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LIMITED ENGLISH PROFICIENCY AND MEDICATION ADHERENCE AMONG PATIENTS WITH CKD IN THE KIDNEY AWARENESS REGISTRY AND EDUCATION (KARE) STUDY
NKF 2014 Spring Clinical Meetings Abstracts
381 LIMITED ENGLISH PROFICIENCY AND MEDICATION ADHERENCE AMONG PATIENTS WITH CKD IN THE KIDNEY AWARENESS REGISTRY AND EDUCATION (KARE) STUDY: Alexandra Velasquez, Delphine Tuot, Tanushree Banerjee and Neil Powe, Center for Vulnerable Populations, San Francisco General Hospital, and University of California, San Francisco, CA, USA Communication among patients and providers is a key component of health care delivery. Language barriers are associated with decreased access to preventive care, but the impact of limited English proficiency (LEP) on medication adherence among patients with chronic kidney disease (CKD) is unknown. Medication adherence, defined by the validated 4-item Morisky Medication Adherence scale, was determined among participants recruited for the KARE study, a randomized control trial that aims to enhance the delivery of CKD care to vulnerable populations in the San Francisco Department of Public Health Community Health Network. LEP was defined by completing the baseline KARE survey in a nonEnglish language. CKD was defined by estimated glomerular filtrate rate (eGFR) < 60 ml/min/1.73m2, urine albumin:creatinine ratio >30mg/g or >1+ dipstick proteinuria, at least twice separated by 3 months. Multivariable ordinal logistic regression, adjusted for age, gender, CKD severity and health literacy was performed to examine the odds of worsening categories of medication adherence by LEP status. Nearly half of the overall cohort (n=71) had LEP, of which 40% spoke Spanish and 7% spoke Cantonese. LEP participants selfreported worse medication adherence than English-speaking patients, (AOR=4.03, 95%CI 1.37-11.87). Male gender and low health literacy were also associated with worse medication adherence, but results were not statistically significant (AOR=1.6, 0.52-4.89 and 1.34, 0.384.76, respectively). CKD patients with LEP self-report lower medication adherence than their English-speaking counterparts. Efforts to improve medication understanding among non-English speakers may help increase medication adherence in patients with CKD.
382 HYPERCALCEMIA AND RENAL FAILURE – A RARE INITIAL MANIFESTATION OF ORBITAL SARCOIDOSIS Ishmeet Walia, Chandandeep Takkar, University of Texas Medical Branch; Galveston, TX, US Sarcoidosis is a multisystem granulomatous disease involving the mediastinal lymph nodes and lungs in 90-95 % cases. Ophthalmic disease is seen in 12% of the patients with uveitis as the usual presentation. We present a case of orbital sarcoidosis presenting with hypercalcemia and renal insufficiency. A 51 year old female with bipolar disorder (on lithium) and psoriatic arthritis (on steroid taper) presented with asymptomatic hypercalcemia (serum Calcium:13mg/dl )and acute renal failure (Cr:3mg/dl). PTH levels were appropriately suppressed (10pg/ml). Lithium level was within therapeutic range (<0.2mmol/L) but a marked increase in the serum Angiotensin converting enzyme (ACE) level was seen when she was off steroids (124U/L). Gallium scan showed increased uptake in bilateral lacrimal glands, nasopharynx and PANDA SIGN (figure1) suggestive of orbital sarcoidosis. Slit lamp exam ruled out asymptomatic uveitis. Patient was started on prednisone with rapid resolution of hypercalcemia and renal insufficiency. We could not establish a tissue diagnosis via renal or lacrimal gland biopsy due to patient refusal. While an elevated ACE level or positive gallium scan per se is neither sensitive not specific for sarcoidosis, the combined specificity and positive predictive value of both tests for diagnosis of Sarcoidosis is close to 100%. In summary, this case highlights extra-pulmonary sarcoidosis as a rare, although important diagnostic consideration for the hypercalcemia and renal failure. Figure1
