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Chronic Kidney Disease and Risk of Infection Related Hospitalization: The Atherosclerosis Risk in Communities (ARIC) Study
NKF 2016 Spring Clinical Meetings Abstracts
Case Report 149 CHRONIC KIDNEY DISEASE AND RISK OF INFECTION RELATED HOSPITALIZATION: THE ATHEROSCLEROSIS RISK IN COMMUNITIES (ARIC) STUDY: Junichi Ishigami, Morgan E. Grams, Josef Coresh, and Kunihiro Matsushita Johns Hopkins School of Public Health, Baltimore, MD, USA Infection is a significant complication among individuals on dialysis. Infection risk has not been extensively investigated in persons with less severe CKD and across the full range of estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (ACR). Using data from 11,203 ARIC participants aged 54-73 years at baseline (1996-98), we investigated the associations of eGFRCr+Cys and ACR with incident infection-related hospitalizations through 2011. Kaplan-Meier estimates and Cox proportional hazards models were used to estimate cumulative incidence and relative hazard. During follow-up, 2,876 cases of infection-related hospitalization were recorded. Fifteen-year cumulative incidence was 26% for eGFR 90+, 33% for 60-89, 55% for 30-59, and 83% for <30 ml/min/1.73m2, whereas the cumulative incidence was 28% for ACR 0-9, 39% for 10-29, 50% for 30-299, and 74% for 300+ mg/g. Cox models adjusted for age, sex, race, BMI, DM, HTN, prior CVD, smoking status, alcohol consumption, education levels, aspirin use, and ACR/eGFR revealed that lower eGFR and higher ACR were associated with increased risk for infection independent of one another (Table). No significant interaction was observed for eGFR or ACR. The results were consistent when the analysis was restricted to infection as primary diagnosis and when major infectious diseases, pneumonia, urinary tract infection, bacteremia or septicemia, and cellulitis, were analyzed separately. eGFR aHR (95%CI) ACR aHR (95%CI) 90+ (n=4395) 1[Reference] 0-9 (n=8137) 1[Reference] 60-89 (n=5158) 1.1 (1.0-1.2) 10-29 (n=1178) 1.3 (1.2-1.5) 30-59 (n=624) 1.6 (1.4-1.8) 30-299 (n=644) 1.6 (1.4-1.8) 0-29 (n=26) 3.0 (1.8-4.9) 300+ (n=149) 2.3 (1.8-3.0) Reduced eGFR and elevated ACR were independently associated with infection-related hospitalization. Reduced eGFR and elevated ACR should both warrant attention regarding risk for infection.
150 PSYCHOSOCIAL IMPACT OF WAR ON SYRIAN REFUGEES WITH ESRD: Majd Isreb, Hisham Al Kukhun, Saif Aldeen Sultan Al-Adwan, Taha A Kass-Hout, Lina Murad, A Oussama Rifai, Fahd Al-Saghir, Akram Al-Makki, Mohamed Sekkarie, The Syrian National Kidney Foundation, 2507 Harrison Ave, Suite 101, Panama City, FL, USA Peer-reviewed publications described the psychosocial impact of war on patients with chronic diseases. Much less is known, however, on its impact on the ESRD population. Survey of 62 Syrian refugees with hemodialysis dependent ESRD in Jordan (57 patients) and Lebanon (5 patients) The average age of the patients was 47 years. Fifty three percent were females and 35% were diabetics. The average number of persons of the household of the patients was six individuals. Thirty eight percent of the patients were not satisfied with their dialysis care. Seventy percent were interested in kidney transplant but only 30% were interested in peritoneal dialysis. Ninety percent of patient had no coverage for oral medications. Only 22% patients reported no interruption to their dialysis. Financial reasons were the most common cause for missing dialysis. Thirty percent of patient reported moving 10 times or more to get hemodialysis. When patients were asked Kidney Disease Quality of Life (KDQOL) questions, the burden of ESRD on patient lives was severe (5/5) in sixty seven percent of the patients. Fifty five percent reported spending great deal of time dealing with their disease (5/5). Thirty six percent related severe depression, 74% were anxious about their disease and forty three percent reported feeling great burden on their families (5/5). Twenty Eight percent of patients reported considering dialysis discontinuation Refugees of conflicts with ESRD suffer from greater burden of their disease and poor quality of life. Attention needs to be paid to managing the psychosocial burden of war and displacement on ESRD patients.
