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FALSE POSITIVE ANTI-HEPATITIS C (HCV) ANTIBODY AFTER A FUNGAL INFECTION
NKF 2015 Spring Clinical Meetings Abstracts
225 ACUTE OXALATE NEPHROPATHY IN A RENAL TRANSPLANT PATIENT WITH COMMUNITY ACQUIRED CLOSTRIDIUM DIFFICILE Minesh Rajpal, Kelly Paschke, Brian Stephany, Cleveland Clinic Foundation, Cleveland, OH, USA Acute oxalate nephropathy (AON) is a rare, but well reported cause of AKI in native kidneys. Secondary hyperoxaluria in the context of acute diarrhea resulting in renal tubular damage from calcium oxalate crystal deposition has not been described in renal transplant patients. Our patient is a 66 YO CM with a PMH of HTN, CAD, DM2, ESRD 2/2 IgA nephropathy status post renal allograft in 2001 with IgAN recurrence since 2009, not on MMF, presented with vomiting, diarrhea, lower extremity edema, SOB and oliguria for 2 weeks after being treated with Augmentin for a suspected sinus infection. Serum creatinine was 20 mg/dL with known baseline 1.7 mg/dl, BUN 162 mg/dl, AG 26, K+ 5.7, and Phos 11. UA revealed gross hematuria and proteinuria. Urine sediment revealed many oxalate crystals with positive birefringence and non-dysmorphic RBCs. Renal ultrasound, C3, C4, BK virus, CMV testing were negative. Stool was positive for C. difficile. Renal biopsy demonstrated calcium oxalate crystal deposition within the renal tubular lumen, chronic glomerular and arteriolar changes, with no evidence of allograft rejection. 24 hour urine oxalate was normal 1 week later with undetectable urine citric acid. Patient had no history of inflammatory bowel disease, chronic diarrhea, chronic dietary fat malabsorption, and serum tissue transglutaminase IgG antibody was negative. The prevalence of AON in renal allografts is relatively low. However, in the early post-transplant period, urine oxalate has been identified in up to one half of patients. While the most common mechanism of AON is presumed to be hyperoxaluria, other mechanisms have to be explored for further understanding of this condition.
226 RELATIONSHIP OF CENTRAL AUGMENTATION INDEX TO LARGE ARTERY STIFFNESS AND DISTAL VASCULAR RESISTANCE Minesh Rajpal, Peter J. Osmond, and Joseph L. Izzo Jr. University at Buffalo, Buffalo, NY, USA Cleveland Clinic Foundation, Cleveland, OH, USA Augmentation index (AI) is often cited as an indicator of arterial stiffness but the magnitude of the reflected pulse wave (and AI) is also dependent on the whole body reflection coefficient (RC). To understand the physiology and clinical relevance of this interaction, we investigated the interrelationships of 4 central arterial stiffness surrogates [aortic impedance index (AZ), pulse wave velocity (PWV), pulse pressure (PP), and systolic pressure (SBP)] and 3 RC surrogates [systemic vascular resistance (SVR), mean arterial pressure, MAP, and diastolic pressure (DBP)]. Participants selected to represent both genders over wide ranges of age and BP were studied supine. AI was determined by arterial tonometry with transfer function (SphygmoCor), heart-femoral PWV by Colin VP2000 , SVR by impedance cardiography (BioZ) and left ventricular outflow velocity by cardiac ultrasonography. We used standard Pearson correlations and bivariate regression analyses on matched pairs of candidate surrogate variables. Of the 78 participants, there were 44 males. Mean (range) for age was 2 55 years (18-91), BMI 30 kg/m (19-48), SBP 139 mmHg (100-192), and DBP 80 mmHg (55-132). R values for simple correlations and bivariate-r values for the chosen models are shown in table 1. AZ was relatively poorly correlated with AI (r = 0.26); multiple r for the AZ-SVR bivariate model was 0.46. Central AI is influenced by both central arterial stiffness and systemic resistance. Although measuring arterial hemodynamics and arterial stiffness can be important in research studies, from a clinical perspective, AZ, PWV, and SVR offers no additional insight over standard BP components (PP, SBP, MAP, DBP) in understanding the magnitude of wave reflection in individual patients.
