Including End Stage Renal Disease Research Articles

#2434 Literature review on the burden of herpes zoster in patients with kidney disease—a need for earlier prevention

Abstract Background and Aims Kidney disease (KD), including end stage renal disease (ESRD), is a global health problem. Both are associated with impaired immune systems, which can lead to infections. Complications such as cardiovascular disease and various infections are leading causes of morbidity and mortality in KD patients. Notably, patients with KD have an increased risk of herpes zoster (HZ). While the link between ESRD and renal transplant with increased HZ risk is understood, knowledge gaps regarding the burden of HZ across the KD spectrum still exist. This review aims to describe the risk and impact of HZ across the KD spectrum in order to guide preventive care strategies for patients with renal diseases. Method A structured literature review was conducted in PubMed using a combination of keywords and Medical Subject Heading (MeSH) terms to identify studies related to HZ risk in adult KD patients aged ≥18 years published in the English language between 01/11/2003–31/10/2023. Data extracted from published studies included the burden of HZ infection in patients with KD (risk of HZ and related complications), impact of HZ on underlying KD, and the efficacy/effectiveness of HZ vaccines among patients with KD. Results A total of 47 studies were identified (Randomized controlled trials [RCT] = 2; observational studies = 45) in this review (Fig. 1). Included studies presented evidence from regions in Europe (n = 18), Asia (n = 17), North America (n = 7), South America (n = 1), multinational (n = 2) and Australia (n = 1); country not reported in one study. Evidence from observational studies (n = 37) reported a high risk of HZ infection and related complications, such as disseminated HZ, and recurrent HZ across the KD spectrum, including chronic KD, polycystic KD, hemodialysis, peritoneal dialysis and kidney transplant patients. Infection with HZ was reported to accelerate KD progression and increased the risk of ESRD and cardiovascular events. In general, for ESRD patients with an inpatient HZ diagnosis, mortality increased with age, followed by malnutrition and bacteremia/septicemia. Studies reporting vaccine efficacy (n = 2) and effectiveness results (n = 8) suggest that HZ vaccination was associated with a reduced risk of HZ when compared to unvaccinated individuals. Furthermore, the recombinant zoster vaccine (RZV) was found to be immunogenic in kidney transplant recipients, with immunogenicity persisting through 12 months post-vaccination. An RCT post-hoc analysis showed high vaccine efficacy in patients aged ≥50 years with medical conditions at enrollment, including KD, which was consistent with the overall population. A favorable benefit-risk profile was reported in randomized and observational studies. Studies evaluating the effectiveness of the zoster live-attenuated vaccine (ZVL) found a lower risk of HZ in patients with ESRD immunized against HZ compared to unvaccinated individuals. In many countries, vaccination guidelines specifically recommended immunization of people with KD to protect against HZ. However, ZVL is contraindicated for immunocompromised (e.g. kidney transplant) patients. Conclusion Findings indicate that HZ has a significant HZ burden across the KD spectrum, which may negatively impact renal disease progression. With effective vaccines offering durable protection against HZ and its complications, the immunization of renal patients at earlier stages could enhance healthcare management and patient outcomes.

PO-05-238 BRASH SYNDROME: A RARE BUT REVERSIBLE CAUSE OF SINUS NODE DYSFUNCTION

Brash syndrome consists of a constellation of symptoms including bradycardia, renal failure, AV nodal blocking medicarions, shock, and hyperkalemia. The pathophysiology comprises of synergistic effects of AV nodal blockers and renal dysfunction with electrolyte abnormalities escalating the effect of AV nodal blockade. As a result, this syndrome is more prevalent in patients with cardiac and renal related comorbidities including end stage renal disease and hypertension requiring AV nodal blockers for treatment. Patients presenting with brash syndrome can develop a wide range of clinical symptoms from asymptomatic bradycardia to cardiogenic shock. Brash syndrome is critical to recognize because if left untreated it can lead to life threatening complications multiorgan failure and death. We present a case of a 57-year-old female with past medical history of CAD s/p PCI, HFpEF with grade 2 diastolic dysfunction, hypertension, hyperlipidemia, diabetes, asthma, ESRD on hemodialysis with frequent admissions for recurrent bradycardic episodes associated with missed hemodialysis sessions who presented to the emergency department with complaints of weakness, nausea, vomiting and multiple syncopal episodes. The patient was found to be hypotensive and bradycardic on admission for which dopamine drip was initialed. The EKG revealed sinus arrest with a junctional escape rythm at 33 beats/minute. The lab work was significant for hyperkalemia for which urgent hemodialysis was performed. The patient's home medication included carvedilol which was discontinued. Several attempts to wean off dopamine during the first 24 hrs were unsuccessful due to perisistent hypotension and bradycardia. The patient was monitored in the ICU for 48hrs on the dopamine drip after which it was successfly weaned off and patient mantained normal sinus rhythm. n/a n/a Brash syndrome is a rare cause of transient, reversible sinus node dysfucntion and bradycardia. Management involves early diagnosis, hemodyncamic support, discontinuation of AV nodal blocking agents. It is important to monitor the patient for 24-48 hrs after potassium correction as the sinus node recovery may not be immediate. Permamnent pacemaker placement should be avoided as this condition is reversible.

