Setting Of Renal Insufficiency Research Articles

Contrast-Enhanced Cardiac Magnetic Resonance Imaging With a Manganese-Based Alternative to Gadolinium for Tissue Characterization of Acute Myocardial Infarction.

Background Late gadolinium enhancement cardiac magnetic resonance imaging is an effective and reproducible method for characterizing myocardialinfarction. However, gadolinium-based contrast agents are contraindicated in patients with acute and chronic renal insufficiency. In addition, several recent studies have noted tissue deposition of free gadolinium in patients who have undergone serial contrast-enhanced magnetic resonance imaging. There is a clinical need for alternative forms of magnetic resonance imaging contrast agents that are acceptable in the setting of renal insufficiency. Methods and Results Three days after 80 minutes of ischemia/reperfusion of the left anterior descending coronary artery, cardiac magnetic resonance imaging was performed to assess myocardial lesion burden using both contrast agents. Late gadolinium enhancement cardiac magnetic resonance imaging was examined 10 and 15 minutes after contrast injection. Contrast agents were administered in alternating manner with a 2- to 3-hour washout period between contrast agent injections. Lesion evaluation and image processing were performed using SegmentMedvisosoftware. Mean infarct size and transmurality, measured using RVP-001, were not different compared with those measured using late gadolinium enhancement images. Bland-Altman analysis demonstrated a nominal bias of 0.13 mL (<1% of average total lesion volume) for RVP-001 in terms of gross infarct size measurement. Conclusions The experimental manganese-based contrast agent RVP-001 appears to be an effective agent for assessment of myocardialinfarction location, size, and transmurality, and it may be useful as an alternative to gadolinium-based agents.

Safety and efficacy of daratumumab use in patients with renal impairment and hemodialysis.

8026 Background: Targeting CD38 in multiple myeloma (MM) using daratumumab-based regimens can prolong remission in both the newly diagnosed and relapsed settings. However clinical trials have excluded patients with creatinine clearances (CrCl) &lt;30 mL/min, warranting real-world analysis of daratumumab use in MM patients with renal insufficiency. Methods: Following IRB approval, we performed a retrospective chart review of relapsed MM patients at our institution who had reduced CrCl and received at least one dose of either daratumumab between October 2018 and January 2022. All subjects received IV daratumumab, 52% went on to receive SQ. Outcomes included change in CrCl during treatment, adverse events, and survival. Survival was estimated using product-limit estimates. CrCl groups at daratumumab initiation of more or less than 30 were compared using the chi-square test or Fisher’s exact test, as deemed appropriate, for categorical variables and the two-sample t-test or Mann-Whitney test for continuous data (SAS Institute Inc., Cary, NC). Results: 101 MM patients were included, with median age of 74 (54-92); 46 (45.5%) were female. 14% were on hemodialysis. Patients had a median of 2 prior lines of therapy. Distribution of R-ISS stages were I (20%), II (35%), and III (45%). High-risk cytogenetics were present in 20%. A median of 23 daratumumab infusions (1-60) were delivered over a median of 18 months (median IV=16, SQ=10). Daratumumab regimens included DRD (32%), DPD (35%), DKD (13%), and DVD (35%). Median CrCl at MM diagnosis and at daratumumab initiation was 45 (7.3-101) and 40 (5.3-107), respectively, with 33% having CrCl &lt;30. Following 3, 6, and 12 months (n = 95, 89, 69) on daratumumab-based regimens, median CrCl were 45, 43, and 41, respectively. There were no differences in renal function in patients who went on to receive SQ daratumumab. 16 patients had died at the time of data collection, and the median survival was 63 months. Of the 101 patients, 16 subjects were deceased at the time of data collection, and 23% of subjects had gone on to subsequent treatments. Analysis showed that there was a progression-free survival of 54% at 5 years. The most common adverse events reported were anemia (37%) and neutropenia (15%). Infusion-related reactions were reported in 19% of patients. Conclusions: This is the largest real-world assessment of outcome for MM patients treated with daratumumab-containing regimens in the setting of renal insufficiency. There was no significant impact of the treatment on renal function at 12 months. Compared to published data on patients treated with CrCl&gt;30, there does not appear to be a detriment to survival or an increase in adverse events when using daratumumab regimens in patients with more advanced renal insufficiency.

