History Of Chronic Kidney Disease Research Articles

286 A CASE REPORT OF TYPE II KOUNIS SYNDROME

Abstract Case presentation and management A 81-years old female presented to the emergency department of our hospital with dyspnea and chest pain. She had a history of chronic kidney disease and left bundle brunch block (LBBB) never further investigated. Non diagnostic ECG was performed in the setting of pre-existing LBBB. HS-T-Troponin level was significantly elevated (986 ng/L). A transthoracic echocardiogram (TTE) revealed inferior and posterior wall hypokinesis. NSTEMI was diagnosed and coronary angiography via the femoral artery revealed subocclusive stenosis of the right coronary artery (RCA) and 80% stenosis of left anterior descending artery (LAD). Coronary stent positioning was performed for the RCA culprit lesion and staged complete revascularization was planned. Complications After two days, the patient experienced sharp pain in the right groin and a femoral pseudoaneurysm was diagnosed by Ultrasound Color Doppler. Subsequently anemia suggested the development of retroperitoneal hematoma but it was excluded by contrast CT. Unfortunately, the patient developed acute chest pain, wheezing and erythematous pruritic rash 10 minutes after injection of contrast medium agent. The ECG didn't show any new ischemic abnormalities in the setting of pre-existing LBBB. The peak CK- MB level was significantly elevated (87 ng/mL). New onset apical region akinesia and anterior wall hypokinesia were detected on TTE. Acute coronary syndrome (ACS) was suspected consistent with symptoms, new onset wall motion abnormalities and CK-MB elevations. The patient was diagnosed with allergic reaction and coronary vessel spasm secondary to contrast agent injection in pre-existing atherosclerotic plaque. Due to the high probability of an hypersensitivity reaction to the contrast medium agent we did not perform a new coronary angiography to confirm the diagnosis. Promethazine, Urbason and Nitroglicerin were administered with clinical improvement. The next day we observed recovery of the anterior and apex wall motion abnormalities consistent with coronary vessel spasm. Echocardiographic wall motion abnormalities before and after coronary spasm: Take home message We presented the case of an allergic reaction leading to the release of inflammatory mediators responsible of coronary vessel spasm causing acute myocardial infarction. It can also be induced by injection of contrast medium like in the presented case. Therefore, clinicians and radiologist should recognize this rare but critical disease to ensure prevention and appropriate management.

905: POST-INTUBATION PARTIAL PRESSURE OF O2/FRACTION OF INSPIRED O2 AND IN-HOSPITAL MORTALITY IN COVID-19

Introduction: Early determinants of clinical outcome for SARS-CoV-2 infection (COVID-19) and pneumonia remain a critical need to guide patient management, goals of care discussions, and resource allocation in times of surges. Our hypothesis, there is an association between the Partial pressure of oxygen/Fraction of inspired oxygen (P:F) ratio immediately after intubation in patients with COVID-19 respiratory failure and in-hospital mortality. Methods: This is a cross sectional retrospective observational study in an urban academic tertiary care intensive care unit (ICU). The study was approved by the University’s Institutional Review Board. Patients included in the study were admitted to the medical ICU who tested positive for SARS-CoV-2 requiring escalation of care with intubation and placement on mechanical ventilation. Patients less than 18 years of age or who were pregnant were excluded from the study. Data analysis was conducted using Stata 17.0 software. Univariate logistic regression analyses of the independent variables on the primary outcome were used individually and odds ratios with confidence intervals calculated. Results: The inclusion criteria were met in 78 patients of which two patients were excluded from the study due to multiple missing data points. Participants had an average age of 57.3 years with 68% under 65 and 78% male. The majority of patients (54%) had a BMI ≥30 while 51% had a history of diabetes. Only 14% had a history of chronic kidney disease. Fifty percent of the total sample had Initial post-intubation P:F ratio values < 100 and 50% had values ≥100. Total in-hospital mortality for all patients through the period of observation was 49%. Patients with a P:F ratio of < 100 had 100% increased odds of in-patient mortality. The OR was 2.1 for in-hospital mortality for patients with P:F ratio < 100 (58%), versus those with P:F ratio ≥100 (39%), [95% CI, 0.84 to 5.27], p = 0.11. Bivariate logistic regression analyses for association of in-hospital mortality with individual independent variables did not show significance. Conclusions: The odds of in-hospital mortality is higher when immediate post-intubation P:F ratio is < 100. While this did not reach statistical significance due to the limited size of the study, it remains of clinical interest and warrants further investigation.

