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SEVERE HYPOPHOSPHATEMIA ASSOCIATED WITH SPONTANEOUS TUMOR LYSIS SYNDROME (STLS)
NKF 2015 Spring Clinical Meetings Abstracts
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91 FACILITY-LEVEL CKD-MBD BIOCHEMICAL CONTROL AND RISK OF ADVERSE CLINICAL OUTCOMES AMONG PATIENTS ON HEMODIALYSIS (HD): David Gilbertson1, Yan Hu1, Heidi Wirtz2, A Yusuf1, T Do2, B Bradbury2, K Cooper2, M Danese3, Allan Collins1, Geoff Block4, Chronic Disease Research Group1, Amgen Inc2, Outcomes Insights3, Denver Nephrology4, Minneapolis, MN, Thousand Oaks, CA, Westlake Village, CA, and Denver, CO, USA A recent epidemiologic study found that HD patients with 2+ CKDMBD biomarkers out of or above KDIGO target ranges (PTH: <150/>600 pg/mL; P:<3.5/>5.5 mg/dL; Ca:<8.4/>10.2 mg/dL) were at significantly higher risk of CV hospitalization or death relative to none out of target. We examined whether patients in facilities with higher proportions of patients with 2+ biomarkers out of or above target are at higher risk of these outcomes. We studied 1,298 dialysis facilities with ≥10 adult Medicare enrollees who had been on HD ≥1 year. We assessed the proportion of patients within each facility with 2+ biomarkers out of, and separately, above, target ranges, and grouped facilities into quintiles (lowest as the reference). We used multi-level modeling to examine the risk of CV hospitalization or death, and separately, parathyroidectomy (PTx), over a 1-year follow-up period, adjusting for case-mix differences. The median proportion of patients with 2+ biomarkers out of target was 0.167 (IQR 0.114) and above target was 0.061 (IQR 0.076). Patients receiving care in facilities in the middle and upper quintiles Adjusted RR (95% CI) (highest out of or above target) Out of target Above target were at significantly higher risk of CV hospitalization or death p0-<20 1.00 (referent) 1.00 (referent) PTx and CV hospitalization/ p20-<40 1.04 (0.99-1.10) 1.07 (1.01-1.13) p40-<60 1.04 (0.99-1.10) 1.06 (1.01-1.12) death. The largest increase in risk p60-<80 1.02 (0.97-1.08) 1.07 (1.01-1.14) was for patients receiving care in p80+ 1.07 (1.01-1.13) 1.12 (1.06-1.19) Parathyroidectomy facilities with the highest p0-<20 1.00 (referent) 1.00 (referent) proportion of patients with 2+ p20-<40 1.60 (0.82-3.10) 1.73 (0.74-4.04) p40-<60 2.05 (1.10-3.82) 3.99 (1.88-8.47) biomarkers above target. p60-<80 2.24 (1.22-4.10) 5.04 (2.39-10.64) p80+ 2.73 (1.50-4.98) 4.26 (2.02-8.96) This composite measure offers an integrated approach to identifying event risk at the facility-level. The classification of at least 2 of 3 biomarkers out of or above target ranges is discriminatory and may be a useful measure in assessing facilitylevel quality of care in managing patients with CKD-MBD.