Outcomes of Orthotopic Heart Transplantation in the Setting of Acute Kidney Injury and Renal Replacement Therapy

Heart transplantation in the setting of renal insufficiency is controversial. The objective of this study was to perform a descriptive analysis of patients who underwent orthotopic heart transplantation and renal replacement therapy (RRT) due to acute kidney injury (AKI). An observational cohort study with retrospective data collection. A tertiary care hospital. Fifty-one patients underwent orthotopic heart transplantation with cardiogenic shock under inotrope dependence, with nine patients having preoperative RRT and 42 patients not having preoperative RRT. There were no interventions. Hospital mortality occurred in eight (15.6%) patients. Although there were no significant differences between the study groups (preoperative RRT 33.3% v controls 11.9%, p=0.1), this study was underpowered to detect differences in mortality. Dialysis also was required in 52.4% of patients who were not on preoperative RRT. All survivors had full recovery of kidney function with similar timing after transplant (18.5 days v 15 days, p=0.75). Actuarial survival was 82.4%, 76.5%, and 66.5% at six months, one year, and five years, respectively. A cold ischemic time greater than 180 minutes (hazard ratio [HR] 4.37 95% confidence interval [CI] 1.51-12.6; p=0.006) and pretransplant RRT (HR=7.19 95% CI 1.13-45.7; p=0.04) were independent predictors of long-term mortality. In a health system with limited funding and availability of mechanical circulatory support, heart transplantation in the setting of AKI, RRT, and low Interagency Registry for Mechanically Assisted Circulatory Support profile was associated with important hospital mortality. Among hospital survivors, however, all patients had full renal recovery and by 25 months there was no difference in mortality between those who required preoperative RRT and those who did not.

MON-694 EDKA and MALA in the Setting of Severe Heart Failure and Acute Renal Failure, Due to SGLT2-i

Background: EDKA is a reported potential side effect of SGLT-2i that presents a unique challenge for diagnosis and management in the setting of HF and concurrent AKI. Literature encourages wide use of SGLT-2i’s, however this case demonstrates the need of proper evaluation before initiating therapy. Case: A 53 year old male with PMH of T2DM, Atrial fibrillation, HFrEF, presented to the Emergency Dept after a week of confusion, nausea, vomiting, and diarrhea. These symptoms were presumed due to gastroenteritis and our patient continued working on his farm in the summer heat. Following 3 days of intractable vomiting, he began to develop confusion, took his medications and presented to the ED. He was on metformin and had recently started empagliflozin following a heart failure exacerbation. Upon arrival the patient was noted to have a severe AKI with Cr of 15, hyperkalemia with potassium of 7.7, Anion gap of 45, bicarbonate of 4. Lactic acid was noted to be 7.7 and BHB was later noted to be 10.5 with a serum blood glucose of 155.Pt was determined to have Euglycemic Diabetic Ketoacidosis with an additional Metformin associated lactic acidosis. He was started on an insulin drip with a concurrent D20 infusion to minimize fluid intake. Dextrose was titrated up to maintain a goal BG of 150-180 while on a stable insulin rate of 5u/hour, while monitoring serum ketones to resolution of DKA. Due to excess fluid intake he required intubation and later, hemodialysis due to metformin associated lactic acidosis and acute renal failure. Following 3 days of dialysis he was able to successfully wean from vent and pressors, making a complete recovery.Conclusion:We present a patient with EDKA likely resulting from dehydration induced AKI compounded by SGLT2i induced diuresis. As he developed his kidney injury, metformin was able to build up to toxic levels inducing lactic acidosis. Treatment in this patient was based on the underlying physiology providing glucose to allow resolution of ketosis. Treatment is not well studied, but given the origin of the pathology should resemble a standard DKA protocol with glucose repletion. SGLT2i and metformin combinations have shown an increased risk of metabolic acidosis1 and lactic acidosis2. This case highlights a potential risk of the combination in the setting of renal insufficiency and tenuous fluid states.

