- Email: [email protected]
PREDOMINANT TUBULOINTERSTITIAL INVOLVEMENT IN A PATIENT WITH LUPUS NEPHRITIS
NKF 2014 Spring Clinical Meetings Abstracts
325 BETA-2 MICROGLOBULIN (B2M) PREDICTS ACUTE REJECTION IN THE EARLY POST TRANSPLANTATION PERIOD Sumaira Shaikh MD, Brad C. Astor PhD, Arjang Djamali, MD, University of Wisconsin Hospital and Clinics, Madison, WI, USA B2M is a HLA class I molecule that is generated at a constant rate and is eliminated by the kidneys. Serum B2M can be elevated in acute rejection for two reasons: decrease in renal function or T cell proliferation. Currently, we depend on renal biopsy to evaluate the cause of renal injury in a transplant recipient. The purpose of this study is to evaluate the relationship of B2MG and acute rejection (AR). We analyzed B2M levels for 2 weeks post transplant in 334 patients who underwent a kidney transplantation at our hospital. Patients in the highest quartile of B2M (> 5.3 mg/ml) were more likely to have AR (11.5%) than patients in the lowest quartile (<2.4mg/ml) of B2M levels (0%) (p=0.01). This relationship remained significant after adjustment for age, race, gender, donor type, induction therapy and delayed graft function (odds ratio 1.12, 0.9% confidence interval: 1.04, 1.23, p=0.009). B2M levels remained higher among patients with AR for the first 7 days. Early post transplant B2M levels are higher in patients who develop acute rejection. B2M may provide early detection of AR.
326 INCREASED SERUM OSMOLALITY GAP IN PESTICIDE INGESTION: CASE REPORT Payam Shakouri, George Coritsidis, Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, NY. 43 year old Caucasian male with Diabetes type 1 presented to the intensive care unit after being found unresponsive at home. He presented tachypneic, hypotensive and tachycardic and was placed on norepinephrine and vasopressin. Laboratory results demonstrated: serum sodium 122 mEq/L, potassium 8.8 mEq/L, chloride 80 mmol/L, HCO3 3 mEq/L, BUN 36 mg/dL, creatinine 3.8 mmol/L, glucose 1625 mg/dL, large acetone and lactate 2.9 mEq/L. Venous blood gas showed PH of 6.55, PCO2 50 mm Hg. Serum osmolality by freezing point technique was 372 mOsm/kg of H2O, and the calculated osmolal gap was 87 mOsm/kg of H2O. Repeat osmole exam indicated a gap of 74 mOsm/kg three hours later. Ethanol, salicylates, methanol, ethylene glycol, diethylene glycol, propylene glycol, and isopropanol were negative. The patient was treated with intravenous insulin, fluids, bicarbonate and Fomepizole. The patient’s acid-base status improved within 12 hours. On day 8 the patient admitted ingesting a brand name pesticide for recreational use by spraying the content into his mouth while deeply inhaling 6-7 times daily for 7 days. The pesticide contains imiprothrin and cypermethrin as the sole active ingredients. Other ingredients include: isobutene 5 %, propane 5 %, isopropanol 1 %, water and fragrances. Except for isopropanol, none of the mentioned ingredients have ever been implicated in any cases of increased serum osmolality. There have been no reports of metabolic or serum osmolality disturbances concerning imiprothrin or cypermethrin except for neurotoxicity and peripheral neuropathy. In conclusion, the increased osmolar gap is likely from the other compounds present in higher concentrations and not imiprothrin or cypermethrin. We believe this is the first case of pesticide induced hyper osmolarity.
A100
327 PREDOMINANT TUBULOINTERSTITIAL INVOLVEMENT IN A PATIENT WITH LUPUS NEPHRITIS Nisha Shankar, Niranjan Sankaranarayanan, University of Connecticut School Of Medicine, Farmington CT and Greater Hartford Nephrology Bloomfield, CT, USA Interstitial involvement in lupus nephritis is common and is seen in approximately two-thirds of cases. However, predominant tubulointerstitial (TIN) involvement in lupus nephritis with relative sparing of the glomeruli is a rare finding with only a handful of cases reported in literature. A 66 y/o African-American woman presented with worsening anemia, pancytopenia and 50 lb. weight loss. Her past medical history was significant for hypertension, osteoarthritis and paroxysmal supraventricular tachycardia. On physical examination BP 110/70, she had conjunctival pallor but an otherwise unremarkable exam. She was noted to have worsening anemia with a decrease in her hemoglobin levels from 9.3 to 7.3 g/dL and an increase in baseline creatinine from 1.0 to 1.4 over a three-month period. A dipstick showed 3+ protein and large blood. Urine microscopy revealed cellular casts and microcytic RBCs. ANCA, hepatitis panel, cryoglobulin level were negative. She had hypocomplementemia and a strongly positive ANA with titers of 1:1280. Renal biopsy was performed which showed immune complex deposition predominantly in the tubular basement membranes with minimal glomerular involvement. She was started on oral prednisone with good response and significant improvement in her renal function. Predominant TIN in lupus nephritis is rare and very few cases have been reported prior in the worldwide literature. Interstitial nephritis probably represents one end of the spectrum of renal involvement due to SLE. The immunopathogenesis is as yet obscure but is likely from autoantibody formation against antigens specifically present in the tubules and interstitium. Most cases report benign clinical course as our patient with good response to oral steroids. There is little data regarding disease relapses while on maintenance steroids in patients with predominant TIN as compared to classic lupus nephritis with glomerular involvement. Whether this disease definitely follows a benign course without a need for cytotoxic agents remains inconclusive and requires further studies with long term follow up.