Am J Kidney Dis. 2015;65(4):A1-A93
227 USING IN-CENTER HEMODIALYSIS CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS (ICH-CAHPS) RESULTS TO MEASURE IMPROVEMENT IN PATIENTPROVIDER COMMUNICATION IN THE DIALYSIS SETTING. Anna Ramirez, Glenda Harbert, Rachelle Caruthers, Robert Bear, Bonnie Noble, Dori Schatell, The End Stage Renal Disease Network of Texas, Inc.; Dallas, TX, USA. The End Stage Renal Disease Network of Texas (Network 14) developed a Patient Engagement Learning and Action Network (PE LAN) to promote patient engagement and patient- and family-centered care. Network 14’s PE LAN developed a quality improvement activity (QIA) focused on improving patient-provider communication. The QIA metric was to obtain a 5% relative improvement in the number of “Always + Usually” responses to question 11 on the ICH-CAHPs survey: “In the last 3 months, how often did dialysis center staff explain things in a way that was easy to understand?” from the 2012 baseline measurement to the October 2013 remeasure. The PE LAN compiled evidence-based interventions focused on improving communication and health literacy skills. Interventions were piloted in sixteen dialysis facilities and tested for statistical significance. Statistical analysis on the primary measure returned a p value of 0.005, demonstrating a statistically significant improvement in patient-provider communications. Interventions focusing on the teachback technique and “communication essentials for patient-centered care” were spread to approximately 65 dialysis facilities encompassing approximately 4,500 patients. Facilities completed the interventions and utilized two educational campaigns designed by patient subject matter experts from July 2013 – October 2013. At baseline, 83.2% of patients in 65 facilities responded “Usually” or “Always” to the primary ICH-CAHPS measure. In the remeasure, 87.6% of patients responded “Usually” or “Always” to the ICHCAHPS question. This resulted in a Relative Improvement of 5.3% thus meeting the project goal. Health literacy and communication trainings coupled with patient education campaigns are effective in improving patient-provider communication and patient-centered care in dialysis facilities.
228 FALSE POSITIVE ANTI-HEPATITIS C (HCV) ANTIBODY AFTER A FUNGAL INFECTION Snigdha Reddy, Jerry Yee, Vivek Soi, Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI. HCV remains an important cause of liver disease in the end stage renal disease (ESRD) population. Recent studies have shown an adverse effect of HCV infection on survival in these patients prompting early identification for timely therapy. We report a case of fungal peritonitis causing a false-positive anti-HCV antibody. The patient is a 61 year-old male with ESRD on continuous ambulatory peritoneal dialysis (PD) with a prior history significant for myocardial infarction, pulmonary embolism, and prostate cancer. He developed abdominal pain, diarrhea, and cloudy dialysate and was diagnosed with culture-positive Candida parapsilosis peritonitis. The PD catheter was removed after initiation of oral fluconazole. His hospital stay was complicated by small bowel pnuematosis and Clostridium difficile infection. Treatment was discontinued upon fungal clearance documented by a negative peritoneal fluid culture 4 weeks later. HCV seroconversion occurred before initiation of hemodialysis but HCV RNA was undetectable by polymerase chain reaction (PCR). The antibody assay used was an indirect two-wash sandwich diagnostic immunoassay for the qualitative determination of immunoglobulin G (IgG) antibodies to HCV (ADVIA Centaur). Notably, additional evaluations for liver disease were unremarkable. The anti-HCV antibody, repeated after 8 weeks of hemodialysis, remained reactive, while PCR was remained negative. Heterophilic antibodies in human serum have been reported to react with reagent immunoglobulins, producing false positive antibody testing. However, there has not been an association between fungal infections and anti-HCV antibody. We presume that antibodies formed after the patient developed fungal peritonitis causing a false positive anti-HCV antibody. This case illustrates the importance of recognizing a potential for cross reactivity of the anti-HCV antibody in different disease states including systemic fungal infections.