Painful Hemidystonia - A Rare Presentation of Uremic Encephalopathy (P5-9.011)

<h3>Objective:</h3> We describe a patient who presented with right painful hemidystonia secondary to uremic encephalopathy. We describe their presentation, clinical course and management with accompanying video. <h3>Background:</h3> Uremic encephalopathy has been associated with basal ganglia abnormalities that cause movement disorders to include chorea, tremor, and asterixis. To date, hemidystonia secondary to uremic encephalopathy, particularly in the pediatric population, has not been described. <h3>Design/Methods:</h3> A ten-year-old girl with Goldenhar syndrome (oculo-auriculo-vertebral syndrome) was admitted with acute respiratory failure which progressed to cardiac arrest leading to multiorgan failure including end stage renal disease requiring continuous renal replacement therapy (CRRT). After a brief period of recovery following extubation, she developed action tremor of the hands followed by painful right hemidystonia. Imaging following the onset of symptoms revealed new parenchymal signal abnormalities with increased T2 hyperintensities affecting the bilateral (left greater than right) caudate nuclei, globus pallidus, putamen, and left external capsule. Review of lab results revealed a correlation between the development of symptoms and a significant increase in urea and creatinine levels from baseline. She was treated with oral clonazepam and targeted botulinum neurotoxin injections with clinically meaningful benefit and closer regulation of electrolytes. Over the coming weeks, her cardiac function and renal function continued to decline, and care was redirected. <h3>Results:</h3> Painful hemidystonia, although rare, can be a presentation of uremic encephalopathy due to basal ganglia involvement. This patient showed symptomatic improvement with oral benzodiazepines and botulinum neurotoxin injections. <h3>Conclusions:</h3> Uremic encephalopathy can present with various movement disorders including chorea, tremor, asterixis and painful hemidystonia with basal ganglia involvement and should be considered in patients with worsening renal function. <b>Disclosure:</b> Dr. Sudheendra has nothing to disclose. Dr. Hull has received publishing royalties from a publication relating to health care.

Abstract 11439: Predictors of Long-Term Heart Failure Readmissions Following PCI in Women

Introduction: Heart failure (CHF) is a common cause of readmission following percutaneous coronary intervention (PCI), particularly within the first 30 days. Female sex has been shown to be an independent predictor of 30-day readmission following PCI, with higher rates of readmission secondary to CHF observed in women. Whether the increased risk for CHF readmission persists beyond this early period has not been well studied. Methods: In this multicenter, retrospective observational study clinical outcomes were analyzed after PCI among patients included in the Indiana University Health Multicenter Cath Registry Study. Hospital readmission for acute CHF was the primary endpoint and analyzed through use of the Indiana network for patient care. Results: Among 13,871 patients included in this study, 14.5% were readmitted for CHF after the index PCI during mean follow up of 2.8 years. Women (n=4,411) were more likely to be readmitted for CHF than men (n=9,460) [HR 1.37,95% CI: 1.26-1.5; p&lt;0.001). Women were older than men (66.1 vs. 63.8 years, p&lt;0.001) and more likely to have diabetes (49% vs. 41%, p&lt;0.001). Female sex persisted as independent predictor of CHF readmission after multivariate adjustment (p=0.004). The higher rate of CHF readmission in women continued to accrue beyond 30 days and event curves continued to diverge over the duration of follow up (Fig.).] Major predictors of CHF readmission included end stage renal disease, cardiogenic shock during index PCI, mechanical ventricular support at time of PCI, diabetes mellitus, and history of COPD, whereas discharge with ACEI or ARB was protective. Conclusions: Heart failure readmission remains a major cause of morbidity for women after undergoing PCI. The excess risk of CHF readmission in women extends beyond the early 30-day post PCI period.

April 2022 Medical Image of the Month: COVID Pericarditis

No abstract available. Manuscript truncated after 150 words. A 76-year-old patient presented with fatigue and shortness of breath after missing one session of dialysis. Past medical history included end stage renal disease on hemodialysis and atrial fibrillation on anticoagulation. Initial labs showed that she was COVID positive with mild elevation in troponin and a BNP 1200. While an inpatient, she had received a few sessions of dialysis and treatment for COVID (including dexamethasone and remdesivir). Initial echo showed an ejection fraction of 60-65% with a small generalized pericardial effusion, a thickened pericardium with calcification. A few days after admission patient was suddenly noted to be hypotensive with systolic blood pressure in the 70s and altered mental status. Repeated labs showed a D-Dimer of 17,232, leukocytosis, lactic acidosis, troponin 0.556 ng/ml and arterial blood gas with metabolic acidosis. With a worsening clinical picture, repeat imaging was obtained. CT angiography of the chest was negative for pulmonary embolism; however, it …