328 PATIENTS’ PERSPECTIVES ON MEDICINE-TAKING IN DIALYSIS: SYSTEMATIC REVIEW AND THEMATIC SYNTHESIS OF QUALITATIVE STUDIES Jenny I. Shen1, Wolfgang C. Winkelmayer1, Allison Tong2,3. 1Stanford University School of Medicine, Palo Alto, CA, USA 2Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia 3Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, NSW, Australia On average, patients on dialysis are prescribed to take more than 10 different medications a day. However, most do not take them as prescribed. We aimed to describe the perspectives and attitudes of patients on dialysis towards medicine-taking. We conducted a comprehensive literature search in Medline, Embase, PsycINFO, and CINAHL to May 2013. Thematic synthesis was used to analyze the findings. We identified and included 36 studies involving 879 patients. Six themes were identified: 1) control (demonstrating self-advocacy, selfefficacy and self-management, justifying the need for medications; preserving autonomy; responding to symptoms; seeking traditional remedies); 2) life intrusion (overwhelming regimen, disruption to daily life, making sacrifices, physical discomfort); 3) doubt and suspicion (wary of professional conflict of interest, uncertain about medication efficacy, intangible benefits); 4) navigating logistical barriers (confusion due to language barriers, financial burdens, limited physical access to medications, complicated insurance systems); 5) shared responsibility (avoiding blame, depending on family support, valuing healthcare provider attentiveness and practical care); and 6) sick identity (unrelenting reminder of illness, seeking medical attention). Patients on dialysis self-regulate their medications based on their need for control, to demonstrate self-efficacy, perceived benefits, and trust in their healthcare providers’ advice. Barriers to adherence include doubts about the effectiveness of medications, complicated healthcare systems, and financial difficulties. Facilitating access to medications, education about medication efficacy, and applying principles of shared decision-making that address patients’ need for control and to maintain quality of life may promote medication adherence and improve treatment outcomes for patients on dialysis.
Am J Kidney Dis. 2014;63(5):A1-A121
325 BETA-2 MICROGLOBULIN (B2M) PREDICTS ACUTE REJECTION IN THE EARLY POST TRANSPLANTATION PERIOD Sumaira Shaikh MD, Brad C. Astor PhD, Arjang Djamali, MD, University of Wisconsin Hospital and Clinics, Madison, WI, USA B2M is a HLA class I molecule that is generated at a constant rate and is eliminated by the kidneys. Serum B2M can be elevated in acute rejection for two reasons: decrease in renal function or T cell proliferation. Currently, we depend on renal biopsy to evaluate the cause of renal injury in a transplant recipient. The purpose of this study is to evaluate the relationship of B2MG and acute rejection (AR). We analyzed B2M levels for 2 weeks post transplant in 334 patients who underwent a kidney transplantation at our hospital. Patients in the highest quartile of B2M (> 5.3 mg/ml) were more likely to have AR (11.5%) than patients in the lowest quartile (<2.4mg/ml) of B2M levels (0%) (p=0.01). This relationship remained significant after adjustment for age, race, gender, donor type, induction therapy and delayed graft function (odds ratio 1.12, 0.9% confidence interval: 1.04, 1.23, p=0.009). B2M levels remained higher among patients with AR for the first 7 days. Early post transplant B2M levels are higher in patients who develop acute rejection. B2M may provide early detection of AR.
326 INCREASED SERUM OSMOLALITY GAP IN PESTICIDE INGESTION: CASE REPORT Payam Shakouri, George Coritsidis, Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, NY. 43 year old Caucasian male with Diabetes type 1 presented to the intensive care unit after being found unresponsive at home. He presented tachypneic, hypotensive and tachycardic and was placed on norepinephrine and vasopressin. Laboratory results demonstrated: serum sodium 122 mEq/L, potassium 8.8 mEq/L, chloride 80 mmol/L, HCO3 3 mEq/L, BUN 36 mg/dL, creatinine 3.8 mmol/L, glucose 1625 mg/dL, large acetone and lactate 2.9 mEq/L. Venous blood gas showed PH of 6.55, PCO2 50 mm Hg. Serum osmolality by freezing point technique was 372 mOsm/kg of H2O, and the calculated osmolal gap was 87 mOsm/kg of H2O. Repeat osmole exam indicated a gap of 74 mOsm/kg three hours later. Ethanol, salicylates, methanol, ethylene glycol, diethylene glycol, propylene glycol, and isopropanol were negative. The patient was treated with intravenous insulin, fluids, bicarbonate and Fomepizole. The patient’s acid-base status improved within 12 hours. On day 8 the patient admitted ingesting a brand name pesticide for recreational use by spraying the content into his mouth while deeply inhaling 6-7 times daily for 7 days. The pesticide contains imiprothrin and cypermethrin as the sole active ingredients. Other ingredients include: isobutene 5 %, propane 5 %, isopropanol 1 %, water and fragrances. Except for isopropanol, none of the mentioned ingredients have ever been implicated in any cases of increased serum osmolality. There have been no reports of metabolic or serum osmolality disturbances concerning imiprothrin or cypermethrin except for neurotoxicity and peripheral neuropathy. In conclusion, the increased osmolar gap is likely from the other compounds present in higher concentrations and not imiprothrin or cypermethrin. We believe this is the first case of pesticide induced hyper osmolarity.