609: NEPHROTOXIC MEDICATIONS AND THEIR ASSOCIATION WITH ACUTE KIDNEY INJURY IN CRITICALLY ILL CHILDREN

Introduction: The incidence of developing acute kidney injury (AKI) in the pediatric intensive care unit (PICU) is estimated to be 26% (Kaddourah, 2017). Nephrotoxic medications are a modifiable risk factor associated with AKI in non-critically ill children & neonates (Moffett, 2011 & Stoops, 2019). The primary objective of this study is to evaluate the association between the number of nephrotoxic medications and the risk of developing AKI in critically ill children. Methods: This is a single center retrospective cohort study of critically ill children admitted to a tertiary care PICU. Inclusion criteria was patients age 0-21 years admitted for >24 hours. Exclusion criteria was history of chronic kidney disease or if expired within 24 hours of admission. We considered the same list of medications used in previous studies to be nephrotoxic, NSAIDs, certain antibiotics, and chemotherapy agents. AKI was defined by Kidney Disease: Improving Global Outcomes (KDIGO) criteria including serum creatinine increase by ≥0.3, >1.5 times baseline, or urine output < 0.5 mL/kg/hr for ≥12 hours. Severe AKI was defined as Stage 2 & 3 AKI. Exposure to the number of nephrotoxic medications and development of AKI was analyzed. Results: 60 patients were analyzed. Median age was 6.55 (1.12-12.71) years and mostly male (55%). Median LOS was 3 (2-5) days. Majority had a respiratory illness as primary diagnosis (31%). Median PELOD2 score was 3.5 (2-7). Incidence of AKI was 40%. 46% of patients who developed AKI did not have any nephrotoxic medications administered. 42% of patients with AKI were administered 1 nephrotoxic medication. 12% of patients with AKI had exposure to ≥2 medications. Amongst all patients with AKI, 88% had severe AKI. The most common medications administered were ibuprofen (22%) and vancomycin (17%). Exposure to the number of nephrotoxic medications and development of AKI was assessed with Fisher’s Exact test. There was no statistical significance with the number of nephrotoxic medications and the development of AKI (p=0.962). Correlation analysis revealed an increased rate of AKI with PICU LOS ≥5 days (p=0.029). Conclusions: There was no statistically significant association between the number of nephrotoxic medications and the development of AKI. Patients with longer LOS had a higher risk of developing AKI.

753: EVALUATION OF SEDATIVE AND ANALGESIC PRACTICES AND OUTCOMES IN MECHANICALLY VENTILATED PATIENTS

Introduction: Sedative and analgesic agents are used for patient comfort during mechanical ventilation (MV) but can cause deleterious effects such as prolonged MV and delirium. Maintaining light sedation and performing daily awakening trials (DATs) can reduce untoward effects. We assessed the relationship between sedative and analgesic dose and 28-day MV-free survival in medical ICU (MICU), surgical ICU (SICU), and cardiac (CICU) patients, hypothesizing that higher doses would be associated with lower 28-day MV-free survival. Methods: In this single-center retrospective study, MICU, SICU, and CICU patients admitted to a tertiary care hospital from 1/1/21-6/30/21 and on MV admitted for 1-7 days were randomly selected if their goal Sedation Agitation Scale (SAS) score was 3-4. Baseline demographics and clinical characteristics were collected. The primary outcome was correlation between average sedative or analgesic dose and 28-day MV-free survival. Secondary outcomes included time at goal SAS score, DAT completion, and deep sedation (SAS < 3) within 48 hours of intubation. The primary outcome was evaluated using linear regression; secondary outcomes were assessed with descriptive statistics. Results: 411 subjects, including 99 MICU, 54 SICU, and 27 CICU patients, were evaluated. 53% were male and the median age and weight were 66.5 years (IQR, 56-77) and 84 kg (IQR 70-100), respectively. 8% of MICU patients but no SICU or CICU patients had Covid-19. A history of chronic opioid use was most common in MICU and SICU patients (19% and 17%, respectively) and CICU patients most often had a history of chronic kidney disease (33%). Doses of dexmedetomidine, propofol, midazolam, and fentanyl demonstrated poor correlation with 28-day MV-free survival among all patients, with R-squared values of 0.002, 0.06, 0.01, and 0.1, respectively. The association of sedative dose was strongest for midazolam in MICU patients, with each 1mg/hr increase corresponding to a 0.6 day reduction in 28-day MV-free survival. SAS scores were 3-4 70% of the time, SATs were completed in 73% of appropriate cases, and 57% of patients were deeply sedated within 48 hours of intubation. Conclusions: In this regression analysis, sedative and analgesic doses were not associated with 28-day MV-free survival in a mixed critically ill population.

An ecological study regarding the association between paraquat exposure and end stage renal disease

BackgroundPersons who experience paraquat poisoning rapidly develop damage to a variety of organ systems including acute kidney injury (AKI), the occurrence of which is associated with an increased risk of death. However, little is known about the effects of chronic paraquat exposure on renal function and the onset of chronic renal disease. The objective of the current study is to assess the association between paraquat exposure and the incidence of end stage renal disease (ESRD) in the United States.MethodsData on the incidence of ESRD for the period 2010 through 2017 and kilograms of paraquat use per square mile for each county in the conterminous United States was obtained from the United States Renal Data System (USRDS) and the National Water Quality Assessment (NAWQA) Program, respectively. Negative binomial regression was used to estimate rate ratios (RRs) and 95% confidence intervals (CIs) for the association between quartiles of paraquat exposure and the incidence of ESRD.ResultsThe incidence of ESRD increased with increasing paraquat density. Based on a 20-year exposure lag, those in the highest paraquat density quartile had a 21% higher rate of ESRD compared to the lowest quartile whereas for a 15-year lag the increase was 26%. Adjusted associations were attenuated though still followed an increasing linear trend across quintiles.ConclusionsThe results of this study are consistent with a large number of studies documenting a high incidence of AKI and a small number of studies chronic renal disease following acute and chronic paraquat exposure, respectively. While the pathophysiological mechanisms underlying kidney injury following paraquat poisoning are well understood, more research is necessary to understand the natural history of chronic kidney disease due to chronic paraquat exposure.

