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Cryptoccal Immune Reconstituition Inflammatory Syndrome Complicated by Hypercalcemia in an HIV-Infected Patient
NKF 2012 Spring Clinical Meetings Abstracts
101 CRYPTOCCAL IMMUNE RECONSTITUITION INFLAMMATORY SYNDROME COMPLICATED BY HYPERCALCEMIA IN AN HIV-INFECTED PATIENT Shabnum Haleem, Sandeep Aggarwal, Irfan Ahmed, Nauman Shahid Hypercalcemia is a rare complication of Immune reconstitution inflammatory syndrome (IRIS) in association with granulomatous disease following Highly active antiretroviral therapy (HAART). The proposed mechanism is increased activity of α-1-hydroxylase in the granulomas. Herein we present a case of a 28 y/o African American HIV infected male patient who developed cryptococcal skin and fungemia 9 days and severe hypercalcemia 57 days after initiation of HAART. At presentation patient’s serum creatinine was 2.8 mg/dl (baseline 0.95 mg/dl) and serum calcium 15.4 mg/dl, on recent blood work. On physical exam he was found to have multiple crusted healing lesions on the face, and upper extremities. Further labs studies showed: iPTH 3 pg/ml, 25(OH)D2 28.6, 1,25(OH)D3 19, and ACEI 96. CT of chest showed nodules consistent with Fungal granulomas (figure attached) The patient was treated with IV fluids and pamidronate and antifungal agent with improvement in serum calcium and renal function. The patient was diagnosed with hypercalcemia from granulomatous disease.
102 ABDOMINAL COMPARTMENT SYNDROME PRESENTING AS DIURETIC-REFRACTORY CARDIORENAL SYNDROME Brigid Hallinan, Lehigh Valley Health Network, Allentown, PA, USA Abdominal compartment syndrome (ACS) is a life-threatening disorder caused by an acute increase in intraabdominal pressure that may complicate various disease processes. We present a case of ACS in a patient with diuretic-refractory cardiorenal syndrome (CRS). An 85-year-old female with chronic systolic CHF with an estimated LVEF of 25% and CKD III with baseline Cr 1.2 presented with progressive shortness of breath, abdominal distention, decreased urine output and increasing lower extremity edema. She was found to be in acute decompensated heart failure (ADHF) and had acute renal failure with Cr 1.8. Despite administration of progressively increased doses of IV diuretics and a constant furosemide IV infusion she remained oliguric. Renal ultrasound demonstrated normal kidneys and mild to moderate ascites. An intrabdominal pressure of 35 mmHg measured by transurethral bladder catheter supported a diagnosis of ACS. The patient underwent therapeutic paracentesis, which yielded 1.5 L of ascitic fluid. Shortly thereafter, urine output increased to 100 cc/hr with diuretics. Within 3 days of paracentesis her weight decreased by 5 kg, Cr returned to baseline and her symptoms resolved. ACS is characterized by sustained intraabdominal pressure ≥20 mmHg with resultant acute organ dysfunction. Traditionally associated with critically ill patients in the setting of trauma, abdominal surgery, sepsis, pancreatitis, massive fluid resuscitation or intraabdominal hemorrhage, ACS can also result from third spacing of fluid into the abdomen in patients with ADHF. Recent studies suggest that intraabdominal hypertension (intraabdominal pressure >12 mmHg) and fulminant ACS may play a more significant role in the pathophysiology of CRS than previously realized. The diagnosis of ACS should be considered- and intraabdominal pressure measurement obtained- in any patient with acute oligoanuric renal failure in the setting of volume overload, such as in ADHF. If ACS is diagnosed, prompt abdominal decompression with percutaneous fluid removal or decompressive laparotomy is indicated to prevent hemodynamic collapse and death.