URGENT-START PERITONEAL DIALYSIS VERSUS OTHER MODALITIES OF DIALYSIS: LONG-TERM OUTCOMES Arshia Ghaffari, Neda Hashemi, Hossein Ghofrani, Gbemi Adenuga University of Southern California, Los Angeles, California, USA Several reports have validated the short-term feasibility of urgentstart peritoneal dialysis (USPD), a modality whereby unplanned ESRD patients are started on peritoneal dialysis (PD) utilizing low-volume, recumbent PD soon after PD catheter placement. While results in short-term studies demonstrate similar outcomes for USPD to other modalities of dialysis, longer-term studies are lacking. This is a single-center prospective cohort study comparing hospitalizations, infections, and technique survival in 161 incident ESRD patients [20 planned HD, 17 planned PD, 78 urgent-start HD with central venous catheter (ICHD-CVC), 46 USPD] admitted to our dialysis unit between March 15, 2010 and March 15, 2013. We performed an intention-to-treat analysis. The mean duration of followup was 810± 390 days. As compared to the USPD group, the ICHD-CVC group had a 43% higher adjusted rate of hospitalizations (IRR 1.43; 95% CI 1.105 – 1.849; p=0.0045) and 4.3 fold higher adjusted rate of catheter-related bacteremia (IRR 4.32; CI 1.48 – 12.62; p=0.0074). As compared to the USPD group, the planned PD group had a similar rate of peritonitis (IRR 1.98; 95% CI 0.71 – 5.56; p=0.19), exit-site infections (IRR 0.87; CI 0.24 – 3.15; p=0.83), and hospitalizations (IRR 1.057; CI 0.67 – 1.66; p=0.81). Technique survival was similar between the different groups at 6 months, 1 year and 2 years respectively (USPD 98% ± 15, 95 ± 23, 78 ± 42; ICHD-CVC 90 ± 31, 86 ± 35, 76 ± 43; planned PD 100 ± 0, 100 ± 0, 91 ± 30; planned HD 95 ± 22; 95 ± 23, 93 ± 44). In this intention-to-treat analysis we have demonstrated that USPD, as part of a structured program, provides superior hospitalization and infectious outcomes as compared to urgent ICHD-CVC population for up to two years after dialysis initiation. Furthermore, when compared to planned dialysis modalities (HD and PD), USPD has similar infectious, hospitalization and technique survival outcomes. These findings suggest USPD should be the preferred modality offered to appropriate PD candidates who present unplanned requiring urgent dialysis.
90 SEVERE HYPOPHOSPHATEMIA ASSOCIATED WITH SPONTANEOUS TUMOR LYSIS SYNDROME (sTLS): Kamel Gharaibeh, Ziad El-Zoghby. Mayo Clinic, Rochester, Minnesota, USA Tumor lysis syndrome (TLS) can occur spontaneously (sTLS) or in response to chemotherapy. Laboratories typically show at least 2 of the following: hyperuricemia, hyperkalemia, hyperphosphatemia, or hypocalcemia. Hyperphosphatemia is not always present in sTLS because of the cellular uptake by the tumor and although rare hypophosphatemia can occur. We report a case of recurrent severe hypophosphatemia associated with sTLS. A 41-year old man presents with AKI in the setting of relapsing Tcell ALL 69 days after allogenic stem cell transplant. The laboratories were consistent with sTLS: WBC 53,000 with 60% blasts, serum creatinine 2.2 mg/dL (baseline 1.0), uric acid 10 mg/dL (baseline 3.3), LDH 1404 U/L, potassium 4.6 mEq/L and calcium 8.8 mg/dL. Serum phosphorus (P) was less than 0.3 mg/dL but surprisingly the patient was asymptomatic. Urine P was less than 2 mg/dl and urine P/creatinine ratio <0.06. Serum PTH was 39 pg/ml. Patient was started on hydroxyurea, intravenous fluid, rasburicase and phosphorus replacement (IV and oral). A few days later, his serum creatinine and P normalized and WBC decreased to 0.4. A review of his record showed that at the initial diagnosis with ALL 6 months earlier, he presented with classical sTLS except for low serum P of 0.3 mg/dL. This is an unusual case of severe hypophosphatemia associated with sTLS. Urinary waste of phosphorus was excluded by the low urinary phosphorous and there was no diarrhea to suggest a bowel loss. Spurious hypophosphatemia was excluded by serial phosphorus measurements using the Cobas and Vitros methods. Further, the development of hypophosphatemia associated with the previous sTLS episode supports the diagnosis of cellular shifting. Rapidly growing neoplasms with high cell turnover rates causes the electrolyte abnormalities including hyperuricemia but in sTLS the tumoral cells are able to reutilize the released phosphorus for synthesis of new cells leading in extreme cases to hypophosphatemia. Although, a 25% increase of serum phosphorus from baseline is one of the criteria of TLS, it may be appropriate to add also hypophosphatemia among the criteria to define spontaneous TLS.
