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Use of Potassium Sparing Diuretics to Address Hypokalemia in Patients on Peritoneal Dialysis
NKF 2016 Spring Clinical Meetings Abstracts
Case Report 5
7 CALCIFIC UREMIC ARTERIOLOPATHY IN A TRANSPLANT PATEINT WITH A FUNCTIONING GRAFT; AN UNUSUAL PRESENTATION. Marwan Abu Minshar, Zeinab Tamam, Oritsegbubemi Adekola, Shakir Hussein, Mona Doshi. Wayne State University S.O.M. Detroit, MI Calcific uremic arteriolopathy (CUA), also known as calciphylaxis is a rare but often fatal syndrome of ischemic necrosis of the skin and adjacent tissues due to medial calcification and intimal hyperplasia of small vessels. It is thought to occur in patients with advanced CKD, and ESRD due to associated secondary hyperparathyroidism and increased calcium- phosphorus (ca-phos) product. We report a case of CUA in a renal transplant recipient with good allograft function and normal ca-phos product. A 60 year-old African American lady with history of DM, HTN, lupus with anti-phospholipid antibody related DVT on Coumadin, status post deceased donor kidney transplant in 2013,presented to hospital with urinary tract infection and ulcers over back of her thighs and firm non ulcerated nodular lesions in front of her thighs. Her laboratory findings were as follows: Creatinine (Cr.) 0.7mg/dL, Calcium 10.2 mg/dL, Phosphorus 1.1 mg/dL, Parathyroid hormone 217 pg/mL, and 24 hour urine Cr. Clearance of 40 mL/min. Her medications were: Prednisone, Tacrolimus, Cellcept and Coumadin. Dermatology biopsied the lesions which showed medial calcification of small vessels that confirmed diagnosis. CUA is typically seen in patients with severely reduced renal function and abnormal ca-phos product, which were absent in our case. Review of literature suggested that Coumadin can be an inciting factor for CUA, she was switched to low molecular weight heparin and was started on I.V. Sodium Thiosulfate three times weekly with wound care. CUA is a rare syndrome with high morbidity and mortality. It usually presents in advanced CKD, ESRD, patients with high ca-phos product and secondary hyperparathyroidism. This complex syndrome can also present in transplant patient with relatively good kidney function and normal ca-phos product, especially with concomitant use of warfarin. High index of suspicion and prompt diagnosis and treatment are needed to avoid patient death.
6 HEMODIALYSIS IN REFRACTORY HYPONATREMIA WITH NORMAL RENAL FUNCTION PRIOR TO LIVER TRANSPLANTATION Anand Achanti, Takamitsu Saigusa, Medical University of South Carolina, Charleston, SC, USA Hyponatremia is a common problem in cirrhotic, but can prevent liver transplantation due to a known complication of osmotic demyelination syndrome in perioperative period. Most transplant surgeons prefer a serum sodium level of 125mmol/L or higher prior to transplant. Our patient is a 47 year old male with alcoholic cirrhosis with a model for end stage liver disease score (MELD) of 26, recurrent ascites, chronic hyponatremia (baseline 115 mmol/L) who presented with enterococcus peritonitis and hypoosmolar hypervolemic hyponatremia with a serum sodium of 103 mmol/L, urine sodium < 20 mmol/L, and serum creatinine of 1.0 mg/dL. Patient failed to reach a sodium level of 125 mmol/L despite optimization of intravascular volume status with fluid restriction, IV albumin, and frequent large volume paracentesis. Patients’ hyponatremia prevented liver transplantation despite other factors making him the highest priority on transplant list. Hypertonic saline (requiring ICU stay), transjugular intrahepatic portosystemic shunt, and peritoneovenous shunts were considered, but due to associated morbidity and potential delay in transplantation, we initiated hemodialysis to manage his hyponatremia . Patient tolerated dialysis to maintain serum sodium level at around 130mmol/L until he successfully underwent a liver transplant in few days. Hemodialysis to correcting refractory hyponatremia prior to liver transplantation should be considered, even in the setting of normal kidney function, due to potential time and cost effectiveness.
