- Email: [email protected]
Recurrent Portal-Systemic Encephalopathy Related to Hemodialysis
NKF 2012 Spring Clinical Meetings Abstracts
29
31 EGG CLUB INITIATIVE DID NOT IMPROVE SERUM ALBUMIN LEVELS IN ESRD PATIENTS Shamik Bhadra, Hiral Desai, Linda Feder, Ziauddin Ahmed Low serum albumin level is a strong predictor of mortality and morbidity among hemodialysis patients. The relative importance of nutritional barriers versus inflammation in contributing to hypoalbuminemia is unclear. Interventions are needed to improve serum albumin levels. Some suggest that lack of nutrition knowledge is an important barrier to optimal albumin levels. In March of 2011, a patient care technician at the DCI clinic in Philadelphia encouraged a group of chronic hemodialysis patients to organize themselves in to an “egg club.” Fourteen patients became active participants. Members of the “club” take turns bringing in hardboiled eggs to share with the other members. The eggs, usually one per person, are eaten at the end of the dialysis treatment session. To support this project, the unit dietitian provided educational handouts about the nutritional value of egg protein, and food safety issues related to eggs. Clinic records show that pre-egg club, 23% of all patients in the clinic (census: 120-130) had serum albumin levels below 3.5 g/dL. Among the 14 egg club members, the mean serum albumin level was 3.85. Eight months later, 22.6% of all patients have a serum albumin level below 3.5 g/dL. Among the egg club participants, the mean serum albumin level is 3.83, despite the intervention. The patient-organized egg club did not have any effect on the serum albumin levels of its participants. This is not an unexpected result, in view of the small intervention (only 6 grams of additional protein, 3 times a week), and the many other factors that affect serum albumin, including fluid overload and inflammation. The egg club participants had a baseline mean serum albumin level that was higher than the overall clinic population. It is unknown if the “egg club” would have had a positive effect on patients with lower serum albumin levels or daily egg intake would have any better effect.
DOES OBTAINING URINARY DIAGNOSTIC STUDIES PRIOR TO RENAL CONSULTATION AFFECT OUTCOMES IN ACUTE KIDNEY INJURY PATIENTS Naing Htike, Adeel Siddiqui, Geoffrey Teehan, Robert L Benz, Nephrology, Lankenau Medical Center and LIMR, Wynnewood, PA, USA. Upon renal consultation for Acute Kidney Injury (AKI), diagnostic urinary data such as urine creatinine, urine electrolytes and urinalyses (UA) are often not available or ordered. We compared outcomes among those who did or did not have preconsult urine diagnostic studies (UDS). This was a six month retrospective cohort study of AKI in a community teaching hospital. We defined AKI as creatinine >/= 0.3 mg/dl increased vs. baseline. Those with at least UA performed were group 1, and those without UA were group 2. Fisher’s Exact Test and T-Test were employed. 116 patient charts were reviewed (Grp 1: N = 67; Grp 2: N = 49). The groups did not differ with respect to overall comorbidities (P = NS). There was a higher likelihood of having a full set of UDS in Grp 1 vs. Grp 2 (P = 0.001). Twice as many patients had renal imaging in Grp 1 (28%) vs. Grp 2 (14%) (P = 0.11). At least a doubling of baseline serum creatinine occurred in 41% of the cohort (48% in Grp 1 vs. 33% Grp 2) (P = 0.13). Death and the need for renal replacement therapy (RRT) occurred more in Grp 1 (3% vs. 2%) but did not reach statistical significance (P = 0.5 and 0.39 respectively). Return to baseline creatinine was similar between groups (P = 0.62) While we support obtaining UDS prior to renal consultation, this study of 116 patients could not support the hypothesis that such studies preconsultation resulted in improved outcome vs. obtaining them upon consultation. We are unaware of evidence based studies to the contrary. A larger study is indicated to verify whether preconsult UDS, while empirically making sense, actually alters outcomes.