Am J Kidney Dis. 2015;65(4):A1-A93
92 ASSOCIATION BETWEEN MARKERS OF INFLAMMATION AND RAPID EGFR DECLINE IN PATIENTS WITH RHEUMATOID ARTHRITIS Mayurkumar Gohel, Androniki Bili, Alexander Chang, Geisinger Medical Center, Danville, PA, USA Inflammation is thought to play a key role in chronic kidney disease. We examined the association between markers of inflammation and rapid estimated glomerular filtration rate (eGFR) decline in a cohort of 1043 patients with rheumatoid arthritis and at least 3 serum creatinine measurements. Mean age in this cohort was 54.8 yrs, 69.9% were female, 8.4% had eGFR < 60 ml/min/1.73m2 at baseline, and 46.4% had positive anti-citrullinated protein (CCP) antibody. Median values of ESR, CRP, and rheumatoid factor were 23 mm/hr, 4.6 mg/L, and 14 units. Rapid eGFR decline was defined as the highest quartile of eGFR decline (>=2.73 ml/min/1.73m2/yr). After adjustment for age, gender, race, blood pressure, and glucose, every 10 mm/hr increase in erythrocyte sedimentation rate (ESR) was associated with an odds ratio (OR) of 1.07 (95% CI: 1.00-1.14, p=0.045) for rapid eGFR decline. Presence of anti-CCP antibody was associated with increased risk of rapid eGFR decline (OR 1.54, 95% CI: 1.02-2.33, p=0.04). Higher systolic blood pressure and higher blood glucose were both significantly associated with increased risk of rapid eGFR decline (p<0.05). Neither baseline CRP (p=0.6) or rheumatoid factor (p=0.3) were associated with rapid eGFR decline. Elevated ESR and anti-CCP antibodies are associated with rapid eGFR decline in patients with rheumatoid arthritis. Future studies should examine whether reducing inflammation can decrease risk of CKD progression.
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91 FACILITY-LEVEL CKD-MBD BIOCHEMICAL CONTROL AND RISK OF ADVERSE CLINICAL OUTCOMES AMONG PATIENTS ON HEMODIALYSIS (HD): David Gilbertson1, Yan Hu1, Heidi Wirtz2, A Yusuf1, T Do2, B Bradbury2, K Cooper2, M Danese3, Allan Collins1, Geoff Block4, Chronic Disease Research Group1, Amgen Inc2, Outcomes Insights3, Denver Nephrology4, Minneapolis, MN, Thousand Oaks, CA, Westlake Village, CA, and Denver, CO, USA A recent epidemiologic study found that HD patients with 2+ CKDMBD biomarkers out of or above KDIGO target ranges (PTH: <150/>600 pg/mL; P:<3.5/>5.5 mg/dL; Ca:<8.4/>10.2 mg/dL) were at significantly higher risk of CV hospitalization or death relative to none out of target. We examined whether patients in facilities with higher proportions of patients with 2+ biomarkers out of or above target are at higher risk of these outcomes. We studied 1,298 dialysis facilities with ≥10 adult Medicare enrollees who had been on HD ≥1 year. We assessed the proportion of patients within each facility with 2+ biomarkers out of, and separately, above, target ranges, and grouped facilities into quintiles (lowest as the reference). We used multi-level modeling to examine the risk of CV hospitalization or death, and separately, parathyroidectomy (PTx), over a 1-year follow-up period, adjusting for case-mix differences. The median proportion of patients with 2+ biomarkers out of target was 0.167 (IQR 0.114) and above target was 0.061 (IQR 0.076). Patients receiving care in facilities in the middle and upper quintiles Adjusted RR (95% CI) (highest out of or above target) Out of target Above target were at significantly higher risk of CV hospitalization or death p0-<20 1.00 (referent) 1.00 (referent) PTx and CV hospitalization/ p20-<40 1.04 (0.99-1.10) 1.07 (1.01-1.13) p40-<60 1.04 (0.99-1.10) 1.06 (1.01-1.12) death. The largest increase in risk p60-<80 1.02 (0.97-1.08) 1.07 (1.01-1.14) was for patients receiving care in p80+ 1.07 (1.01-1.13) 1.12 (1.06-1.19) Parathyroidectomy facilities with the highest p0-<20 1.00 (referent) 1.00 (referent) proportion of patients with 2+ p20-<40 1.60 (0.82-3.10) 1.73 (0.74-4.04) p40-<60 2.05 (1.10-3.82) 3.99 (1.88-8.47) biomarkers above target. p60-<80 2.24 (1.22-4.10) 5.04 (2.39-10.64) p80+ 2.73 (1.50-4.98) 4.26 (2.02-8.96) This composite measure offers an integrated approach to identifying event risk at the facility-level. The classification of at least 2 of 3 biomarkers out of or above target ranges is discriminatory and may be a useful measure in assessing facilitylevel quality of care in managing patients with CKD-MBD.
