Improvement In Creatinine Research Articles

Clinical Course and Outcomes of Acute Heart Failure with Moderate-to-Severe Mitral or Tricuspid Regurgitation: Decongestion in Heart Failure with Atrioventricular Valve Regurgitation

Moderate-to-severe mitral regurgitation (MR) and tricuspid regurgitation (TR) are common in patients hospitalized with heart failure (HF) and have been associated with poor quality of life and increased mortality. The impact of these valve lesions on in-hospital decongestion and post-discharge outcomes is less clear. This study analyzed 617 patients hospitalized for acute HF in the DOSE-AHF, ROSE-AHF, and CARESS-HF trials. We assessed biomarkers, physical exam findings, and symptom scores in 288 patients without moderate-to-severe regurgitation, 221 patients with moderate-to-severe MR, and 242 patients with moderate-to-severe TR to evaluate decongestion efficacy and outcomes. For patients with moderate-to-severe MR, there was no difference in weight loss, net fluid loss, or change in creatinine compared to those without moderate-to-severe regurgitation (all: p > 0.05 at 72h). For patients with moderate-to-severe TR, there was more weight loss (-4.77 lbs vs -2.83 lbs at 24 h, p = 0.029; -9.32 lbs vs -6.99 lbs at 72 h, p = 0.007), net fluid loss (-4988mL vs -4581mL, p = 0.008) and improvement in creatinine (-0.09 mg/dl vs +0.06 mg/dl at 72 h, p = 0.002) compared to those without moderate-to-severe regurgitation. Among those with and without moderate-to-severe regurgitation, there was no difference in the change in patient-reported dyspnea or global well-being (all: p > 0.05 at 72 h or 96 h). For post-discharge outcomes, compared to patients without moderate-to-severe regurgitation, moderate-to-severe MR was associated with a non-significant trend towards increased death, rehospitalization, or unscheduled clinic or emergency department visit 60 days following hospital discharge (48.4% vs 38.2% of patients; p = 0.098). This association was not clearly apparent in patients with moderate-to-severe TR (43.8% vs 38.2%, p = 0.407). In conclusion, patients with moderate-to-severe MR experienced similar in-hospital decongestion compared with those without significant regurgitation but had a trend towards worse post-discharge outcomes. Patients with moderate-to-severe TR experienced significantly more decongestion but this was not associated with incremental improvement in dyspnea, global well-being, or clinical outcomes.

7027 A Rare And Multifactorial Etiology Of Severe Parathyroid Hormone Independent Hypercalcemia In An Adult Female With Rett Syndrome

Abstract Disclosure: M.I. Foo: None. M. Thompson: None. Background: Symptomatic hypercalcemia is a rare, but potentially life-threatening disorder. Although dehydration is an unusual cause of severe hypercalcemia, in the appropriate clinical setting dehydration may amplify underlying mild or moderate hypercalcemia to dangerous levels.Case: A 46-year-old non-verbal, non-mobile Caucasian female with Rett Syndrome (RS) with Stage III Chronic Kidney Disease (CKD3) who is dependent on percutaneous endoscopic gastrostomy (PEG) tube for nutrition and known PTH independent hypercalcemia of unknown etiology presented to the hospital with intractable vomiting and constipation, an outpatient serum calcium level of 16.0 mg/dL, and serum creatinine 4.03 mg/dL (baseline 1.2 mg/dL). Initial laboratory assessment revealed elevated corrected serum calcium levels (15.7 mg/dL), with appropriately suppressed PTH levels (12.5 pg/mL) and hypernatremia (146 mmol/L). Thyroid function tests, both Vitamin D 1,25(OH)2D and D 25(OH)D levels and PTH-RP were normal. Computed tomography of the abdomen and pelvis revealed bilateral nephrolithiasis and moderate stool burden, but no evidence of malignancy or granulomatous disease. Skeletal scintigraphy was also without evidence of osseous metastatic disease or Paget’s disease of bone. An in-depth interview with the patient’s caregiver uncovered that the patient had a relative intolerance to enteral hydration and had been receiving minimal water flushes prior to admission, contributing to severe dehydration. Hypercalcemia was ultimately ascribed to prolonged immobilization due to RS compounded by inadequate fluid intake and auto-diuresis secondary to hypercalciuria in the setting of CKD (prior baseline eGFR 45 mL/min/1.73m2).Outcome: The patient's hypercalcemia improved after a multidisciplinary and multi-directed approach involving intravenous and enteral fluid resuscitation, calcitonin, furosemide, and ultimately zoledronic acid following improvement in creatinine with fluid resuscitation. The dietary service employed a strategy of 24-hour enteral feeding, increasing both the frequency and amount of enteral water, which the patient tolerated well, and provided her with a new pump for home use. Education on monitoring tube feed tolerance and providing adequate enteral hydration was provided to both the caregiver and group home. On discharge, eGFR stabilized at 33 mL/min/1.73m2 and corrected calcium stabilized at 10.0–10.4 mg/dl. She was provided with an endocrinology follow-up to continue bisphosphonate therapy.Discussion: Hypercalcemia of immobility should remain a differential diagnosis in severe hypercalcemia, especially PEG tube dependent patients with underlying kidney disease. This case highlights the importance of thorough history taking and a multidisciplinary strategy to guarantee optimal care and mitigate potential adverse outcomes in medically complex patients. Presentation: 6/2/2024