Telephonic Follow-up and the Risk of Death in Ambulatory Patients with COVID-19.

Primary care level close monitoring of mild COVID-19 patients has shown to provide a risk reduction in hospitalization and death. We aimed to compare the risk of all-cause death among COVID-19 ambulatory patients who received and did not receive telephonic follow-up in primary health care settings. A secondary database analysis, 2-group comparative study, was conducted with data from the medical information systems of the Mexican Institute of Social Security. A total of 1,498,808 ambulatory patients aged 20 years old and over and with laboratory confirmed SARS-CoV-2 by PCR or rapid antigen test were analyzed. Of them, 535,898 (35.8%) where followed by telephonic calls. The cases were attended from October 14, 2020, to April 10, 2022. Death incidence was evaluated. To assess the association between death and telephonic follow-up we calculated risk ratio using a multivariate logistic model. Case fatality rate was 1.29% in the patients who received telephonic follow-up and 2.95% in the cases who did not receive phone calls. Medical history of chronic kidney disease, COPD, cardiovascular disease, tobacco consumption and diabetes were associated with increased risk of death. In the multivariate model, telephonic follow-up was associated with lower risk of all-cause death, with an adjusted risk ratio of 0.61 (95% confidence interval from 0.59, 0.64). Our data suggest that telephonic follow-up is associated with a risk of death reduction in adult outpatients with mild COVID-19, in the context of a multimodal strategy in the primary health care settings.

Ethnic differences in 25-year risk of incident chronic kidney disease among people with type 2 diabetes in New Zealand

IntroductionInsights into ethnic differences in the natural history of chronic kidney disease (CKD) among people with type 2 diabetes mellitus (T2DM) might inform clinical strategies to address disparities in hospitalization...

Risk factors for heart failure in patients with COVID-19

Aim. To establish risk factors for heart failure (HF) in patients with coronavirus disease 2019 (COVID-19).Material and methods. Medical records of 151 patients treated in an infectious disease hospital from November 3, 2020 to February 2, 2021 with a confirmed diagnosis of COVID-19 were retrospectively selected. The collection of clinical, history and laboratory data were carried out by analyzing electronic medical records. We analyzed information on age, sex, body mass index, smoking, and comorbidities. Following laboratory studies were analyzed: complete blood count, biochemical blood tests, coagulation profile, acute phase proteins (C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH)), procalcitonin. The diagnosis of HF was confirmed by clinical performance, echocardiography, and elevated levels of the N-terminal pro-brain natriuretic peptide (NT-proBNP). The risk of HF was taken as the endpoint of the study.Results. The studied sample of patients was divided into two groups depending on HF: the 1st group included 46 patients with HF, the 2nd group — 105 patients without HF. The median age was 66,2 (50-92) years (women, 91 (60,3%)). Laboratory indicators, such as the levels of CRP, LDH, procalcitonin, creatinine, bilirubin, differed significantly from each other, and the median values were higher in patients with HF. The neutrophil-to-lymphocyte ratio (NLR) showed significant intergroup differences: in the group of patients with HF, the median was 4,97% vs 3,62% (p=0,011) in the group of patients without HF. There were following most significant predictors increasing the HF risk: age ≥66 years (odds ratio, 8,038, p&lt;0,001), procalcitonin level, which increases the HF risk in patients by 3,8 times (p&gt;&lt;0,001), NLR ≥4,11% (p=0,010), thrombocytopenia ≤220×109/l (p=0,010), history of chronic kidney disease (CKD) (p=0,018). Conclusion. The following predictors of HF were established: age ≥66 years, procalcitonin ≥0,09 ng/ml, NLR ≥4,11%, thrombocytopenia ≤220×109/l, history of CKD, LDH ≥685 U/l and creatinine ≥102 µmol/l, international normalized ratio ≥1,19, QTc interval ≥407,5 ms, bilirubin ≤10,7 µmol/l. It is worth noting that the best accuracy values are demonstrated by the Random Forest algorithm (88,5% on the validation set), but the mathematical model of the neural network turned out to be the most sensitive (90,0% on the validation set). Keywords: novel coronavirus infection, heart failure, prognosis&gt;˂0,001), procalcitonin level, which increases the HF risk in patients by 3,8 times (p˂0,001), NLR ≥4,11% (p=0,010), thrombocytopenia ≤220×109/l (p=0,010), history of chronic kidney disease (CKD) (p=0,018).Conclusion. The following predictors of HF were established: age ≥66 years, procalcitonin ≥0,09 ng/ml, NLR ≥4,11%, thrombocytopenia ≤220×109/l, history of CKD, LDH ≥685 U/l and creatinine ≥102 µmol/l, international normalized ratio ≥1,19, QTc interval ≥407,5 ms, bilirubin ≤10,7 µmol/l. It is worth noting that the best accuracy values are demonstrated by the Random Forest algorithm (88,5% on the validation set), but the mathematical model of the neural network turned out to be the most sensitive (90,0% on the validation set).