Multi-Organ Transplant in Cystic Fibrosis and its Impact on Long-Term Survival

PurposeCystic fibrosis (CF) can lead to end stage lung disease for which lung transplantation can be a life-saving therapy. CF has systemic manifestations that can lead to other end organ damage. In addition, immune suppression following single organ transplantation has adverse effects including end stage renal disease. Multi-organ transplant in CF has had a significant impact on long-term survival of CF patients. In this study, we aim to assess the impact of multi-organ transplant on the survival of CF patients.MethodsThis is a retrospective review of all CF patients who have been multi-organ recipients after their initial lung transplant (March 1988 to July 2020). Lung re- transplant only were excluded.ResultsFrom 435 lung transplant recipients we identified 19 patients with CF who had received multi-organ transplant either simultaneously with the lung transplant or consecutively over time. 7 recipients received simultaneously 15 organs that included: 1 heart and lung, 5 lung and liver and 1 lung, liver, pancreas. The median survival for this group was: 8.9 years. 12 recipients received consecutively 30 organs that included: 6 lung followed by kidney transplant; 1 lung followed by liver transplant; 1 lung followed by combined kidney+liver; 1 lung followed by combined kidney + pancreas; 1 lung followed by liver and then kidney transplant; 1 lung transplant followed by a second lung transplant and later on kidney transplant and finally 1 lung followed by another lung transplant and later on combined kidney+ pancreas.The median survival of these multiorgan recipients is 14 years. The current median survival for CF patients in our program excluding re-transplants is 8.2 years.ConclusionLung transplant for CF offers survival benefit and improved quality of life, such that a subgroup of these patients qualify for a second and even a third organ transplant to further prolong life. Cystic fibrosis (CF) can lead to end stage lung disease for which lung transplantation can be a life-saving therapy. CF has systemic manifestations that can lead to other end organ damage. In addition, immune suppression following single organ transplantation has adverse effects including end stage renal disease. Multi-organ transplant in CF has had a significant impact on long-term survival of CF patients. In this study, we aim to assess the impact of multi-organ transplant on the survival of CF patients. This is a retrospective review of all CF patients who have been multi-organ recipients after their initial lung transplant (March 1988 to July 2020). Lung re- transplant only were excluded. From 435 lung transplant recipients we identified 19 patients with CF who had received multi-organ transplant either simultaneously with the lung transplant or consecutively over time. 7 recipients received simultaneously 15 organs that included: 1 heart and lung, 5 lung and liver and 1 lung, liver, pancreas. The median survival for this group was: 8.9 years. 12 recipients received consecutively 30 organs that included: 6 lung followed by kidney transplant; 1 lung followed by liver transplant; 1 lung followed by combined kidney+liver; 1 lung followed by combined kidney + pancreas; 1 lung followed by liver and then kidney transplant; 1 lung transplant followed by a second lung transplant and later on kidney transplant and finally 1 lung followed by another lung transplant and later on combined kidney+ pancreas.The median survival of these multiorgan recipients is 14 years. The current median survival for CF patients in our program excluding re-transplants is 8.2 years. Lung transplant for CF offers survival benefit and improved quality of life, such that a subgroup of these patients qualify for a second and even a third organ transplant to further prolong life.

Outcome stratification of patients with impaired renal functions after isolated prosthetic mitral valve replacement

Objectives: Patients with impaired renal functions have a variable risk of morbidity and mortality in cardiovascular surgery. Poor outcome was reported among patients who underwent valve surgery. Current study is presumed to compare the early outcomes of patients having different degrees of impaired renal functions and undergoing mitral valve replacement surgery. Methods: 135 patients were admitted into the three highly specialized centers in Cairo and Ismailia–Egypt between Dec.2018 and Jan.2020 Preoperative, intraoperative and early post-operative data were recorded. Impairment may present as one of these strata: early reversible (G1-2 included strata 1 &amp; 2 kidney disease patients), moderate G3-4 included strata 3 &amp; 4 kidney disease patients) or advanced irreversible renal damage. (The 5th stratum or G5-KD included end stage renal disease patients undergoing 4-hour hemodialysis sessions, three times a week, with bicarbonate dialysate). We correlated outcome among each stratum with cardiac and renal functions in that stratum. Results: The more is the impairment of renal functions at any peri- operative stage, the longer is the need for prolonged mechanical ventilation and the longer is the hospital stay. We found that levels of serum creatinine were significantly increased postoperatively Also, the more is the reversibility of the renal impairment, even by renal dialysis, the much better is the outcome (P=.0019). We also found insignificant difference between different strata of irreversible renal impairment in the early outcome of the prosthetic mitral valve replacement surgery. The early reversible damage can be repaired peri-operatively. Conclusions: Prosthetic mitral valve replacement among patients with different degrees of impaired renal functions is not only feasible but also it does not seem to add any more deterioration into renal function. Prolonged mechanical ventilation and hospital stay are the only drawbacks of irreversibly impaired renal damage by dialysis or renal transplant.

