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Relapsing Acute Kidney Injury Associated With Pegfilgrastim
NKF 2012 Spring Clinical Meetings Abstracts
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19 NEW ONSET HYPERTENSION FOLLOWING ABRUPT DISCONTINUATION OF CITALOPRAM Walter Astorne, Sandra Herrmann, Qi Qian Mayo Clinic, Rochester, MN Abrupt cessation of selective serotonin (5-HT) re-uptake inhibitors (SSRIs) has been associated with dizziness, nausea, myalgias, anxiety and irritability. It is unclear whether blood pressure (BP) can be perturbed in the setting of abrupt SSRI withdrawal. A 48-year-old woman on chronic citalopram (40mg daily) therapy for depression was referred to Nephrology for new-onset hypertension. Her BP was 172-180/103-110mmHg on an ambulatory BP recording. On presentation, she appeared restless and irritable. Her BMI was 34. On further questioning, she revealed self-discontinued citalopram two weeks prior for non-medical reasons. She subsequently developed headache, but denied NSAID, tobacco, alcohol, or illegal drug use. Her examination was benign. Her serum creatinine and urinalysis were normal, and urine drug screen negative. She was advised to resume citalopram and to try lifestyle modification including weight reduction and dietary salt restriction. At two-month follow-up, her BP was normalized (110-120/64-70 mmHg), without any weight change or adhering to a low salt diet. Citalopram is one of the SSRIs commonly prescribed for depression and affective disorders. It blocks serotonin re-uptake, resulting in its therapeutic effects. Studies have shown that norepinephrine (NE) neurons from the locus coeruleus reciprocally interact with the 5-HT neurons in the brainstem. In rats, chronic administration of SSRI inhibits the activity of NE neurons, and abrupt removal of such inhibition could cause NE neuron hyperactivation. Abrupt cessation of SSRI may therefore trigger adrenergic hyperactivation and hypertension. In this patient, the temporal association of SSRI cessation and the occurrence of hypertension, as well as the complete BP normalization with the re-institution of citalopram and without needing antihypertensive medication strongly suggest that the abrupt SSRI withdrawal was the trigger for BP elevation. As illustrated in this case, the degree of hypertension in such setting could be severe. Abrupt cessation of SSRI should be considered in the differential diagnosis of new onset hypertension.
ASSESSMENT OF COST EFFECTIVENESS OF AQUAPHERESIS IN CHF PATIENTS Hasan Arif, Walter Shakespeare, Irfan Ahmed, Nauman Shahid, Ziauddin Ahmed Drexel University College of Medicine In patients with CHF, the standard treatment for fluid overload has classically been IV diuretics. Diuretic use is associated with many potential problems i.e.; prolonged hospitalization, diuretic resistance in CKD patients, uncontrolled overdiuresis resulting in hypotension, worsening renal function, and development of metabolic alkalosis and hypokalemia. Patients with CHF who already have significantly decreased kidney function and diuretic resistance can be successfully treated with ulttrafiltation (UF). Recently a smaller UF machine called AquaDex has been tried by cardiologists for treatment of CHF. This machine is designed for continuous UF and is considered an expensive alternative of usual intermittent HD machine for stable patients. We have decided to do a cost analysis of the UF treatment between aquapheresis and HD machine. We have reviewed the charts of 12 patients who had received UF by Aquapheresis machine .The mean BP of patients was 131± 29.8 /77±22mm/hg. The average filtration volume was 4.2 L/day. The life of filter was 38.75 hours. The cost of disposable supplies with Aquapheresis is $900 per treatment. The cost of disposable supplies by regular HD machine is $15 per treatment. Total cost of Aquapheresis in these patients was $28,800 and predicted UF with HD machines would have been $480 for the same number of supplies. The UF therapy for treatment of CHF is better than diuretics in diuretics resistance patients or with CKD. The new Aquapheresis machine is not only very costly but also has no capacity to provide dialysis when needed in case of hyperkalemia, metabolic acidosis and in worsening renal functions which are commonly associated with progression of CHF. Use of isolated UF in CKD patients with Aquapheresis is not cost effective.