A71
225 ACUTE OXALATE NEPHROPATHY IN A RENAL TRANSPLANT PATIENT WITH COMMUNITY ACQUIRED CLOSTRIDIUM DIFFICILE Minesh Rajpal, Kelly Paschke, Brian Stephany, Cleveland Clinic Foundation, Cleveland, OH, USA Acute oxalate nephropathy (AON) is a rare, but well reported cause of AKI in native kidneys. Secondary hyperoxaluria in the context of acute diarrhea resulting in renal tubular damage from calcium oxalate crystal deposition has not been described in renal transplant patients. Our patient is a 66 YO CM with a PMH of HTN, CAD, DM2, ESRD 2/2 IgA nephropathy status post renal allograft in 2001 with IgAN recurrence since 2009, not on MMF, presented with vomiting, diarrhea, lower extremity edema, SOB and oliguria for 2 weeks after being treated with Augmentin for a suspected sinus infection. Serum creatinine was 20 mg/dL with known baseline 1.7 mg/dl, BUN 162 mg/dl, AG 26, K+ 5.7, and Phos 11. UA revealed gross hematuria and proteinuria. Urine sediment revealed many oxalate crystals with positive birefringence and non-dysmorphic RBCs. Renal ultrasound, C3, C4, BK virus, CMV testing were negative. Stool was positive for C. difficile. Renal biopsy demonstrated calcium oxalate crystal deposition within the renal tubular lumen, chronic glomerular and arteriolar changes, with no evidence of allograft rejection. 24 hour urine oxalate was normal 1 week later with undetectable urine citric acid. Patient had no history of inflammatory bowel disease, chronic diarrhea, chronic dietary fat malabsorption, and serum tissue transglutaminase IgG antibody was negative. The prevalence of AON in renal allografts is relatively low. However, in the early post-transplant period, urine oxalate has been identified in up to one half of patients. While the most common mechanism of AON is presumed to be hyperoxaluria, other mechanisms have to be explored for further understanding of this condition.
226 RELATIONSHIP OF CENTRAL AUGMENTATION INDEX TO LARGE ARTERY STIFFNESS AND DISTAL VASCULAR RESISTANCE Minesh Rajpal, Peter J. Osmond, and Joseph L. Izzo Jr. University at Buffalo, Buffalo, NY, USA Cleveland Clinic Foundation, Cleveland, OH, USA Augmentation index (AI) is often cited as an indicator of arterial stiffness but the magnitude of the reflected pulse wave (and AI) is also dependent on the whole body reflection coefficient (RC). To understand the physiology and clinical relevance of this interaction, we investigated the interrelationships of 4 central arterial stiffness surrogates [aortic impedance index (AZ), pulse wave velocity (PWV), pulse pressure (PP), and systolic pressure (SBP)] and 3 RC surrogates [systemic vascular resistance (SVR), mean arterial pressure, MAP, and diastolic pressure (DBP)]. Participants selected to represent both genders over wide ranges of age and BP were studied supine. AI was determined by arterial tonometry with transfer function (SphygmoCor), heart-femoral PWV by Colin VP2000 , SVR by impedance cardiography (BioZ) and left ventricular outflow velocity by cardiac ultrasonography. We used standard Pearson correlations and bivariate regression analyses on matched pairs of candidate surrogate variables. Of the 78 participants, there were 44 males. Mean (range) for age was 2 55 years (18-91), BMI 30 kg/m (19-48), SBP 139 mmHg (100-192), and DBP 80 mmHg (55-132). R values for simple correlations and bivariate-r values for the chosen models are shown in table 1. AZ was relatively poorly correlated with AI (r = 0.26); multiple r for the AZ-SVR bivariate model was 0.46. Central AI is influenced by both central arterial stiffness and systemic resistance. Although measuring arterial hemodynamics and arterial stiffness can be important in research studies, from a clinical perspective, AZ, PWV, and SVR offers no additional insight over standard BP components (PP, SBP, MAP, DBP) in understanding the magnitude of wave reflection in individual patients.