The Current Practice of Opioid for Cancer Dyspnea: The Result From the Nationwide Survey of Japanese Palliative Care Physicians

ContextMorphine is recommended as the first-line pharmacological therapy for cancer dyspnea. However, the detailed practice of morphine has not been evaluated and consensus about other opioids for cancer dyspnea has not been established. ObjectivesTo explore the physician-reported practice of opioid for cancer dyspnea. MethodsA nationwide mail-questionnaire survey was conducted among 536 Japanese certified palliative care physicians. We randomly selected 268 and asked the following: 1) how the physicians themselves initiate and use morphine for cancer dyspnea, 2) opioid choice for dyspnea in patients who have already used opioid other than morphine regularly, and 3) opioid choice for dyspnea in patients with various degrees of renal impairment in their daily practice. ResultsOverall, 192 physicians responded (response rate, 71.6%). The major (58.3%) practice of initiating morphine was “immediate-release morphine as needed” in opioid-naïve patients, and the mean % increase when they titrate morphine for cancer dyspnea was 29.4 ± 11.3% of the baseline dose. Although “titrate baseline oxycodone” was the most frequent (42.3%) for low-to-moderate–dose regular oxycodone cases, “stepwise switch to morphine” (30.0%) and “add morphine on baseline oxycodone” (27.1%) were the more frequent practices for high-dose regular oxycodone. Regardless of the baseline dose, “add morphine on baseline fentanyl” was the most frequent practice for regular transdermal fentanyl cases. Oxycodone was the most frequent choice in renal insufficiency cases, regardless of its degree. ConclusionsAmong Japanese palliative care physicians, using oxycodone for cancer dyspnea was relatively popular practice, whereas fentanyl was not. Oxycodone was the most preferred opioid for cancer dyspnea in the setting of renal insufficiency among Japanese palliative care physicians. We should conduct studies to confirm the safety and effectiveness of these opioid practices for cancer dyspnea.

Renal Safety of Intravenous Gadolinium-enhanced MRI in Patients Following Liver Transplantation.

Intravenous contrast-enhanced imaging is invaluable in diagnosing pathology following liver transplantation. Given the potential risk of contrast nephropathy associated with iodinated computed tomography contrast, alternate contrast modalities need to be examined, especially in the setting of renal insufficiency. The purpose of this study was to examine the renal safety of MRI with gadolinium following liver transplantation. The study involved a retrospective analysis of 549 cases of abdominal MRI with low-dose gadobenate dimeglumine in liver transplant recipients at a single center. For each case, serum creatinine values before and after the MRI were compared. In addition, cases were analyzed for the development of nephrogenic systemic fibrosis. Pre-MRI creatinine values ranged from 0.32 to 6.57 mg/dL (median, 1.28 g/dL), with 191 cases having values ≥1.5 mg/dL (median, 1.86 g/dL). A comparison of the pre- and post-MRI creatinine values showed no significant difference, including those patients with pre-MRI values ≥1.5 mg/dL (mean change of -0.04 [95% confidence interval, -0.07 to -0.01; P = 0.004]). No cases of nephrogenic systemic fibrosis were noted. Our findings suggest that, irrespective of baseline renal function, MRI with gadobenate dimeglumine is a nonnephrotoxic imaging modality in liver transplant recipients. Importantly, this intravenous contrast-enhanced imaging modality can be considered in those posttransplant patients who have a contraindication to computed tomography contrast due to renal insufficiency.

Gabapentin or pregabalin induced myoclonus: A case series and literature review

Gabapentin (GBP) and pregabalin (PGB) are FDA approved for adjunctive treatment of partial seizures and for treatment of post-herpetic neuralgia. Both drugs are primarily eliminated by renal excretion. However, PGB or GBP induced myoclonus has only been reported infrequently in case reports/series. It is not discussed with patients and its sudden occurrence can lead to anxiety because of “seizure-like” nature. In addition, first-contact physicians might treat it as seizures, leading to unnecessary tests and aggressive management. Medical records of patients who had myoclonus because of PGB or GBP seen by Neurology service between Jan & May 2017 in inpatient or outpatient setting at our tertiary care setting were reviewed. We identified six patients who were on either GBP or PGB or both who developed likely subcortical myoclonus in the setting of renal insufficiency and one patient who developed myoclonus independent of renal dysfunction. Our results indicate that myoclonus is commonly seen in patients in various clinical settings with or without renal insufficiency, and is independent of the severity of the renal failure. However, this is a reversible side effect of medication and it resolves either by discontinuing the medication, removing the medication with hemodialysis or by improvement of renal dysfunction. With a high index of suspicion, aggressive testing and treatment for other possible conditions like seizures (in non-epilepsy patients) or CNS infections can be avoided. In patients with renal failure and with decreased physiological renal clearance such as the elderly, GBP or PGB dose initiation and changes should be conservative.

