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KIDNEY CARE PROGRAM IN AN URBAN MANAGED CARE SETTING PREPARES CKD PATIENTS FOR ESRD
NKF 2014 Spring Clinical Meetings Abstracts
345 KIDNEY CARE PROGRAM IN AN URBAN MANAGED CARE SETTING PREPARES CKD PATIENTS FOR ESRD T Smith-Jules; L Prlesi; J Manganelli; H Chung, A Meara, S Felleman, C Bauer Montefiore Care Management Organization, Yonkers, NY USA. The prevalence of ESRD in the Bronx is higher than the average prevalence of ESRD in the US. Timely vascular access placement reduces morbidity, mortality and is cost effective. Incident hemodialysis initiation is associated with high rates of hospitalizations. The Kidney Care Program (KCP) at Montefiore is a multidisciplinary clinic for patients with advanced CKD. In addition to usual nephrology care, this program offers patients care coordination from a nurse practitioner, educational classes, pharmacist medication reconciliation, dietary counseling, geriatric and palliative care assessments, navigation through dialysis preparation and listing for kidney transplantation. In its first year, KCP provided nurse practitioner evaluations to all of the 155 enrolled patients, renal dietician evaluations to 16%, a geriatric palliative care evaluation to 45% of patients over age 80 or with multiple co-morbidities, and a pharmacy evaluation to 91% of its patients. Patients had polypharmacy use (85%) (>8 medications) and 47% were non-adherent. Of the drugs considered inappropriate by the pharmacist, 39% of prescription drugs and 9% of OTC drugs were discontinued. Pharmacist recommended one or more dosing changes in 35% of cases, and doctors implemented 46% of those changes. Formal Group educational sessions were attended by 35 percent. Of KCP patients, 14% (21) progressed to ESRD within one year. One patient was transplanted and 2 patients opted for peritoneal dialysis. Of the 18 patients who started hemodialysis, 50% were started as outpatients, compared to 34% historical rate in prior years (20072011.) During the 1st dialysis, 56% (10) of patients had an AVF/AVG in use. In addition, either a mature or maturing vascular access was present in 94% (17) of our hemodialysis patients. A multidisciplinary approach to CKD care facilitated outpatient dialysis initiation and improved AVF rates. Pharmacy evaluations led to discontinuation of inappropriate medications and improved medication dosing. These results suggest that multidisciplinary care can improve outcomes as patients transition from CKD to ESRD.
346 DO MULTIPLE URETEROSCOPIES ALTER LONG TERM RENAL FUNCTION? A STUDY USING ESTIMATED GLOMERULAR FILTRATION RATE: Brian C Sninsky, Stephen Y Nakada, R Allan Jhagroo, University of Wisconsin Hospital and Clinics, Madison, WI, USA Though considered standard of care for nephrolithiasis, little data are available evaluating the effects of multiple ureteroscopic laser lithotripsies (URS) on long term renal function. We investigated this relationship as measured by the estimated glomerular filtration rate (eGFR) in a population with pre-existing mild to moderate kidney disease. To our knowledge, this is the first study using a baseline eGFR as opposed to eGFR calculated from creatinine during acute stone obstruction, and excluding patients with a history of other stone procedures such as shockwave lithotripsy (SWL) or percutaneous nephrolithotomy (PCNL). A retrospective chart review was performed for patients with a baseline eGFR below 90 mL/min/1.73m2 who underwent at least 2 URS for nephrolithiasis at our institution from 2004-2012. Patients undergoing SWL or PCNL at any point in their history were excluded. A total of 26 patients (2.3 ± 0.6 URS procedures each) were included with a mean follow up of 28.1 months (range 5-75 months). Both creatinine and eGFR were recorded at baseline prior to acute stone presentation and surgery, and at the last recorded follow up visit. Stone location, total stone burden, and co-morbidities were also recorded. The overall mean change in eGFR was a 4.2% increase, with a per year eGFR increase of 2.6 ± 10.4%. There was no statistical significance for stones treated in the kidney alone versus the ureter and kidney combined (6.3% v. 2.3% mean increase in eGFR; p=0.67). Other factors including age, presence of DM or hypertension, baseline creatinine level, total stone burden, and number of URS performed were not statistically significant. Using an objective metric, eGFR, our data indicate that multiple ureteroscopies for stones are not detrimental to long term renal function, even in patients with pre-existing chronic kidney disease.