A20
WHAT IS THE UTILITY OF ROUTINE RENAL ULTRASOUND IN THE EVALUATION AND MANAGEMENT OF ACUTE KIDNEY INJURY IN HOSPITALIZED PATIENTS? Paul Adjei, Thendrex Estrella, Paul Bernstein, Rochester General Hospital, Rochester, NY, USA Laith Al-Rabadi, MBBS,1,* Rivka Evidence shows that routine renal sonogram in patients with acute E.uropathy Ballard, MD,2,y Alan kidney injury (AKI) without history suggestive Jennifer of obstructive to look for correctible causes is not indicated. Yet clinicians routinely David J. Salant, MD,1 check renal ultrasounds in such patients. The aim of this study is to determine the utility of routine renal sonogram in the evaluation and management of AKI in hospitalized patients. We hypothesized that There is little information about pregnancy o routine renal sonogram in the evaluation of AKI in hospitalized patients those with circulating autoantibod is of low yield and likely does not impactespecially management. autoantigen primary MN. Under IRB approval, we reviewed all renal sonogramsinperformed in We present what a 39-year-old woman our institution during a 3 year period on inpatients for evaluation of with PLA2R-associate AKI. We included adult medicine inpatients admitted hypoalbuminemia with a nonanasarca, (albumin, 1.3-2. urologic diagnosis. We excluded patientsopsy with signs/symptoms/history revealed MN with staining for PLA2R, a of obstructive uropathy/urologic stents, contraindication to Foley to conservative therapy a She did not respond catheterization, and poor study quality. Using the electronic medical Several weeks after presentation, she was fou record, we recorded sonogram findings, any change(s) in management further course. immunosuppressive treatment. Protei as a result of the sonogram findings and hospital Sonographic anti-PLA2R levels declined but w reports were reviewed for the presence orCirculating absence of hydronephrosis, and other significant incidental findings. without proteinuria at birth or at her subseque One hundred renal ultrasound studies performed on 100 patients had detectable circulating anti-PLA2R of imm meeting criteria were included in the study. studies weretrace positive lowFive titers. Only amounts of IgG4 ant for hydronephrosis, of which only 1 required an intervention. Routine discrepancy between anti-PLA2R levels in th renal ultrasound did not change management in 99/100. Incidental Kidney Dis. 67(5):775-778. ª 2016 by findings not immediately affecting patientAm careJ including mostly renal cysts and structural changes due to chronic kidney disease were INDEX WORDS: Membranous nephropathy ( identified in 56 patients. In hospitalized patients with AKI and no history or(PLA physical receptor autoantibody; placenta; ritu 2R); findings suggestive of obstructive uropathy, routine renal sonography is unlikely to change management.
Pregnancy in a Patient Wit and Circulating Anti-P
P
regnant patients with autoimmune disease deliver newborns with a spectrum of cl manifestations due to the transplacental passa 8 circulating autoantibodies. Pregnant patients USE OF POTASSIUM SPARING DIURETICS TO ADDRESS HYPOKALEMIA lupus or myasthenia gravis can deliver babies IN PATIENTS ON PERITONEAL DIALYSIS 2; Rodríguez, Betzaida2; Zsom, Lajos3; Afshan, Sabahat1; Davidson, Jamie corresponding disease in the neonate.1,2 Neo Dixit, Mehul1; Fulop, Tibor2 membranous nephropathy (MN) not associated 1. Department of Pediatrics, Division of Pediatric Nephrology, University of congenital was first described in 199 Mississippi Medical Center, Jackson, MS, Unitedinfection States 2. Department of Medicine, Division of Nephrology, of Mississippi attributed to University the passive transfer of maternal Medical Center, Jackson, MS, United States. 3 bodies to putative renal antigens. More than a d 3. Department of Surgery, Division of Transplantation, University of Debrecen, 4 Debrecen, Hungary. later, Debiec et al identified the first antigen inv Hypokalemia is a common and dangerous problem in end-stage renal in such aspotassium neutral endopeptidase (NE disease (ESRD) patients on peritoneal dialysiscases (PD). Oral present(Kon the surface of the pod supplements (OPS) are used tometalloprotease achieve normal serum potassium +) level, however they have limited palatability. Potassium-sparing diuretics (KSD) and involved in the proteolytic regulation of va (spironolactone, amiloride) may be effective in these patients and may help tive peptides. Debiec