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UNEXPLAINED GEOGRAPHIC AND FACILITY VARIATION IN THE INITIAL USE OF TEMPORARY NON-TUNNELED CATHETERS FOR CHRONIC DIALYSIS PATIENTS
NKF 2015 Spring Clinical Meetings Abstracts
49 “DEAD ON ARRIVAL”: A SYNTHETIC CANNABINOID WITH DETRIMENTAL EFFECTS Chyi Chyi Chong, Adrian Sequeira. LSU Health Shreveport School of Medicine, Shreveport, LA, USA Synthetic cannabinoid (SC) are drugs of abuse with highest use amongst young adults. Their affordability and avoidance of detection in the urine contributes to their abuse. However, their use is associated with numerous deleterious effects. We present a case of acute renal failure and extensive barotrauma after SC use in a healthy young male. A 22-year-old white male presented with 4 day history of vomiting, abdominal pain and body cramps, which started approximately 10 hours after smoking synthetic marijuana. In the ER, he was unarousable with shallow respirations. Subcutaneous emphysema was noted around his neck. He was intubated. CT chest showed pneumomediastinum, bilateral pneumothoraces and pneumorachis. No bullous or cystic lung disease was noted. Laboratory data revealed: WBC 30K/uL, BUN 192mg/dl, creatinine 16.8mg/dl, Na 159mmol/L, CO2 12mmol/L, phosphorus 9.6mg/dl and calcium 6.7mg/dl. Urine drug screen was negative. Infectious etiologies were negative. An esophagogram ruled out a tear as a factor for subcutaneous emphysema. After three dialysis sessions, his urine output and renal functions improved gradually. He refused a kidney biopsy. While on oxygen, the pneumothoraces also resolved. His creatinine was 2.8mg/dl on day of discharge. Cannabimimetics are adulterated with other compounds and sold under various trade names such as DOA and Spice. Acute coronary syndrome and seizures may occur in addition to the above presentation. Barotrauma is related to the way the agent is smoked thereby causing alveolar rupture. The kidney biopsy usually reveals acute tubular necrosis or interstitial nephritis. Treatment is supportive. This case was presented to increase awareness among physicians to enquire about designer drugs in patient who present with acute kidney injury of unknown etiology especially when the urine drug screen is negative.
50 RECURRENT FOCAL SEGMENTAL GLOMERULAR SCLEROSIS FOLLOWING HLA IDENTICAL LIVING DONOR KIDNEY TRANSPLANTATION Chyi Chyi Chong, Ramya Vejella, Ramesh Marahatta, Pallavi Shirsat, and Neeraj Singh. Department of Nephrology and Hypertension, Louisiana State University Health-Shreveport, Shreveport, LA, USA. The risk of recurrent primary focal segmental glomeruloscelerosis (FSGS) and graft failure in HLA identical living donor kidney transplants has not been quantified due to paucity of such cases in the literature. We report a patient with HLA identical kidney transplant from his twin brother, who had fulminant early recurrent FSGS posttransplant, and has so far failed to respond to the treatment. A 30 yearold white male with nephrotic syndrome secondary to minimal change disease diagnosed 10 years ago, sustained complete remission (normal renal function and no proteinuria) for nine years after steroid therapy. One year ago, patient developed recurrent proteinuria with biopsy proven FSGS. He failed therapy with steroids, cellcept, abatacept and Acthar gel requiring initiation of hemodialysis 6 months ago. Bilateral nephrectomy was performed 4 months ago for persistent heavy proteinuria (30gms), hypoalbuminemia and severe anasarca followed by kidney transplant. Patient received only I.V steroids for induction but no maintenance immunosuppression early post-transplant. Posttransplant day 3, he developed new onset proteinuria of 20 grams/day, and renal biopsy showed recurrent FSGS. So far, patient has failed to respond to high dose I.V steroids (3 grams), plasmapheresis 3 times/week (continuous since transplant), rituximab 4 doses, and abatacept 2 doses. He has been on cellcept 500mg twice daily, cyclosporin 100mg twice daily, prednisone 5mg daily, and Acthar gel 80 U subcutaneous twice weekly since post-transplant day 4. His serum creatinine is 3.5-4 mg/dl and proteinuria 20-25 grams/day. Genetic mutation studies, Apolipoprotein L1 analysis, and soluble urokinasetype plasminogen activator receptor (SUPAR) levels are pending. We conclude that caution should be advised prior to pursuing HLA identical living donor kidney transplant in patients with primary FSGS, as despite aggressive therapy and use of new treatments like abatecept and Acthar gel, the risk of recurrent disease and graft failure may be high.