Am J Kidney Dis. 2014;63(5):A1-A121
347 CONCOMITANT INTRAVENOUS IRON USE DRIVES CHANGES IN IRON INDICES IN A PHASE 3 STUDY OF PA21 S.M. Sprague1, A. Covic, J. Floege, M. Ketteler, B. Spinowitz, S. Gaillard, P. Moneuse, A. Rastogi. 1NorthShore University Health System University of Chicago Pritzker School of Medicine, Evanston, IL, USA A randomized, open-label, Phase 3 study assessed PA21, a polynuclear iron(III)-oxyhydroxide phosphate binder, vs sevelamer carbonate (SEV), in dialysis patients with hyperphosphatemia. 1059 patients were randomized to PA21 (1.0–3.0 g/day; n=710) or SEV (2.4–14.4 g/day; n=349) for 12 weeks’ dose titration followed by 12 weeks’ maintenance. Eligible patients enrolled in a 28-week safety extension study. Concomitant intravenous (iv) iron use was permitted at the investigator’s discretion. A post hoc analysis compared iron indices in patients who had received iv iron vs those who had not during the study. 549 patients completed the extension study; 73.6% (PA21) and 80.6% (SEV) received concomitant iv iron. Changes in iron indices (baseline to Week 52) are shown (Table). In summary, changes in iron indices in both study arms were mainly attributable to concomitant iv iron use. Differences between treatment groups may be due to minimal iron uptake from PA21, although no signs of iron accumulation/overload were observed over 52 weeks. PA21 (n=322) SEV (n=227) iv iron No iv iv iron No iv iron Median (n=237 iron (n=183) (n=44) (IQR) [TSAT:236]) (n=85) 619 347 735 360 Ferritin, ng/mL (398, 907) (136, (428, 982) (157, 925) Baseline (Wk 0) 754) 196 58 87 –24 Δ Ferritin, (–28, 414)* (–126, (–94, (–121,76) ng/mL 247) 257)* (Wk 0 to 52) 25 23 26 23 TSAT, % (19, 32) (15, 29) (20, 33) (17, 29) (Wk 0) 4 4 –1 0 Δ TSAT, % (–4, 12)* (–3, 11) (–7, 7)* (–4, 8) (Wk 0 to 52) 115 111 115 112 Hb, g/L (107, 122) (96, 117) (109, 122) (96, 119) (Wk 0) 0 5 –2 1 Δ Hb, g/L (–9, 10) (–6, 14) (–10, 7) (–9, 11) (Wk 0 to 52) *P<0.05 for between-group comparison of changes (Wk 0 to Wk 52)
348 ASSOCIATION BETWEEN CHANGE IN TRIGLYCERIDES OVER TIME AND MORTALITY AMONG INCIDENT HEMODYALSIS PATIENTS: Shah Steiner1; Elani Streja1; Connie M. Rhee1; Hamid Moradi1; Csaba P. Kovesdy2; Kamyar Kalantar-Zadeh1 1Harold Simmons Center, UC Irvine Medical Center, Orange, CA; 2Division of Nephrology, University of Tennessee, Memphis, TN. Although increasing triglycerides (TG) has been directly associated with increased risk of death in the general population, an inverse or non-significant association has been found in maintenance hemodialysis (MHD) patients. However, studies on change in TG levels over time and its effect of mortality have not been examined in MHD patients. We hypothesize that decreasing TG levels over time are associated with increased risk of mortality. We examined the risk of death in subsequent quarter given change in triglyceride from baseline levels in a 1.5-year/6 quarter (July 2004-December 2005) cohort of 9,318 incident MHD patients. We reported means and standard deviations of triglyceride levels per patient quarter stratified by death in subsequent quarter. We additionally used cox proportional hazards regression models adjusted for baseline triglyceride levels, case-mix and markers of malnutrition-inflammation complex for estimate risk of death for each 10 unit decrease in triglyceride per quarter over 6 quarters. Patients were age 63±15 years old, 45% female, 29% black, and 64% diabetics. For each quarter, patients who died in the subsequent quarter had a significantly larger decrease in TG compared to those patients who survived into the subsequent quarter. In fully adjusted models, each 10 unit decrease in TG per quarter was associated with a 2% increased risk of death (HR, 1.02; 95% CI, 1.01-1.03). Hence, decreasing TG from baseline over time is associated with a modest but significant increased risk of death in MHD patients, even after adjustment for MICS. Further studies are required to understand the significance and/or reasons for this relationship.