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383 UNUSUAL CASE OF MEMBRANOUS GLOMERULONEPHRITIS ASSOCIATED WITH LEVAMISOLE: Jackson Wang, Jose Morfin, Division of Nephrology, University of California, Davis School of Medicine, Sacramento, CA, United States Levamisole has increasingly been used an adulterant in cocaine. This has resulted in significant clinical manifestations, specifically, antineutrophil cytoplasmic antibody (ANCA) vaculitis with systemic and renal involvement. Case reports in the literature describing these presentations have had difficulty in distinguishing denovo vasculitis versus a drug induced process. In this context, we report an unusual case of a patient presenting with ANCA mediated skin vasculitis with documented secondary membranous glomerulonephritis associated with levamisole contaminated cocaine use. Patient was a 58-year-old Caucasian man with no significant medical history other than chronic cocaine use presented to the hospital with generalized anasarca and pupuric lesions. Serum creatinine on admission was noted to be 1.5 mg/dL, with no prior baseline. Urine microscopy did not show dysmorphic red cells or casts, but noted to have 14 grams of protein on 24 hour urine protein collection. Pertinent data includes serum albumin of 1.6 mg/dL ANCA 1:640 with p-ANCA predominance, anti-MPO 141 U/ml, anti-PR-3 36 U/ml, negative ANA, normal C3 and C4, negative HIV, negative RPR, and negative Hepatitis B and C titers. Punch biopsy of the skin on the day of admission showed evidence of thrombotic coagulopathy and kidney biopsy done on hospital day 4 showed thickened loops on light microscopy, granular deposition of IgG staining on immunofluorescence, and subepithelial mixed with intramembranous deposits on electron microscopy. There was no positive staining for IgG4 which suggested a secondary process. Decrease in proteinuria and swelling noted after starting an aceinhibitor. Despite high ANCA titers, renal pathology was inconsistent with a pauci-immune glomerulonephritis. The negative staining for igG4 strongly suggests secondary membranous glomerulonephritis, with the possibility of drug induced as demonstrated in our case. To our knowledge, this is the first case of membranous glomerulonephritis associated with cocaine use contaminated by levamisole.
384 CHARACTERISTICS ASSOCIATED WITH PARATHYROIDECTOMY IN MEDICARE DIALYSIS PATIENTS James Wetmore,1 Jiannong Liu,1 Kimberly Lowe,2 Areef Ishani,1 Thy Do,2 Brian Bradbury,2 Geoff Block,3 Allan Collins.1 1Chronic Disease Research Group, Minneapolis, MN, USA; 2Amgen, Inc, Thousand Oaks, CA, USA; 3Denver Nephrologists PC, Denver, CO, USA. Parathyroidectomy (PTX) is a treatment for severe secondary hyperparathyroidism in maintenance dialysis patients. Differences between patients who do and do not undergo PTX have never been rigorously examined in a large cohort of Medicare dialysis patients. Data from the United States Renal Data System were used to identify prevalent hemodialysis (HD) patients, 2007-2009. PTX was identified by ICD-9 procedure codes 06.8x from inpatient claims. In each year, an index date was defined as the PTX date for PTX patients and January 1 for non-PTX patients. Only patients on HD with Medicare as primary payer for at least 1 year before the index date were included. The year prior to the index date was used as the baseline period to derive demographic information and comorbid conditions. Characteristics of patients who did and did not undergo PTX were compared, and adjusted odds ratios (AORs) for PTX were calculated using logistic regression. A total of 4435 patients out of 319,747 (1.4%) underwent PTX. Younger age (19-44 yrs., AOR 2.0 vs. 45-64 yrs.), female sex (1.27), black race (1.29 vs. white), body mass index > 35 kg/m2 (1.41 vs. 1825 kg/m2), dialysis duration > 5 yrs. (3.57 vs. < 3 yrs.), atherosclerotic heart disease (1.15), and other cardiovascular disease (1.33) were significantly associated with PTX (P < 0.001). Diabetes (AOR 0.82), peripheral vascular disease (0.92), and history of a stroke (0.78) were inversely proportional to odds of PTX; presence of heart failure was not associated with PTX. End-stage renal disease (ESRD) network was associated with substantial variability in PTX rate, with a 2.1-fold difference between the most- and least-frequently performing networks. These data suggest that patients who undergo PTX differ clinically from those who do not in many ways, and that there is a > 2-fold difference in likelihood of PTX across ESRD networks, even after adjustment for other factors. Further investigation into the factors associated with PTX is required.