Preliminary Safety and Efficacy of Bgb-11417, a Novel Bcl-2 Inhibitor, in Combination with Azacitidine in Patients with Acute Myeloid Leukemia (AML)

Background/Introduction: The efficacy of Bcl-2 inhibitors for treating AML was recognized by the approval of venetoclax and azacitidine (aza) in patients (pts) with newly diagnosed AML ineligible for intensive chemotherapy. However, survival rates beyond 2 years are low. Compared to venetoclax, BGB-11417 is a much more potent Bcl-2 inhibitor (>10-fold in biochemical assays) with improved selectivity and the potential to achieve deeper target inhibition and responses in the clinical setting. Here, we present updated preliminary results of pts with AML enrolled in BGB-11417-103 (NCT04771130). Methods: BGB-11417-103 is an ongoing dose finding/expansion study evaluating BGB-11417 and aza in pts with AML (treatment-naïve [TN] unfit for intensive chemotherapy or relapsed/refractory [R/R]), myelodysplastic syndrome (MDS), or MDS/myeloproliferative neoplasm. For all indications, pts who received prior aza or Bcl-2 inhibitors were excluded. For pts with AML, the 10-day regimen comprised BGB-11417 at 40 mg (cohort 1), 80 mg (cohort 2), or 160 mg (cohort 3); 160 mg was also used in a 28-day regimen (cohort 4). All dose levels were given in combination with aza (75 mg/m2 x 7 days). In cycle 1, a 4-day ramp-up of BGB-11417 starting at 1/8 target dose was used. Patients with dose-limiting toxicities (DLTs) in cycle 1 were assessed against the number of patients dosed. The safety stopping criteria were based on the number of patients with events where posterior probability of event rate exceeding 0.25 was at least 80%. Responses were determined using 2017 European LeukemiaNet (ELN) criteria with assessment of hematologic improvement. Treatment-emergent adverse events (TEAEs), minimal residual disease (MRD) by flow cytometry, and pharmacokinetics (PK) were also assessed. Results: As of June 1, 2022, 51 pts with AML were treated (16 in cohort 1; 17 in cohort 2; 14 in cohort 3; 4 in cohort 4). Median age was 77 yrs (TN, n=28) and 64 yrs (R/R, n=23) (Table 1). At baseline, 23 pts (45.1%) had adverse-risk cytogenetics, 37 (72.5%) had grade ≥3 neutropenia, and 27 (52.9%) had grade ≥3 thrombocytopenia. At a median follow-up of 2.8 mo (range 0.1-12.3) and median duration of treatment of 1.9 mo (range 0.0-12.3), 2 of 41 evaluable pts experienced DLTs (grade 4 neutropenia and grade 4 thrombocytopenia at 80 mg) (Table 2), which did not meet the safety stopping protocol criteria. Laboratory tumor lysis syndrome (TLS; Howard criteria) was observed in 1 pt (160 mg x 10 days) with a known history of chronic kidney disease; TLS resolved within 4 days. Twenty-one (41%) pts discontinued study drugs: 7 (13.7%) due to AEs, 5 (9.8%) due to disease progression, 4 (7.8%) proceeded to transplant, 3 (5.9%) withdrew consent, 1 (2.0%) per investigator decision, and 1 (2.0%) started new anti-cancer treatment. The most common TEAEs were neutropenia (58.8%), thrombocytopenia (45.1%), anemia (43.1%), febrile neutropenia (33.3%), nausea (39.2%), and constipation (37.3%). Neutropenia was the most common grade ≥3 TEAE observed in 30 (58.8%) pts; most cases did not require dose modification. Grade ≥3 infections occurred in 23 (45.1%) pts, mostly in cycle 1. The general incidence of febrile neutropenia and infections decreased with subsequent cycles. Four (7.8%) pts died due to unrelated TEAEs: bronchopulmonary aspergillosis, pneumonia, pulmonary sepsis, and possible intracranial hemorrhage after a fall. TEAEs leading to dose reduction (5.9%) or dose interruption (11.8%) were infrequent. In TN AML, complete remission (CR)/CR with partial hematologic recovery (CRh) was achieved in 16 (59.3%) and CR in 13 (48.1%) evaluable pts (Table 1). Of the 13 pts in CR, 7 (53.8 %) reached CR by end of cycle 1. In cohort 2 with the longest follow-up, CR was achieved in 8 (72.7%) pts with TN AML. Notably, 7 of these pts are continuing study treatment (median of 5 cycles, range 1-12) without progression. In R/R AML, CR/CRh was seen in 50% of evaluable pts, with a CR rate of 25%. Nine (50.0%; 6 TN, 3 R/R) of 18 evaluable pts with CR/CRh achieved MRD negativity (<0.1% per ELN 2018). In pts with AML treated with 40, 80, and 160 mg, PK increased in a dose-dependent manner at steady state with no drug-drug interaction observed with aza. Conclusion: These results demonstrate that BGB-11417 in combination with aza was effective and generally well tolerated at the 4 dose levels tested in pts with AML, with no dose-dependent toxicities observed. Further evaluation of the 28-day regimen is underway. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