A105
345 KIDNEY CARE PROGRAM IN AN URBAN MANAGED CARE SETTING PREPARES CKD PATIENTS FOR ESRD T Smith-Jules; L Prlesi; J Manganelli; H Chung, A Meara, S Felleman, C Bauer Montefiore Care Management Organization, Yonkers, NY USA. The prevalence of ESRD in the Bronx is higher than the average prevalence of ESRD in the US. Timely vascular access placement reduces morbidity, mortality and is cost effective. Incident hemodialysis initiation is associated with high rates of hospitalizations. The Kidney Care Program (KCP) at Montefiore is a multidisciplinary clinic for patients with advanced CKD. In addition to usual nephrology care, this program offers patients care coordination from a nurse practitioner, educational classes, pharmacist medication reconciliation, dietary counseling, geriatric and palliative care assessments, navigation through dialysis preparation and listing for kidney transplantation. In its first year, KCP provided nurse practitioner evaluations to all of the 155 enrolled patients, renal dietician evaluations to 16%, a geriatric palliative care evaluation to 45% of patients over age 80 or with multiple co-morbidities, and a pharmacy evaluation to 91% of its patients. Patients had polypharmacy use (85%) (>8 medications) and 47% were non-adherent. Of the drugs considered inappropriate by the pharmacist, 39% of prescription drugs and 9% of OTC drugs were discontinued. Pharmacist recommended one or more dosing changes in 35% of cases, and doctors implemented 46% of those changes. Formal Group educational sessions were attended by 35 percent. Of KCP patients, 14% (21) progressed to ESRD within one year. One patient was transplanted and 2 patients opted for peritoneal dialysis. Of the 18 patients who started hemodialysis, 50% were started as outpatients, compared to 34% historical rate in prior years (20072011.) During the 1st dialysis, 56% (10) of patients had an AVF/AVG in use. In addition, either a mature or maturing vascular access was present in 94% (17) of our hemodialysis patients. A multidisciplinary approach to CKD care facilitated outpatient dialysis initiation and improved AVF rates. Pharmacy evaluations led to discontinuation of inappropriate medications and improved medication dosing. These results suggest that multidisciplinary care can improve outcomes as patients transition from CKD to ESRD.
346 DO MULTIPLE URETEROSCOPIES ALTER LONG TERM RENAL FUNCTION? A STUDY USING ESTIMATED GLOMERULAR FILTRATION RATE: Brian C Sninsky, Stephen Y Nakada, R Allan Jhagroo, University of Wisconsin Hospital and Clinics, Madison, WI, USA Though considered standard of care for nephrolithiasis, little data are available evaluating the effects of multiple ureteroscopic laser lithotripsies (URS) on long term renal function. We investigated this relationship as measured by the estimated glomerular filtration rate (eGFR) in a population with pre-existing mild to moderate kidney disease. To our knowledge, this is the first study using a baseline eGFR as opposed to eGFR calculated from creatinine during acute stone obstruction, and excluding patients with a history of other stone procedures such as shockwave lithotripsy (SWL) or percutaneous nephrolithotomy (PCNL). A retrospective chart review was performed for patients with a baseline eGFR below 90 mL/min/1.73m2 who underwent at least 2 URS for nephrolithiasis at our institution from 2004-2012. Patients undergoing SWL or PCNL at any point in their history were excluded. A total of 26 patients (2.3 ± 0.6 URS procedures each) were included with a mean follow up of 28.1 months (range 5-75 months). Both creatinine and eGFR were recorded at baseline prior to acute stone presentation and surgery, and at the last recorded follow up visit. Stone location, total stone burden, and co-morbidities were also recorded. The overall mean change in eGFR was a 4.2% increase, with a per year eGFR increase of 2.6 ± 10.4%. There was no statistical significance for stones treated in the kidney alone versus the ureter and kidney combined (6.3% v. 2.3% mean increase in eGFR; p=0.67). Other factors including age, presence of DM or hypertension, baseline creatinine level, total stone burden, and number of URS performed were not statistically significant. Using an objective metric, eGFR, our data indicate that multiple ureteroscopies for stones are not detrimental to long term renal function, even in patients with pre-existing chronic kidney disease.