Parathyroid Hormone as a Marker for the Red Cell Fragility in Different Stages of Chronic Kidney Disease

Objective: The aim of the work is to study the relationship between Red blood cell osmotic fragility and level of parathyroid hormone in patients with different stages of Chronic Kidney Disease including End Stage Renal Disease. Background: Anaemia is one of the common complications associated with Chronic Kidney Disease (CKD) responsible for the increase in the morbidity and mortality in such patients. Several factors have been attributed to causing renal anaemia, amongst which hyperparathyroidism is one of the less recognised reasons. The level of PTH in early stages of chronic kidney disease has not been much studied. The excess amount of Parathyroid Hormone (PTH) secondary to CKD has been suggested to be a causative factor for anaemia. Method: A number of chronic kidney disease patients were studied for the relationship between Red cell osmotic fragility and level of parathyroid hormone. Results: This study was conducted on a number of 111 patients with chronic kidney disease classified into three groups. The study revealed a significant fall in Hb%, along with a rise in Median Osmotic Fragility (MOF) and PTH in the CKD patients. iPTH and MOF were significantly lower in group 3 as compared with cases in group 1. Also, iPTH and MOF were significantly lower in cases in group 2 as compared with cases in group 1. Conclusions: Based on our findings, secondary hyperparathyroidism has considerable effects on erythrocyte survival, contributing to increased fragility and anemia.

Vaccination in Older Adults: The Who and What

Aging brings increased impact of infectious disease in terms of hospitalization, morbidity, and mortality. This increased susceptibility to infection results from immunosenescence, age-related changes in the immune system, anatomic and functional changes, and environmental exposure to infections. Adults age 65 and over are at increased risk of pertussis, shingles, influenza and pneumococcal disease, and evidence-based recommendations for vaccination are protect older adults against these diseases. Underlying medical conditions including end stage renal disease, chronic lung, heart and liver disease, diabetes and immunocompromised place adults age 65 and over at increased risk of infectious diseases, therefore evidence-based vaccine recommendations in older adults with additional risk factors are in place to protect against varicella, hepatitis A and B, meningococcal meningitidis and Haemophilus influenzae type b. Investigational vaccines are developed to protect against infectious diseases causing significant morbidity and mortality in older adults, for example, respiratory syncytial virus, to further promote healthy aging. Part of a symposium sponsored by the Health Behavior Change Interest Group.

Validity of Claims Diagnosis Codes for Cardiovascular Diseases in Diabetes Patients in Japanese Administrative Database.

BackgroundObservational studies using large claims databases for diabetes patients have been increasingly conducted. While validation of outcomes is important in such studies, validation studies from Japan are still scarce and small in scale with questions remaining on the representativeness of their findings. We examined the positive predictive value (PPV) of outcomes that often develop in type 2 diabetes patients: cardiovascular outcomes including congestive heart failure (CHF), myocardial infarction (MI), stroke-related diseases, and renal outcomes including end stage renal disease (ESRD), and death using a large Japanese database containing administrative claims and electronic medical record (EMR) data.Patients and MethodsWe used patient-level administrative claims data from 2003 and EMR data from 1985 to the most recent data up to December 2018 provided by Real World Data Co., Ltd. The database consisted of data from over 200 hospitals including ≥12 million uniquely identifiable patients. Among patients who had ≥1 type 2 diabetes diagnosis in the EMR, those who had administrative claims for each outcome were identified, and then the PPV was calculated for each outcome using the EMR as the gold standard.ResultsThe numbers of patients identified for each outcome were 1,700 for MI, 2,027 for hemorrhagic stroke, 3,722 for ESRD, 4,723 for ischemic stroke, 5,404 for CHF, 6,678 for any type of stroke, and 10,815 for death. PPVs ranged from 67.4% for ESRD, 78.7% for MI, 80.3% for death, 85.7% for ischemic stroke, 88.9% for any type of stroke, 89.9% for hemorrhagic stroke, and 95.7% for CHF. A post hoc analysis showed PPV for ESRD as 83.8%.ConclusionThis large-scale validation study on diagnosis in administrative claims showed reasonable PPVs for the outcomes. We believe that the definitions of outcomes can be considered to be appropriate for future studies using Japanese administrative claims data.

Case Study: An Unusual Presentation of Smoldering Multiple Myeloma in a patient with End Stage Renal Disease

A 59-Year-Old Male patient presented to the benign hematology clinic with a chief complaint of persistent macrocytic anemia with mild thrombocytopenia of unclear etiology. The patient has an extensive medical history including end stage renal disease on hemodialysis post failed kidney transplant and recurrent gastrointestinal bleeds. Two colonoscopies have recently been unable to identify a bleeding source that would account for prolonged anemia. The degree of anemia that the patient was experiencing was disproportionate to clinical documentation of bleeding, and high MCV with normal TSH, Folate, B12 and no alcohol intake ruled out a deficiency as cause of anemia. Iron studies indicated that the cause was Anemia of Chronic disease. A Bone Marrow Biopsy was requested to rule out a Hematologic Malignancy. The Bone Marrow Biopsy came back with a reported diagnosis of Plasma Cell Myeloma as the core biopsy was fifty percent cellular and plasma cells made up fifteen to twenty percent of core biopsy cellularity. Paraprotein and radiologic studies were ordered to further differentiate between multiple myeloma, plasma cell leukemia and smoldering multiple myeloma. Radiologic studies were negative for pathogenic lesions, while paraprotein studies showed a monoclonal gammopathy of IgG Kappa and a bioclonal IgA region that couldn9t be further quantified. The patient was further refered to the malignant hematology Myeloma team. The patient hasn9t returned to make any further appointments with hematology, but has been admitted once for complications related to his end stage renal disease. Asymptomatic myeloma, also known as smoldering myeloma, is characterized by having a clonal plasma cell population in the bone marrow that is greater than 10 percent while having no organ damage. Some patients will start out asymptomatic before progressing to full blown disease. Treatment normally begins after symptoms evolve.