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LACK OF CORRELATION BETWEEN IMMUNE FUNCTION ASSAY AND BK VIREMIA IN KIDNEY TRANSPLANT PATIENTS INDUCED WITH ALEMTUZUMAB: Riffat Jafrin, Chelsea Estrada, Yezina Nigatu, Frank Darras, Mersema Abate, Edward Nord, Stony Brook Medicine, Stony Brook, NY, USA 1, Laithtool Al-Rabadi, The ImmuKnow Assay (IKA) is a FDA-approved to assess cell MBBS, * Rivka mediated immunoreactivity in immunocompromised patients.E. LowBallard, IKA Jennifer MD,2,y Alan levels are predicted to correlate with over immunosuppression and David J. Salant, MD,1 increased risk of viral infections such as BK viremia (BKV). However, the effectiveness of IKA as a screening tool to stratify patients according to their risk of future viral infection has not been established. There is little After alemtuzumab induction it has been suggested that IKAinformation levels are about pregnancy o lower than induction with other agents. BKV has deleterious on especially those effects with circulating autoantibod graft survival, with highest incidence in the first 12inmonths autoantigen primaryafter MN. We present what transplantation. a 39-year-old woman with PLA2R-associate From 7/1/2014-6/30/2015, we prospectively screened 59 renal anasarca, hypoalbuminemia (albumin, 1.3-2. transplant patients for IKA and BKV at months 1, 3, 6. Primary MNmonth with 6.staining for PLA2R, a outcome was the development of positiveopsy serumrevealed BK PCR by did not respond to conservative therapy a Induction therapy was with alemtuzumabShe and rapid steroid withdrawal and maintenance therapy with tacrolimusSeveral and mycophenolate mofetil. weeks after presentation, she was fou Continuous variables were expressed as mean ± sd. Independent T-test treatment. Protei further immunosuppressive was used to compare groups. Circulating anti-PLA2R levels declined but w Overall 92 IKA determinations were reported (38 at month 1, 31 at without proteinuria month 3 and 23 at month 6) in 59 patients. Mean IKA at monthat1 birth was or at her subseque circulating 233.8 ± 59.6, at month 3 was 180.9 ± 19.1had anddetectable at month 6 was 187.7 ± anti-PLA2R of imm low titers. 6;Only trace1,amounts of IgG4 ant 29.3. BKV was detected in 8 of 59 patients by month 3 in month 3 in month 3 and 2 at month 5. Mean IKAdiscrepancy of patients with and without between anti-PLA2R levels in th BKV at month 1 was 287.5 and 223.7 (NS), and Am Jrespectively, Kidney Dis.262.3 67(5):775-778. ª 2016 by 171.1 at month 3 and 127 and 206.9 at month 6 (NS). By month 6 mean IK in the BKV positive group fell to 127 from 288 at month 1, WORDS: Membranous nephropathy ( whereas in the BK negative group monthINDEX 6 IK was 206 compared to receptor (PLA2R); autoantibody; placenta; ritu 223 at month 1. Concurrent tracking of IKA and BKV in the first 6 months posttransplant does not correlate with onset of BKV. However, by 6 months the delta IKA appears to be greater in the BKV positive group but this did not reach statistical significance. regnant patients with autoimmune disease
Pregnancy in a Patient Wit and Circulating Anti-P
P
deliver newborns with a spectrum of cl manifestations due to the transplacental passa 152 circulating autoantibodies. Pregnant patients ISOLATED ULTRAFILTRATION THERAPY IMPROVES lupusBUT or DOES myasthenia gravis can deliver babies REHOSPITALIZATION RATE NOT IMPROVE RENAL FUNCTION OR MORTALITY IN PATIENTS corresponding disease WITH in the neonate.1,2 Neo ACUTE DECOMPENSATED HEART FAILURE nephropathy (MN) not associated Ankur Jain, Nikhil Agrawal,membranous Amir Kazory Department of Medicine, University of Florida, Gainesville, Florida, congenital infection was first described in 199 USA attributed to the passive transfer of maternal Background: There has been a renewed interest in the use of isolated 3 bodies to putative renal antigens. More than a d ultrafiltration (iUF) for management of patients with acute 4 decompensated heart failurelater, (ADHF). While a et number of studies Debiec al identified the first antigen inv reported on the efficacy of this therapy in improvement of congestion, insafety. such asstudy neutral endopeptidase (NE there is conflicting data on its The cases aim of this is to provide a reappraisal of the current evidence on the impact present of iUF on on the surface of the pod metalloprotease rehospitalization, renal