Am J Kidney Dis. 2014;63(5):A1-A121
381 LIMITED ENGLISH PROFICIENCY AND MEDICATION ADHERENCE AMONG PATIENTS WITH CKD IN THE KIDNEY AWARENESS REGISTRY AND EDUCATION (KARE) STUDY: Alexandra Velasquez, Delphine Tuot, Tanushree Banerjee and Neil Powe, Center for Vulnerable Populations, San Francisco General Hospital, and University of California, San Francisco, CA, USA Communication among patients and providers is a key component of health care delivery. Language barriers are associated with decreased access to preventive care, but the impact of limited English proficiency (LEP) on medication adherence among patients with chronic kidney disease (CKD) is unknown. Medication adherence, defined by the validated 4-item Morisky Medication Adherence scale, was determined among participants recruited for the KARE study, a randomized control trial that aims to enhance the delivery of CKD care to vulnerable populations in the San Francisco Department of Public Health Community Health Network. LEP was defined by completing the baseline KARE survey in a nonEnglish language. CKD was defined by estimated glomerular filtrate rate (eGFR) < 60 ml/min/1.73m2, urine albumin:creatinine ratio >30mg/g or >1+ dipstick proteinuria, at least twice separated by 3 months. Multivariable ordinal logistic regression, adjusted for age, gender, CKD severity and health literacy was performed to examine the odds of worsening categories of medication adherence by LEP status. Nearly half of the overall cohort (n=71) had LEP, of which 40% spoke Spanish and 7% spoke Cantonese. LEP participants selfreported worse medication adherence than English-speaking patients, (AOR=4.03, 95%CI 1.37-11.87). Male gender and low health literacy were also associated with worse medication adherence, but results were not statistically significant (AOR=1.6, 0.52-4.89 and 1.34, 0.384.76, respectively). CKD patients with LEP self-report lower medication adherence than their English-speaking counterparts. Efforts to improve medication understanding among non-English speakers may help increase medication adherence in patients with CKD.
382 HYPERCALCEMIA AND RENAL FAILURE – A RARE INITIAL MANIFESTATION OF ORBITAL SARCOIDOSIS Ishmeet Walia, Chandandeep Takkar, University of Texas Medical Branch; Galveston, TX, US Sarcoidosis is a multisystem granulomatous disease involving the mediastinal lymph nodes and lungs in 90-95 % cases. Ophthalmic disease is seen in 12% of the patients with uveitis as the usual presentation. We present a case of orbital sarcoidosis presenting with hypercalcemia and renal insufficiency. A 51 year old female with bipolar disorder (on lithium) and psoriatic arthritis (on steroid taper) presented with asymptomatic hypercalcemia (serum Calcium:13mg/dl )and acute renal failure (Cr:3mg/dl). PTH levels were appropriately suppressed (10pg/ml). Lithium level was within therapeutic range (<0.2mmol/L) but a marked increase in the serum Angiotensin converting enzyme (ACE) level was seen when she was off steroids (124U/L). Gallium scan showed increased uptake in bilateral lacrimal glands, nasopharynx and PANDA SIGN (figure1) suggestive of orbital sarcoidosis. Slit lamp exam ruled out asymptomatic uveitis. Patient was started on prednisone with rapid resolution of hypercalcemia and renal insufficiency. We could not establish a tissue diagnosis via renal or lacrimal gland biopsy due to patient refusal. While an elevated ACE level or positive gallium scan per se is neither sensitive not specific for sarcoidosis, the combined specificity and positive predictive value of both tests for diagnosis of Sarcoidosis is close to 100%. In summary, this case highlights extra-pulmonary sarcoidosis as a rare, although important diagnostic consideration for the hypercalcemia and renal failure. Figure1
A114