INFLUENZA A VIRAL PNEUMONIA ASSOCIATED WITH DIFFUSE ALVEOLAR HEMORRHAGE

SESSION TITLE: Chest Infections 2 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Diffuse alveolar hemorrhage (DAH) represents a life-threatening complication of many respiratory infections. We present a case of Influenza A pneumonia associated with DAH, an uncommon but likely unrecognized complication. CASE PRESENTATION: An 80-year-old female was admitted with lethargy, dyspnea and chest pain. Medical history included end stage renal disease and compensated systolic heart failure. On examination, she was afebrile with bilateral basal inspiratory crackles. Laboratory evaluation was unremarkable apart from mild anemia. Chest-roentgenogram revealed retro-cardiac infiltrate; computed tomography of chest showed left lower lobe consolidation and scattered ground glasses opacification. The patient required intubation and pressors for acute hypoxic respiratory failure and septic shock. Nasopharyngeal swabs rapid testing was positive for influenza A. She received vancomycin, piperacillin-tazobactam, azithromycin and oseltamivir. Bronchoscopy showed bilateral airway erythema and diffuse bleeding, and no endobronchial lesions. Bronchoalveolar lavage (BAL) of the left lower lobe had progressively bloody returns, consistent with DAH (Fig 1). Respiratory, urine and blood cultures were negative. Methylprednisolone 250 mg daily was started, with improvement in oxygenation. Repeat bronchoscopy 2 days later revealed normal mucosa and no mucosal bleeding (Fig 2). The patient's clinical status continued to deteriorate and she died two weeks after admission. DISCUSSION: In immunocompromised patients, the main infectious diseases that cause DAH are cytomegalovirus, adenovirus, invasive aspergillosis, Mycoplasma, Legionella, and Strongyloides. In immunocompetent patients, the infections most frequently causing DAH are influenza A (H1N1), dengue, leptospirosis, malaria, and Staphylococcus aureus infection (1). Higher fatality has been reported in patients with influenza A complicated by DAH (2). Pathological review of the influenza A (H1N1) 2009 pandemic reported mild-intense alveolar hemorrhage and intraalveolar edema (3). Advanced age and the presence of significant co-morbidities may predispose a patient not only to the development of influenza, but also to one if its most feared complications. The use of steroids, while controversial, may be a useful adjunct in patients with influenza A pneumonia and DAH. CONCLUSIONS: Elderly patients with significant co-morbidities may be at increased risk of developing DAH with influenza A pneumonia. Clinicians should maintain a high suspicion for DAH, as it may increase fatality rate. Steroids, in addition to supportive care, may have a role in management. Reference #1: von Ranke FM, Zanetti G, Hochhegger B, Marchiori E. Infectious diseases causing diffuse alveolar hemorrhage in immunocompetent patients: a state-of-the-art review. Lung. 2013 Feb;191(1):9-18 Reference #2: Prasad HB, Puranik SC, Kadam DB, Sangle SA, Borse RT, Basavraj A, Umarji PB, Mave V, Ghorpade SV, Bharadwaj R, Jamkar AV, Mishra AC (2011) Retrospective analysis of necropsy findings in patients of H1N1 and their correlation to the clinical features. J Assoc Physicians India 59:498-500 Reference #3: Soto-Abraham MV, Soriano-Rosas J, Díaz-Quiñónez A, Silva-Pereyra J, Vazquez-Hernandez P, Torres-López O, et al. Pathological Changes associated with the 2009 H1N1 virus. N Engl J Med 2009;361(20):2001-2003. DISCLOSURES: No relevant relationships by Gilda Diaz-Fuentes, source=Web Response No relevant relationships by OMESH TOOLSIE, source=Web Response

Changes in urinary risk profile after short-term low sodium and low calcium diet in recurrent Swiss kidney stone formers

