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SILVER NITRATE CAUTERY IN RECURRENT PERITONEAL DIALYSIS CATHETER EXIT-SITE INFECTION: A CASE REPORT
NKF 2015 Spring Clinical Meetings Abstracts
309 SILVER NITRATE CAUTERY IN RECURRENT PERITONEAL DIALYSIS CATHETER EXIT-SITE INFECTION: A CASE REPORT Maria B. Yballe, Sandeep Aggarwal, Drexel University, Philadelphia, Pennsylvania, USA Peritoneal dialysis catheter exit-site infections can be a burdensome problem in patients on peritoneal dialysis (PD). Inadequate treatment can lead to significant morbidity with prolonged treatment course and recurrent peritonitis with subsequent catheter failure. We present a case of a 41 year-old African American male with end-stage renal disease secondary to hypertension who presented with recurrent PD catheter exit-site infection. He has been on PD since June 2012 with history of Pseudomonas catheter exit-site infection. He has had multiple recurrent episodes of exit site infections treated with both topical and oral antibiotics without peritonitis. Patient also reports repeatedly tying the catheter to one side of the abdomen. On careful examination of the site and manipulation of the tunnel revealed granulomatous tissue with mild purulent drainage. We performed a 75%-silver nitrate cautery of the granulomatous tissue with continued topical gentamicin as outpatient with complete resolution of the infection on subsequent follow-up. Our case demonstrates the role of chemical cauterization with topical silver nitrate solution as an effective adjunctive treatment of a PD catheter site-infection resistant to oral and topical antibiotic.
310 ACUTE RESCUE HEMODIALYSIS IN A PATIENT WITH ANTIBIOTIC IMPREGNATED KNEE CEMENT SPACER PREVENTING KIDNEY INJURY: AN INNOVATIVE APPROACH Ronald Yglesias, Alvin Ong, Ian Kane, Randel Bruney, Diane Marchesani, Tamim Naber. Atlanticare Hospital, Atlantic City, NJ Antibiotic impregnated bone-cement spacers (AIBS) are commonly used as adjunct therapy following infected prosthetic knee joint replacement extraction. A few case reports are available in the literature of AIBS causing acute kidney injury secondary to high level of serum Tobramycin leading to permanent renal failure requiring hemodialysis. We present our institute experience in 2 cases with Tobramycin toxicity due to AIBS, and the first case to our knowledge reporting temporary rescue hemodialysis preventing kidney injury and long term dialysis. Case 1: 71 year old man, presented with infected knee prosthesis removal with AIBS insertion. He developed a slow deterioration of his kidney function requiring hemodialysis. Delayed recognition of serum Tobramycin toxicity was found with level of 2.6ug/ml. AIBS was removed without improvement in patient’s kidney function. Case 2: 83 year old Caucasian male with an extensive past medical history including chronic kidney disease stage IIIa (baseline creatinine 1.5mg/dL), history of bilateral knee arthroplasty. He developed right knee infection with Methicillin resistant staphylococcus aureus. He underwent a right total knee revision with placement of an AIBS. The spacer cement was mixed with 10.8gm of Tobramycin and 9gm of Vancomycin. Subsequently, his renal function started to deteriorate. A blood Tobramycin level was very high of 2.6 ug/mL (normal 0.5-1.5) and his creatinine peaked at 2.7 mg/dL. Due to his multiple comorbidities; surgical removal of the spacer was deferred. Therefore, rescue hemodialysis was initiated with daily hemodialysis for two weeks followed by 3 treatments per week was with daily Tobramycin trough levels. A downward trend of the Tobramycin levels was observed. Currently the patient is off hemodialysis for 2 weeks, last Tobramycin level <0.9ug/mL, and his Cr 2.4mg/dL. We propose an innovative approach for the treatment of Tobramycin toxicity from AIBS utilizing acute rescue hemodialysis to clear serum Tobramycin; preventing irreversible kidney injury and long-term hemodialysis.