Axillary mechanical circulatory support improves renal function prior to heart transplantation in patients with chronic kidney disease

Impaired kidney function is often associated with acute decompensation of chronic heart failure and portends a poor prognosis. Unfortunately, current data have demonstrated worse survival in patients with acute kidney injury than in patients with chronic kidney disease during durable LVAD placement as bridge therapy. Furthermore, end-stage heart failure patients undergoing combined heart-kidney transplantation have poorer short- and long-term survival than heart transplants alone. We evaluated the kidney function recovery in our heart failure population awaiting heart transplantation at our institution, supported by temporary Mechanical Circulatory Support (tMCS) with Impella 5.5. The protocol (#22004000) was approved by the Mayo Clinic institutional review board, after which we performed a retrospective review of all patients with acute on chronic heart failure and kidney disease in patients considered for only heart and kidney combined organ transplant and supported by tMCS between January 2020 and February 2021. Hemodynamic and kidney function trends were recorded and analyzed before and after tMCS placement and transplantation. After placement of tMCS, we observed a trend towards improvement in creatinine, Fick cardiac index, mixed venous saturation, and glomerular filtration rate (GFR), which persisted through transplantation and discharge. The average duration of support with tMCS was 16.5 days before organ transplantation. The median pre-tMCS creatinine was 2.1 mg/dL (IQR 1.75–2.3). Median hematocrit at the time of tMCS placement was 32% (IQR 32–34), and the median estimated glomerular filtration rate was 34 mL/min/BSA (34–40). The median GFR improved to 44 mL/min/BSA (IQR 45–51), and serum creatinine improved to 1.5 mg/dL (1.5–1.8) after tMCS. Median discharge creatinine was 1.1 mg/dL (1.19–1.25) with a GFR of 72 (65–74). None of these six patients supported with tMCS required renal replacement therapy after heart transplantation. Early adoption of Impella 5.5 in this patient population resulted in renal recovery without needing renal replacement therapies or dual organ transplantation and should be further evaluated.

Purslane-induced oxalate nephropathy: case report and literature review

BackgroundThe kidney is particularly vulnerable to toxins due to its abundant blood supply, active tubular reabsorption, and medullary interstitial concentration. Currently, calcium phosphate-induced and calcium oxalate-induced nephropathies are the most common crystalline nephropathies. Hyperoxaluria may lead to kidney stones and progressive kidney disease due to calcium oxalate deposition leading to oxalate nephropathy. Hyperoxaluria can be primary or secondary. Primary hyperoxaluria is an autosomal recessive disease that usually develops in childhood, whereas secondary hyperoxaluria is observed following excessive oxalate intake or reduced excretion, with no difference in age of onset. Oxalate nephropathy may be overlooked, and the diagnosis is often delayed or missed owning to the physician’s inadequate awareness of its etiology and pathogenesis. Herein, we discuss the pathogenesis of hyperoxaluria with two case reports, and our report may be helpful to make appropriate treatment plans in clinical settings in the future.Case presentationWe report two cases of acute kidney injury, which were considered to be due to oxalate nephropathy in the setting of purslane (portulaca oleracea) ingestion. The two patients were elderly and presented with oliguria, nausea, vomiting, and clinical manifestations of acute kidney injury requiring renal replacement therapy. One patient underwent an ultrasound-guided renal biopsy, which showed acute tubulointerstitial injury and partial tubular oxalate deposition. Both patients underwent hemodialysis and were discharged following improvement in creatinine levels.ConclusionsOur report illustrates two cases of acute oxalate nephropathy in the setting of high dietary consumption of purslane. If a renal biopsy shows calcium oxalate crystals and acute tubular injury, oxalate nephropathy should be considered and the secondary causes of hyperoxaluria should be eliminated.

How Should Acute T Cell-mediated Rejection of Kidney Transplants be Treated: Importance of Follow-up Biopsy From Kidney Transplantation.