30
32 CARDIOVASCULAR EVENTS AND RATE OF HEMOGLOBIN CHANGE IN HEMODIALYSIS PATIENTS ON PEGINESATIDE Anatole Besarab1, Wadi Suki1, Bruce Spinowitz1, Anne-Marie Duliege2, Hina Patel2, Dan Cooper2, Helen Tang2, Hong-Ye Gao2, Martha Mayo2, Steven Fishbane1 1 AFX01-12 and -14 Peginesatide Study Groups; 2Affymax, Inc., Palo Alto, CA Rapid hemoglobin (Hb) change after ESA treatment has been associated with cardiovascular (CV) event risk (Unger et al. 2010 NEJM 362:189). Peginesatide, a synthetic, PEGylated, investigational, peptide-based ESA, was shown noninferior to epoetin in maintaining Hb in hemodialysis (HD) pts with anemia due to chronic kidney disease in two Phase 3 randomized, active-controlled, open-label trials (EMERALD 1, 2). This is a retrospective, event-based analysis of the temporal relationship of CV events and rate of Hb change. The two trials compared peginesatide (1x monthly; N=1066) with epoetin (1-3x wkly; N=542) in HD pts previously on stable epoetin. Pooled, adjudicated CV composite safety endpoints (CSE; including stroke, myocardial infarction, death, and SAEs of congestive heart failure, unstable angina, and arrhythmia) were evaluated for association with rate of pre-event Hb change (estimated by linear regression). Event rate (CSEs/pt-year) was calculated as number of CSEs divided by time-at-risk for each category of Hb rate of change. While on study medication, 18% (195/1066) pts on peginesatide had 343 total CSE events,vs 22% (121/542) pts on epoetin with 242 events.
Both arms had higher CSE rates associated with rapid Hb decline. The epoetin arm showed higher CSE rates with rapidly increasing Hb. These results suggest an association of CV events with decreasing Hb levels (<-1 g/dL per 2 wks) for both peginesatide and epoetin; the association with increasing Hb (>1 g/dL per 2 wks) was less clear.
A22
RECURRENT PORTAL-SYSTEMIC ENCEPHALOPATHY RELATED TO HEMODIALYSIS Keer Bhanushali, Ambarish Athavale, George Dunea, Peter Hart John H Stroger Jr. Hospital of Cook County, Chicago, Illinois. Hepac encephalopathy is usually observed in paents with severe hepatocellular dysfuncon or portal-systemic shunts. We describe here a rare case of recurrent hepac encephalopathy in a compensated cirrhoc paent with portal-systemic shunt related to hemodialysis (HD). A 65 year-old man with Child’s A alcoholic cirrhosis developed ESRD secondary to diabec nephropathy. Two weeks aer starng dialysis, he lost consciousness following a session of dialysis. Neurologic examinaon revealed no focal deficits. Serum electrolytes and liver enzymes were normal but serum ammonia level (µmol/L) was markedly elevated to 252 versus baseline 76 (normal range <53). Brain CT scan was negave. Paent improved aer treatment with lactulose. Loss of consciousness recurred oen aer HD and on reviewing the paent’s records, intra-dialysis hypotension frequently preceded encephalopathy. Hyperammonemia during HD was confirmed- pre, mid and post-dialysis levels were 116, 141 and 151 µmol/L respecvely Intra-dialysis hypotension concurrent with high post-dialysis ammonia levels, raised concern for a portal - systemic shunt and abdominal CT angiogram confirmed a large spleno-renal shunt. Portal systemic encephalopathy related to hemodialysis has been rarely reported. The postulated mechanism is that during ultrafiltraon and intra-dialysis hypotension, ammonia-rich portal venous blood flows into the systemic circulaon through a large shunt causing encephalopathy. Treatment opons include extended or nocturnal dialysis, ultrafiltraon profiling, sodium modeling or shunt ligaon. The paent is currently being dialyzed for 4 hrs thrice weekly with ultrafiltraon profiling and had no further episodes of hepac encephalopathy. Portal – systemic shunt should be recognized as an important cause of hepac encephalopathy in paents undergoing hemodialysis.