A40
103 ASSOCIATION BETWEEN CYSTATIN C AND FRAILTY STATUS IN OLDER MEN Allyson Hart1, Misti Paudel1, Brent Taylor1, Areef Ishani1, Eric Orwoll2, Kristine Ensrud1. Minneapolis VAMC and University of MN1, Minneapolis, MN; OHSU2, Portland, OR. Declining renal function and frailty are common with aging, but the association between these conditions is uncertain. To determine whether mild to moderate reductions in renal function are associated with greater frailty status in older men, we measured serum cystatin C (cys C) and creatinine (Cr) and ascertained frailty status in a random sample of 1602 community-dwelling men age ≥ 65 yrs participating in the MrOS study. Cys C, Cr, and Cr-based estimated GFR (eGFR) were expressed in quartiles. Frailty status (comprised of shrinking, weakness, exhaustion, slowness and low physical activity) was analyzed as an ordinal outcome of robust, intermediate stage, and frail based on the number of frailty components present (0, 1-2, or ≥ 3 respectively) using a multinomial logistic regression model to simultaneously evaluate the odds of being classified as intermediate vs. robust and frail vs. robust. Outcomes were adjusted for age, race, clinical site and BMI. The mean age of the cohort was 73.8 yrs; 8.4% were frail and 46.4% were intermediate stage. Higher cys C was associated with higher odds of being classified as intermediate or frail vs. robust: Odds Ratio (95% Confidence Interval) Intermed vs robustb Frail vs. robustb Cys Ca Quartile 1 1.0 (ref) 1.0 (ref) Quartile 2 1.22 (0.91-1.65) 1.93 (0.96-3.87) Quartile 3 1.10 (0.81-1.51) 1.47 (0.72-2.99) Quartile 4 2.16 (1.54-3.04) 5.31 (2.72-10.38) a b Cutpoints 0.80, 0.90, and1.03 mg/L. p-value for trend <0.001 In contrast, neither higher serum Cr (p trend > 0.76) nor lower Cr-based eGFR (p trend > 0.47) was associated with higher odds of frailty. In conclusion, higher cys C was associated with increased odds of frailty status in this cohort of older men whereas Cr based measures were not. This difference may be due to lower specificity of Cr based measures compared to cys C in older adults with modest reductions in kidney function, or because cys C is associated with frailty by a mechanism that is unrelated to kidney function.
104 ADAPTING DBT FOR MEDICALLY NON-ADHERENT YOUTH WITH CHRONIC KIDNEY DISEASE Becky Hashim, Erin Lauinger Children’s Hospital at Montefiore Medical Center, Bronx, NY. Non-adherence is common in adolescents with CKD and is linked to high incidences of transplant graft rejection as well as other serious physical and psychological consequences. Non-adherence in adolescents with CKD at a pre-transplant stage has received limited study. The purpose of this pilot study was to adapt an innovative therapeutic approach to enhance adherence in pre-transplant adolescents with CKD 14-21 years of age who were placed on behavioral hold by their transplant team. A six-week individualized Dialectical Behavior Therapy (DBT) intervention targeted emotional avoidance, illness acceptance, and self management skills. Six adolescent patients participated in the treatment, all of which were listed as active post-treatment and presented with the following results: PrePostPercent Self-Report Treatment Treatment Improvement Mean (s.d.) Mean (s.d.) 12% Quality of Life 114.8(14.3) 128.6(2.3) 87.5% Depression 12.8(4.9) 1.6(1.1) Illness Acceptance 37.2(9.3) 45.3(10.0) 21.8% Transplant Team Report
PreTreatment Mean(s.d.) 5.8(0.8)
PostPercent Treatment Improvement Mean(s.d.) 58.6% Non-adherence 2.4(0.9) Overall improvement 3(2) Note: non-adherence range from 1 (normal) to 7 (extremely nonadherent); health condition range from 1 (very much improved) to 7 (very much worse) In conclusion, we believe that our approach is a promising one. It warrants replication and further investigation in order to evaluate its effectiveness for adolescents with CKD and other chronic health conditions.