URGENT-START PERITONEAL DIALYSIS VERSUS OTHER MODALITIES OF DIALYSIS: LONG-TERM OUTCOMES Arshia Ghaffari, Neda Hashemi, Hossein Ghofrani, Gbemi Adenuga University of Southern California, Los Angeles, California, USA Several reports have validated the short-term feasibility of urgentstart peritoneal dialysis (USPD), a modality whereby unplanned ESRD patients are started on peritoneal dialysis (PD) utilizing low-volume, recumbent PD soon after PD catheter placement. While results in short-term studies demonstrate similar outcomes for USPD to other modalities of dialysis, longer-term studies are lacking. This is a single-center prospective cohort study comparing hospitalizations, infections, and technique survival in 161 incident ESRD patients [20 planned HD, 17 planned PD, 78 urgent-start HD with central venous catheter (ICHD-CVC), 46 USPD] admitted to our dialysis unit between March 15, 2010 and March 15, 2013. We performed an intention-to-treat analysis. The mean duration of followup was 810± 390 days. As compared to the USPD group, the ICHD-CVC group had a 43% higher adjusted rate of hospitalizations (IRR 1.43; 95% CI 1.105 – 1.849; p=0.0045) and 4.3 fold higher adjusted rate of catheter-related bacteremia (IRR 4.32; CI 1.48 – 12.62; p=0.0074). As compared to the USPD group, the planned PD group had a similar rate of peritonitis (IRR 1.98; 95% CI 0.71 – 5.56; p=0.19), exit-site infections (IRR 0.87; CI 0.24 – 3.15; p=0.83), and hospitalizations (IRR 1.057; CI 0.67 – 1.66; p=0.81). Technique survival was similar between the different groups at 6 months, 1 year and 2 years respectively (USPD 98% ± 15, 95 ± 23, 78 ± 42; ICHD-CVC 90 ± 31, 86 ± 35, 76 ± 43; planned PD 100 ± 0, 100 ± 0, 91 ± 30; planned HD 95 ± 22; 95 ± 23, 93 ± 44). In this intention-to-treat analysis we have demonstrated that USPD, as part of a structured program, provides superior hospitalization and infectious outcomes as compared to urgent ICHD-CVC population for up to two years after dialysis initiation. Furthermore, when compared to planned dialysis modalities (HD and PD), USPD has similar infectious, hospitalization and technique survival outcomes. These findings suggest USPD should be the preferred modality offered to appropriate PD candidates who present unplanned requiring urgent dialysis.