Am J Kidney Dis. 2012;59(4):A1-A92
29
31 EGG CLUB INITIATIVE DID NOT IMPROVE SERUM ALBUMIN LEVELS IN ESRD PATIENTS Shamik Bhadra, Hiral Desai, Linda Feder, Ziauddin Ahmed Low serum albumin level is a strong predictor of mortality and morbidity among hemodialysis patients. The relative importance of nutritional barriers versus inflammation in contributing to hypoalbuminemia is unclear. Interventions are needed to improve serum albumin levels. Some suggest that lack of nutrition knowledge is an important barrier to optimal albumin levels. In March of 2011, a patient care technician at the DCI clinic in Philadelphia encouraged a group of chronic hemodialysis patients to organize themselves in to an “egg club.” Fourteen patients became active participants. Members of the “club” take turns bringing in hardboiled eggs to share with the other members. The eggs, usually one per person, are eaten at the end of the dialysis treatment session. To support this project, the unit dietitian provided educational handouts about the nutritional value of egg protein, and food safety issues related to eggs. Clinic records show that pre-egg club, 23% of all patients in the clinic (census: 120-130) had serum albumin levels below 3.5 g/dL. Among the 14 egg club members, the mean serum albumin level was 3.85. Eight months later, 22.6% of all patients have a serum albumin level below 3.5 g/dL. Among the egg club participants, the mean serum albumin level is 3.83, despite the intervention. The patient-organized egg club did not have any effect on the serum albumin levels of its participants. This is not an unexpected result, in view of the small intervention (only 6 grams of additional protein, 3 times a week), and the many other factors that affect serum albumin, including fluid overload and inflammation. The egg club participants had a baseline mean serum albumin level that was higher than the overall clinic population. It is unknown if the “egg club” would have had a positive effect on patients with lower serum albumin levels or daily egg intake would have any better effect.
DOES OBTAINING URINARY DIAGNOSTIC STUDIES PRIOR TO RENAL CONSULTATION AFFECT OUTCOMES IN ACUTE KIDNEY INJURY PATIENTS Naing Htike, Adeel Siddiqui, Geoffrey Teehan, Robert L Benz, Nephrology, Lankenau Medical Center and LIMR, Wynnewood, PA, USA. Upon renal consultation for Acute Kidney Injury (AKI), diagnostic urinary data such as urine creatinine, urine electrolytes and urinalyses (UA) are often not available or ordered. We compared outcomes among those who did or did not have preconsult urine diagnostic studies (UDS). This was a six month retrospective cohort study of AKI in a community teaching hospital. We defined AKI as creatinine >/= 0.3 mg/dl increased vs. baseline. Those with at least UA performed were group 1, and those without UA were group 2. Fisher’s Exact Test and T-Test were employed. 116 patient charts were reviewed (Grp 1: N = 67; Grp 2: N = 49). The groups did not differ with respect to overall comorbidities (P = NS). There was a higher likelihood of having a full set of UDS in Grp 1 vs. Grp 2 (P = 0.001). Twice as many patients had renal imaging in Grp 1 (28%) vs. Grp 2 (14%) (P = 0.11). At least a doubling of baseline serum creatinine occurred in 41% of the cohort (48% in Grp 1 vs. 33% Grp 2) (P = 0.13). Death and the need for renal replacement therapy (RRT) occurred more in Grp 1 (3% vs. 2%) but did not reach statistical significance (P = 0.5 and 0.39 respectively). Return to baseline creatinine was similar between groups (P = 0.62) While we support obtaining UDS prior to renal consultation, this study of 116 patients could not support the hypothesis that such studies preconsultation resulted in improved outcome vs. obtaining them upon consultation. We are unaware of evidence based studies to the contrary. A larger study is indicated to verify whether preconsult UDS, while empirically making sense, actually alters outcomes.