Am J Kidney Dis. 2012;59(4):A1-A92
101 CRYPTOCCAL IMMUNE RECONSTITUITION INFLAMMATORY SYNDROME COMPLICATED BY HYPERCALCEMIA IN AN HIV-INFECTED PATIENT Shabnum Haleem, Sandeep Aggarwal, Irfan Ahmed, Nauman Shahid Hypercalcemia is a rare complication of Immune reconstitution inflammatory syndrome (IRIS) in association with granulomatous disease following Highly active antiretroviral therapy (HAART). The proposed mechanism is increased activity of α-1-hydroxylase in the granulomas. Herein we present a case of a 28 y/o African American HIV infected male patient who developed cryptococcal skin and fungemia 9 days and severe hypercalcemia 57 days after initiation of HAART. At presentation patient’s serum creatinine was 2.8 mg/dl (baseline 0.95 mg/dl) and serum calcium 15.4 mg/dl, on recent blood work. On physical exam he was found to have multiple crusted healing lesions on the face, and upper extremities. Further labs studies showed: iPTH 3 pg/ml, 25(OH)D2 28.6, 1,25(OH)D3 19, and ACEI 96. CT of chest showed nodules consistent with Fungal granulomas (figure attached) The patient was treated with IV fluids and pamidronate and antifungal agent with improvement in serum calcium and renal function. The patient was diagnosed with hypercalcemia from granulomatous disease.
102 ABDOMINAL COMPARTMENT SYNDROME PRESENTING AS DIURETIC-REFRACTORY CARDIORENAL SYNDROME Brigid Hallinan, Lehigh Valley Health Network, Allentown, PA, USA Abdominal compartment syndrome (ACS) is a life-threatening disorder caused by an acute increase in intraabdominal pressure that may complicate various disease processes. We present a case of ACS in a patient with diuretic-refractory cardiorenal syndrome (CRS). An 85-year-old female with chronic systolic CHF with an estimated LVEF of 25% and CKD III with baseline Cr 1.2 presented with progressive shortness of breath, abdominal distention, decreased urine output and increasing lower extremity edema. She was found to be in acute decompensated heart failure (ADHF) and had acute renal failure with Cr 1.8. Despite administration of progressively increased doses of IV diuretics and a constant furosemide IV infusion she remained oliguric. Renal ultrasound demonstrated normal kidneys and mild to moderate ascites. An intrabdominal pressure of 35 mmHg measured by transurethral bladder catheter supported a diagnosis of ACS. The patient underwent therapeutic paracentesis, which yielded 1.5 L of ascitic fluid. Shortly thereafter, urine output increased to 100 cc/hr with diuretics. Within 3 days of paracentesis her weight decreased by 5 kg, Cr returned to baseline and her symptoms resolved. ACS is characterized by sustained intraabdominal pressure ≥20 mmHg with resultant acute organ dysfunction. Traditionally associated with critically ill patients in the setting of trauma, abdominal surgery, sepsis, pancreatitis, massive fluid resuscitation or intraabdominal hemorrhage, ACS can also result from third spacing of fluid into the abdomen in patients with ADHF. Recent studies suggest that intraabdominal hypertension (intraabdominal pressure >12 mmHg) and fulminant ACS may play a more significant role in the pathophysiology of CRS than previously realized. The diagnosis of ACS should be considered- and intraabdominal pressure measurement obtained- in any patient with acute oligoanuric renal failure in the setting of volume overload, such as in ADHF. If ACS is diagnosed, prompt abdominal decompression with percutaneous fluid removal or decompressive laparotomy is indicated to prevent hemodynamic collapse and death.
