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Intravenous Immunoglobulins for Osmotic Demyelination Syndrome (ODS)
NKF 2012 Spring Clinical Meetings Abstracts
249 INTRAVENOUS IMMUNOGLOBULINS FOR OSMOTIC DEMYELINATION SYNDROME (ODS). Tulsi Sharma, Pearl Dy, Arnold M. Moses. Upstate Medical University, Syracuse, NY, USA. Introduction: Hyponatremia is a common medical problem but can be challenging in the presence of an associated endocrine disorder. Case: A 21year-old female with central Diabetes insipidus (DI) well controlled on DDAVP (Desmopressin) presented to an outside facility with vomiting and serum Na127meq/L. She improved with normal saline (NS). Her symptoms however recurred a week later (Na-129). This time however the Na decreased to 119 despite NS over next 2days! DDAVP was discontinued and hypertonic saline was initiated. Why did Na go down despite therapy? Adrenal insufficiency was suspected and treated with hydrocortisone. Na rose to 132 in 10 hours. She became increasingly lethargic, nonverbal and developed a blank affect. She was transferred to Upstate Hospital. Her Na at arrival was 157, a rise of 38meq/L in 18 hours. She had multiple episodes of seizures, and had to be intubated. MRI suggested extrapontine ODS. Considering the hypernatremia with hypotonic urine (osmolality-80mosm/kg) DDAVP was restarted. She was treated with hydrocortisone, antiepileptics and NS. Urine osmolality normalized, Na was slowly brought down to 140 in 48 hours. Her clinical status however failed to improve despite the correction of hyponatremia. She was then given IVIG for 5 days and her motor functions improved dramatically, followed by speech and cognition. Even though she had tremendous clinical improvement, repeat MRI showed worsening of the brain lesions. Discussion: This case highlights multiple teaching points:-1) Adrenal insufficiency should be strongly considered when hyponatremia develops in a patient with DI who was previously in good control. Repletion with corticosteroids should be done cautiously as it can lead to rapid diuresis of hypotonic urine. 2) IVIG therapy may accelerate recovery of ODS based on data from a few case reports. Effect is possibly caused by the reduction of myelinotoxic substances and antimyelin antibodies. 3) MRI changes in ODS may be delayed and are not prognostic. 4) Prognosis of ODS is not uniformly bad. Significant improvement may occur with aggressive supportive therapy as in our patient however, prevention is obviously better than cure. This can cause a rapid rise in S.Na predisposing to myelinolysis.During this period, there was no record of urine volume or osmolality and she had not received any DDAVP.
250 CKD MANAGEMENT IN PRIMARY CARE SETTING. Yuvraj Sharma, Sean Flynn, Linet Lonappan, Saurabh Bansal, Sarun Thomas, Karthik Bekal, Nathan Okechukwu. Crozer Chester Medical Center, Upland, PA, USA. Chronic Kidney Disease (CKD) is a major public health problem, affecting 1 in 9 US adults. Majority of the CKD patients are currently being managed by PCPs, and they are 20 times more likely to die from cardiovascular disease before they progress to hemodialysis or renal transplantation or see a nephrologist. Goal of the study was to evaluate the management of CKD patients in our Internal Medicine Resident Continuity Clinic and to increase residents’ knowledge about CKD management. A retrospective study was conducted and the data was collected from electronic medical records. A total of 77 patients with CKD stage 3 and above were identified in the continuity clinic and included in the study. Patients already on hemodialysis and those followed by nephrologists were excluded. Anemia was present in 33 patients and its proper evaluation (i.e. iron studies, vitamin B12, folate levels and stool heme occult) was done in less than 60%. Bone mineral disease was also being under-evaluated, with the serum phosphorus, iPTH and vitamin D levels being checked in only 29%, 10% and 18% patients respectively. Urine protein/creatinine ratio was identified in only 14% patients. Diabetes was present in 39 patients and in only 54 % HbA1C was at recommended goal (i.e. HbA1C < 7%). In 43 % patients, hypertension was uncontrolled (two B.P readings >130/80 mm of Hg). Lipid profile was checked in 72 patients and goal LDL (i.e. LDL less than 100 mg/dl) was reached in less than 47% patients. Only 35% of the patients were immunized for the recommended pneumococcal and influenza vaccine. In conclusion, CKD is being under-evaluated and under-treated, leading to loss of the opportunities to prevent its complications. There is a need to increase the awareness among PCPs to provide CKD patients with better quality care, to slow their progression to End Stage Kidney Disease and for timely referral to the nephrologists.