Am J Kidney Dis. 2015;65(4):A1-A93
51 ASYMPTOMATIC PNEUMOHYDROTHORAX IN A PERITONEAL DIALYSIS PATIENT WITH TUBEROUS SCLEROSIS-A DIAGNOSTIC DILEMMA Nanette Chua, Stephan Migdal, Nivin Haroon, Zeenat Bhat Pleuroperitoneal leakage is a known but uncommon noninfectious complication of peritoneal dialysis (PD). It can be a diagnostic dilemma. Its incidence is higher in women and in patients with polycystic kidney disease. It usually occurs during initiation of peritoneal dialysis but has been reported later in the course as well. A 41 year-old Caucasian lady with past medical history significant for tuberous sclerosis and End Stage Renal Disease (due to Polycystic kidney disease), on continuous ambulatory peritoneal dialysis for year was found to have a right-sided hydropneumothorax on a Chest X-Ray done for pre-renal transplant work up. She was asymptomatic. Her Chest C T scan confirmed the large right-sided pleural effusion with pneumothorax and lung findings of lymphagioleiomyomatosis. She underwent right thorascopic drainage of pleural fluid, pleural and lymph node biopsies, and wedge resection. Surgery was complicated by bleeding of inferior pulmonary vein, which was repaired through open thoracotomy. She had a chest tube placed after the procedure. Pleural fluid was clear, colorless with pleural fluid glucose of 341 mg/dL, serum glucose was normal. Biopsy of lung and lymph node tissues were positive for lymphagioleiomyomatosis while pleural tissue was negative. Post surgery, there was increase in chest tube drainage after re-initiation of PD. Pleural and peritoneal fluid glucose tested simultaneously were 289mg/dL and 213 mg/dL respectively. PD was held and she was started on hemodialysis. The patient will be reevaluated in a few months to see if the leak spontaneously seals. If leakage recurs, the plan is for surgical pleurodesis or repair. Pleuroperitoneal leakage though uncommon complication of PD, should always be a differential diagnosis for pleural effusion in PD pt Awareness of the condition is the key to early detection and management. Diagnosis is confirmed by high pleural-to-serum glucose gradient, low pleural-to-peritoneal glucose gradient, peritoneal scintigraphy or CT scan with intraperitoneal dye. Once diagnosed, PD should be temporary held. In recurrent effusions, surgical correction or permanent switch to hemodialysis are the definitive treatment.
52 UNEXPLAINED GEOGRAPHIC AND FACILITY VARIATION IN THE INITIAL USE OF TEMPORARY NON-TUNNELED CATHETERS FOR CHRONIC DIALYSIS PATIENTS: Edward G. Clark, Ayub Akbari, Swapnil Hiremath, Manish M. Sood, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada. Non-tunneled (temporary) hemodialysis catheters (NTHCs) are the least-optimal initial vascular access for chronic dialysis patients but little is known about factors associated with NTHC use in this context. We sought to determine factors associated with initial NTHC use for chronic dialysis patients. We analyzed registry data collected between January 2001 and December 2010 from 82 dialysis facilities in 14 geographic regions in Canada. Multi-level models and intra-class correlation coefficients were used to evaluate variation in NTHC use as initial dialysis access across facilities and geographic regions. Facility and patient characteristics associated with the lowest and highest quartiles of NTHC use were compared. During the study period, 21,091 patients initiated chronic dialysis with central venous catheters (CVCs) of which 10,183 (48.3%) were NTHCs. Crude variation in NTHC use across facilities ranged from 3.7 to 99.4% and across geographic regions from 32.4 to 85.1%. In an adjusted multi-level logistic regression model, explained variation at the facility and regional levels was 40.0% and 34.1%, respectively. Similar results were observed for the subgroups of patients who had received > 90 days and > 1 year of pre-dialysis nephrology care. Adjusted odds ratios for initial NTHC use ranged from 0.59 to 9.3 across geographic regions. Male sex, coronary artery disease, pulmonary edema, COPD, increasing distance from dialysis facility, hypertension, higher serum phosphate, lower serum albumin and calendar year were associated with NTHC use. There is wide variation in NTHC use as initial vascular access for chronic dialysis patients across facilities and geographic regions in Canada. Defining the factors that underpin this variation could facilitate a reduction of NTHC use in favor of more optimal initial vascular access.