Aziz et al1 in Wisconsin published their experience with protocol repeat biopsies in 163 episodes of T cell–mediated rejection (TCMR) between 2015 and 2020. Among their patients with a complete response as assessed by kidney function, 14% had a partial or no response histologically. Among patients with no kidney function response, 68% had a complete response histologically. They concluded that responses based on kidney function alone did not correlate with histology. These findings were echoed in the meta-analysis by Ho et al.2 We present our single-center experience of for-cause renal biopsy in which isolated TCMR was found between 2018 and 2021. There were 22 cases (total 349 transplantations) of isolated TCMR in which a repeat biopsy at a median of 14 (range, 5–30) d was performed. There were 6 episodes of borderline TCMR, 5 episodes of Banff 1A, 2 episodes of Banff 1B, 7 episodes of Banff 2A, and 2 episodes of Banff 2B rejections. Borderline TCMR and 1A Banff rejections were invariably treated with 250 to 500 mg IV methylprednisolone for 3 d. Three episodes of 2A and 2 episodes of 2B rejections were additionally treated with 3 to 7 mg/kg of antithymocyte globulin. The remainder episodes of the 2A rejection were treated with methylprednisolone alone. Seventeen of 22 patients (77%) had improved creatinine with these treatment regimens. Nine of 17 patients (53%) had complete resolution of interstitial inflammation, tubulitis, or vascular lesions. Eight of 17 patients (47%) had residual histology requiring higher target tacrolimus trough levels (n = 5), 2 patients required 3 additional doses of 250 to 500 mg intravenous methylprednisolone, and 1 patient changed from mycophenolate to everolimus. Five of 22 patients (23%) showed no improvement in creatinine (3 had borderline TCMR, 1 had 1A rejection, and 1 had 2A Banff rejection) with repeat biopsies at 6, 14, 14, 14, and 22 d. Complete resolution of histology occurred in 2 of 5 patients (40%). Three of 5 patients (60%) had residual histological features requiring a further 3 doses of 500 mg of methylprednisolone and 2 patients aimed for higher tacrolimus trough targets. Although our data represent for-cause biopsy, rather than protocol biopsy, they reemphasize the data from Aziz et al1 and Ho et al.2 Irrespective of the improvement in creatinine, a repeat biopsy showed complete resolution of histology in only 40% to 53% of patients at a median of 2 wk after the first biopsy. With the global pandemic, delivery of patient care was frequently dictated by the level of lock down, and telehealth was used at a rate unlike ever before. However, the experience of our center together with the published literature highlights the importance of rebiopsy posttreatment of TCMR.

Effects of different levels of dietary crude protein on the physiological response, reproductive performance, blood profiles, milk composition and odor emission in gestating sows.

This study was conducted to evaluate the effects of crude protein (CP) levels on the physiological response, reproductive performance, blood profiles, milk composition and odor emission in gestating sows. Seventy-two multiparous sows (Yorkshire×Landrace) of average body weight (BW), backfat thickness, and parity were assigned to one of six treatments with 10 or 11 sows per treatment in a completely randomized design. Experimental diets with different CP levels were as follows: i) CP11, corn‒soybean-based diet containing 11% CP; ii) CP12, corn‒soybean-based diet containing 12% CP; iii) CP13, corn‒soybean-based diet containing 13% CP; iv) CP14, corn‒soybean-based diet containing 14% CP; v) CP15, corn‒soybean-based diet containing 15% CP; and vi) CP16: corn‒soybean-based diet containing 16% CP. There was no significant difference in the performance of sow or piglet growth when sows were fed different dietary protein levels. Milk fat (linear, p = 0.05) and total solids (linear, p = 0.04) decreased as dietary CP levels increased. Increasing dietary CP levels in the gestation diet caused a significant increase in creatinine at days 35 and 110 of gestation (linear, p = 0.01; linear, p = 0.01). The total protein in sows also increased as dietary CP levels increased during the gestation period and 24 hours postpartum (linear, p = 0.01; linear, p = 0.01). During the whole experimental period, an increase in urea in sows was observed when sows were fed increasing levels of dietary CP (linear, p = 0.01), and increasing blood urea nitrogen (BUN) concentrations were observed as well. In the blood parameters of piglets, there were linear improvements in creatinine (linear, p = 0.01), total protein (linear, p = 0.01), urea (linear, p = 0.01), and BUN (linear, p = 0.01) with increasing levels of dietary CP as measured 24 hours postpartum. At two measurement points (days 35 and 110) of gestation, the odor gas concentration, including amine, ammonia, and hydrogen sulfide, increased linearly when sows fed diets with increasing levels of dietary CP (linear, p = 0.01). Moreover, as dietary CP levels increased to 16%, the odor gas concentration was increased with a quadratic response (quadratic, p = 0.01). Reducing dietary CP levels from 16% to 11% in a gestating diet did not exert detrimental effects on sow body condition or piglet performance. Moreover, a low protein diet (11% CP) may improve dietary protein utilization and metabolism to reduce odor gas emissions in manure and urine in gestating sows.

Lifestyle Interventions, Kidney Disease Progression, and Quality of Life: A Systematic Review and Meta-analysis