Am J Kidney Dis. 2012;59(4):A1-A92
251 COLLAPSING GLOMERULOPATHY DUE TO PARVOVIRUS: A MYSTERIOUS CASE OF ACUTE KIDNEY INJURY. Yuvraj Sharma, Glenn Ladinsky and Alan Barman. Crozer Chester Medical Center, Upland, PA, USA Collapsing focal segmental glomerulosclerosis (FSGS) is characterized by higher incidence of nephrotic syndrome and rapid progression to renal failure. The causes of collapsing glomerulopathy include idiopathic, heroin abuse, HIV, parvovirus B19 infection and pamidronate. We report the case of a 29 year old African American male who presented with 3 day history of abdominal pain with nausea, myalgias and decreased urine output. He had a past medical history of poly-substance abuse and depression. Examination was unremarkable, except for 2+ pitting edema in lower extremities. Initial laboratory data revealed blood urea nitrogen (BUN) of 44 mg/dl and serum creatinine of 10.2 mg/dl. Two weeks prior, his BUN was 8 mg/dl and serum creatinine was 1.3 mg/dl. So, he was evaluated for acute kidney injury (AKI). Urine analysis showed 500 mg/dl proteins, 1+ blood with no casts; and his 24 hour urinary protein was 3.1 grams. Urinary drug screen was positive for cannabis, cocaine and PCP. CT scan of abdomen showed no hydronephrosis. An extensive workup including hepatitis B/C serology, HIV serology, ANA, P-ANCA and C-ANCA was negative. On further evaluation, patient was found to have positive Parvovirus Ig M serology. This was attributed as the cause of AKI after his renal biopsy showed collapsing FSGS with immunoperoxidase staining positive for Parvovirus. He was treated with hemodialysis and corticosteroid therapy. Over the course of 4 months, the patient had a dramatic response to corticosteroids. He was taken off hemodialysis, with the BUN and serum creatinine at 37 mg/dl and 2.9 mg/dl respectively. Collapsing FSGS associated with Parvovirus B19 infection is a rare disease with no clear optimum treatment, immunosuppressive have been tried by some with limited success. This case illustrates that Parvovirus B19 infection should be considered in the differential diagnosis of acute renal failure with nephrotic presentation and supports the role of corticosteroids in treating Parvovirus B19 infection associated collapsing FSGS.
252 USE OF HEPARIN-FREE MAINTENANCE HEMODIALYSIS AND ITS CLINICAL CORRELATES IN THE UNITED STATES Jenny I. Shen, Aya A. Mitani, Wolfgang C. Winkelmayer Stanford University School of Medicine, Palo Alto, CA., U.S.A. Heparin facilitates hemodialysis (HD) as it prevents clotting of blood in the extracorporeal circuit. However, heparin also has a number of side effects, chiefly an increased risk of bleeding. Despite these safety issues, there are no standards for heparin administration during HD. We defined the use of heparin-free HD and identified clinical correlates of it in older patients initiating HD with a large national dialysis provider. Patients >67 years of age at initiation of HD in 2007-08 whose primary payer was Medicare (Part A&B) were eligible; we arbitrarily chose the HD treatment closest to day 90 after initiation (index date) assuming that any heparin regimen would be stable at that point. Using data from both the U.S. Renal Data System and the electronic medical records of the dialysis provider, we assessed potential determinants of heparin-free maintenance HD on or during the year prior to this index date: demographics, comorbidities, laboratory measurements, vital signs, and dialysis characteristics. We used multiple logistic regression to examine associations between heparin-free HD and these covariates. Of 10,965 older patients who initiated HD in 2007-2008 and received care at a participating facility at day 90, 723 (6.8%) dialyzed heparinfree. In multivariable analyses, a history of arrhythmia, gastrointestinal bleeding, and warfarin use were associated with higher odds of heparinfree HD; diabetes mellitus was associated with lower odds (table). Lower weight, hemoglobin level, platelet count (all P-values for trend <0.001), and shorter duration of HD session (P for trend =0.05) were all associated with higher odds of undergoing heparin-free HD. None of the demographic factors were associated with heparin-free HD. Comorbidity Odds Ratio (95% CI) Arrhythmia 1.22 (1.02 - 1.47) Diabetes Mellitus 0.85 (0.72 - 1.00) Gastrointestinal Bleeding 1.47 (1.17 - 1.85) Warfarin Use 1.94 (1.41 - 2.67) Use of heparin-free maintenance HD correlated with conditions that are markers for an increased risk of bleeding. Our findings also showed patterns of weight-based and time-dependent dosage of heparin.