A27
49 “DEAD ON ARRIVAL”: A SYNTHETIC CANNABINOID WITH DETRIMENTAL EFFECTS Chyi Chyi Chong, Adrian Sequeira. LSU Health Shreveport School of Medicine, Shreveport, LA, USA Synthetic cannabinoid (SC) are drugs of abuse with highest use amongst young adults. Their affordability and avoidance of detection in the urine contributes to their abuse. However, their use is associated with numerous deleterious effects. We present a case of acute renal failure and extensive barotrauma after SC use in a healthy young male. A 22-year-old white male presented with 4 day history of vomiting, abdominal pain and body cramps, which started approximately 10 hours after smoking synthetic marijuana. In the ER, he was unarousable with shallow respirations. Subcutaneous emphysema was noted around his neck. He was intubated. CT chest showed pneumomediastinum, bilateral pneumothoraces and pneumorachis. No bullous or cystic lung disease was noted. Laboratory data revealed: WBC 30K/uL, BUN 192mg/dl, creatinine 16.8mg/dl, Na 159mmol/L, CO2 12mmol/L, phosphorus 9.6mg/dl and calcium 6.7mg/dl. Urine drug screen was negative. Infectious etiologies were negative. An esophagogram ruled out a tear as a factor for subcutaneous emphysema. After three dialysis sessions, his urine output and renal functions improved gradually. He refused a kidney biopsy. While on oxygen, the pneumothoraces also resolved. His creatinine was 2.8mg/dl on day of discharge. Cannabimimetics are adulterated with other compounds and sold under various trade names such as DOA and Spice. Acute coronary syndrome and seizures may occur in addition to the above presentation. Barotrauma is related to the way the agent is smoked thereby causing alveolar rupture. The kidney biopsy usually reveals acute tubular necrosis or interstitial nephritis. Treatment is supportive. This case was presented to increase awareness among physicians to enquire about designer drugs in patient who present with acute kidney injury of unknown etiology especially when the urine drug screen is negative.
50 RECURRENT FOCAL SEGMENTAL GLOMERULAR SCLEROSIS FOLLOWING HLA IDENTICAL LIVING DONOR KIDNEY TRANSPLANTATION Chyi Chyi Chong, Ramya Vejella, Ramesh Marahatta, Pallavi Shirsat, and Neeraj Singh. Department of Nephrology and Hypertension, Louisiana State University Health-Shreveport, Shreveport, LA, USA. The risk of recurrent primary focal segmental glomeruloscelerosis (FSGS) and graft failure in HLA identical living donor kidney transplants has not been quantified due to paucity of such cases in the literature. We report a patient with HLA identical kidney transplant from his twin brother, who had fulminant early recurrent FSGS posttransplant, and has so far failed to respond to the treatment. A 30 yearold white male with nephrotic syndrome secondary to minimal change disease diagnosed 10 years ago, sustained complete remission (normal renal function and no proteinuria) for nine years after steroid therapy. One year ago, patient developed recurrent proteinuria with biopsy proven FSGS. He failed therapy with steroids, cellcept, abatacept and Acthar gel requiring initiation of hemodialysis 6 months ago. Bilateral nephrectomy was performed 4 months ago for persistent heavy proteinuria (30gms), hypoalbuminemia and severe anasarca followed by kidney transplant. Patient received only I.V steroids for induction but no maintenance immunosuppression early post-transplant. Posttransplant day 3, he developed new onset proteinuria of 20 grams/day, and renal biopsy showed recurrent FSGS. So far, patient has failed to respond to high dose I.V steroids (3 grams), plasmapheresis 3 times/week (continuous since transplant), rituximab 4 doses, and abatacept 2 doses. He has been on cellcept 500mg twice daily, cyclosporin 100mg twice daily, prednisone 5mg daily, and Acthar gel 80 U subcutaneous twice weekly since post-transplant day 4. His serum creatinine is 3.5-4 mg/dl and proteinuria 20-25 grams/day. Genetic mutation studies, Apolipoprotein L1 analysis, and soluble urokinasetype plasminogen activator receptor (SUPAR) levels are pending. We conclude that caution should be advised prior to pursuing HLA identical living donor kidney transplant in patients with primary FSGS, as despite aggressive therapy and use of new treatments like abatecept and Acthar gel, the risk of recurrent disease and graft failure may be high.