Am J Kidney Dis. 2015;65(4):A1-A93
227 USING IN-CENTER HEMODIALYSIS CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS (ICH-CAHPS) RESULTS TO MEASURE IMPROVEMENT IN PATIENTPROVIDER COMMUNICATION IN THE DIALYSIS SETTING. Anna Ramirez, Glenda Harbert, Rachelle Caruthers, Robert Bear, Bonnie Noble, Dori Schatell, The End Stage Renal Disease Network of Texas, Inc.; Dallas, TX, USA. The End Stage Renal Disease Network of Texas (Network 14) developed a Patient Engagement Learning and Action Network (PE LAN) to promote patient engagement and patient- and family-centered care. Network 14’s PE LAN developed a quality improvement activity (QIA) focused on improving patient-provider communication. The QIA metric was to obtain a 5% relative improvement in the number of “Always + Usually” responses to question 11 on the ICH-CAHPs survey: “In the last 3 months, how often did dialysis center staff explain things in a way that was easy to understand?” from the 2012 baseline measurement to the October 2013 remeasure. The PE LAN compiled evidence-based interventions focused on improving communication and health literacy skills. Interventions were piloted in sixteen dialysis facilities and tested for statistical significance. Statistical analysis on the primary measure returned a p value of 0.005, demonstrating a statistically significant improvement in patient-provider communications. Interventions focusing on the teachback technique and “communication essentials for patient-centered care” were spread to approximately 65 dialysis facilities encompassing approximately 4,500 patients. Facilities completed the interventions and utilized two educational campaigns designed by patient subject matter experts from July 2013 – October 2013. At baseline, 83.2% of patients in 65 facilities responded “Usually” or “Always” to the primary ICH-CAHPS measure. In the remeasure, 87.6% of patients responded “Usually” or “Always” to the ICHCAHPS question. This resulted in a Relative Improvement of 5.3% thus meeting the project goal. Health literacy and communication trainings coupled with patient education campaigns are effective in improving patient-provider communication and patient-centered care in dialysis facilities.
228 FALSE POSITIVE ANTI-HEPATITIS C (HCV) ANTIBODY AFTER A FUNGAL INFECTION Snigdha Reddy, Jerry Yee, Vivek Soi, Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI. HCV remains an important cause of liver disease in the end stage renal disease (ESRD) population. Recent studies have shown an adverse effect of HCV infection on survival in these patients prompting early identification for timely therapy. We report a case of fungal peritonitis causing a false-positive anti-HCV antibody. The patient is a 61 year-old male with ESRD on continuous ambulatory peritoneal dialysis (PD) with a prior history significant for myocardial infarction, pulmonary embolism, and prostate cancer. He developed abdominal pain, diarrhea, and cloudy dialysate and was diagnosed with culture-positive Candida parapsilosis peritonitis. The PD catheter was removed after initiation of oral fluconazole. His hospital stay was complicated by small bowel pnuematosis and Clostridium difficile infection. Treatment was discontinued upon fungal clearance documented by a negative peritoneal fluid culture 4 weeks later. HCV seroconversion occurred before initiation of hemodialysis but HCV RNA was undetectable by polymerase chain reaction (PCR). The antibody assay used was an indirect two-wash sandwich diagnostic immunoassay for the qualitative determination of immunoglobulin G (IgG) antibodies to HCV (ADVIA Centaur). Notably, additional evaluations for liver disease were unremarkable. The anti-HCV antibody, repeated after 8 weeks of hemodialysis, remained reactive, while PCR was remained negative. Heterophilic antibodies in human serum have been reported to react with reagent immunoglobulins, producing false positive antibody testing. However, there has not been an association between fungal infections and anti-HCV antibody. We presume that antibodies formed after the patient developed fungal peritonitis causing a false positive anti-HCV antibody. This case illustrates the importance of recognizing a potential for cross reactivity of the anti-HCV antibody in different disease states including systemic fungal infections.
A71