Implications of Renin-Angiotensin-System Blocker Discontinuation in Advanced Decompensated Heart Failure

Introduction: The impact of renin-angiotensin-system blocker (RASB) use, or lack of, on renal function, blood pressure, and clinical outcomes during treatment for acute decompensated heart failure (ADHF) needs further clarification. Hypothesis: In comparison to patients with RASB use, discontinuing or non-use of a RASB will associate with worsening renal function, hypotension, and adverse long-term outcomes. Methods: Participants with an LVEF ≤ 40% in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization (ESCAPE) trial were included. Mixed effects models compared RASB use on serial serum creatinine and systolic blood pressure (SBP) measurements. Cox-proportional hazard models tested the association between RASB use and outcomes adjusted for age, male sex, potassium, SBP < 140 mmHg and baseline creatinine. Outcomes were validated in an independent ADHF cohort admitted to the Cleveland Clinic (n = 253). Results: Patients in the ESCAPE cohort (N = 402, age 56 ± 14 y, 74% male, 49% ischemic, LVEF 19 ± 6 %, and creatinine 1.5 ± 0.6 mg/dL) were separated into 4 groups based on RASB use at baseline and discharge: continued (n = 316), discontinued (n = 21), initiated (n = 42), and non-use (n = 23). RASB discontinuation or non-use was associated with higher serial serum creatinine levels than RASB continuation or initiation (P < .001 for both) but not with SBP measurements (P > .3 for both). In comparison to RASB continuation, RASB discontinuation and non-use was associated with ~75% increased risk of a 180-day composite of death, transplant, or re-hospitalization (HR 1.87, 95% CI 1.09–3.20, P = .02 and HR 1.72 1.04–2.82, P = .03, respectively, Figure A). Similarly in the validation cohort, RASB discontinuation and non-use versus RASB continuation were associated with ~65% and ~75% risk for 180-day death, transplant, LVAD, or re-hospitalization (HR 1.85, 95% CI 1.02–3.34, P = .04 and HR 95% CI 1.64, 95% CI 1.03–2.5, P = .04, respectively, Figure B). Conclusions: In comparison to RASB continuation, RASB discontinuation and non-use was associated with higher baseline and serial serum creatinine levels during treatment for ADHF, but not with changes in SBP. Furthermore, RASB discontinuation and non-use in ADHF were associated with an increased risk of adverse clinical outcomes. Given the persistent elevation of serum creatinine and unchanged blood pressures these findings question the practice of withholding RASB in the setting of renal insufficiency and marginal blood pressure in ADHF.

Evaluation of Dosing Practices of Rivaroxaban and Dabigatran.

Background: Anticoagulation is standard practice for the prevention and treatment of thromboembolic events. Two of the newer agents, rivaroxaban (Xarelto) and dabigatran (Pradaxa) are being utilized frequently in the inpatient and outpatient settings. Prescribers may not appreciate the need for dose reduction in the setting of renal insufficiency. Objective: The objective of this study was to evaluate whether rivaroxaban and dabigatran were dosed according to recommendations in the package insert for patients with renal insufficiency. Methods: Eligible patients were those >18 years of age who received rivaroxaban or dabigatran as an inpatient or had a prescription filled from the outpatient pharmacy. The use of the Cockcroft-Gault equation was utilized to calculate creatinine clearance to evaluate whether patients had appropriate manufacturer recommended dose reductions based on their renal function. Results: There were very few patients (8 of 355, or 2.3%) who should have received a reduced dose when creatinine clearance was calculated utilizing actual body weight. In those patients with renal insufficiency, 3 of 6 (50.0%) patients receiving rivaroxaban and 1 of 2 (50%) patients receiving dabigatran were appropriately dosed. When ideal body weight was substituted for creatinine clearance calculation, there were 15 patients receiving rivaroxaban and 10 patients receiving dabigatran who fell below the creatinine clearance threshold for dose reduction. Conclusions: Based on this evaluation, very few patients required a dose reduction due to renal insufficiency. It is important for clinicians to always monitor renal function when utilizing these medications to optimize the benefits of the new oral anticoagulants while limiting potential deleterious effects. Furthermore, it is necessary to ensure that actual body weight is being utilized for creatinine clearance calculations with the new oral anticoagulants and not to base dosing on estimated glomerular filtration rate or other calculated creatinine clearance as this could lead to inappropriate dose reductions.