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249 INTRAVENOUS IMMUNOGLOBULINS FOR OSMOTIC DEMYELINATION SYNDROME (ODS). Tulsi Sharma, Pearl Dy, Arnold M. Moses. Upstate Medical University, Syracuse, NY, USA. Introduction: Hyponatremia is a common medical problem but can be challenging in the presence of an associated endocrine disorder. Case: A 21year-old female with central Diabetes insipidus (DI) well controlled on DDAVP (Desmopressin) presented to an outside facility with vomiting and serum Na127meq/L. She improved with normal saline (NS). Her symptoms however recurred a week later (Na-129). This time however the Na decreased to 119 despite NS over next 2days! DDAVP was discontinued and hypertonic saline was initiated. Why did Na go down despite therapy? Adrenal insufficiency was suspected and treated with hydrocortisone. Na rose to 132 in 10 hours. She became increasingly lethargic, nonverbal and developed a blank affect. She was transferred to Upstate Hospital. Her Na at arrival was 157, a rise of 38meq/L in 18 hours. She had multiple episodes of seizures, and had to be intubated. MRI suggested extrapontine ODS. Considering the hypernatremia with hypotonic urine (osmolality-80mosm/kg) DDAVP was restarted. She was treated with hydrocortisone, antiepileptics and NS. Urine osmolality normalized, Na was slowly brought down to 140 in 48 hours. Her clinical status however failed to improve despite the correction of hyponatremia. She was then given IVIG for 5 days and her motor functions improved dramatically, followed by speech and cognition. Even though she had tremendous clinical improvement, repeat MRI showed worsening of the brain lesions. Discussion: This case highlights multiple teaching points:-1) Adrenal insufficiency should be strongly considered when hyponatremia develops in a patient with DI who was previously in good control. Repletion with corticosteroids should be done cautiously as it can lead to rapid diuresis of hypotonic urine. 2) IVIG therapy may accelerate recovery of ODS based on data from a few case reports. Effect is possibly caused by the reduction of myelinotoxic substances and antimyelin antibodies. 3) MRI changes in ODS may be delayed and are not prognostic. 4) Prognosis of ODS is not uniformly bad. Significant improvement may occur with aggressive supportive therapy as in our patient however, prevention is obviously better than cure. This can cause a rapid rise in S.Na predisposing to myelinolysis.During this period, there was no record of urine volume or osmolality and she had not received any DDAVP.
250 CKD MANAGEMENT IN PRIMARY CARE SETTING. Yuvraj Sharma, Sean Flynn, Linet Lonappan, Saurabh Bansal, Sarun Thomas, Karthik Bekal, Nathan Okechukwu. Crozer Chester Medical Center, Upland, PA, USA. Chronic Kidney Disease (CKD) is a major public health problem, affecting 1 in 9 US adults. Majority of the CKD patients are currently being managed by PCPs, and they are 20 times more likely to die from cardiovascular disease before they progress to hemodialysis or renal transplantation or see a nephrologist. Goal of the study was to evaluate the management of CKD patients in our Internal Medicine Resident Continuity Clinic and to increase residents’ knowledge about CKD management. A retrospective study was conducted and the data was collected from electronic medical records. A total of 77 patients with CKD stage 3 and above were identified in the continuity clinic and included in the study. Patients already on hemodialysis and those followed by nephrologists were excluded. Anemia was present in 33 patients and its proper evaluation (i.e. iron studies, vitamin B12, folate levels and stool heme occult) was done in less than 60%. Bone mineral disease was also being under-evaluated, with the serum phosphorus, iPTH and vitamin D levels being checked in only 29%, 10% and 18% patients respectively. Urine protein/creatinine ratio was identified in only 14% patients. Diabetes was present in 39 patients and in only 54 % HbA1C was at recommended goal (i.e. HbA1C < 7%). In 43 % patients, hypertension was uncontrolled (two B.P readings >130/80 mm of Hg). Lipid profile was checked in 72 patients and goal LDL (i.e. LDL less than 100 mg/dl) was reached in less than 47% patients. Only 35% of the patients were immunized for the recommended pneumococcal and influenza vaccine. In conclusion, CKD is being under-evaluated and under-treated, leading to loss of the opportunities to prevent its complications. There is a need to increase the awareness among PCPs to provide CKD patients with better quality care, to slow their progression to End Stage Kidney Disease and for timely referral to the nephrologists.