A92
311 SUCCESSFUL TREATMENT OF ATYPICAL HUS IN A KIDNEY TRANSPLANT RECIPIENT WITH ECULIZUMAB AND BELATACEPT Jia Zhang, Sabiha Hussain, Khaled Nashar, Bhavna Chopra, Tina Ko, Robert Kaplan, Katherine Jasnosz, Kalathil Sureshkumar, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA Atypical HUS (aHUS) is characterized by thrombotic microangiopathy. It results from hereditary alternative complement pathway dysregulation and activation. Atypical HUS is triggered in situations like autoimmunity, infection, pregnancy, and calcineurin inhibitor use, when the baseline disease activity is amplified. In kidney allografts, aHUS may be de novo or recurrent. A 55-year old white male with history of end stage kidney disease from membranous nephropathy presented with an increase in serum creatinine from baseline of 1.5 to 2.3 mg/dl, proteinuria, anemia, and thrombocytopenia, four months after receiving a deceased donor kidney transplant. His maintenance immunosuppression included tacrolimus and mycophenolate mofetil. He had low serum haptoglobin level, elevated LDH, negative DIC panel, and normal ADAMTS 13 activity. Kidney allograft biopsy showed evidence of thrombotic microangiopathy. A subsequent non-lesional skin biopsy, revealed focally intense C5B-9 deposition consistent with a systematic process. Due to concern for the role of tacrolimus as the inciting agent in this clinical presentation, it was replaced with belatacept, a co-stimulation blocker. He was also started on eculizumab, a humanized monoclonal ant-C5 antibody, which inhibits terminal complement formation. With this regimen, a year later, his anemia and thrombocytopenia improved, which was followed by improvement of serum creatinine to baseline, along with improvement of proteinuria from 1000 mg to <300mg/d. He currently has no evidence for hemolysis. Post-transplant aHUS is associated with extremely poor allograft prognosis. Genetic testing for complement factor mutations has become more accessible. High index of clinical suspicion is needed in the appropriate setting. Combination therapy with belatacept and eculizumab could be a viable option in treatment of aHUS related to calcineurin inhibitors use, as seen in our patient.
312 TRENDS IN DIABETES PREVALENCE, AWARENESS, TREATMENT AND CONTROL IN OLDER ADULT GENERAL AND CKD POPULATIONS OF THE UNITED STATES, 19992012 Y Zhu1, T Banerjee1, NR Burrows3, WH Herman2, R Saran2, NR Powe1 1UCSF, San Francisco, CA 2UM, Ann Arbor, MI 3CDC, Atlanta, GA Diabetes mellitus (diabetes) is the leading cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the United States (U.S.). There is age-related decline in kidney function, with the greatest prevalence of ESRD found in the elderly population. We sought to determine trends in diabetes prevalence amongst the elderly in the general and CKD populations. We used 1999-2012 NHANES data of non-pregnant adults aged ≥ 60 years (N=4,187-5,991). CKD was defined by 15≤eGFR<60 ml/min/1.73 m2 or ACR≥30 mg/g. Diabetes was defined by measured HbA1C ≥6.5%, use of prescription diabetes medication, or answering “yes” to the question “Have you ever been told…you have diabetes?” Diabetes awareness was determined if participants who had identified HbA1C ≥6.5% or were using diabetes medication answered “yes” to the self-report question above. Treatment was defined as persons with diabetes also using diabetes medication; control of diabetes was defined at HbA1C < 8% amongst treated individuals. All prevalence estimates were age-adjusted to the 2010 U.S. Census population. The overall prevalence of diabetes amongst the general population was 22.3% and increased from 19.8% to 23.7% in 1999-2012 (ptrend <.0001). In the CKD population, prevalence has increased from 25.0% to 35.3% (ptrend<0.0001) over the 14-years with an overall prevalence of 30.7%. Diabetes awareness increased from 78.1% to 83.5% in the general population, and from 80.0% to 90.6% in the CKD population (p<.0001). Diabetes treatment increased in both the general and CKD populations (ptrend<.0001). In the CKD population, control of HbA1C increased from 63.4% to 77.4%, similar to the general population’s increase from 67.1% to 74.6% (ptrend<.0001). Diabetes prevalence increased in both general and CKD older adult populations. Understanding the special dynamics of older adult patients will facilitate the optimal management of their CKD and diabetes.