Ferumoxytol-Enhanced Magnetic Resonance Angiography is a Feasible Method for the Clinical Evaluation of Lower Extremity Arterial Disease

Renal toxicity from conventional, iodinated, intravenous contrast agents is a common complication in patients with peripheral artery disease (PAD). Similarly, the potential for serious side effects prevents the use of gadolinium-based agents in many patients with depressed renal function. Ferumoxytol-enhanced magnetic resonance angiography (Fe-MRA) is a novel technique that uses an intravenous, ultrasmall, superparamagnetic, iron oxide preparation, currently approved by the Food and Drug Administration for the treatment of iron deficiency anemia in adults with chronic kidney disease. Our objective was to determine the feasibility of Fe-MRA for clinical decision making in PAD patients. This was a prospective pilot study assessing 10 patients with suspected arterial occlusive disease with contrast-enhanced MRA of the aorta and lower extremities. Of those, 5 had renal insufficiency and were imaged with Fe-MRA, whereas the remainder underwent gadolinium-enhanced MRA. Qualitative and quantitative evaluations of deidentified images at each arterial station were independently performed by 4 blinded vascular surgeons. All patients were men, with an average age of 68 ± 4 years. The 2 groups had similar incidences of diabetes, hypertension, hyperlipidemia, and coronary artery disease. Patients undergoing Fe-MRA had significantly decreased renal function (estimated glomerular filtration rate, 35.4 vs. 77.6; P = 0.02). There were no adverse events during contrast administration in either group. No difference was found in the overall quality of the ferumoxytol versus the gadolinium studies (7.1 ± 2.0 vs. 7.4 ± 2.4, P = 0.67). Similarly, reviewers felt comfortable basing clinical decisions on the images 89% of the time with both the ferumoxytol and gadolinium groups (P = 1.00). This is the first report of an important alternative to conventional computed tomography angiography and MRA in PAD patients, particularly in the setting of renal insufficiency. Fe-MRA provides a useful tool in patients with suspected lower extremity PAD without the potential risks of gadolinium.

Evidence-based guidance on venous thromboembolism in patients with solid tumours.

Venous thromboembolism (vte) is a serious, life-threatening complication of cancer. Anticoagulation therapy such as low molecular weight heparin (lmwh) has been shown to treat and prevent vte. Cancer therapy is often complex and ongoing, making the management of vte less straightforward in patients with cancer. There are no published Canadian guidelines available to suggest appropriate strategies for the management of vte in patients with solid tumours. We therefore aimed to develop a clear, evidence-based guideline on this topic. A systematic review of clinical trials and meta-analyses published between 2002 and 2013 in PubMed was conducted. Reference lists were hand-searched for additional publications. The National Guidelines Clearinghouse was searched for relevant guidelines. Recommendations were developed based on the best available evidence. In patients with solid tumours, lmwh is recommended for those with established vte and for those without established vte but with a high risk for developing vte. Options for lmwh include dalteparin, enoxaparin, and tinzaparin. No one agent can be recommended over another, but in the setting of renal insufficiency, tinzaparin is preferred. Unfractionated heparin can be used under select circumstances only (that is, when rapid clearance of the anticoagulant is desired). The most common adverse event is bleeding, but major events are rare, and with appropriate follow-up care, bleeding can be monitored and appropriately managed.

The treatment of type 2 diabetes.