function and mortality in ADHF. and involved proteolytic Methods: Articles cited in PubMed, EMBASE,in andthe Cochrane database regulation of va from 1980 to 2015 using keytive words: “ultrafiltration” and “heart peptides. Debiec et alfailure” described a mother w were searched and those randomized controlled trials (RCT) that expression who had fo mutation preventing NEP addressed the role of iUF in ADHF were identified. A total of 289 antibodies due to fetomaternal alloi studies were identified after anti-NEP extensive database search. A meta-analysis was performed. Mantel-Haenszel random-effects was used to nization from a model previous miscarriage; these antib calculate mean differences (MDs) and relative risk (RR) for continuous were to cross the placenta and cause subepit and dichotomous data, respectively, with 95% confidence intervals (CIs). deposits in the fetal kidney of a subsequent Results: After excluding duplicate, non-randomized and studies not nancy. M-type phospholipase A2 receptor (PL relevant to question, a total of 7 RCT with 768 participants were was later identified thewasmajor autoantigen fo eligible for analysis. The rehospitalization rate in the iUFas group 5 The significantly lower with RR mary 0.60(95%MN CI; 0.38-0.98; p=0.04). in adults. Little literature exists mean difference in creatinine change was 0.04mg/dl and was not pregnancy outcomes in patients with nephrotic statistically significant (95% CI; -0.16-0.24; p=0.69). The overall mortality was not significantly differentdue in theto twoprimary groups withMN, RR - with no data ava drome 1.010(95% CI; 0.74-1.428, p=0.96). about pregnancy in PLA R-associated disease Conclusion: While previous studies have reported on the higher 2 present what believe to with be the first known ca efficacy of iUF in decongestion of patients withwe ADHF compared conventional diuretic-based pregnancy regimens, currently data does in available a patient withnotPLA2R-associated support its beneficial impact on renal function or medium-term who was seropositive for anti-PLA2R autoantib survival. However the rate of rehospitalzation is lower with iUF. throughout the course of her pregnancy. Am J Kidney Dis. 2016;67(5):A1-A118
Case Report 149 CHRONIC KIDNEY DISEASE AND RISK OF INFECTION RELATED HOSPITALIZATION: THE ATHEROSCLEROSIS RISK IN COMMUNITIES (ARIC) STUDY: Junichi Ishigami, Morgan E. Grams, Josef Coresh, and Kunihiro Matsushita Johns Hopkins School of Public Health, Baltimore, MD, USA Infection is a significant complication among individuals on dialysis. Infection risk has not been extensively investigated in persons with less severe CKD and across the full range of estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (ACR). Using data from 11,203 ARIC participants aged 54-73 years at baseline (1996-98), we investigated the associations of eGFRCr+Cys and ACR with incident infection-related hospitalizations through 2011. Kaplan-Meier estimates and Cox proportional hazards models were used to estimate cumulative incidence and relative hazard. During follow-up, 2,876 cases of infection-related hospitalization were recorded. Fifteen-year cumulative incidence was 26% for eGFR 90+, 33% for 60-89, 55% for 30-59, and 83% for <30 ml/min/1.73m2, whereas the cumulative incidence was 28% for ACR 0-9, 39% for 10-29, 50% for 30-299, and 74% for 300+ mg/g. Cox models adjusted for age, sex, race, BMI, DM, HTN, prior CVD, smoking status, alcohol consumption, education levels, aspirin use, and ACR/eGFR revealed that lower eGFR and higher ACR were associated with increased risk for infection independent of one another (Table). No significant interaction was observed for eGFR or ACR. The results were consistent when the analysis was restricted to infection as primary diagnosis and when major infectious diseases, pneumonia, urinary tract infection, bacteremia or septicemia, and cellulitis, were analyzed separately. eGFR aHR (95%CI) ACR aHR (95%CI) 90+ (n=4395) 1[Reference] 0-9 (n=8137) 1[Reference] 60-89 (n=5158) 1.1 (1.0-1.2) 10-29 (n=1178) 1.3 (1.2-1.5) 30-59 (n=624) 1.6 (1.4-1.8) 30-299 (n=644) 1.6 (1.4-1.8) 0-29 (n=26) 3.0 (1.8-4.9) 300+ (n=149) 2.3 (1.8-3.0) Reduced eGFR and elevated ACR were independently associated with infection-related hospitalization. Reduced eGFR and elevated ACR should both warrant attention regarding risk for infection.