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20 RELAPSING ACUTE KIDNEY INJURY ASSOCIATED WITH PEGFILGRASTIM Swati Arora, Arpit Bhargava, Barbara Clark, Allegheny General Hospital, Pittsburgh, PA We report a previously unrecognized complication of severe acute kidney injury (AKI) after the administration of Pegfilgrastim with biopsy findings of mesangio-proliferative glomerulonephritis (GN). A 51 year old white female with a history of breast cancer presented to the hospital with AKI with serum creatinine (Cr) of 6.9 mg/dl (baseline Cr 1.1mg/dl). Two weeks earlier, she had central line associated bacteremia, treated successfully with daptomycin and port removal. One week before that, she had received chemotherapy with Cyclophosphamide and Docetaxel along with Pegfilgrastim. Her AKI was initially thought to be secondary to sepsis and/or daptomycin. Patient was subsequently hemodialyzed for six weeks following which her kidney function recovered to near baseline but her urine analysis showed 3.5gm protein/day and dysmorphic hematuria. Repeat blood cultures and serological work up (complement levels, hepatitis panel, ANA, ANCA and anti-GBM) were negative. She received her next cycle of chemotherapy with the same drugs. Two weeks later, she developed recurrent AKI with a Cr of 6.7 mg/dl. A native kidney biopsy was consistent with mesangio-proliferative GN, tubular epithelial damage and rare immune complex. Pegfilgrastim was suspected as the inciting agent after exclusion of other causes. Her Cr improved to 1.4 mg/dl over the next 3 weeks, this time without dialysis. Patient had the next two cycles of chemotherapy without Pegfilgrastim, with no further episodes of AKI. Literature review revealed a few cases of possible association of filgrastim to a self-limited acute GN but none of those patients required dialysis. In conclusion, pegfilgrastim may cause GN with severe AKI requiring dialysis. Milder cases may be missed and therefore routine monitoring of renal function and urine analysis is important.
Am J Kidney Dis. 2012;59(4):A1-A92
RACIAL DIFFERENCES IN CHRONIC KIDNEY DISEASE (CKD) IN MEDICARE BENEFICIARIES, Robert Bailey1, Amanda Forys2, Lianna Weissblum2, Huai-Chi Shih2, Rachel Feldman2, 1Janssen Services, LLC, Horsham, PA, 2The Moran Company, Arlington, VA Previous studies have described a higher prevalence of CKD in minority populations. This retrospective, observational study describes demographics and comorbidities by race in Medicare Beneficiaries (MB) with CKD. ICD-9 Codes were used to identify CKD and comorbidities in the Medicare 5% Standard Analytic Files (2006-2009). MBs with CKD were stratified by race (White, Black, Other). Demographics and comorbidities were then compared between racial groups. Significant differences (p<0.001) in demographics and comorbidities were observed (presented below) for the 78,586 MBs with CKD. N=78,586 White Black Other (65,376) (9,198) (4,012) Mean age, years 76 71 74 Female, %
50
55
51
Urban , %
75
82
87
State Medicare Premium Support,% Anemia (%)
15
40
62
55
46
50
Diabetes (%)
44
56
58
Hypertension (%)
36
45
43
These observed racial differences in demographics and comorbidities may help inform health care policy-makers to address healthcare disparities, a core element of health care reform.
A19
17
19 NEW ONSET HYPERTENSION FOLLOWING ABRUPT DISCONTINUATION OF CITALOPRAM Walter Astorne, Sandra Herrmann, Qi Qian Mayo Clinic, Rochester, MN Abrupt cessation of selective serotonin (5-HT) re-uptake inhibitors (SSRIs) has been associated with dizziness, nausea, myalgias, anxiety and irritability. It is unclear whether blood pressure (BP) can be perturbed in the setting of abrupt SSRI withdrawal. A 48-year-old woman on chronic citalopram (40mg daily) therapy for depression was referred to Nephrology for new-onset hypertension. Her BP was 172-180/103-110mmHg on an ambulatory BP recording. On presentation, she appeared restless and irritable. Her BMI was 34. On further questioning, she revealed self-discontinued citalopram two weeks prior for non-medical reasons. She subsequently developed headache, but denied NSAID, tobacco, alcohol, or illegal drug use. Her examination was benign. Her serum creatinine and urinalysis were normal, and urine drug screen negative. She was advised to resume citalopram and to try lifestyle modification including weight reduction and dietary salt restriction. At two-month follow-up, her BP was normalized (110-120/64-70 mmHg), without any weight change or adhering to a low salt diet. Citalopram is one of the SSRIs commonly prescribed for depression and affective disorders. It blocks serotonin re-uptake, resulting in its therapeutic effects. Studies have shown that norepinephrine (NE) neurons from the locus coeruleus reciprocally interact with the 5-HT neurons in the brainstem. In rats, chronic administration of SSRI inhibits the activity of NE neurons, and abrupt removal of such inhibition could cause NE neuron hyperactivation. Abrupt cessation of SSRI may therefore trigger adrenergic hyperactivation and hypertension. In this patient, the temporal association of SSRI cessation and the occurrence of hypertension, as well as the complete BP normalization with the re-institution of citalopram and without needing antihypertensive medication strongly suggest that the abrupt SSRI withdrawal was the trigger for BP elevation. As illustrated in this case, the degree of hypertension in such setting could be severe. Abrupt cessation of SSRI should be considered in the differential diagnosis of new onset hypertension.