NCMP-14. NEUROTOXICITY AFTER A SINGLE CYCLE OF INTRAVENOUS CYTARABINE

Abstract Cytarabine neurotoxicity is well-documented, typically occurring after intrathecal treatment or a cumulative systemic dose of 36 g/m2. Encephalopathy, myelopathy, and acute cerebellar syndrome have all been described, with risk factors including advanced age and renal dysfunction. Here, we report a case of acute cerebellar syndrome after a single cycle of intravenous cytarabine 3 g/m2. This 65 year old man with history of chronic kidney disease (baseline creatinine 2.0 mg/dL) and primary central nervous system lymphoma had unconfirmed complete response after induction therapy with rituximab, methotrexate, and vincristine. Methotrexate was dosed between 1 -2 g/m2 due to renal dysfunction and delayed clearance. Given patient’s performance status and comorbidities, high-dose cytarabine consolidation was chosen. He received 3 g/m2 intravenously on days 1 and 2 of a 28-day cycle. On day 5, he developed acute truncal ataxia and was no longer able to sit or stand unsupported. He then presented to the emergency department on day 8 with persistent symptoms. Vital signs showed mild hypertension without orthostatic hypotension. Neurologic exam revealed postural instability, titubation, and inability to maintain seated posture with eyes closed. He had no dysmetria on finger-nose or heel-shin testing. Blood values were notable only for an elevated creatinine of 2.1 mg/dL. CT head revealed no acute pathology. MRI brain showed no infarct or recurrent disease. He was discharged home and symptoms resolved by day 10. Given clinical syndrome of truncal ataxia shortly after cytarabine, we diagnosed cytarabine-related neurotoxicity. Further cycles of consolidation were withheld for close observation. While cytarabine-related neurotoxicity is more common after an increased cumulative dose, it can occur after only a single cycle of 3 g/m2. Our patient’s age and baseline renal dysfunction likely predisposed him. Cytarabine dose-reduction can be considered in patients with these risk factors.

Abstract 11165: Characterization of Heart Failure Patients in an Academic Home Hospital Program and Identification of Patient Factors Requiring Escalation of Care

Background: Hospital capacity concerns exacerbated by the COVID-19 pandemic have accelerated growth of hospital at home (HaH) programs. However, for HaH admissions related to heart failure, information on patient characteristics and clinical outcomes remain sparse. We aimed to better characterize heart failure admissions in a HaH model and assess characteristics of patients who later needed escalation of care to a traditional hospitalization. Methods: This retrospective, descriptive study examined HaH admissions for heart failure at an academic medical center between 2017 and 2022. We compared baseline characteristics and outcomes using the Chi-squared test for categorical variables and t-test for continuous variables for patients who required escalation of care to those who did not. Using the same methods, we also compared patients based on their location prior to admission (e.g. emergency department (ED), home). Results: Heart failure was the primary diagnosis for 32% of HaH admissions. The majority of the heart failure cohort (N=199, average age 80.6 years), 73.9%, had heart failure with preserved ejection fraction (HFpEF). Escalation of care to traditional hospitalization was required for 22.6% of patients. 9.0% of patients died within 90 days, and 20.1% and 36.2% of patients were readmitted for any reason within 30 and 90 days respectively. Patients whose care was escalated were more likely to have a history of chronic kidney disease (84.1% vs 66.9%, p=0.043), higher admission BUN (41.5 vs 31.1, p=0.004) and creatinine (1.74 vs 1.41, p=0.011), and a history of PCI (20.5% vs 5.3%, p=0.005). Patients referred directly from home compared to the ED had similar baseline characteristics and rates of 90 day inpatient readmission and mortality. Conclusions: Patients admitted to HaH for heart failure represent a high risk cohort who are commonly older with multiple comorbidities and more likely to have HFpEF. Among this cohort, patients with kidney dysfunction and/or history of percutaneous coronary intervention are more likely to require escalation of care. These results suggest that heart failure patients admitted to HaH who will later need traditional hospitalization could be identified prospectively using these characteristics.

Incidence and predictors of acute kidney injury among women with severe pre-eclampsia at Mbarara Regional Referral Hospital