et al described a mother w normalize K+ level with the lower dose of OPS. We have performed a cross-sectional review of 75 current orNEP past ESRD mutation preventing expression who had fo patients who were on PD for more than 6 month, with regard to serum anti-NEP antibodies potassium K+, OPS and KSD utilization. We reviewed charts for due multipleto fetomaternal alloi nization fromadequacy, a previous these antib clinical and laboratory variables, including dialysis residualmiscarriage; renal function, nutritional status and were co-existing condition treatment. and cause subepit tomedical cross the and placenta The cohort consisted of 75 patients with ESRD on PD for 28.2 (24.3) month, inbody themassfetal kidney mean age 49.2 (SD=14.7) anddeposits overweight with index of 29.5 (6.7) of a subsequent kg/m2; 57.3% were females, 73.3% African-American 48% diabetic. nancy. M-type and phospholipase A2 receptor (PL Weekly Kt/V was 2.12 (0.43), creatinine clearance was 73.5 (33.6) L/week with was later identified as the major autoantigen fo total exchanged volume 10.8 (2.7) L. Residual urine output (RUO) measured 5 mary MN Three-month in adults. 440 (494) mL and 30.6% patients were anuric. averageLittle serum K+literature exists measured 4 (0.5) mEq/L, 36% pregnancy of participants were taking K+ supplements outcomes in patients with nephrotic (median: 20 [0;20] mEq/day) and 41.3% were taking KSD (spironolactone drome due to primary MN, with no data ava dose: 25-200 mg/day; amiloride dose: 5-10 mg/day). Potassium correlated positively with weekly Kt/V (p=0.039) PD vintage (p=0.018) not 2with PD aboutandpregnancy in but PLA R-associated disease modality, exchange volume, RUO or KSD use. KSD use was associated with present what we believe to be the first known ca decreased use of OPS (r: -0.646; p<0.0001). pregnancy patient with Patients on PD frequently develop hypokalemiainandarequire OPS that have PLA2R-associated limited tolerance due to their side effects including dyspepsia, nausea, who was seropositive for vomiting anti-PLA2R autoantib and diarrhea. Our study concluded that KSD are well tolerated and decrease throughout the course of her pregnancy. the need for OPS. Am J Kidney Dis. 2016;67(5):A1-A118
Case Report 5
7 CALCIFIC UREMIC ARTERIOLOPATHY IN A TRANSPLANT PATEINT WITH A FUNCTIONING GRAFT; AN UNUSUAL PRESENTATION. Marwan Abu Minshar, Zeinab Tamam, Oritsegbubemi Adekola, Shakir Hussein, Mona Doshi. Wayne State University S.O.M. Detroit, MI Calcific uremic arteriolopathy (CUA), also known as calciphylaxis is a rare but often fatal syndrome of ischemic necrosis of the skin and adjacent tissues due to medial calcification and intimal hyperplasia of small vessels. It is thought to occur in patients with advanced CKD, and ESRD due to associated secondary hyperparathyroidism and increased calcium- phosphorus (ca-phos) product. We report a case of CUA in a renal transplant recipient with good allograft function and normal ca-phos product. A 60 year-old African American lady with history of DM, HTN, lupus with anti-phospholipid antibody related DVT on Coumadin, status post deceased donor kidney transplant in 2013,presented to hospital with urinary tract infection and ulcers over back of her thighs and firm non ulcerated nodular lesions in front of her thighs. Her laboratory findings were as follows: Creatinine (Cr.) 0.7mg/dL, Calcium 10.2 mg/dL, Phosphorus 1.1 mg/dL, Parathyroid hormone 217 pg/mL, and 24 hour urine Cr. Clearance of 40 mL/min. Her medications were: Prednisone, Tacrolimus, Cellcept and Coumadin. Dermatology biopsied the lesions which showed medial calcification of small vessels that confirmed diagnosis. CUA is typically seen in patients with severely reduced renal function and abnormal ca-phos product, which were absent in our case. Review of literature suggested that Coumadin can be an inciting factor for CUA, she was switched to low molecular weight heparin and was started on I.V. Sodium Thiosulfate three times weekly with wound care. CUA is a rare syndrome with high morbidity and mortality. It usually presents in advanced CKD, ESRD, patients with high ca-phos product and secondary hyperparathyroidism. This complex syndrome can also present in transplant patient with relatively good kidney function and normal ca-phos product, especially with concomitant use of warfarin. High index of suspicion and prompt diagnosis and treatment are needed to avoid patient death.