Poor dietary patterns and low physical activity levels are important lifestyle-related factors that contribute to negative health outcomes in individuals with chronic kidney disease (CKD). Previous systematic reviews have not explicitly focused on these lifestyle factors, nor undertaken meta-analyses of any effects. We aimed to evaluate the effect of lifestyle interventions (such as diet, exercise, and other lifestyle-related interventions) on the risk factors for and progression of CKD and the quality of life. Systematic review and meta-analysis. Individuals aged 16 years or older with CKD stages 1 to 5 not requiring kidney replacement therapy. Randomized controlled trials of interventions. Kidney function, albuminuria, creatinine, systolic blood pressure, diastolic blood pressure, body weight, glucose control, and quality of life. A random-effects meta-analysis with evidence certainty assessed using GRADE. Seventy-eight records describing 68 studies were included. Twenty-four studies (35%) were dietary interventions, 23 (34%) exercise, 9 (13%) behavioral, 1 (2%) hydration, and 11 (16%) multiple component. Lifestyle interventions resulted in significant improvements in creatinine (weighted mean difference [WMD],-0.43mg/dL; 95% CI,-0.74 to-0.11; P=0.008); 24-hour albuminuria (WMD,-53mg/24h; 95% CI,-56 to-50; P<0.001); systolic blood pressure (WMD,-4.5mm Hg; 95% CI,-6.7 to-2.4; P<0.001); diastolic blood pressure (WMD,-2.2mm Hg; 95% CI,-3.7 to-0.8; P=0.003); and body weight (WMD,-1.1kg; 95% CI,-2.0 to-0.1; P=0.025). Lifestyle interventions did not result in significant changes in the estimated glomerular filtration rate (0.9mL/min/1.73m2; 95% CI,-0.6 to 2.3; P=0.251). However, narrative synthesis indicated that lifestyle intervention resulted in improvements in the quality of life. Certainty of the evidence was rated very low for most outcomes, primarily owing to the risk of bias and inconsistency. No meta-analysis was possible for quality-of-life outcomes because of variations in measurement tools. Lifestyle interventions seem to positively affect some risk factors for progression of CKD and quality of life.

Comparative outcomes of anticoagulation alone versus anticoagulation plus endovascular intervention in adults with isolated renal vein thrombosis

BackgroundLimited therapeutic strategies are available for adults with isolated renal vein thrombosis (RVT). In the present study, we explore and compare the efficacy of anticoagulation therapy alone vs anticoagulation plus endovascular intervention in the treatment of this rare disease. MethodsIn the present study, we analyzed the clinical data of RVT patients treated in a tertiary referral center in urban China from April 2012 to April 2022. These patients were classified into anticoagulation therapy (best medical treatment [BMT]) and endovascular intervention (endovascular-based treatment [EBT]) groups. The primary end points, including thrombus clearance and renal function changes, were evaluated by measuring the serum creatinine levels and glomerular filtration rates (GFRs). ResultsA total of 40 consecutive patients with RVT (25 men and 15 women) were included in the present study, with a median age of 37 years (range, 18-72 years). Some patients developed symptoms, including 12 with low back pain (30%), 11 with lower extremity edema (28%), and 10 with abdominal pain (30%). Nephrotic syndrome was the underlying etiology for most patients (30 of 40; 75%). Additionally, 28 patients (70%) developed unilateral RVT, including 18 cases of left RVT (45%). Of the 40 patients, 17 had received BMT (42%) and 23 had received EBT (58%). In the acute phase of RVT, defined as <14 days from symptom onset, the EBT group had higher thrombus clearance and better improvement of creatinine and GFR after treatment compared with the BMT group (P < .05). In the subacute phase, defined as 14 to 30 days after symptom onset, thrombus clearance was higher in the EBT group than in the BMT group (P < .05). However, the improvement in creatinine and GFR were insignificantly different between the two groups (P > .05). ConclusionsThe etiologies of RVT can and should be investigated. In the present study, RVT was primarily caused by nephrotic syndrome in young patients and also was attributed to malignancy and lupus nephritis. In addition to anticoagulation therapy, endovascular intervention, including catheter-directed thrombolysis and mechanical thrombectomy, contributed to the improvement of renal function in patients with acute RVT. Endovascular intervention markedly promoted thrombus clearance in patients in the subacute phase but did not improve renal function. Therefore, endovascular intervention should be considered if RVT is diagnosed in the acute phase.

Is percutaneous nephrolithotomy effective and safe for children with solitary kidney?

To evaluate the safety and efficacy of percutaneous nephrolithotomy (PCNL) in pediatric patients with solitary kidneys and kidney stones. Thirty-nine patients (group A) with solitary kidney under 18years of age who underwent PCNL between January 2015 and December 2021 were evaluated and analyzed. Forty-two patients (group B) with bilateral kidneys who underwent PCNL were determined as the control group and included in the analysis. Intraoperative and postoperative data such as demographic data, stone localization, bleeding and transfusion rates, operation time, complications, hospital stay, stone-free rates (SFR) and kidney function (glomerular filtration rate (eGFR)) were compared between the two groups. PCNL was performed with all patients in the prone position. Only a laser was used to fragment the stone in all cases. Stone-free was defined as the absence of residual stone fragments ≥ 2mm in maximum diameter at 3months on kidney, ureter and bladder (KUB) graphy, ultrasonography (US) or non-contrast tomography (NCCT). The mean ages of the patients in Group A and B were 7.5 ± 2.6 and 8.5 ± 3.1years, respectively. The mean stone size was 16.5 ± 4.1 and 17.0 ± 3.2mm in group A and group B, respectively (p = 0.49). SFR rates in Groups A and B were 97.4% and 95.2% (p = 1.00). There was no statistically significant difference in terms of the operation time, perioperative blood transfusion, hemoglobin decrease and Clavien grade 1 complication rates (p > 0.05). However, double-J (JJ) stent placement, duration of nephrostomy and hospital stay were longer in the solitary kidney group (p < 0.05). There was a significant improvement in creatinine and eGFR levels in both groups at the postoperative sixth month (p < 0.05). Our results show that PCNL is a safe and effective method in pediatric patients with solitary kidneys.