A40
103 ASSOCIATION BETWEEN CYSTATIN C AND FRAILTY STATUS IN OLDER MEN Allyson Hart1, Misti Paudel1, Brent Taylor1, Areef Ishani1, Eric Orwoll2, Kristine Ensrud1. Minneapolis VAMC and University of MN1, Minneapolis, MN; OHSU2, Portland, OR. Declining renal function and frailty are common with aging, but the association between these conditions is uncertain. To determine whether mild to moderate reductions in renal function are associated with greater frailty status in older men, we measured serum cystatin C (cys C) and creatinine (Cr) and ascertained frailty status in a random sample of 1602 community-dwelling men age ≥ 65 yrs participating in the MrOS study. Cys C, Cr, and Cr-based estimated GFR (eGFR) were expressed in quartiles. Frailty status (comprised of shrinking, weakness, exhaustion, slowness and low physical activity) was analyzed as an ordinal outcome of robust, intermediate stage, and frail based on the number of frailty components present (0, 1-2, or ≥ 3 respectively) using a multinomial logistic regression model to simultaneously evaluate the odds of being classified as intermediate vs. robust and frail vs. robust. Outcomes were adjusted for age, race, clinical site and BMI. The mean age of the cohort was 73.8 yrs; 8.4% were frail and 46.4% were intermediate stage. Higher cys C was associated with higher odds of being classified as intermediate or frail vs. robust: Odds Ratio (95% Confidence Interval) Intermed vs robustb Frail vs. robustb Cys Ca Quartile 1 1.0 (ref) 1.0 (ref) Quartile 2 1.22 (0.91-1.65) 1.93 (0.96-3.87) Quartile 3 1.10 (0.81-1.51) 1.47 (0.72-2.99) Quartile 4 2.16 (1.54-3.04) 5.31 (2.72-10.38) a b Cutpoints 0.80, 0.90, and1.03 mg/L. p-value for trend <0.001 In contrast, neither higher serum Cr (p trend > 0.76) nor lower Cr-based eGFR (p trend > 0.47) was associated with higher odds of frailty. In conclusion, higher cys C was associated with increased odds of frailty status in this cohort of older men whereas Cr based measures were not. This difference may be due to lower specificity of Cr based measures compared to cys C in older adults with modest reductions in kidney function, or because cys C is associated with frailty by a mechanism that is unrelated to kidney function.
104 ADAPTING DBT FOR MEDICALLY NON-ADHERENT YOUTH WITH CHRONIC KIDNEY DISEASE Becky Hashim, Erin Lauinger Children’s Hospital at Montefiore Medical Center, Bronx, NY. Non-adherence is common in adolescents with CKD and is linked to high incidences of transplant graft rejection as well as other serious physical and psychological consequences. Non-adherence in adolescents with CKD at a pre-transplant stage has received limited study. The purpose of this pilot study was to adapt an innovative therapeutic approach to enhance adherence in pre-transplant adolescents with CKD 14-21 years of age who were placed on behavioral hold by their transplant team. A six-week individualized Dialectical Behavior Therapy (DBT) intervention targeted emotional avoidance, illness acceptance, and self management skills. Six adolescent patients participated in the treatment, all of which were listed as active post-treatment and presented with the following results: PrePostPercent Self-Report Treatment Treatment Improvement Mean (s.d.) Mean (s.d.) 12% Quality of Life 114.8(14.3) 128.6(2.3) 87.5% Depression 12.8(4.9) 1.6(1.1) Illness Acceptance 37.2(9.3) 45.3(10.0) 21.8% Transplant Team Report
PreTreatment Mean(s.d.) 5.8(0.8)
PostPercent Treatment Improvement Mean(s.d.) 58.6% Non-adherence 2.4(0.9) Overall improvement 3(2) Note: non-adherence range from 1 (normal) to 7 (extremely nonadherent); health condition range from 1 (very much improved) to 7 (very much worse) In conclusion, we believe that our approach is a promising one. It warrants replication and further investigation in order to evaluate its effectiveness for adolescents with CKD and other chronic health conditions.
Am J Kidney Dis. 2012;59(4):A1-A92