5% to 8% of adults have type 2 diabetes, a disease that is usually asymptomatic at first. The goals of management are timely diagnosis and the prevention of complications. Selective review of the literature, including guidelines from Germany and abroad. High caloric intake and lack of exercise are the main contributing causes of type 2 diabetes and the principal targets of intervention. If lifestyle changes do not yield adequate improvement, then drug treatment should be initiated (or intensified) and managed on the basis of the HbA1c fraction. Guidelines recommend an HbA1c target range of 6.5% to 7.5%; the individual target value should be chosen in consideration of patient-specific factors and established in collaboration with the patient. Metformin is recommended for initial drug treatment. If metformin is contraindicated, poorly tolerated, or inadequately effective, many therapeutic alternatives and supplements are available. Clinical trials have shown that sulfonylureas and insulin are beneficial with respect to patient-relevant endpoints, but comparable data from clinical trials are not yet available for any other antidiabetic drug (except metformin). For individual patients, other drugs may have advantages such as a lower risk of hypoglycemia, less weight gain, oral administration, and/or applicability in the setting of renal insufficiency. The treatment is individually oriented, depending on the patient's age, disease stage, body weight, comorbidities, work situation, adherence, and personal priorities. Combining more than two antidiabetic drugs is not recommended. Although there are many treatment options, individualized long-term treatment still presents a challenge in many cases.

Contemporary view of the clinical relevance of magnesium homeostasis

Magnesium is one of the most abundant cations in the body and is essential for a wide variety of metabolically important reactions. Serum magnesium concentration is regulated by the balance between intestinal absorption and renal excretion. Hypomagnesaemia is relatively common, with an estimated prevalence in the general population ranging from 2.5 to 15%. It may result from inadequate magnesium intake, increased gastrointestinal or renal loss or redistribution from extracellular to intracellular space. Drug-induced hypomagnesaemia, particularly related to proton-pump inhibitor (PPI) therapy, is being increasingly recognized. Although most patients with hypomagnesaemia are asymptomatic, manifestations may include neuromuscular, cardiovascular and metabolic features. Due to the kidney's ability to increase fractional excretion to nearly 100% when the renal magnesium threshold is exceeded, clinically significant hypermagnesaemia is uncommon, generally occurring only in the setting of renal insufficiency and excessive magnesium intake. Symptoms include hypotension, nausea, facial flushing, ileus and flaccid muscle paralysis. In most cases, simply withdrawing exogenous magnesium is sufficient to restore normal magnesium concentrations, although occasionally administration of intravenous calcium or even dialysis may be required.

Intricacies Of Treating Heparin Induced Thrombocytopenia With Preexisting Antiphospholipid Syndrome and Renal Insufficiency

Treatment of heparin induced thrombocytopenia (HIT) requires the use of alternatives anticoagulants, such as a direct thrombin inhibitor – argatroban. Use of argatroban relies on frequent laboratory monitoring of the activated partial thromboplastin time (aPTT) to maintain an adequate level of anticoagulation. This requirement poses a challenge in patients with prolonged baseline aPTT, such as in antiphospholipid syndrome. While other assays are being explored they require an extended turn around time because of their limited availability. We present a case of a 63 year old male with a history of antiphospholipid syndrome, end stage renal disease on hemodialysis, hepatitis C, and on long term anticoagulation with warfarin for cerebral vein thrombosis. His hospital course required transition to unfractionated heparin and subsequently developed thrombocytopenia. A heparin-platelet factor 4 ELISA antibody assay was performed for an intermediate clinical likelihood of HIT and returned positive. Although not confirmed with the gold standard serotonin release assay (SRA), clinical suspicion for HIT obligated treatment with an alternative anticoagulant. Conventional dosing and administration of argatroban however could not be performed because of the patient’s prolonged baseline aPTT. Other agents such as fondaparinux were also not possible in the setting of renal insufficiency. Short of other treatment techniques accepted in this unique set of circumstances we practiced a fixed dose argatroban (0.5 mcg/kg/min for Child’s class B cirrhosis). The patient tolerated the empiric dosing well until discontinued because of a negative SRA. This case demonstrates the limitations of current treatment recommendations of HIT and need for further investigation in similar patients. Disclosures: No relevant conflicts of interest to declare.