Effect of High-intensity Aerobic Exercise Versus Moderate-intensity Aerobic Exercise on Serum Uric Acid in Hypertension

Background &amp; purpose: Methods: Thirty hypertensive men (Mild Essential Hypertension) with ages ranging from 45 to 55 years old and BMIs ranging from 25 to 35 kg/m2 took part in the study (overweight and class1 obesity). The participants were classified randomly into two main domains; A and B. As for the first Group, (A) did high-intensity (interval) aerobic activity, while group (B) did moderate-intensity (continuous) aerobic exercise. Both categories exercised for 30-40 minutes on an electrical treadmill three times a week for eight weeks. Blood uric acid, serum creatinine, and serum urea were tested for each patient before and after the trial. The arterial blood pressure measurements were also taken before and after the study to draw comparisons and to set evaluations. Results: Both high-intensity interval and continuous moderate exercise had a significant lowering effect on serum uric acid and creatinine (p.05), with continuous moderate exercise having a better effect with a 16 percent improvement in serum uric acid and a 27.5 percent improvement in creatinine, while high-intensity interval exercise had an 8 percent improvement in serum uric acid and a 17 percent improvement in creatinine. On the other hand, arterial blood pressure and blood urea levels improved at the same rate. Conclusion: Moderate continuous exercise reduces serum uric acid and creatinine better than high-intensity interval exercise. Both have the same effect on blood pressure and urea, but moderate continuous exercise has a crystal-clear effect that cannot be denied.

Renal involvement in sarcoidosis

Sarcoidosis is a systemic granulomatosis that affects the lungs and mediastinum. Renal involvement is rare in this disease. It's most commonly granulomatous interstitial nephritis. The most common form of presentation is naked renal failure. This is a retrospective study that collected 12 cases of sarcoidosis complicated by acute renal failure. The study consisted of identifying the epidemiological, clinical, biological and histologic data that confirmed the diagnosis from January 1994 to January 2016. A search for extra-renal placement of sarcoidosis concerned all cases. Then, a study of the therapeutic and evolutionary profile was carried out in all cases. Twelve patients (8 males and 4 females) with a mean age of 43 years. The intradermal tuberculin reaction sit negative in 6 cases. Biological analysis showed acute renal failure with a median creatinine of 54.32 mg/L, biological inflammatory syndrome in all cases, normal blood calcium in 9 cases, hypercalcaemia in 6 cases, hypercalciuria in 4 cases, hypergammaglobulinemia of polyclonal appearance in 3 cases and elevated proteinuria in 2 cases. Renal ultrasound was normal in all patients. The renal biopsy performed in all cases showed tubulointerstitial nephropathy. The extra-renal signs found were pulmonary interstitial syndrome in 4 cases, dry syndrome in 4 cases, mediastinal lymphadenopathy in 4 cases, one patient presented a unilateral uveitis. Two patients underwent extra-renal treatment. All patients were on corticosteroids with a clear improvement in creatinine and normalisation of renal function in all patients. The average follow-up time was 18 months. Renal involvement during sarcoidosis is rare (10%) but may progress to renal failure (3% of cases). The renal biopsy is of great interest to maintain the diagnosis of sarcoidosis, especially in the absence of other extra-renal signs. Renal involvement during sarcoidosis is rarely revealing and may delay diagnosis, leading to chronic and even end-stage renal disease.

The Effect of Temperature, Sulfonation, and PEG Addition on Physicochemical Characteristics of PVDF Membranes and Its Application on Hemodialysis Membrane

Polyvinylidene fluoride (PVDF) membrane and its derivative have been investigated the permeation ability for creatinine and urea. The membrane was made by an inversion precipitation system in N,N-dimethyl acetamide (DMAc) and water as non-solvents. In this study, the modification of PVDF membrane permeability with PEG additives, CBT variations, and sulfonation was successfully carried out. The membrane solidification process was carried out on three variations of the coagulation bath temperature (CBT): 30, 45, and 60 °C. Eight types of membranes were characterized by using FT-IR and TGA/DSC, followed by the analysis of their porosity, hydrophilicity, water uptake, swelling degree, tensile strength, and permeability of creatinine and urea. The FT-IR spectra indicate that PVDF modification has been successfully carried out. The porosity, hydrophilicity, water uptake, and swelling degree values increase with the modification of functional groups. Furthermore, improvements in creatinine and urea permeability and clearances are achieved by increasing CBT and sulfonation in the PVDF/PEG membrane. The presence of sulfonate groups improves the membrane permeability through the interaction of intermolecular hydrogen with water and dialysate compounds. The existence of PEG as a porogen enhanced membrane porosity. Creatinine and urea clearance values increase from 0.29–0.58 and 6.38–20.63 mg/dL, respectively.