Am J Kidney Dis. 2012;59(4):A1-A92
251 COLLAPSING GLOMERULOPATHY DUE TO PARVOVIRUS: A MYSTERIOUS CASE OF ACUTE KIDNEY INJURY. Yuvraj Sharma, Glenn Ladinsky and Alan Barman. Crozer Chester Medical Center, Upland, PA, USA Collapsing focal segmental glomerulosclerosis (FSGS) is characterized by higher incidence of nephrotic syndrome and rapid progression to renal failure. The causes of collapsing glomerulopathy include idiopathic, heroin abuse, HIV, parvovirus B19 infection and pamidronate. We report the case of a 29 year old African American male who presented with 3 day history of abdominal pain with nausea, myalgias and decreased urine output. He had a past medical history of poly-substance abuse and depression. Examination was unremarkable, except for 2+ pitting edema in lower extremities. Initial laboratory data revealed blood urea nitrogen (BUN) of 44 mg/dl and serum creatinine of 10.2 mg/dl. Two weeks prior, his BUN was 8 mg/dl and serum creatinine was 1.3 mg/dl. So, he was evaluated for acute kidney injury (AKI). Urine analysis showed 500 mg/dl proteins, 1+ blood with no casts; and his 24 hour urinary protein was 3.1 grams. Urinary drug screen was positive for cannabis, cocaine and PCP. CT scan of abdomen showed no hydronephrosis. An extensive workup including hepatitis B/C serology, HIV serology, ANA, P-ANCA and C-ANCA was negative. On further evaluation, patient was found to have positive Parvovirus Ig M serology. This was attributed as the cause of AKI after his renal biopsy showed collapsing FSGS with immunoperoxidase staining positive for Parvovirus. He was treated with hemodialysis and corticosteroid therapy. Over the course of 4 months, the patient had a dramatic response to corticosteroids. He was taken off hemodialysis, with the BUN and serum creatinine at 37 mg/dl and 2.9 mg/dl respectively. Collapsing FSGS associated with Parvovirus B19 infection is a rare disease with no clear optimum treatment, immunosuppressive have been tried by some with limited success. This case illustrates that Parvovirus B19 infection should be considered in the differential diagnosis of acute renal failure with nephrotic presentation and supports the role of corticosteroids in treating Parvovirus B19 infection associated collapsing FSGS.
252 USE OF HEPARIN-FREE MAINTENANCE HEMODIALYSIS AND ITS CLINICAL CORRELATES IN THE UNITED STATES Jenny I. Shen, Aya A. Mitani, Wolfgang C. Winkelmayer Stanford University School of Medicine, Palo Alto, CA., U.S.A. Heparin facilitates hemodialysis (HD) as it prevents clotting of blood in the extracorporeal circuit. However, heparin also has a number of side effects, chiefly an increased risk of bleeding. Despite these safety issues, there are no standards for heparin administration during HD. We defined the use of heparin-free HD and identified clinical correlates of it in older patients initiating HD with a large national dialysis provider. Patients >67 years of age at initiation of HD in 2007-08 whose primary payer was Medicare (Part A&B) were eligible; we arbitrarily chose the HD treatment closest to day 90 after initiation (index date) assuming that any heparin regimen would be stable at that point. Using data from both the U.S. Renal Data System and the electronic medical records of the dialysis provider, we assessed potential determinants of heparin-free maintenance HD on or during the year prior to this index date: demographics, comorbidities, laboratory measurements, vital signs, and dialysis characteristics. We used multiple logistic regression to examine associations between heparin-free HD and these covariates. Of 10,965 older patients who initiated HD in 2007-2008 and received care at a participating facility at day 90, 723 (6.8%) dialyzed heparinfree. In multivariable analyses, a history of arrhythmia, gastrointestinal bleeding, and warfarin use were associated with higher odds of heparinfree HD; diabetes mellitus was associated with lower odds (table). Lower weight, hemoglobin level, platelet count (all P-values for trend <0.001), and shorter duration of HD session (P for trend =0.05) were all associated with higher odds of undergoing heparin-free HD. None of the demographic factors were associated with heparin-free HD. Comorbidity Odds Ratio (95% CI) Arrhythmia 1.22 (1.02 - 1.47) Diabetes Mellitus 0.85 (0.72 - 1.00) Gastrointestinal Bleeding 1.47 (1.17 - 1.85) Warfarin Use 1.94 (1.41 - 2.67) Use of heparin-free maintenance HD correlated with conditions that are markers for an increased risk of bleeding. Our findings also showed patterns of weight-based and time-dependent dosage of heparin.
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