90 SEVERE HYPOPHOSPHATEMIA ASSOCIATED WITH SPONTANEOUS TUMOR LYSIS SYNDROME (sTLS): Kamel Gharaibeh, Ziad El-Zoghby. Mayo Clinic, Rochester, Minnesota, USA Tumor lysis syndrome (TLS) can occur spontaneously (sTLS) or in response to chemotherapy. Laboratories typically show at least 2 of the following: hyperuricemia, hyperkalemia, hyperphosphatemia, or hypocalcemia. Hyperphosphatemia is not always present in sTLS because of the cellular uptake by the tumor and although rare hypophosphatemia can occur. We report a case of recurrent severe hypophosphatemia associated with sTLS. A 41-year old man presents with AKI in the setting of relapsing Tcell ALL 69 days after allogenic stem cell transplant. The laboratories were consistent with sTLS: WBC 53,000 with 60% blasts, serum creatinine 2.2 mg/dL (baseline 1.0), uric acid 10 mg/dL (baseline 3.3), LDH 1404 U/L, potassium 4.6 mEq/L and calcium 8.8 mg/dL. Serum phosphorus (P) was less than 0.3 mg/dL but surprisingly the patient was asymptomatic. Urine P was less than 2 mg/dl and urine P/creatinine ratio <0.06. Serum PTH was 39 pg/ml. Patient was started on hydroxyurea, intravenous fluid, rasburicase and phosphorus replacement (IV and oral). A few days later, his serum creatinine and P normalized and WBC decreased to 0.4. A review of his record showed that at the initial diagnosis with ALL 6 months earlier, he presented with classical sTLS except for low serum P of 0.3 mg/dL. This is an unusual case of severe hypophosphatemia associated with sTLS. Urinary waste of phosphorus was excluded by the low urinary phosphorous and there was no diarrhea to suggest a bowel loss. Spurious hypophosphatemia was excluded by serial phosphorus measurements using the Cobas and Vitros methods. Further, the development of hypophosphatemia associated with the previous sTLS episode supports the diagnosis of cellular shifting. Rapidly growing neoplasms with high cell turnover rates causes the electrolyte abnormalities including hyperuricemia but in sTLS the tumoral cells are able to reutilize the released phosphorus for synthesis of new cells leading in extreme cases to hypophosphatemia. Although, a 25% increase of serum phosphorus from baseline is one of the criteria of TLS, it may be appropriate to add also hypophosphatemia among the criteria to define spontaneous TLS.
Am J Kidney Dis. 2015;65(4):A1-A93
92 ASSOCIATION BETWEEN MARKERS OF INFLAMMATION AND RAPID EGFR DECLINE IN PATIENTS WITH RHEUMATOID ARTHRITIS Mayurkumar Gohel, Androniki Bili, Alexander Chang, Geisinger Medical Center, Danville, PA, USA Inflammation is thought to play a key role in chronic kidney disease. We examined the association between markers of inflammation and rapid estimated glomerular filtration rate (eGFR) decline in a cohort of 1043 patients with rheumatoid arthritis and at least 3 serum creatinine measurements. Mean age in this cohort was 54.8 yrs, 69.9% were female, 8.4% had eGFR < 60 ml/min/1.73m2 at baseline, and 46.4% had positive anti-citrullinated protein (CCP) antibody. Median values of ESR, CRP, and rheumatoid factor were 23 mm/hr, 4.6 mg/L, and 14 units. Rapid eGFR decline was defined as the highest quartile of eGFR decline (>=2.73 ml/min/1.73m2/yr). After adjustment for age, gender, race, blood pressure, and glucose, every 10 mm/hr increase in erythrocyte sedimentation rate (ESR) was associated with an odds ratio (OR) of 1.07 (95% CI: 1.00-1.14, p=0.045) for rapid eGFR decline. Presence of anti-CCP antibody was associated with increased risk of rapid eGFR decline (OR 1.54, 95% CI: 1.02-2.33, p=0.04). Higher systolic blood pressure and higher blood glucose were both significantly associated with increased risk of rapid eGFR decline (p<0.05). Neither baseline CRP (p=0.6) or rheumatoid factor (p=0.3) were associated with rapid eGFR decline. Elevated ESR and anti-CCP antibodies are associated with rapid eGFR decline in patients with rheumatoid arthritis. Future studies should examine whether reducing inflammation can decrease risk of CKD progression.
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