Characteristics of Light Chain Deposition Disease (LCDD) and Factors Affecting Outcome after Treatment

Introduction. LCDD is a plasma cell dyscrasia in which monoclonal immunoglobulin light chains are deposited in organs, principally kidneys. Frequently kidney biopsy confirms the diagnosis, but other organs may be involved. We hypothesize that pure LCDD has better prognosis than LCDD as part of multiple myeloma (MM). Methods. We conducted a retrospective study in which our goal was to describe the outcomes, hematologic and clinical, of LCDD patients treated at our center. We assessed level of hematologic response like in MM, and clinical response was measured by improvement in the end organ function. We also compared PFS and OS in pure LCDD cases versus LCDD as part of MM (LCDD/MM). Results. Ten patients with biopsy proven LCDD, including one with mixed LCDD and cast nephropathy, were evaluated (Table 1). The median age at presentation was 59 yrs. Four patients had LCDD and active multiple myeloma (MM) while 6 patients had pure LCDD. Two patients had chronic kidney disease (CKD) stage 3, 6 had CKD stage 4 and 2 had CKD stage 5 at diagnosis. Five patients needed renal replacement therapy (RRT) (2 peritoneal dialysis and 3 Hemodialysis). Five patients had heavy chains (all IgG kappa) and 5 had only kappa light chain disease. Urine immunofixation showed Kappa light chain in 5 patients, rest were negative. All patients were treated with standard therapy consisting of proteasome inhibitors (PI), either cyclophosphamide or Immunomodulators (IMiDs) and Steroids with 9 going on to receive an autologous stem cell transplant (ASCT). Median time to ASCT was 7 months after diagnosis (range 4-24). Nine patients reached VGPR or CR while one had PR. Two patients died, one with pure LCDD died due to dialysis related complications and one with LCDD/MM due to disease progression, 4 and 2 years after ASCT, respectively. Therapy led to a fall in creatinine from a mean of 4.984 to 3.29 mg/dL (p=0.383) and significant improvement in GFR from mean of 22.5 to 38.1 mg/ml (p=0.049). In subgroup analysis, improvement in creatinine, GFR, creatinine clearance and was not statistically significant in the patients with pure LCDD. In contrast, the group with LCDD and MM showed significant improvement in creatinine from 4.41 to 1.95 (p=0.0061), GFR from 17.25 to 37.25 (p=0.0001) and creatinine clearance from 18.75 to 3.65 (p=0.0022). In the pure LCDD group, 2 patients were on RRT before ASCT, and both continued to need RRT post-Transplant. In the LCDD/MM , 2 patients needed RRT before ASCT and one could get off Dialysis after ASCT. None of the patients who had hematologic VGPR/CR and clinical renal improvement have shown progression of LCDD. The median overall survival for both groups hasn't been reached after a median follow up of 5 years (range, 0.5 to 10 years). Conclusions. Our series, though small, provides hints into prognostic variables affecting outcomes in LCDD. Our study shows that patients with LCDD/MM had a greater improvement in kidney function in comparison to pure LCDD. On the other hand, LCDD/MM patients were more likely to have hematologic progression. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Response Rates, Non-Relapse Mortality, and Financial Implications of Transplant-Associated Thrombotic Microangiopathy Treated with Eculizumab