150 PSYCHOSOCIAL IMPACT OF WAR ON SYRIAN REFUGEES WITH ESRD: Majd Isreb, Hisham Al Kukhun, Saif Aldeen Sultan Al-Adwan, Taha A Kass-Hout, Lina Murad, A Oussama Rifai, Fahd Al-Saghir, Akram Al-Makki, Mohamed Sekkarie, The Syrian National Kidney Foundation, 2507 Harrison Ave, Suite 101, Panama City, FL, USA Peer-reviewed publications described the psychosocial impact of war on patients with chronic diseases. Much less is known, however, on its impact on the ESRD population. Survey of 62 Syrian refugees with hemodialysis dependent ESRD in Jordan (57 patients) and Lebanon (5 patients) The average age of the patients was 47 years. Fifty three percent were females and 35% were diabetics. The average number of persons of the household of the patients was six individuals. Thirty eight percent of the patients were not satisfied with their dialysis care. Seventy percent were interested in kidney transplant but only 30% were interested in peritoneal dialysis. Ninety percent of patient had no coverage for oral medications. Only 22% patients reported no interruption to their dialysis. Financial reasons were the most common cause for missing dialysis. Thirty percent of patient reported moving 10 times or more to get hemodialysis. When patients were asked Kidney Disease Quality of Life (KDQOL) questions, the burden of ESRD on patient lives was severe (5/5) in sixty seven percent of the patients. Fifty five percent reported spending great deal of time dealing with their disease (5/5). Thirty six percent related severe depression, 74% were anxious about their disease and forty three percent reported feeling great burden on their families (5/5). Twenty Eight percent of patients reported considering dialysis discontinuation Refugees of conflicts with ESRD suffer from greater burden of their disease and poor quality of life. Attention needs to be paid to managing the psychosocial burden of war and displacement on ESRD patients.
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LACK OF CORRELATION BETWEEN IMMUNE FUNCTION ASSAY AND BK VIREMIA IN KIDNEY TRANSPLANT PATIENTS INDUCED WITH ALEMTUZUMAB: Riffat Jafrin, Chelsea Estrada, Yezina Nigatu, Frank Darras, Mersema Abate, Edward Nord, Stony Brook Medicine, Stony Brook, NY, USA 1, Laithtool Al-Rabadi, The ImmuKnow Assay (IKA) is a FDA-approved to assess cell MBBS, * Rivka mediated immunoreactivity in immunocompromised patients.E. LowBallard, IKA Jennifer MD,2,y Alan levels are predicted to correlate with over immunosuppression and David J. Salant, MD,1 increased risk of viral infections such as BK viremia (BKV). However, the effectiveness of IKA as a screening tool to stratify patients according to their risk of future viral infection has not been established. There is little After alemtuzumab induction it has been suggested that IKAinformation levels are about pregnancy o lower than induction with other agents. BKV has deleterious on especially those effects with circulating autoantibod graft survival, with highest incidence in the first 12inmonths autoantigen primaryafter MN. We present what transplantation. a 39-year-old woman with PLA2R-associate From 7/1/2014-6/30/2015, we prospectively screened 59 renal anasarca, hypoalbuminemia (albumin, 1.3-2. transplant patients for IKA and BKV at months 1, 3, 6. Primary MNmonth with 6.staining for PLA2R, a outcome was the development of positiveopsy serumrevealed BK PCR by did not respond to conservative therapy a Induction therapy was with alemtuzumabShe and rapid steroid withdrawal and maintenance therapy with tacrolimusSeveral and mycophenolate mofetil. weeks after presentation, she was fou Continuous variables were expressed as mean ± sd. Independent T-test treatment. Protei further immunosuppressive was used to compare groups. Circulating anti-PLA2R levels declined but w Overall 92 IKA determinations were reported (38 at month 1, 31 at without proteinuria month 3 and 23 at month 6) in 59 patients. Mean IKA at monthat1 birth was or at her subseque circulating 233.8 ± 59.6, at month 3 was 180.9 ± 19.1had anddetectable at month 6 was 187.7 ± anti-PLA2R of imm low titers. 