ASSESSMENT OF COST EFFECTIVENESS OF AQUAPHERESIS IN CHF PATIENTS Hasan Arif, Walter Shakespeare, Irfan Ahmed, Nauman Shahid, Ziauddin Ahmed Drexel University College of Medicine In patients with CHF, the standard treatment for fluid overload has classically been IV diuretics. Diuretic use is associated with many potential problems i.e.; prolonged hospitalization, diuretic resistance in CKD patients, uncontrolled overdiuresis resulting in hypotension, worsening renal function, and development of metabolic alkalosis and hypokalemia. Patients with CHF who already have significantly decreased kidney function and diuretic resistance can be successfully treated with ulttrafiltation (UF). Recently a smaller UF machine called AquaDex has been tried by cardiologists for treatment of CHF. This machine is designed for continuous UF and is considered an expensive alternative of usual intermittent HD machine for stable patients. We have decided to do a cost analysis of the UF treatment between aquapheresis and HD machine. We have reviewed the charts of 12 patients who had received UF by Aquapheresis machine .The mean BP of patients was 131± 29.8 /77±22mm/hg. The average filtration volume was 4.2 L/day. The life of filter was 38.75 hours. The cost of disposable supplies with Aquapheresis is $900 per treatment. The cost of disposable supplies by regular HD machine is $15 per treatment. Total cost of Aquapheresis in these patients was $28,800 and predicted UF with HD machines would have been $480 for the same number of supplies. The UF therapy for treatment of CHF is better than diuretics in diuretics resistance patients or with CKD. The new Aquapheresis machine is not only very costly but also has no capacity to provide dialysis when needed in case of hyperkalemia, metabolic acidosis and in worsening renal functions which are commonly associated with progression of CHF. Use of isolated UF in CKD patients with Aquapheresis is not cost effective.
18
20 RELAPSING ACUTE KIDNEY INJURY ASSOCIATED WITH PEGFILGRASTIM Swati Arora, Arpit Bhargava, Barbara Clark, Allegheny General Hospital, Pittsburgh, PA We report a previously unrecognized complication of severe acute kidney injury (AKI) after the administration of Pegfilgrastim with biopsy findings of mesangio-proliferative glomerulonephritis (GN). A 51 year old white female with a history of breast cancer presented to the hospital with AKI with serum creatinine (Cr) of 6.9 mg/dl (baseline Cr 1.1mg/dl). Two weeks earlier, she had central line associated bacteremia, treated successfully with daptomycin and port removal. One week before that, she had received chemotherapy with Cyclophosphamide and Docetaxel along with Pegfilgrastim. Her AKI was initially thought to be secondary to sepsis and/or daptomycin. Patient was subsequently hemodialyzed for six weeks following which her kidney function recovered to near baseline but her urine analysis showed 3.5gm protein/day and dysmorphic hematuria. Repeat blood cultures and serological work up (complement levels, hepatitis panel, ANA, ANCA and anti-GBM) were negative. She received her next cycle of chemotherapy with the same drugs. Two weeks later, she developed recurrent AKI with a Cr of 6.7 mg/dl. A native kidney biopsy was consistent with mesangio-proliferative GN, tubular epithelial damage and rare immune complex. Pegfilgrastim was suspected as the inciting agent after exclusion of other causes. Her Cr improved to 1.4 mg/dl over the next 3 weeks, this time without dialysis. Patient had the next two cycles of chemotherapy without Pegfilgrastim, with no further episodes of AKI. Literature review revealed a few cases of possible association of filgrastim to a self-limited acute GN but none of those patients required dialysis. In conclusion, pegfilgrastim may cause GN with severe AKI requiring dialysis. Milder cases may be missed and therefore routine monitoring of renal function and urine analysis is important.
Am J Kidney Dis. 2012;59(4):A1-A92
RACIAL DIFFERENCES IN CHRONIC KIDNEY DISEASE (CKD) IN MEDICARE BENEFICIARIES, Robert Bailey1, Amanda Forys2, Lianna Weissblum2, Huai-Chi Shih2, Rachel Feldman2, 1Janssen Services, LLC, Horsham, PA, 2The Moran Company, Arlington, VA Previous studies have described a higher prevalence of CKD in minority populations. This retrospective, observational study describes demographics and comorbidities by race in Medicare Beneficiaries (MB) with CKD. ICD-9 Codes were used to identify CKD and comorbidities in the Medicare 5% Standard Analytic Files (2006-2009). MBs with CKD were stratified by race (White, Black, Other). Demographics and comorbidities were then compared between racial groups. Significant differences (p<0.001) in demographics and comorbidities were observed (presented below) for the 78,586 MBs with CKD. N=78,586 White Black Other (65,376) (9,198) (4,012) Mean age, years 76 71 74 Female, %
50
55
51
Urban , %
75
82
87
State Medicare Premium Support,% Anemia (%)
15
40
62
55
46
50
Diabetes (%)
44
56
58
Hypertension (%)
36
45
43
These observed racial differences in demographics and comorbidities may help inform health care policy-makers to address healthcare disparities, a core element of health care reform.
A19