383 UNUSUAL CASE OF MEMBRANOUS GLOMERULONEPHRITIS ASSOCIATED WITH LEVAMISOLE: Jackson Wang, Jose Morfin, Division of Nephrology, University of California, Davis School of Medicine, Sacramento, CA, United States Levamisole has increasingly been used an adulterant in cocaine. This has resulted in significant clinical manifestations, specifically, antineutrophil cytoplasmic antibody (ANCA) vaculitis with systemic and renal involvement. Case reports in the literature describing these presentations have had difficulty in distinguishing denovo vasculitis versus a drug induced process. In this context, we report an unusual case of a patient presenting with ANCA mediated skin vasculitis with documented secondary membranous glomerulonephritis associated with levamisole contaminated cocaine use. Patient was a 58-year-old Caucasian man with no significant medical history other than chronic cocaine use presented to the hospital with generalized anasarca and pupuric lesions. Serum creatinine on admission was noted to be 1.5 mg/dL, with no prior baseline. Urine microscopy did not show dysmorphic red cells or casts, but noted to have 14 grams of protein on 24 hour urine protein collection. Pertinent data includes serum albumin of 1.6 mg/dL ANCA 1:640 with p-ANCA predominance, anti-MPO 141 U/ml, anti-PR-3 36 U/ml, negative ANA, normal C3 and C4, negative HIV, negative RPR, and negative Hepatitis B and C titers. Punch biopsy of the skin on the day of admission showed evidence of thrombotic coagulopathy and kidney biopsy done on hospital day 4 showed thickened loops on light microscopy, granular deposition of IgG staining on immunofluorescence, and subepithelial mixed with intramembranous deposits on electron microscopy. There was no positive staining for IgG4 which suggested a secondary process. Decrease in proteinuria and swelling noted after starting an aceinhibitor. Despite high ANCA titers, renal pathology was inconsistent with a pauci-immune glomerulonephritis. The negative staining for igG4 strongly suggests secondary membranous glomerulonephritis, with the possibility of drug induced as demonstrated in our case. To our knowledge, this is the first case of membranous glomerulonephritis associated with cocaine use contaminated by levamisole.
384 CHARACTERISTICS ASSOCIATED WITH PARATHYROIDECTOMY IN MEDICARE DIALYSIS PATIENTS James Wetmore,1 Jiannong Liu,1 Kimberly Lowe,2 Areef Ishani,1 Thy Do,2 Brian Bradbury,2 Geoff Block,3 Allan Collins.1 1Chronic Disease Research Group, Minneapolis, MN, USA; 2Amgen, Inc, Thousand Oaks, CA, USA; 3Denver Nephrologists PC, Denver, CO, USA. Parathyroidectomy (PTX) is a treatment for severe secondary hyperparathyroidism in maintenance dialysis patients. Differences between patients who do and do not undergo PTX have never been rigorously examined in a large cohort of Medicare dialysis patients. Data from the United States Renal Data System were used to identify prevalent hemodialysis (HD) patients, 2007-2009. PTX was identified by ICD-9 procedure codes 06.8x from inpatient claims. In each year, an index date was defined as the PTX date for PTX patients and January 1 for non-PTX patients. Only patients on HD with Medicare as primary payer for at least 1 year before the index date were included. The year prior to the index date was used as the baseline period to derive demographic information and comorbid conditions. Characteristics of patients who did and did not undergo PTX were compared, and adjusted odds ratios (AORs) for PTX were calculated using logistic regression. A total of 4435 patients out of 319,747 (1.4%) underwent PTX. Younger age (19-44 yrs., AOR 2.0 vs. 45-64 yrs.), female sex (1.27), black race (1.29 vs. white), body mass index > 35 kg/m2 (1.41 vs. 1825 kg/m2), dialysis duration > 5 yrs. (3.57 vs. < 3 yrs.), atherosclerotic heart disease (1.15), and other cardiovascular disease (1.33) were significantly associated with PTX (P < 0.001). Diabetes (AOR 0.82), peripheral vascular disease (0.92), and history of a stroke (0.78) were inversely proportional to odds of PTX; presence of heart failure was not associated with PTX. End-stage renal disease (ESRD) network was associated with substantial variability in PTX rate, with a 2.1-fold difference between the most- and least-frequently performing networks. These data suggest that patients who undergo PTX differ clinically from those who do not in many ways, and that there is a > 2-fold difference in likelihood of PTX across ESRD networks, even after adjustment for other factors. Further investigation into the factors associated with PTX is required.
Am J Kidney Dis. 2014;63(5):A1-A121