BackgroundKidney stone disease is common in industrialized countries. Recently, it has attracted growing attention, because of its significant association with adverse renal outcomes, including end stage renal disease. Calcium-containing kidney stones are frequent with high recurrence rates. While hypercalciuria is a well-known risk factor, restricted intake of animal protein and sodium, combined with normal dietary calcium, has been shown to be more effective in stone prevention compared with a low-calcium diet. Notably, the average sodium intake in Switzerland is twice as high as the WHO recommendation, while the intake of milk and dairy products is low.MethodsWe retrospectively analyzed Swiss recurrent kidney stone formers (rKSF) to test the impact of a low-sodium in combination with a low-calcium diet on the urinary risk profile. In patients with recurrent calcium oxalate containing stones, we investigated both, the consequence of a low-sodium diet on urinary volume and calcium excretion, and the influence of a low-sodium low-calcium diet on urinary oxalate excretion.ResultsOf the 169 patients with CaOx stones, 49 presented with hypercalciuria at baseline. The diet resulted in a highly significant reduction in 24-h urinary sodium and calcium excretion: from 201 ± 89 at baseline to 128 ± 88 mmol/d for sodium (p < 0.0001), and from 5.67 ± 3.01 to 4.06 ± 2.46 mmol/d (p < 0.0001) for calcium, respectively. Urine volume remained unchanged. Notably, no increase in oxalate excretion occurred on the restricted diet (0.39 ± 0.26 vs 0.39 ± 0.19 mmol/d, p = 0.277). Calculated Psf (probability of stone formation) values were only predictive for the risk of calcium phosphate stones.ConclusionA diet low in sodium and calcium in recurrent calcium oxalate stone formers resulted in a significant reduction of urinary calcium excretion, but no change in urine volume. In this population with apparently low intake of dairy products, calcium restriction does not necessarily result in increased urinary oxalate excretion. However, based on previous studies, we recommend a normal dietary calcium intake to avoid a potential increase in urinary oxalate excretion and unfavorable effects on bone metabolism in hypercalciuric KSFs.

Teneligliptin in Management of Diabetic Kidney Disease: A Review of Place in Therapy.

Diabetes is a global health emergency of this century. Diabetic nephropathy is the most common microvascular complication associated with Type 2 Diabetes Mellitus (T2DM). T2DM has been reported as a major etiological factor in almost 45% of patients undergoing dialysis due to kidney failure. Lifestyle modifications; cessation of smoking, optimum control of blood glucose, blood pressure and lipids are required to reduce the progression of Diabetic Kidney Disease (DKD). Presently, Dipeptidyl peptidase-4 (DPP-4) inhibitors are preferred in the management of T2DM due to their established efficacy; favorable tolerability including, low risk of hypoglycaemia; weight neutrality and convenient once-a-day dosage. Present evidence suggests that linagliptin and teneligliptin can be used safely without dose adjustments in patients with T2DM with renal impairment, including End Stage Renal Disease (ESRD). There is a limited data about teneligliptin particularly in T2DM patients with renal impairment. The objective of this review is to evaluate efficacy and safety of teneligliptin in T2DM patients with renal impairment, in order to assess the current place in therapy and future prospects of teneligliptin. Reported evidence suggests that teneligliptin has consistent pharmacokinetic in mild, moderate, severe or ESRD, without any need for dose adjustments. Limited data from small sample studies of teneligliptin in DKD patients reported significant improvements in glycaemic parameters. Additionally, there is an improvement in kidney parameters like glycated albumin, urinary albumin and eGFR. There is an evidence of reduction in biomarkers of kidney impairment like P-selectin (sP-selectin), Platelet-Derived Microparticles (PDMPs) and Plasminogen Activator Inhibitor 1 (PAI-1). Clinical significance of these will be known in near future. Thus, teneligliptin has an important place of therapy in the management of T2DM with renal impairment.

Remote Monitoring of Chronic Diseases: A Landscape Assessment of Policies in Four European Countries.

BackgroundRemote monitoring (RM) is defined as the surveillance of device-transmitted outpatient data. RM is expected to enable better management of chronic diseases. The objective of this research was to identify public policies concerning RM in four European countries.MethodsSearches of the medical literature, the Internet, and Ministry of Health websites for the United Kingdom (UK), Germany, Italy, and Spain were performed in order to identify RM policies for chronic diseases, including end stage renal disease (ESRD), chronic pulmonary obstructive disease (COPD), diabetes, heart failure, and hypertension. Searches were first performed in Q1 2014 and updated in Q4 2015. In addition, in depth interviews were conducted with payers/policymakers in each country. Information was obtained on existing policies, disease areas and RM services covered and level of reimbursement, other incentives such as quality indicators, past/current assessments of RM technologies, diseases perceived to benefit most from RM, and concerns about RM.ResultsPolicies on RM and/or telemedicine were identified in all four countries. Pilot projects (mostly in diabetes, COPD, and/or heart failure) existed or were planned in most countries. Perceived value of RM was moderate to high, with the highest rating given for heart failure. Interviewees expressed concerns about sharing of medical information, and the need for capital investment. Patients recently discharged from hospital, and patients living remotely, or with serious and/or complicated diseases, were believed to be the most likely to benefit from RM. Formal reimbursement is scarce, but more commonly available for patients with heart failure.ConclusionsIn the four European countries surveyed, RM has attracted considerable interest for its potential to increase the efficiency of healthcare for chronic diseases. Although rare at this moment, incentives to use RM technology are likely to increase in the near future as the body of evidence of clinical and/or economic benefit grows.