6;Only trace1,amounts of IgG4 ant 29.3. BKV was detected in 8 of 59 patients by month 3 in month 3 in month 3 and 2 at month 5. Mean IKAdiscrepancy of patients with and without between anti-PLA2R levels in th BKV at month 1 was 287.5 and 223.7 (NS), and Am Jrespectively, Kidney Dis.262.3 67(5):775-778. ª 2016 by 171.1 at month 3 and 127 and 206.9 at month 6 (NS). By month 6 mean IK in the BKV positive group fell to 127 from 288 at month 1, WORDS: Membranous nephropathy ( whereas in the BK negative group monthINDEX 6 IK was 206 compared to receptor (PLA2R); autoantibody; placenta; ritu 223 at month 1. Concurrent tracking of IKA and BKV in the first 6 months posttransplant does not correlate with onset of BKV. However, by 6 months the delta IKA appears to be greater in the BKV positive group but this did not reach statistical significance. regnant patients with autoimmune disease
Pregnancy in a Patient Wit and Circulating Anti-P
P
deliver newborns with a spectrum of cl manifestations due to the transplacental passa 152 circulating autoantibodies. Pregnant patients ISOLATED ULTRAFILTRATION THERAPY IMPROVES lupusBUT or DOES myasthenia gravis can deliver babies REHOSPITALIZATION RATE NOT IMPROVE RENAL FUNCTION OR MORTALITY IN PATIENTS corresponding disease WITH in the neonate.1,2 Neo ACUTE DECOMPENSATED HEART FAILURE nephropathy (MN) not associated Ankur Jain, Nikhil Agrawal,membranous Amir Kazory Department of Medicine, University of Florida, Gainesville, Florida, congenital infection was first described in 199 USA attributed to the passive transfer of maternal Background: There has been a renewed interest in the use of isolated 3 bodies to putative renal antigens. More than a d ultrafiltration (iUF) for management of patients with acute 4 decompensated heart failurelater, (ADHF). While a et number of studies Debiec al identified the first antigen inv reported on the efficacy of this therapy in improvement of congestion, insafety. such asstudy neutral endopeptidase (NE there is conflicting data on its The cases aim of this is to provide a reappraisal of the current evidence on the impact present of iUF on on the surface of the pod metalloprotease rehospitalization, renal function and mortality in ADHF. and involved proteolytic Methods: Articles cited in PubMed, EMBASE,in andthe Cochrane database regulation of va from 1980 to 2015 using keytive words: “ultrafiltration” and “heart peptides. Debiec et alfailure” described a mother w were searched and those randomized controlled trials (RCT) that expression who had fo mutation preventing NEP addressed the role of iUF in ADHF were identified. A total of 289 antibodies due to fetomaternal alloi studies were identified after anti-NEP extensive database search. A meta-analysis was performed. Mantel-Haenszel random-effects was used to nization from a model previous miscarriage; these antib calculate mean differences (MDs) and relative risk (RR) for continuous were to cross the placenta and cause subepit and dichotomous data, respectively, with 95% confidence intervals (CIs). deposits in the fetal kidney of a subsequent Results: After excluding duplicate, non-randomized and studies not nancy. M-type phospholipase A2 receptor (PL relevant to question, a total of 7 RCT with 768 participants were was later identified thewasmajor autoantigen fo eligible for analysis. The rehospitalization rate in the iUFas group 5 The significantly lower with RR mary 0.60(95%MN CI; 0.38-0.98; p=0.04). in adults. Little literature exists mean difference in creatinine change was 0.04mg/dl and was not pregnancy outcomes in patients with nephrotic statistically significant (95% CI; -0.16-0.24; p=0.69). The overall mortality was not significantly differentdue in theto twoprimary groups withMN, RR - with no data ava drome 1.010(95% CI; 0.74-1.428, p=0.96). about pregnancy in PLA R-associated disease Conclusion: While previous studies have reported on the higher 2 present what believe to with be the first known ca efficacy of iUF in decongestion of patients withwe ADHF compared conventional diuretic-based pregnancy regimens, currently data does in available a patient withnotPLA2R-associated support its beneficial impact on renal function or medium-term who was seropositive for anti-PLA2R autoantib survival. However the rate of rehospitalzation is lower with iUF. throughout the course of her pregnancy. Am J Kidney Dis. 2016;67(5):A1-A118