Am J Kidney Dis. 2015;65(4):A1-A93
309 SILVER NITRATE CAUTERY IN RECURRENT PERITONEAL DIALYSIS CATHETER EXIT-SITE INFECTION: A CASE REPORT Maria B. Yballe, Sandeep Aggarwal, Drexel University, Philadelphia, Pennsylvania, USA Peritoneal dialysis catheter exit-site infections can be a burdensome problem in patients on peritoneal dialysis (PD). Inadequate treatment can lead to significant morbidity with prolonged treatment course and recurrent peritonitis with subsequent catheter failure. We present a case of a 41 year-old African American male with end-stage renal disease secondary to hypertension who presented with recurrent PD catheter exit-site infection. He has been on PD since June 2012 with history of Pseudomonas catheter exit-site infection. He has had multiple recurrent episodes of exit site infections treated with both topical and oral antibiotics without peritonitis. Patient also reports repeatedly tying the catheter to one side of the abdomen. On careful examination of the site and manipulation of the tunnel revealed granulomatous tissue with mild purulent drainage. We performed a 75%-silver nitrate cautery of the granulomatous tissue with continued topical gentamicin as outpatient with complete resolution of the infection on subsequent follow-up. Our case demonstrates the role of chemical cauterization with topical silver nitrate solution as an effective adjunctive treatment of a PD catheter site-infection resistant to oral and topical antibiotic.
310 ACUTE RESCUE HEMODIALYSIS IN A PATIENT WITH ANTIBIOTIC IMPREGNATED KNEE CEMENT SPACER PREVENTING KIDNEY INJURY: AN INNOVATIVE APPROACH Ronald Yglesias, Alvin Ong, Ian Kane, Randel Bruney, Diane Marchesani, Tamim Naber. Atlanticare Hospital, Atlantic City, NJ Antibiotic impregnated bone-cement spacers (AIBS) are commonly used as adjunct therapy following infected prosthetic knee joint replacement extraction. A few case reports are available in the literature of AIBS causing acute kidney injury secondary to high level of serum Tobramycin leading to permanent renal failure requiring hemodialysis. We present our institute experience in 2 cases with Tobramycin toxicity due to AIBS, and the first case to our knowledge reporting temporary rescue hemodialysis preventing kidney injury and long term dialysis. Case 1: 71 year old man, presented with infected knee prosthesis removal with AIBS insertion. He developed a slow deterioration of his kidney function requiring hemodialysis. Delayed recognition of serum Tobramycin toxicity was found with level of 2.6ug/ml. AIBS was removed without improvement in patient’s kidney function. Case 2: 83 year old Caucasian male with an extensive past medical history including chronic kidney disease stage IIIa (baseline creatinine 1.5mg/dL), history of bilateral knee arthroplasty. He developed right knee infection with Methicillin resistant staphylococcus aureus. He underwent a right total knee revision with placement of an AIBS. The spacer cement was mixed with 10.8gm of Tobramycin and 9gm of Vancomycin. Subsequently, his renal function started to deteriorate. A blood Tobramycin level was very high of 2.6 ug/mL (normal 0.5-1.5) and his creatinine peaked at 2.7 mg/dL. Due to his multiple comorbidities; surgical removal of the spacer was deferred. Therefore, rescue hemodialysis was initiated with daily hemodialysis for two weeks followed by 3 treatments per week was with daily Tobramycin trough levels. A downward trend of the Tobramycin levels was observed. Currently the patient is off hemodialysis for 2 weeks, last Tobramycin level <0.9ug/mL, and his Cr 2.4mg/dL. We propose an innovative approach for the treatment of Tobramycin toxicity from AIBS utilizing acute rescue hemodialysis to clear serum Tobramycin; preventing irreversible kidney injury and long-term hemodialysis.