BackgroundThe presence of acute kidney injury (AKI) in pre-eclampsia complicates treatment including; increasing length of hospital stay and a need to access services like dialysis which are largely expensive in resource-limited settings. We aimed to determine incidence and predictors of acute kidney injury among women with severe pre-eclampsia at Mbarara Regional Referral Hospital in southwestern Uganda.MethodsWe carried out a hospital-based prospective cohort study from 16 November 2018 to 18 April 2019, among pregnant women with severe pre-eclampsia followed up in the hospital. We enrolled 70 mothers with severe pre-eclampsia and eclampsia; we excluded patients with a history of chronic kidney disease, chronic hypertension, and gestational hypertension. Data on socio-demographics, laboratory parameters, health system, obstetric and medical factors were collected. Baseline serum creatinine, complete blood count, and CD4 T-cell count were all done at admission (0-hour). A second serum creatinine was done at 48-hours to determine the presence of AKI and AKI was defined as a relative change of serum creatinine value at least 1.5 times the baseline (i.e., at admission) within 48 h. The proportion of women diagnosed with acute kidney injury among the total number of women with severe pre-eclampsia was reported as incidence proportion. Univariate and multivariate logistic regression was used to establish the association between acute kidney injury and severe pre-eclampsia.ResultsIncidence of acute kidney injury was high (42.86%) among women with severe pre-eclampsia. Antenatal care attendance was protective with an odds ratio of 0.14 (0.03, 0.73), p-value 0.020 at bivariate analysis but had no statistical significance at multivariate analysis. Eclampsia was an independent risk factor for acute kidney injury. (aOR 5.89 (1.51, 38.88), p-value 0.014.ConclusionThe incidence of acute kidney injury in patients with severe pre-eclampsia is high. Eclampsia is an independent risk factor of acute kidney injury. The findings of this study highlight the urgent need for more research and better perinatal care for these women.

A RARE MANIFESTATION OF KIDNEY DISEASE IN COMMON VARIABLE IMMUNODEFICIENCY

<h3>Introduction</h3> Patients with Common Variable Immunodeficiency (CVID) are at risk for developing both infectious and non-infectious complications. An uncommon complication in patients with CVID is kidney disease. <h3>Case Description</h3> A 39 year old male with history of CVID, granulomatous and lymphocytic interstitial lung disease (GLILD), immune thrombocytopenia purpura, splenomegaly, Raynaud's phenomenon and autoimmune thyroiditis was found to have an asymptomatic elevated creatinine. He developed a gradual increase in creatinine starting in 2020 with a peak creatinine of 2.17 and blood urea nitrogen of 30 in 2022. His creatinine and blood urea nitrogen were 0.91 and 18 in 2019. CVID was originally diagnosed in 2016. He was managed on subcutaneous immunoglobulin replacement therapy for several years. He did not have a known family history of chronic kidney disease. Kidney biopsy demonstrated dense lymphocytic infiltration with B and T lymphocytes. He was started on slow prednisone taper, rituximab, and trimethoprim-sulfamethoxazole for <i>Pneumocystis</i> pneumonia prophylaxis. His kidney function improved and has remained stable with a creatinine and blood urea nitrogen of 1.68 and 27, respectively. <h3>Discussion</h3> This case serves as an example of a rare complication in a patient with CVID. The mechanism of kidney disease in CVID is not well known. Previous reported cases of kidney disease in CVID have demonstrated evidence of glomerulonephritis and tubulointerstitial nephritis. This case is also unique in that the patient was treated with rituximab. Further investigation is needed into the appropriate monitoring and treatment options for kidney disease with CVID.

ODP425 Potassium Level Trends in Trans Females Using Spironolactone: A Retrospective Chart Review

Abstract Introduction Endocrine Society guidelines for the treatment of gender dysphoric individuals recommend close monitoring of serum electrolytes, particularly potassium in trans females using spironolactone every 3 months (first year) and annually afterwards (1) due to risk of hyperkalemia from mineralocorticoid antagonism (2). Unless patients have kidney disease, the risk of hyperkalemia with spironolactone use is low and therefore monitoring of potassium levels has been questioned. A study conducted in trans youth on spironolactone treatment showed asymptomatic hyperkalemia in 2.2% of study subjects but no clinically significant hyperkalemia (3). Objectives We hypothesized that the incidence of hyperkalemia in trans females using spironolactone is low and therefore when present is clinically insignificant. Methods This was a retrospective chart review of trans females who received gender-affirming hormone therapy that included spironolactone from the endocrinology clinic between January 1, 2000 and September 6, 2018. Out of a cohort of 244 trans subjects, 77 trans females had serum potassium levels documented. 6 trans women only on estrogen and 21 trans women with only one potassium measurement were excluded. The remaining 50 subjects that had an initial and at least 1 follow-up potassium were included and analyzed. ​ Study outcomes included incidence of hyperkalemia (serum potassium &amp;gt;5.5 mmol/L), the relationship between duration and degree of hyperkalemia and difference between potassium levels at the beginning of spironolactone treatment vs last potassium level as of September 2018. Results The mean age of the subjects was 42.8 years (SD 14.39 years). The cohort was predominantly of Caucasian race (62.8%). All subjects had spironolactone doses in the range of 100- 400 mg/ day. No potassium level was above 5.5 mmol/ L and all subjects had creatinine &amp;lt; 2 mg/dL. The average duration of treatment was 25 months (range 2- 142 months) and total 140 post-spironolactone potassium levels were available. The mean pre-spironolactone potassium level (3.88 mmol/L) was lower than mean post spironolactone potassium level (3.98 mmol/L) but the difference was statistically and clinically insignificant (p=0.106, paired t-test). The mean of cumulative post spironolactone potassium levels (4.03mmol/L) was higher than the mean of baseline potassium levels (p=0.012, unpaired t-test) but clinically insignificant. Conclusion No subjects had laboratory evidence of hyperkalemia in our cohort of patients. This implies that frequent measurement of potassium levels might be unnecessary in trans women taking spironolactone, in patients with no history of chronic kidney disease. References 1 Hembree, W.C., et al., Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, 2017 2 Epstein, M. and D.A. Calhoun, Aldosterone blockers (mineralocorticoid receptor antagonism) and potassium-sparing diuretics. J Clin Hypertens (Greenwich), 2011 3 Millington, K., E. Liu, and Y.M. Chan, The Utility of Potassium Monitoring in Gender-Diverse Adolescents Taking Spironolactone. J Endocr Soc, 2019 Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Ultrasound findings in severe COVID-19: a deeper look through the carotid arteries.