Am J Kidney Dis. 2015;65(4):A1-A93
51 ASYMPTOMATIC PNEUMOHYDROTHORAX IN A PERITONEAL DIALYSIS PATIENT WITH TUBEROUS SCLEROSIS-A DIAGNOSTIC DILEMMA Nanette Chua, Stephan Migdal, Nivin Haroon, Zeenat Bhat Pleuroperitoneal leakage is a known but uncommon noninfectious complication of peritoneal dialysis (PD). It can be a diagnostic dilemma. Its incidence is higher in women and in patients with polycystic kidney disease. It usually occurs during initiation of peritoneal dialysis but has been reported later in the course as well. A 41 year-old Caucasian lady with past medical history significant for tuberous sclerosis and End Stage Renal Disease (due to Polycystic kidney disease), on continuous ambulatory peritoneal dialysis for year was found to have a right-sided hydropneumothorax on a Chest X-Ray done for pre-renal transplant work up. She was asymptomatic. Her Chest C T scan confirmed the large right-sided pleural effusion with pneumothorax and lung findings of lymphagioleiomyomatosis. She underwent right thorascopic drainage of pleural fluid, pleural and lymph node biopsies, and wedge resection. Surgery was complicated by bleeding of inferior pulmonary vein, which was repaired through open thoracotomy. She had a chest tube placed after the procedure. Pleural fluid was clear, colorless with pleural fluid glucose of 341 mg/dL, serum glucose was normal. Biopsy of lung and lymph node tissues were positive for lymphagioleiomyomatosis while pleural tissue was negative. Post surgery, there was increase in chest tube drainage after re-initiation of PD. Pleural and peritoneal fluid glucose tested simultaneously were 289mg/dL and 213 mg/dL respectively. PD was held and she was started on hemodialysis. The patient will be reevaluated in a few months to see if the leak spontaneously seals. If leakage recurs, the plan is for surgical pleurodesis or repair. Pleuroperitoneal leakage though uncommon complication of PD, should always be a differential diagnosis for pleural effusion in PD pt Awareness of the condition is the key to early detection and management. Diagnosis is confirmed by high pleural-to-serum glucose gradient, low pleural-to-peritoneal glucose gradient, peritoneal scintigraphy or CT scan with intraperitoneal dye. Once diagnosed, PD should be temporary held. In recurrent effusions, surgical correction or permanent switch to hemodialysis are the definitive treatment.
52 UNEXPLAINED GEOGRAPHIC AND FACILITY VARIATION IN THE INITIAL USE OF TEMPORARY NON-TUNNELED CATHETERS FOR CHRONIC DIALYSIS PATIENTS: Edward G. Clark, Ayub Akbari, Swapnil Hiremath, Manish M. Sood, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada. Non-tunneled (temporary) hemodialysis catheters (NTHCs) are the least-optimal initial vascular access for chronic dialysis patients but little is known about factors associated with NTHC use in this context. We sought to determine factors associated with initial NTHC use for chronic dialysis patients. We analyzed registry data collected between January 2001 and December 2010 from 82 dialysis facilities in 14 geographic regions in Canada. Multi-level models and intra-class correlation coefficients were used to evaluate variation in NTHC use as initial dialysis access across facilities and geographic regions. Facility and patient characteristics associated with the lowest and highest quartiles of NTHC use were compared. During the study period, 21,091 patients initiated chronic dialysis with central venous catheters (CVCs) of which 10,183 (48.3%) were NTHCs. Crude variation in NTHC use across facilities ranged from 3.7 to 99.4% and across geographic regions from 32.4 to 85.1%. In an adjusted multi-level logistic regression model, explained variation at the facility and regional levels was 40.0% and 34.1%, respectively. Similar results were observed for the subgroups of patients who had received > 90 days and > 1 year of pre-dialysis nephrology care. Adjusted odds ratios for initial NTHC use ranged from 0.59 to 9.3 across geographic regions. Male sex, coronary artery disease, pulmonary edema, COPD, increasing distance from dialysis facility, hypertension, higher serum phosphate, lower serum albumin and calendar year were associated with NTHC use. There is wide variation in NTHC use as initial vascular access for chronic dialysis patients across facilities and geographic regions in Canada. Defining the factors that underpin this variation could facilitate a reduction of NTHC use in favor of more optimal initial vascular access.
A27