6 HEMODIALYSIS IN REFRACTORY HYPONATREMIA WITH NORMAL RENAL FUNCTION PRIOR TO LIVER TRANSPLANTATION Anand Achanti, Takamitsu Saigusa, Medical University of South Carolina, Charleston, SC, USA Hyponatremia is a common problem in cirrhotic, but can prevent liver transplantation due to a known complication of osmotic demyelination syndrome in perioperative period. Most transplant surgeons prefer a serum sodium level of 125mmol/L or higher prior to transplant. Our patient is a 47 year old male with alcoholic cirrhosis with a model for end stage liver disease score (MELD) of 26, recurrent ascites, chronic hyponatremia (baseline 115 mmol/L) who presented with enterococcus peritonitis and hypoosmolar hypervolemic hyponatremia with a serum sodium of 103 mmol/L, urine sodium < 20 mmol/L, and serum creatinine of 1.0 mg/dL. Patient failed to reach a sodium level of 125 mmol/L despite optimization of intravascular volume status with fluid restriction, IV albumin, and frequent large volume paracentesis. Patients’ hyponatremia prevented liver transplantation despite other factors making him the highest priority on transplant list. Hypertonic saline (requiring ICU stay), transjugular intrahepatic portosystemic shunt, and peritoneovenous shunts were considered, but due to associated morbidity and potential delay in transplantation, we initiated hemodialysis to manage his hyponatremia . Patient tolerated dialysis to maintain serum sodium level at around 130mmol/L until he successfully underwent a liver transplant in few days. Hemodialysis to correcting refractory hyponatremia prior to liver transplantation should be considered, even in the setting of normal kidney function, due to potential time and cost effectiveness.
A20
WHAT IS THE UTILITY OF ROUTINE RENAL ULTRASOUND IN THE EVALUATION AND MANAGEMENT OF ACUTE KIDNEY INJURY IN HOSPITALIZED PATIENTS? Paul Adjei, Thendrex Estrella, Paul Bernstein, Rochester General Hospital, Rochester, NY, USA Laith Al-Rabadi, MBBS,1,* Rivka Evidence shows that routine renal sonogram in patients with acute E.uropathy Ballard, MD,2,y Alan kidney injury (AKI) without history suggestive Jennifer of obstructive to look for correctible causes is not indicated. Yet clinicians routinely David J. Salant, MD,1 check renal ultrasounds in such patients. The aim of this study is to determine the utility of routine renal sonogram in the evaluation and management of AKI in hospitalized patients. We hypothesized that There is little information about pregnancy o routine renal sonogram in the evaluation of AKI in hospitalized patients those with circulating autoantibod is of low yield and likely does not impactespecially management. autoantigen primary MN. Under IRB approval, we reviewed all renal sonogramsinperformed in We present what a 39-year-old woman our institution during a 3 year period on inpatients for evaluation of with PLA2R-associate AKI. We included adult medicine inpatients admitted hypoalbuminemia with a nonanasarca, (albumin, 1.3-2. urologic diagnosis. We excluded patientsopsy with signs/symptoms/history revealed MN with staining for PLA2R, a of obstructive uropathy/urologic stents, contraindication to Foley to conservative therapy a She did not respond catheterization, and poor study quality. Using the electronic medical Several weeks after presentation, she was fou record, we recorded sonogram findings, any change(s) in management further course. immunosuppressive treatment. Protei as a result of the sonogram findings and hospital Sonographic anti-PLA2R levels declined but w reports were reviewed for the presence orCirculating absence of hydronephrosis, and other significant incidental findings. without proteinuria at birth or at her subseque One hundred renal ultrasound studies performed on 100 patients had detectable circulating anti-PLA2R of imm meeting criteria were included in the study. studies weretrace positive lowFive titers. Only amounts of IgG4 ant for hydronephrosis, of which only 1 required an intervention. Routine discrepancy between anti-PLA2R levels in th renal ultrasound did not change management in 99/100. Incidental Kidney Dis. 67(5):775-778. ª 2016 by findings not immediately affecting patientAm careJ including mostly renal cysts and structural changes due to chronic kidney disease were INDEX WORDS: Membranous nephropathy ( identified in 56 patients. In hospitalized patients with AKI and no history or(PLA physical receptor autoantibody; placenta; ritu 2R); findings suggestive of obstructive uropathy, routine renal sonography is unlikely to change management.