To investigate vascular and perivascular abnormalities in the carotid arteries using ultrasound, as well as to evaluate their association with mortality and clinical variables in hospitalized patients with coronavirus disease 2019 (COVID-19). This was a prospective study in which 53 hospitalized patients with severe COVID-19 were evaluated and underwent carotid ultrasound. We documented the carotid ultrasound findings in these patients. Clinical, demographic, laboratory, and imaging features were analyzed and compared by statistical analysis to detect correlations between them. Carotid ultrasound demonstrated luminal surface irregularity in 29 patients (55%), carotid plaques in 30 (57%), perivascular infiltration in four (8%), and increased intima-media thickness (IMT) in 31 (58%). Of the 31 patients with increased IMT, 19 (61%) died, and the association between increased IMT and COVID-19-related mortality was significant (p = 0.03). Logistic regression showed that the risk of death was 85% in patients who had increased IMT in combination with acute kidney injury at admission or a history of chronic kidney disease (p < 0.05). In hospitalized patients with severe COVID-19, carotid ultrasound can show increased IMT, luminal surface irregularity, carotid plaques, and perivascular infiltrates. The combination of increased IMT and kidney damage appears to increase the risk of death in such patients.

Mortality and 30-Day Readmission Rates After Inpatient Leadless Pacemaker Implantation: Insights From a Nationwide Readmissions Database.

This study aimed to provide real-world data on the rates, trends, and predictors of in-hospital complications and 30-day readmission following leadless pacemaker (LP) implantation. We analysed leadless and conventional pacemaker implantations with the use of the all-payer, nationally representative Nationwide Readmissions Database from 2017 to 2019. The national trends of in-hospital mortality, in-hospital complications, and 30-day readmission rates after pacemaker implantation were analysed. Mixed-effects multivariable logistic regression analysis was performed to identify factors associated with in-hospital death and 30-day readmission in LP patients. A total of 137,732 admissions (age 78 years, IQR 70-85 years, 5986 LP implantations) were analysed. The in-hospital mortality, overall in-hospital complication, and 30-day readmission rates after LP implantations were 5.0%, 16%, and 16%, respectively. In LP recipients, the national estimate of in-hospital mortality declined from 10.9% in the second quarter of 2017 to 4.3% in the fourth quarter of 2019 (P < 0.001). Furthermore, the national estimate of overall complications declined from 20.6% in the second quarter of 2017 to 13.0% in the fourth quarter of 2019 (P < 0.001). In LP recipients, female sex, history of chronic kidney disease, heart failure, and malnutrition were factors associated with in-hospital death. Analysis of the nationally representative claims database from the United States showed in-hospital mortality and complication rates (for LP implantation performed during hospitalisation) of 5.0% and 16%, respectively. Although these rates showed a decreasing trend over time, ongoing surveillance is needed for the safety of LP implantation.

ОПЫТ ПРИМЕНЕНИЯ ДАСАБУВИРА / ОМБИТАСВИРА / ПАРИТАПРЕВИРА / РИТОНАВИРА У ПАЦИЕНТОВ, НАХОДЯЩИХСЯ НА ГЕМОДИАЛИЗЕ, С ВИРУСНОЙ ИНФЕКЦИЕЙ ГЕПАТИТА С

Abstract. Introduction. Hepatitis C virus is very common in patients on maintenance hemodialysis, resulting in high morbidity and mortality. Currently, new direct antiviral agents lead to a cure of Hepatitis C virus among most patients with a very good safety profile, which has allowed their use in the treatment of patients with Chronic Kidney Disease as well.Aim. To analyze the practical experience of using dasabuvir/ ombitasvir/ paritaprevir/ ritonavir in patients with chronic hepatitis C with history of chronic kidney disease. Material and methods. Treatment with dasabuvir/ ombitasvir/ paritaprevir/ ritonavir was carried out in 11 patients on hemodialysis with chronic hepatitis C. The virologic response was evaluated in 4 and 8 weeks at the end of the treatment, as well as sustained virologic response in 12 and 24 weeks after the start of treatment. Tolerability and safety of the drugs were also evaluated. Laboratory parameters and adverse reactions during treatment were analyzed.Results and discussion. Treatment using dasabuvir/ ombitasvir/ paritaprevir/ ritonavir was tolerated satisfactorily by all patients. There were no undesirable events. All patients completed the treatment cycle with a 100% rapid virologic response and 100% sustained virological response. No serious adverse reactions were registered. Upon follow-up, the hepatitis C virus was again detected in one patient, but of a different genotype.Conclusion. Treatment using dasabuvir/ ombitasvir/ paritaprevir/ ritonavir is effective for patients with chronic hepatitis C of the first genotype of the virus on the background of chronic kidney disease with program hemodialysis. Patients with chronic kidney disease are at high risk of infection and reinfection with parenteral viral hepatitis.