Factors associated with left ventricle diastolic function impairment in patients with moderate arterial hypertension

Caractériser les indications des premières césariennes et discuter des différentes possibilités permettant d’en réduire le taux.Étude rétrospective réalisée sur un an dans un établissement hospitalo-universitaire ayant une activité périnatale de niveau III, incluant les 499 premières césariennes de l’année 2013. Définition de 2 groupes selon la parité : patientes nullipares (groupe 1) et multipares jamais césarisées préalablement (groupe 2). L’indication de chaque césarienne ainsi que l’état des nouveau-nés à la naissance ont été étudiés pour chaque groupe.Les groupes 1 et 2 comprenaient respectivement 369 et 130 patientes. Le taux global de césarienne en 2013 était de 24,7 % avec un taux de première césarienne de 17 %. Soixante-quatorze pour cent des premières césariennes réalisées concernaient des nullipares et 26 % concernaient des multipares (p < 0,001). Soixante-trois pour cent des premières césariennes concernaient des patientes nullipares avec un singleton en présentation céphalique. Les indications les plus fréquentes de première césarienne étaient les anomalies du rythme cardiaque fœtal (47,1 %), les défauts de progression de la présentation (24,8 %) pour lesquels les nullipares étaient plus césarisées (29 % vs 13 %, p < 0,001) et les présentations dystociques (9,6 %).Analyser de façon plus rigoureuse le rythme cardiaque fœtal en cours de travail, avoir recours aux moyens de surveillance de seconde ligne, utiliser une limite d’au moins 6 cm pour définir l’entrée dans la phase active du travail et encourager le recours aux extractions instrumentales constituent les principales stratégies pour diminuer le taux des premières césariennes.To characterize the indications of primary cesarean sections and discuss the various possibilities to reduce them.Retrospective study, carried out over a period of 1 year in a university hospital having a level 3 perinatal activity, including the 499 primary cesarean sections of 2013. Two groups were defined by parity: nulliparous patients (group 1) and multiparous patients who had never previously been delivered by cesarean section (group 2). We have assessed the indication of every primary cesarean section and health status of newborns in each group.Groups 1 and 2 respectively included 369 and 130 patients. The cesarean section rate in 2013 was 24.7% with a primary cesarean section rate of 17%. Seventy-four percent of the primary caesarean deliveries were performed on nulliparous women and 26% on multiparous (P < 0.001). Sixty-three percent of the primary caesarean deliveries were performed on nulliparous women with a singleton fetus in cephalic presentation. The most common indications for primary cesarean delivery were non-reassuring fetal heart rate tracing (47.1%), failure to progress (24.8%) for which nulliparous women were more involved (29% vs. 13%, P < 0.001) and fetal malpresentation (9.6%).Further analysis of fetal heart rate during labor, a larger use of second line means to evaluate the fetal status during labor, using 6 cm as the cut off for active labor, and encouraging vaginal operative delivery constitute the best way to decrease the primary cesarean section rate.

Prevalence of hypokalemia in an academic internal medicine clinic

Published studies have shown that all-cause mortality increases in patients diagnosed with congestive heart failure (CHF) and chronic kidney disease, including end stage renal disease, whose potassium levels are less than 4.0mEq/L. As of yet unpublished data presented at this meeting three years go in an abstract form shows a similar pattern in patients recruited to the ACCOMPLISH trial. In this retrospective pilot study, hypokalemia is defined as potassium level (K+) below 4.0 mEq/L and the hypothesis is that hypokalemia is more prevalent in the hypertensive group as compared to non-hypertensive group. The two cohorts were populated based on diagnostic billing codes and 200 electronic medical charts were reviewed in each hypertensive and non-hypertensive arms. Patients were required to have at least two visits in the outpatient clinic from October 2011 through January 2015. We excluded patients with an estimated GFR of less than 15ml/min/1.73m2, absent medication lists, age greater than 90 or less than 18, and those who did not have an outpatient blood work (i.e. electrolyte panel). Three-outpatient blood pressure readings were documented using an Omron device and other variables that were evaluated are: presence or absence of diabetes mellitus, CHF, hyperlipidemia and medications. Medications were divided into antihypertensive drugs and diuretics. Diuretics were subdivided into hydrochlorothiazide (HCTZ), chlorthalidone, and loop diuretics. Hypertensive patients had a mean age of 57 years, mean blood pressure of 150/89 mmHg, 49% had K+ below 4.0mEq/L, 88% had an eGFR greater than 60 ml/min/1.73m2. Forty percent of hypertensive patients were on diuretics; of those 20% of them were taking chlorthalidone and 70% were on HCTZ and 7.5% were on loop diuretics. The non-hypertensive cohort had a mean age of 49 years, mean blood pressure of 120/72 mmHg, 23% had a K+ less than 4.0mEq/L, and 100 % had an eGFR greater than 60 ml/min/1.73m2. None of these patients were on diuretics. The hypertensive population who had a K+ less than 4.0mEq/L, only 10% had further evaluation with a magnesium level or aldosterone to renin ratio. We conclude that hypokalemia is common, neither acknowledged nor evaluated frequently enough. We plan to re-study this after an educational intervention is implemented. A review of much larger cohorts would be critical to confirm the significance of these findings regarding frequencies, evaluation of hypokalemia, and outcomes.