A100
327 PREDOMINANT TUBULOINTERSTITIAL INVOLVEMENT IN A PATIENT WITH LUPUS NEPHRITIS Nisha Shankar, Niranjan Sankaranarayanan, University of Connecticut School Of Medicine, Farmington CT and Greater Hartford Nephrology Bloomfield, CT, USA Interstitial involvement in lupus nephritis is common and is seen in approximately two-thirds of cases. However, predominant tubulointerstitial (TIN) involvement in lupus nephritis with relative sparing of the glomeruli is a rare finding with only a handful of cases reported in literature. A 66 y/o African-American woman presented with worsening anemia, pancytopenia and 50 lb. weight loss. Her past medical history was significant for hypertension, osteoarthritis and paroxysmal supraventricular tachycardia. On physical examination BP 110/70, she had conjunctival pallor but an otherwise unremarkable exam. She was noted to have worsening anemia with a decrease in her hemoglobin levels from 9.3 to 7.3 g/dL and an increase in baseline creatinine from 1.0 to 1.4 over a three-month period. A dipstick showed 3+ protein and large blood. Urine microscopy revealed cellular casts and microcytic RBCs. ANCA, hepatitis panel, cryoglobulin level were negative. She had hypocomplementemia and a strongly positive ANA with titers of 1:1280. Renal biopsy was performed which showed immune complex deposition predominantly in the tubular basement membranes with minimal glomerular involvement. She was started on oral prednisone with good response and significant improvement in her renal function. Predominant TIN in lupus nephritis is rare and very few cases have been reported prior in the worldwide literature. Interstitial nephritis probably represents one end of the spectrum of renal involvement due to SLE. The immunopathogenesis is as yet obscure but is likely from autoantibody formation against antigens specifically present in the tubules and interstitium. Most cases report benign clinical course as our patient with good response to oral steroids. There is little data regarding disease relapses while on maintenance steroids in patients with predominant TIN as compared to classic lupus nephritis with glomerular involvement. Whether this disease definitely follows a benign course without a need for cytotoxic agents remains inconclusive and requires further studies with long term follow up.
328 PATIENTS’ PERSPECTIVES ON MEDICINE-TAKING IN DIALYSIS: SYSTEMATIC REVIEW AND THEMATIC SYNTHESIS OF QUALITATIVE STUDIES Jenny I. Shen1, Wolfgang C. Winkelmayer1, Allison Tong2,3. 1Stanford University School of Medicine, Palo Alto, CA, USA 2Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia 3Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, NSW, Australia On average, patients on dialysis are prescribed to take more than 10 different medications a day. However, most do not take them as prescribed. We aimed to describe the perspectives and attitudes of patients on dialysis towards medicine-taking. We conducted a comprehensive literature search in Medline, Embase, PsycINFO, and CINAHL to May 2013. Thematic synthesis was used to analyze the findings. We identified and included 36 studies involving 879 patients. Six themes were identified: 1) control (demonstrating self-advocacy, selfefficacy and self-management, justifying the need for medications; preserving autonomy; responding to symptoms; seeking traditional remedies); 2) life intrusion (overwhelming regimen, disruption to daily life, making sacrifices, physical discomfort); 3) doubt and suspicion (wary of professional conflict of interest, uncertain about medication efficacy, intangible benefits); 4) navigating logistical barriers (confusion due to language barriers, financial burdens, limited physical access to medications, complicated insurance systems); 5) shared responsibility (avoiding blame, depending on family support, valuing healthcare provider attentiveness and practical care); and 6) sick identity (unrelenting reminder of illness, seeking medical attention). Patients on dialysis self-regulate their medications based on their need for control, to demonstrate self-efficacy, perceived benefits, and trust in their healthcare providers’ advice. Barriers to adherence include doubts about the effectiveness of medications, complicated healthcare systems, and financial difficulties. Facilitating access to medications, education about medication efficacy, and applying principles of shared decision-making that address patients’ need for control and to maintain quality of life may promote medication adherence and improve treatment outcomes for patients on dialysis.
Am J Kidney Dis. 2014;63(5):A1-A121