year-old woman with PLA2R-associate He was admitted for IV diuresis, blood pressure control and work up anasarca, hypoalbuminemia (albumin, 1.3-2. of his nephrotic syndrome. Skeletal survey was negative. Kidney opsy revealed MN with staining for PLA2R, a biopsy showed MPGN with negative cryoglobulins, moderate tubular She did not respond to conservative therapy a atrophy and interstitial fibrosis with mild arteriosclerosis. No crescents were seen. EM showed effacement of footSeveral process and no immune weeks after presentation, she was fou deposits. . Bone marrow flow cytometry studies revealed 1% lambda further immunosuppressive treatment. Protei light chain-restricted plasma cells. After discussing the case with R levels declined but w Circulating anti-PLA 2 hematologist, we concluded that his MPGN was secondary to MGRS. without proteinuria at birth or at her subseque He was treated with dexamethasone and bortezomib which detectable circulating immediately caused a drop in creatinine tohad 1.5 mg/dL, improvement in anti-PLA2R of imm low titers. trace amounts of IgG4 ant serum albumin to 3.6 mg/dL, and normalization of ESROnly to 18 mm/hr. MGRS is a rare cause of membranoproliferative glomerulonephritis discrepancy between anti-PLA2R levels in th (MPGN) due to deposition of monoclonal Am immunoglobulin complexes J Kidney Dis. 67(5):775-778. ª 2016 by in the kidney without the characteristic systemic manifestations of paraproteinemia. Nephrologists should be aware of this entity and WORDS: Membranous nephropathy ( consider it in the differential diagnosis forINDEX any patient presenting with receptor (PLA2SPIEP/ R); autoantibody; placenta; ritu elevated creatinine and nephrotic syndrome, and abnormal UPIEP with no other explanation for renal findings. Collaboration with hematologist is crucial for diagnosis that can lead to early recognition and treatment.
Pregnancy in a Patient Wit and Circulating Anti-P
P
regnant patients with autoimmune disease deliver newborns with a spectrum of cl manifestations due to the transplacental passa 104 circulating autoantibodies. Pregnant patients USING DIGITAL MEDIA TO DECREASE PERITONEAL or myasthenia gravis can deliver babies DIAYLSIS RELATED lupus INFECTIONS: Simone Fertel, Mihran 1,2 corresponding disease in the Neo Naljayan, Louisiana State University School of Medicine, New neonate. Orleans, LA, USA membranous nephropathy (MN) not associated Peritonitis remains a major cause of morbidity and mortality congenital infection was first described in 199 for peritoneal dialysis (PD) patients. Studies have shown that attributed to the passive transfer of maternal peritonitis leads to increase in mortality, as well as increase in 3 bodies to putative renal antigens. ultrafiltration failure which eventually leads to PD failure. At More than a d this time, there is no later, formal Debiec and standardized handwashing et al4 identified the first antigen inv education in PD units nationwide. We have developed a 14 step in such cases as neutral endopeptidase (NE handwashing sheet which includes written and visual cues to metalloprotease present on the surface of the pod describe each step, based on World Health Organization handwashing guidelines and as well as a 4 minute to review regulation of va involved in thevideo proteolytic proper handwashing technique. tive peptides. Debiec et al described a mother w Under IRB approval, we randomized 9 patients to two groups. mutation preventing NEP expression who had fo Both groups reviewed the 14 step handwashing sheet, and all anti-NEP antibodies to fetomaternal alloi patients were tested to have a baseline score usingdue a checklist with all 14 steps. Then, patients in Group A watched the nization from a previous miscarriage; these antib handwashing video every month draw visit, were to during cross their the lab placenta and cause subepit while Group B had no further review of the technique. All deposits in the fetal kidney of a subsequent patients were tested at month 3. nancy. M-type At baseline, Group A had an average score phospholipase of 83.25 and GroupA2 receptor (PL B had an average score of 82.20. 3 months,asGroup A had autoantigen fo was laterAfter identified the major 5 an average score of 90.25 and Group an average score of mary MN Binhadadults. Little literature exists 94.8. There were no cases of peritonitis in Group A and one exit pregnancy outcomes in patients site infection in Group A. There was one case of peritonitis in with nephrotic due to primary Group B and no cases of drome exit site infections in Group B.MN, with no data ava Our study showed thatabout using digital media to in promote pregnancy PLAefficient 2R-associated disease handwashing was just present as effective as we the believe control and could what to be the first known ca possibly be used as a tool for patients who do PD at home. For pregnancy in a patient with PLA the patient who does not have to come into the clinic daily, 2R-associated wasproper seropositive for anti-PLA2R autoantib digital media allows one who to review hygiene remotely. throughout the course of her pregnancy. Am J Kidney Dis. 2016;67(5):A1-A118