Background: Hematopoietic cell transplantation associated thrombotic microangiopathy (TA-TMA) shares common features with atypical hemolytic uremic syndrome (aHUS) and thrombotic thrombocytopenic purpura. TA-TMA affects multiple organ systems resulting in multi-organ failure and non-relapse mortality (NRM). Recently, complement activation has been associated with TA-TMA leading to utilization of complement blockade in TMA. Eculizumab is a humanized monoclonal antibody that binds to C5 and prevents the formation of the membrane attack complex (C5b-9) or the terminal complement pathway. Eculizumab may be an effective treatment for pediatric TA-TMA patients; however, there are limited data regarding its use in adult TA-TMA patients. Furthermore, eculizumab is an expensive medication and there are no published data regarding the financial implications of TA-TMA treated with eculizumab. The purpose of this study was to examine the response rates, NRM, and financial implications of TA-TMA treated with eculizumab.Methods: We performed a retrospective cohort study of patients with TA-TMA who received eculizumab at our institution between January 1, 2012, and April 9, 2017. TA-TMA was defined according to the BMT-CTN criteria with evidence of hemolysis, elevated LDH, renal dysfunction and negative Coombs' test. Serum complement biomarkers (C5b-9) were used to support the diagnosis when platelet or red blood cell transfusion dependence occurred with organ dysfunction or tissue evidence of microangiopathy. Patients were vaccinated against Neisseria meningitides and received appropriate antibiotic prophylaxis. Eculizumab therapy was initiated at the Food and Drug Administration-approved dosing schedule for aHUS: 900 mg intravenously weekly for the first 4 weeks followed by 1200 mg intravenously every other week beginning on week 5 for a total of 8 weeks, with some patients requiring longer than an 8 week course. The primary outcome was complete response to eculizumab therapy and responders were defined by achievement of transfusion independence and improvement in creatinine. Secondary outcomes included non-relapse mortality (NRM), inpatient cost, number of comorbidities, number of infections, number of hospitalizations, and hospital length of stay (LOS). Comorbidities were defined as any documented medical problem other than the reason for transplant and TA-TMA.Results: Twenty patients were included in the study (Table 1). The median (range) time from transplant to diagnosis of TA-TMA was 139 (14-388) days. The median (range) time from diagnosis of TA-TMA to first dose of eculizumab was 2 (0-272) days. The complete response rate was 55%. The median (range) number of doses of eculizumab was 6.5 (2-17) for responders compared to 3 (1-7) for non-responders including both inpatient and outpatient doses (p= 0.01). There were no significant differences between the number of hospitalizations for responders and non-responders. However, responders had shorter LOS and lower inpatient costs than non-responders. The median (range) LOS was 9 days (0-92) for responders compared to 61 days (26-94) for non-responders (p= 0.03). The median (range) total inpatient cost was $259,734 (0-1,670,070) for responders compared to $1,525,758 (385,092-1,948,190) for non-responders (p= 0.003). The itemized inpatient costs are shown in Figure 1. Patients who responded to eculizumab tended to be younger with less comorbidities. In fact, patients were 33% less likely to respond to eculizumab for every additional documented comorbidity at the time of TA-TMA diagnosis (HR=0.67 [95% CI 0.49-0.92]). The NRM was 1/11 (9%) for responders and 9/9 (100%) for non-responders (HR=0.07 [95% CI: 0.007-0.66]).Conclusions: TA-TMA is an important complication of HCT that is associated with high NRM and financial toxicity. Our data suggests that patients who respond to eculizumab have lower NRM, LOS, and financial costs than non-responders. There was a statistically non-significant trend in incidence of steroid-refractory GVHD in the non-responder group; additionally non-responders received significantly fewer doses than responders, which may explain partly the lower response rates compared to the 80% response rates in aHUS. Patient age and the number of comorbidities at the time of diagnosis of TA-TMA may be important predictive factors for response to eculizumab. [Display omitted] DisclosuresMims:Novartis: Honoraria. Hofmeister:Janssen: Research Funding; Karyopharm: Research Funding; Celgene: Research Funding; Thrassos: Honoraria, Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb: Research Funding; Adaptive Biotechnologies: Honoraria, Membership on an entity's Board of Directors or advisory committees; Roche: Research Funding; Takeda: Research Funding. Walker:Gilead: Research Funding. Vasu:Stemline Therapeutics: Research Funding; Boehringer-Ingelheim: Research Funding.

STUDY ON THE EFFECTIVENESS OF PLASMA EXCHANGE THERAPY IN PATIENTS WITH HYPERTRIGLYCERIDEMIA-INDUCED SEVERE ACUTE PANCREATITIS AT CHO RAY HOSPITAL

Objective: Data about effectiveness and safety of plasma exchange therapy for patients of hypertriglyceridemia-induced severe acute pancreatitis in Vietnam is still limited. This study is aimed at assessing the effectiveness of plasma exchange therapy in patients with hypertriglyceridemia-induced severe acute pancreatitis. Methods: A descriptive prospective study of 49 hypertriglyceridemia-induced severe acute pancreatitis patients, who were received plasma exchange therapy at ICU of Cho Ray Hospital from 02/2019 to 07/2020. Results: After one plasma exchange therapy session: The TG level decreased by (72.5%), mean arterial pressure increased significantly (80.71 ± 23.42/90.61 ± 13.68) with (p&lt;0.05); pulse (134.02 ± 23.59/110.61± 20.59), SOFA score (6.20 ± 3.16/3.69 ± 2.90) and Intra-abdominal hypertension (18.43 ± 5.55/16.40 ± 4.86 mmHg) decreased significantly (p&lt;0.01). There were improvement of creatinine (1.75 ± 1.81/1.16 ± 1.02 mg/dL), HCO3- (15.68 ± 5.19/21.13 ± 5.60 mmol/L), and pH (7.31 ± 0.09/7.40 ± 0.07). The most common complication was mild hypokalemia (9 patients, 18.3%), allergic reactions with plasma (5 patients, 10.2%). Mortality rate was 12.2%. Conclusions: Plasma exchange therapy appeared effectively and safely in hypertriglyceridemia - induced severe acute pancreatitis patients.

Belatacept Conversion Protocols and Outcomes in Kidney Transplant Recipients

BackgroundConversion from calcineurin inhibitor (CNI)-based to belatacept-based immunosuppression has become common; however, numerous protocols have emerged in lieu of a standardized protocol. The purpose of this study was to characterize belatacept conversion protocols from multiple centers and observe outcomes. MethodsThis was a retrospective study that included Kaiser Permanente Southern California members. The primary outcome was rejection 6 months after conversion and secondary outcomes included change in serum creatinine and graft loss. ResultsSeventy-eight patients were included. Thirteen distinct protocols were identified from 8 different transplant centers. Protocols varied by initial dose, induction schedule, and CNI taper. The observed rate of rejection was 6%. There was a trend toward an association of rejection with lower tacrolimus exposure at the time of conversion and lower mycophenolic acid dosing postconversion. Graft survival was 88% and patient survival was 94%. There was a significant improvement in creatinine after conversion. Those with early conversions and creatinine >2.0 mg/dL at the time of conversion had the best response. ConclusionsA large variety of belatacept conversion protocols were identified. Protocols were defined by the initial dose, induction regimen, and CNI taper. Rejection rates were low and may be influenced by exposure to maintenance immunosuppression during and after conversion. Most patients showed stabilization and improvement in creatinine postconversion, with the largest effect in those with an early conversion and serum creatinine >2.0 mg/dL.