30
32 CARDIOVASCULAR EVENTS AND RATE OF HEMOGLOBIN CHANGE IN HEMODIALYSIS PATIENTS ON PEGINESATIDE Anatole Besarab1, Wadi Suki1, Bruce Spinowitz1, Anne-Marie Duliege2, Hina Patel2, Dan Cooper2, Helen Tang2, Hong-Ye Gao2, Martha Mayo2, Steven Fishbane1 1 AFX01-12 and -14 Peginesatide Study Groups; 2Affymax, Inc., Palo Alto, CA Rapid hemoglobin (Hb) change after ESA treatment has been associated with cardiovascular (CV) event risk (Unger et al. 2010 NEJM 362:189). Peginesatide, a synthetic, PEGylated, investigational, peptide-based ESA, was shown noninferior to epoetin in maintaining Hb in hemodialysis (HD) pts with anemia due to chronic kidney disease in two Phase 3 randomized, active-controlled, open-label trials (EMERALD 1, 2). This is a retrospective, event-based analysis of the temporal relationship of CV events and rate of Hb change. The two trials compared peginesatide (1x monthly; N=1066) with epoetin (1-3x wkly; N=542) in HD pts previously on stable epoetin. Pooled, adjudicated CV composite safety endpoints (CSE; including stroke, myocardial infarction, death, and SAEs of congestive heart failure, unstable angina, and arrhythmia) were evaluated for association with rate of pre-event Hb change (estimated by linear regression). Event rate (CSEs/pt-year) was calculated as number of CSEs divided by time-at-risk for each category of Hb rate of change. While on study medication, 18% (195/1066) pts on peginesatide had 343 total CSE events,vs 22% (121/542) pts on epoetin with 242 events.
Both arms had higher CSE rates associated with rapid Hb decline. The epoetin arm showed higher CSE rates with rapidly increasing Hb. These results suggest an association of CV events with decreasing Hb levels (<-1 g/dL per 2 wks) for both peginesatide and epoetin; the association with increasing Hb (>1 g/dL per 2 wks) was less clear.
A22
RECURRENT PORTAL-SYSTEMIC ENCEPHALOPATHY RELATED TO HEMODIALYSIS Keer Bhanushali, Ambarish Athavale, George Dunea, Peter Hart John H Stroger Jr. Hospital of Cook County, Chicago, Illinois. Hepac encephalopathy is usually observed in paents with severe hepatocellular dysfuncon or portal-systemic shunts. We describe here a rare case of recurrent hepac encephalopathy in a compensated cirrhoc paent with portal-systemic shunt related to hemodialysis (HD). A 65 year-old man with Child’s A alcoholic cirrhosis developed ESRD secondary to diabec nephropathy. Two weeks aer starng dialysis, he lost consciousness following a session of dialysis. Neurologic examinaon revealed no focal deficits. Serum electrolytes and liver enzymes were normal but serum ammonia level (µmol/L) was markedly elevated to 252 versus baseline 76 (normal range <53). Brain CT scan was negave. Paent improved aer treatment with lactulose. Loss of consciousness recurred oen aer HD and on reviewing the paent’s records, intra-dialysis hypotension frequently preceded encephalopathy. Hyperammonemia during HD was confirmed- pre, mid and post-dialysis levels were 116, 141 and 151 µmol/L respecvely Intra-dialysis hypotension concurrent with high post-dialysis ammonia levels, raised concern for a portal - systemic shunt and abdominal CT angiogram confirmed a large spleno-renal shunt. Portal systemic encephalopathy related to hemodialysis has been rarely reported. The postulated mechanism is that during ultrafiltraon and intra-dialysis hypotension, ammonia-rich portal venous blood flows into the systemic circulaon through a large shunt causing encephalopathy. Treatment opons include extended or nocturnal dialysis, ultrafiltraon profiling, sodium modeling or shunt ligaon. The paent is currently being dialyzed for 4 hrs thrice weekly with ultrafiltraon profiling and had no further episodes of hepac encephalopathy. Portal – systemic shunt should be recognized as an important cause of hepac encephalopathy in paents undergoing hemodialysis.
Am J Kidney Dis. 2012;59(4):A1-A92