MM-218 Plasma Cell Myeloma-Associated Crystal-Storing Histiocytosis

This study reports a plasma cell myeloma case, which presented with cytoplastic crystalline inclusions both in plasma myeloma cells and histiocytes in the bone marrow smears. A 39-year-old man with a history of chronic kidney disease (uremic stage) has been treated with regular dialysis in the past 6 years. He recently presented with anemia (hemoglobin, 99 g/L), and laboratory studies showed an IgA kappa paraprotein (30.5 g/L). Wright-stained bone marrow aspirate smears detected two types of cells containing globular, azurophilic, crystalline inclusions in the cytoplasm; one was relatively small in size with round eccentric nuclei, condensed chromatin, and scattered cytoplasmic crystals, consistent with plasma cells. Another was much larger in size with an irregular contour and abundant cytoplasmic crystals, consistent with histiocytes. The bone marrow biopsy showed 30% abnormal plasma cells associated with prominent proliferation of histiocytes. By immunohistochemistry, plasma cells were highlighted by CD138 and histiocytes were highlighted by CD68, corresponding to the two populations detected on smears. Plasma cells and histiocytes were both positive for K light chain by immunostain, which demonstrated that they contained the same immunoglobin deposition. The presence of immunoglobin crystals in plasma cells or histiocytes has been reported, but the detection of immunoglobin crystals in plasma cells and histiocytes simultaneously, as described in this case, is extremely rare. The pathogenesis of the clinical presence should be further studied.

Return to Work and Associated Factors After the First Hospitalization for Heart Failure.

Heart failure (HF) is a public health problem worldwide. Employment is vital in terms of personal, social, and economic aspects for patients with chronic diseases. The aim of this study is to investigate returning to work and the associated factors after first hospitalization for HF in working- age patients. In this retrospective cohort study, patients with the first hospitalization for HF in 2017-2020 who were employed before hospitalization were included. The demographic, occupational, and disease-related variables were compared in subjects with and without returning to work. Next, the relationship between the variables and the number of days off work was examined in participants who had returned to work. The data of 204 participants were analyzed. About 90% of the participants returned to work after one year. There was a significant relationship between not returning to work and higher age, female sex, higher New York Heart Association (NYHA) class, Ejection fraction (EF) ≤ 40%, and history of chronic kidney disease (CKD). Among the participants who had returned to work, income level, cause of work exit, employer support, and the number of rehabilitation sessions had a significant relationship with the number of days off work. The results of this study showed that gender, age, EF level, history of CKD, and NHYA class were the most influential factors in returning to work after first HF hospitalization. Furthermore, income, cause of work exit, employer support, and the number of rehabilitation sessions were the most important factors contributing to the number of days off work.

Long-term use of renin-angiotensin-system inhibitors after acute myocardial infarction is not associated with survival benefits: Analysis of data from the Korean acute myocardial infarction registry-national institutes of health registry.

IntroductionRenin-angiotensin-system inhibitors (RASi) have shown survival benefits after acute myocardial infarction (MI), but the role of routine long-term use of RASi remains unclear. Thereby, we explored the therapeutic effects of RASi medication at 1-year follow-up from acute MI.MethodsUsing the nationwide Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH) registry, we included and analyzed 10,822 subjects. Patients were stratified into those taking RASi at 1-year follow-up (n = 7,696) and those not taking RASi at 1-year follow-up (n = 3,126). Patients were followed up for 2-years from the 1-year follow-up; 2-year all-cause mortality and cardiac mortality were analyzed as primary and secondary outcomes, respectively.ResultsThe use of RASi at 1-year follow-up was not associated with decreased all-cause mortality (log-rank P = 0.195) or cardiac mortality (log-rank P = 0.337). In multivariate analyses, RASi medication at 1-year follow-up did not reduce all-cause mortality (P = 0.758) or cardiac mortality (P = 0.923), while RASi medication at discharge substantially reduced 1-year all-cause and cardiac mortality. Treatment with either an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker at 1-year follow-up did not show survival benefits from 1-year follow-up, respectively. The use of RASi at 1-year follow-up did not show a prognostic interaction between previous history of chronic kidney disease, post-MI acute heart failure, concomitant use of beta-blockers at 1-year follow-up, or 1-year LVEF.ConclusionAcute MI patients taking RASi at 1-year follow-up were not associated with improved 2-year all-cause mortality or cardiac mortality from the 1-year follow-up. This study provides valuable information regarding tailored medication strategy after acute MI.Clinical trial registration[www.ClinicalTrials.gov], identifier [KCT0000863].