Pregnancy in a Patient Wit and Circulating Anti-P
P
regnant patients with autoimmune disease deliver newborns with a spectrum of cl manifestations due to the transplacental passa 8 circulating autoantibodies. Pregnant patients USE OF POTASSIUM SPARING DIURETICS TO ADDRESS HYPOKALEMIA lupus or myasthenia gravis can deliver babies IN PATIENTS ON PERITONEAL DIALYSIS 2; Rodríguez, Betzaida2; Zsom, Lajos3; Afshan, Sabahat1; Davidson, Jamie corresponding disease in the neonate.1,2 Neo Dixit, Mehul1; Fulop, Tibor2 membranous nephropathy (MN) not associated 1. Department of Pediatrics, Division of Pediatric Nephrology, University of congenital was first described in 199 Mississippi Medical Center, Jackson, MS, Unitedinfection States 2. Department of Medicine, Division of Nephrology, of Mississippi attributed to University the passive transfer of maternal Medical Center, Jackson, MS, United States. 3 bodies to putative renal antigens. More than a d 3. Department of Surgery, Division of Transplantation, University of Debrecen, 4 Debrecen, Hungary. later, Debiec et al identified the first antigen inv Hypokalemia is a common and dangerous problem in end-stage renal in such aspotassium neutral endopeptidase (NE disease (ESRD) patients on peritoneal dialysiscases (PD). Oral present(Kon the surface of the pod supplements (OPS) are used tometalloprotease achieve normal serum potassium +) level, however they have limited palatability. Potassium-sparing diuretics (KSD) and involved in the proteolytic regulation of va (spironolactone, amiloride) may be effective in these patients and may help tive peptides. Debiec et al described a mother w normalize K+ level with the lower dose of OPS. We have performed a cross-sectional review of 75 current orNEP past ESRD mutation preventing expression who had fo patients who were on PD for more than 6 month, with regard to serum anti-NEP antibodies potassium K+, OPS and KSD utilization. We reviewed charts for due multipleto fetomaternal alloi nization fromadequacy, a previous these antib clinical and laboratory variables, including dialysis residualmiscarriage; renal function, nutritional status and were co-existing condition treatment. and cause subepit tomedical cross the and placenta The cohort consisted of 75 patients with ESRD on PD for 28.2 (24.3) month, inbody themassfetal kidney mean age 49.2 (SD=14.7) anddeposits overweight with index of 29.5 (6.7) of a subsequent kg/m2; 57.3% were females, 73.3% African-American 48% diabetic. nancy. M-type and phospholipase A2 receptor (PL Weekly Kt/V was 2.12 (0.43), creatinine clearance was 73.5 (33.6) L/week with was later identified as the major autoantigen fo total exchanged volume 10.8 (2.7) L. Residual urine output (RUO) measured 5 mary MN Three-month in adults. 440 (494) mL and 30.6% patients were anuric. averageLittle serum K+literature exists measured 4 (0.5) mEq/L, 36% pregnancy of participants were taking K+ supplements outcomes in patients with nephrotic (median: 20 [0;20] mEq/day) and 41.3% were taking KSD (spironolactone drome due to primary MN, with no data ava dose: 25-200 mg/day; amiloride dose: 5-10 mg/day). Potassium correlated positively with weekly Kt/V (p=0.039) PD vintage (p=0.018) not 2with PD aboutandpregnancy in but PLA R-associated disease modality, exchange volume, RUO or KSD use. KSD use was associated with present what we believe to be the first known ca decreased use of OPS (r: -0.646; p<0.0001). pregnancy patient with Patients on PD frequently develop hypokalemiainandarequire OPS that have PLA2R-associated limited tolerance due to their side effects including dyspepsia, nausea, who was seropositive for vomiting anti-PLA2R autoantib and diarrhea. Our study concluded that KSD are well tolerated and decrease throughout the course of her pregnancy. the need for OPS. Am J Kidney Dis. 2016;67(5):A1-A118