EP19 Renal sarcoidosis associated with certolizumab pegol treatment for psoriatic arthritis: a case report

EP19 Renal sarcoidosis associated with certolizumab pegol treatment for psoriatic arthritis: a case report

A detailed appraisal of renal manifestations in primary hyperparathyroidism from Indian PHPT registry: Before and after curative parathyroidectomy.

Primary hyperparathyroidism (PHPT) is a systemic disorder characterized by hypercalcaemia and inappropriately elevated parathyroid hormone (PTH). Renal manifestations are one of the main presenting features both in symptomatic and asymptomatic PHPT patients. We aimed to compare demographic, clinical and biochemical parameters of PHPT patients with and without renal manifestations and also analysed the influence of curative parathyroidectomy on renal functions. We retrospectively analysed the data of PHPT patients from the last 25years (1995- March 2019) and compared the demographic and clinical presentation and biochemical measurements between patients with and without renal manifestations and evaluated the changes in renal functions after 1year of curative parathyroidectomy. Of the total 544 PHPT patients, 299 (55%) including 91 out of 141 (65%) males had renal manifestations. Among renal manifestations, nephrolithiasis and nephrocalcinosis were found in 41.7% and 27.6% PHPT patients, respectively. PHPT patients with renal manifestations had significantly higher creatinine (109.7 vs 79.6µmol/L; P<.0001) and lower eGFR level (78.8 vs 93.9mL/min/1.73m2 ; P<.0001) compared to patients without renal manifestations. Parathyroidectomy resolved the clinical symptoms with biochemical cure in the patients from both the groups. Patients with renal manifestations showed improvement in creatinine and eGFR levels after 1year of curative parathyroidectomy; however, patients without renal manifestations showed no change in creatinine and eGFR levels. Young age and male gender are predictors of renal manifestations in PHPT. Curative parathyroidectomy improves renal functions in PHPT patients with renal manifestations compared to PHPT patients without renal manifestation.

Value of Renal Vascular Doppler Sonography in Cardiorenal Syndrome Type 1.

Worsening of renal function in a patient with acute decompensated heart failure is called cardiorenal syndrome (CRS) type 1. Recent studies have shown an association of persistent systemic venous congestion with renal dysfunction. This trial was set up to investigate the changes of renal Doppler parameters with diuretic therapy in patients with CRS type 1. Cases of CRS type 1 were identified among patients hospitalized for decompensated heart failure. Serial measurements of the renal venous impedance index (VII) and arterial resistive index (ARI) were calculated by pulsed wave Doppler sonography. A total of 30 patients who had creatinine improvement with diuresis (group 1) and 34 patients without any improvement (group 2) were analyzed. Patients in group 1 had higher median VII and ARI (VII, 0.86 versus 0.66; P < .001; ARI, 0.78 versus 0.65; P < .001) on admission. A high ARI on admission (odds ratio, 6.25; 95% confidence interval, 1.84-14.3; P = .003) predicted the improvement of serum creatinine levels with diuretic therapy independent of confounding factors in patients with CRS type 1. Renal vascular Doppler parameters might offer guidance on the diagnostic and therapeutic strategies in prescribing decongestive therapy for decompensated heart failure.

Tertiary Hyperparathyroidism: Why the Delay?

To evaluate the reason for delay of surgical referral in tertiary hyperparathyroidism (THPT) and its impact on renal allograft function. Persistent hyperparathyroidism after renal transplant has been shown to negatively impact allograft function, yet referral for definitive treatment of THPT is often delayed. A retrospective review was performed of patients undergoing parathyroidectomy for THPT (n = 38) at a single institution from May 2016 to June 2018. The first elevated serum calcium after transplant and time to referral for parathyroid surgery were recorded. Baseline creatinine post-transplant and the most recent creatinine level were used to assess allograft function. Thirty-eight patients were included, with mean age 53 ± 2 years and 66% male. Mean preoperative calcium and parathyroid hormone were 10.8 ± 0.1 mg/dL and 328 ± 48 pg/mL, respectively. THPT after renal transplant was diagnosed at a median of 15 days (range of 1-4892 days). Median time to parathyroidectomy referral was 320 days (range 16-6281 days). In over 50% of patients, the cited reason for referral to an endocrine surgeon was difficulty with cinacalcet - either cost, poor calcium control, and poor compliance or tolerance. In comparing renal function between patients referred early (<278 days, n = 19) versus later (>278 days, n = 19) for parathyroidectomy, those referred early had an improvement in creatinine (27.6% vs -5%, P = 0.007). Patients with THPT wait approximately a year, on average, before referral to an endocrine surgeon for curative parathyroidectomy; earlier referral was associated with improvement in serum creatinine.