A92
311 SUCCESSFUL TREATMENT OF ATYPICAL HUS IN A KIDNEY TRANSPLANT RECIPIENT WITH ECULIZUMAB AND BELATACEPT Jia Zhang, Sabiha Hussain, Khaled Nashar, Bhavna Chopra, Tina Ko, Robert Kaplan, Katherine Jasnosz, Kalathil Sureshkumar, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA Atypical HUS (aHUS) is characterized by thrombotic microangiopathy. It results from hereditary alternative complement pathway dysregulation and activation. Atypical HUS is triggered in situations like autoimmunity, infection, pregnancy, and calcineurin inhibitor use, when the baseline disease activity is amplified. In kidney allografts, aHUS may be de novo or recurrent. A 55-year old white male with history of end stage kidney disease from membranous nephropathy presented with an increase in serum creatinine from baseline of 1.5 to 2.3 mg/dl, proteinuria, anemia, and thrombocytopenia, four months after receiving a deceased donor kidney transplant. His maintenance immunosuppression included tacrolimus and mycophenolate mofetil. He had low serum haptoglobin level, elevated LDH, negative DIC panel, and normal ADAMTS 13 activity. Kidney allograft biopsy showed evidence of thrombotic microangiopathy. A subsequent non-lesional skin biopsy, revealed focally intense C5B-9 deposition consistent with a systematic process. Due to concern for the role of tacrolimus as the inciting agent in this clinical presentation, it was replaced with belatacept, a co-stimulation blocker. He was also started on eculizumab, a humanized monoclonal ant-C5 antibody, which inhibits terminal complement formation. With this regimen, a year later, his anemia and thrombocytopenia improved, which was followed by improvement of serum creatinine to baseline, along with improvement of proteinuria from 1000 mg to <300mg/d. He currently has no evidence for hemolysis. Post-transplant aHUS is associated with extremely poor allograft prognosis. Genetic testing for complement factor mutations has become more accessible. High index of clinical suspicion is needed in the appropriate setting. Combination therapy with belatacept and eculizumab could be a viable option in treatment of aHUS related to calcineurin inhibitors use, as seen in our patient.
312 TRENDS IN DIABETES PREVALENCE, AWARENESS, TREATMENT AND CONTROL IN OLDER ADULT GENERAL AND CKD POPULATIONS OF THE UNITED STATES, 19992012 Y Zhu1, T Banerjee1, NR Burrows3, WH Herman2, R Saran2, NR Powe1 1UCSF, San Francisco, CA 2UM, Ann Arbor, MI 3CDC, Atlanta, GA Diabetes mellitus (diabetes) is the leading cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the United States (U.S.). There is age-related decline in kidney function, with the greatest prevalence of ESRD found in the elderly population. We sought to determine trends in diabetes prevalence amongst the elderly in the general and CKD populations. We used 1999-2012 NHANES data of non-pregnant adults aged ≥ 60 years (N=4,187-5,991). CKD was defined by 15≤eGFR<60 ml/min/1.73 m2 or ACR≥30 mg/g. Diabetes was defined by measured HbA1C ≥6.5%, use of prescription diabetes medication, or answering “yes” to the question “Have you ever been told…you have diabetes?” Diabetes awareness was determined if participants who had identified HbA1C ≥6.5% or were using diabetes medication answered “yes” to the self-report question above. Treatment was defined as persons with diabetes also using diabetes medication; control of diabetes was defined at HbA1C < 8% amongst treated individuals. All prevalence estimates were age-adjusted to the 2010 U.S. Census population. The overall prevalence of diabetes amongst the general population was 22.3% and increased from 19.8% to 23.7% in 1999-2012 (ptrend <.0001). In the CKD population, prevalence has increased from 25.0% to 35.3% (ptrend<0.0001) over the 14-years with an overall prevalence of 30.7%. Diabetes awareness increased from 78.1% to 83.5% in the general population, and from 80.0% to 90.6% in the CKD population (p<.0001). Diabetes treatment increased in both the general and CKD populations (ptrend<.0001). In the CKD population, control of HbA1C increased from 63.4% to 77.4%, similar to the general population’s increase from 67.1% to 74.6% (ptrend<.0001). Diabetes prevalence increased in both general and CKD older adult populations. Understanding the special dynamics of older adult patients will facilitate the optimal management of their CKD and diabetes.
Am J Kidney Dis. 2015;65(4):A1-A93