Am J Kidney Dis. 2014;63(5):A1-A121
347 CONCOMITANT INTRAVENOUS IRON USE DRIVES CHANGES IN IRON INDICES IN A PHASE 3 STUDY OF PA21 S.M. Sprague1, A. Covic, J. Floege, M. Ketteler, B. Spinowitz, S. Gaillard, P. Moneuse, A. Rastogi. 1NorthShore University Health System University of Chicago Pritzker School of Medicine, Evanston, IL, USA A randomized, open-label, Phase 3 study assessed PA21, a polynuclear iron(III)-oxyhydroxide phosphate binder, vs sevelamer carbonate (SEV), in dialysis patients with hyperphosphatemia. 1059 patients were randomized to PA21 (1.0–3.0 g/day; n=710) or SEV (2.4–14.4 g/day; n=349) for 12 weeks’ dose titration followed by 12 weeks’ maintenance. Eligible patients enrolled in a 28-week safety extension study. Concomitant intravenous (iv) iron use was permitted at the investigator’s discretion. A post hoc analysis compared iron indices in patients who had received iv iron vs those who had not during the study. 549 patients completed the extension study; 73.6% (PA21) and 80.6% (SEV) received concomitant iv iron. Changes in iron indices (baseline to Week 52) are shown (Table). In summary, changes in iron indices in both study arms were mainly attributable to concomitant iv iron use. Differences between treatment groups may be due to minimal iron uptake from PA21, although no signs of iron accumulation/overload were observed over 52 weeks. PA21 (n=322) SEV (n=227) iv iron No iv iv iron No iv iron Median (n=237 iron (n=183) (n=44) (IQR) [TSAT:236]) (n=85) 619 347 735 360 Ferritin, ng/mL (398, 907) (136, (428, 982) (157, 925) Baseline (Wk 0) 754) 196 58 87 –24 Δ Ferritin, (–28, 414)* (–126, (–94, (–121,76) ng/mL 247) 257)* (Wk 0 to 52) 25 23 26 23 TSAT, % (19, 32) (15, 29) (20, 33) (17, 29) (Wk 0) 4 4 –1 0 Δ TSAT, % (–4, 12)* (–3, 11) (–7, 7)* (–4, 8) (Wk 0 to 52) 115 111 115 112 Hb, g/L (107, 122) (96, 117) (109, 122) (96, 119) (Wk 0) 0 5 –2 1 Δ Hb, g/L (–9, 10) (–6, 14) (–10, 7) (–9, 11) (Wk 0 to 52) *P<0.05 for between-group comparison of changes (Wk 0 to Wk 52)
348 ASSOCIATION BETWEEN CHANGE IN TRIGLYCERIDES OVER TIME AND MORTALITY AMONG INCIDENT HEMODYALSIS PATIENTS: Shah Steiner1; Elani Streja1; Connie M. Rhee1; Hamid Moradi1; Csaba P. Kovesdy2; Kamyar Kalantar-Zadeh1 1Harold Simmons Center, UC Irvine Medical Center, Orange, CA; 2Division of Nephrology, University of Tennessee, Memphis, TN. Although increasing triglycerides (TG) has been directly associated with increased risk of death in the general population, an inverse or non-significant association has been found in maintenance hemodialysis (MHD) patients. However, studies on change in TG levels over time and its effect of mortality have not been examined in MHD patients. We hypothesize that decreasing TG levels over time are associated with increased risk of mortality. We examined the risk of death in subsequent quarter given change in triglyceride from baseline levels in a 1.5-year/6 quarter (July 2004-December 2005) cohort of 9,318 incident MHD patients. We reported means and standard deviations of triglyceride levels per patient quarter stratified by death in subsequent quarter. We additionally used cox proportional hazards regression models adjusted for baseline triglyceride levels, case-mix and markers of malnutrition-inflammation complex for estimate risk of death for each 10 unit decrease in triglyceride per quarter over 6 quarters. Patients were age 63±15 years old, 45% female, 29% black, and 64% diabetics. For each quarter, patients who died in the subsequent quarter had a significantly larger decrease in TG compared to those patients who survived into the subsequent quarter. In fully adjusted models, each 10 unit decrease in TG per quarter was associated with a 2% increased risk of death (HR, 1.02; 95% CI, 1.01-1.03). Hence, decreasing TG from baseline over time is associated with a modest but significant increased risk of death in MHD patients, even after adjustment for MICS. Further studies are required to understand the significance and/or reasons for this relationship.
A105