Teneligliptin: a review on cardio-renal safety

Type 2 diabetes mellitus (T2DM) is a well-known risk factor for cardiovascular disease and chronic kidney disease (CKD). Various drugs including DPP4 inhibitors with different pharmacologic profile are being used in patients with type 2 diabetes for improving glycaemic control. Cardiovascular (CV) safety is one of the important aspects while selecting the glucose lowering therapies. In addition, DPP-4 inhibitors differ in their mode of excretion and degree of accumulation, which require dose/frequency modification in patients with impaired renal function. Therefore, understanding the cardio-renal safety profile of DPP4 inhibitors is of great importance. Teneligliptin is a DPP4 inhibitor, approved recently for the management of type 2 diabetes mellitus. The purpose of the present review is to integrate published literature and evaluate the cardio-renal safety of teneligliptin in type 2 diabetic patients. As per the available evidence, teneligliptin has apparently positive effects on CV safety markers like no QT prolongation at clinically relevant dose, small but significant improvement in left ventricular (LV) function, improvement in adiponectin levels and improvement in endothelial dysfunction. These findings support the cardiovascular safety of teneligliptin in T2DM patients. Dual route of excretion makes teneligliptin suitable (no dose adjustment required) for T2DM patients with renal failure. Available clinical evidence suggests that teneligliptin exerts cardiovascular safety in T2DM patients. This drug can be used in T2DM patients with CKD including end stage renal disease patients without any major safety concern.

Henoch Schonlein Purpura as a Cause of Renal Failure in an Adult

Henoch Schonlein purpura (HSP) is an immune mediated disease associated Immunoglobulin A (IgA) deposition within the affected organs. While the disease is commonly seen in the pediatric age group, it is rarely seen in adults. We report the case of a 93-year-old Caucasian lady who presented with nonthrombocytopenic purpuric rash and acute kidney injury after an episode of bronchitis. Rapid and progressive deterioration of renal function prompted a kidney biopsy, which showed findings consistent with IgA nephropathy confirming the diagnosis of HSP. The patient was treated with high dose intravenous methylprednisolone followed by oral prednisone; however, her kidney disease progressed to end stage renal disease requiring hemodialysis. HSP is usually a self-limiting disease in children. However, adults are at an increased risk of severe renal involvement including end stage renal disease. Purpuric skin rash with renal involvement should raise suspicion for HSP. This is the oldest known patient with HSP.

Gastic Mucosal Calcinosis Associated With Gastrointestinal Bleeding

Purpose: Gastric mucosal calcinosis (GMC) is a rare cause of gastrointestinal bleeding, and usually an incidental finding on endoscopy. Histopathology characteristically reveals deposits of irregular, amorphous microcalcifications in the gastric mucosa. GMC is classified as metastatic, dystrophic or idiopathic. Metastatic calcinosis is the most common, occurring in the setting of abnormal calciumphosphate metabolism, and resulting in deposition of calcium salts. We report a case of gastric mucosal calcinosis associated with overt gastrointestinal bleed. Case: A 59 year old Hispanic man presented with 1 week of black stools. Past medical history included end stage renal disease on hemodialysis for 8 years, atrial fibrillation on anticoagulation, diabetes, and coronary artery disease. He denied nausea, vomiting, hematemesis, or abdominal pain. No NSAID use other than daily aspirin was reported. Vital signs on presentation were unremarkable. Physical exam was notable for pale conjunctiva, soft, non-tender abdomen, and melena on rectal exam. Laboratory tests revealed hemoglobin of 5.9 g/dL (baseline 10 g/dL), creatinine 5.87 mg/dL, corrected calcium 9.3 mg/dL, phosphorus 3.4 mg/dL, calcium-phosphate product 31, and INR 2.8. The patient received 2 units of packed red blood cells and 4 units of fresh frozen plasma with appropriate response. EGD showed thickened antral folds (Figure 1), which were further evaluated with endoscopic ultrasound showing hyperechoic foci and shadowing with intact gastric layers (Figure 2). Histopathology of thickened folds showed foveolar hyperplasia and histiocytes in the lamina propria containing calcium deposits. Von Kossa stain confirmed calcium deposition (Figure 3). Steiner stain was negative for Helicobacter pylori. No other source of bleeding was identified on repeat EGD, colonoscopy, and capsule endoscopy. At 4 months follow up, patient has had no further bleeding.Figure 1Figure 2Figure 3Conclusions: The presentation above is suggestive of upper GI bleed secondary to gastric mucosal calcinosis in the setting of end stage renal disease. GMC has been rarely reported as a cause of GI bleeding. This case emphasizes that gastric mucosal calcinosis should be considered as a possible GI bleeding source especially in the clinical setting of chronic kidney disease.