Non-Contrast Enhanced 3D SSFP MRA of the Renal Allograft Vasculature: A Comparison Between Radial Linear Combination and Cartesian Inflow-Weighted Acquisitions

Renal transplant patients often require imaging to ensure appropriate graft placement, to assess integrity of transplant vessel anastomosis and to evaluate for stenosis that can be a cause of graft failure. Because there is risk for nephrogenic systemic fibrosis in the setting of renal insufficiency, the use of non-contrast MRA in these patients is helpful. In this study, the ability of two non-contrast MRA methods – 3D radial linear combination balanced SSFP (VIPR-SSFP) and inflow-weighted Cartesian SSFP (IFIR) – to visualize the transplant renal vessels is compared. Twenty-one renal transplant patients were scanned using the VIPR-SSFP and IFIR sequences. Diagnostic efficacy of the sequences was scored using a four point Likert scale according to the following criteria: overall image quality, fat suppression, and arterial/venous visualization quality. Average scores for each criterion were compared using the Wilcoxon signed-rank test. In addition to significantly improved venous visualization, the VIPR-SSFP sequence provided significantly improved fat suppression quality (p<0.03) compared to IFIR. VIPR-SSFP also identified several pathologies such as renal arterial pseudoaneurysm that were not visible on the IFIR images. However, IFIR afforded superior quality of arterial visualization (p<0.005). These two methods of non-contrast MR imaging each have significant strengths and are complementary to each other in evaluating the vasculature of renal allografts.

Primary care providers' knowledge, beliefs and treatment practices for gout: results of a physician questionnaire

We sought to examine primary care providers' gout knowledge and reported treatment patterns in comparison with current treatment recommendations. We conducted a national survey of a random sample of US primary care physicians to assess their treatment of acute, intercritical and tophaceous gout using published European and American gout treatment recommendations and guidelines as a gold standard. There were 838 respondents (response rate of 41%), most of whom worked in private practice (63%) with >16 years experience (52%). Inappropriate dosing of medications in the setting of renal disease and lack of prophylaxis when initiating urate-lowering therapy (ULT) accounted for much of the lack of compliance with treatment recommendations. Specifically for acute podagra, 53% reported avoidance of anti-inflammatory drugs in the setting of renal insufficiency, use of colchicine at a dose of ≤2.4 mg/day and no initiation of a ULT during an acute attack. For intercritical gout in the setting of renal disease, 3% would provide care consistent with the recommendations, including initiating a ULT at the appropriate dose with dosing titration to a serum urate level of ≤6 mg/dl and providing prophylaxis. For tophaceous gout, 17% reported care consistent with the recommendations, including ULT use with dosing titration to a serum urate level of ≤6 mg/dl and prophylaxis. Only half of primary care providers reported optimal treatment practices for the management of acute gout and <20% for intercritical or tophaceous gout, suggesting that care deficiencies are common.

Chest Computed Tomography Features Predictive of Elevated B-Type Natriuretic Peptide Independent of Renal Function

B-type natriuretic peptide (BNP), commonly evaluated in patients suspected of congestive heart failure, is also elevated in patients with renal insufficiency. The objective of our study was to identify chest computed tomography features that correlate with BNP levels independent of renal function. A total of 162 (of which 76 had normal BNP and 86 had elevated BNP) patients with chest computed tomography and serum BNP levels measured within 24 hours were evaluated for the presence of ground-glass opacities, interlobular septal thickening, mediastinal lymphadenopathy, mosaic perfusion, peribronchovascular thickening, pericardial effusion, and pleural effusion. Both univariate and multivariate analysis were used to correlate these features with the serum BNP. Multiple logistic regression was used to identify statistically significant correlates of BNP controlling for the glomerular filtration rate. Ground-glass opacity, interlobular septal thickening, pericardial effusion, and left- and right-sided pleural effusion were statistically significant predictors of elevated BNP on separate logistic regression incorporating the glomerular filtration rate. After multiple logistic regression, interlobular septal thickening (odds ratio, 5.69) and pleural effusion (odds ratio, 3.88) remained significant predictors of BNP independent of the glomerular filtration rate. Interlobular septal thickening and pleural effusion appear to be independent predictors of BNP, and this may be useful in the evaluation of patients for congestive heart failure in the setting of renal insufficiency.

Dantrolene Sodium for the Treatment of Aldesleukin-lnduced Rigors in a Melanoma Patient

To report the case of a 58-year-old male with melanoma who developed aldesleukin-induced rigors and was successfully treated with intravenous dantrolene sodium 20 mg and provide a review of the literature discussing other agents that have been used to treat drug-induced rigors. A 58-year-old male was treated with 720,000 IU/kg of aldesleukin every 8 hours as part of his antimelanoma therapy. The patient developed rigors after aldesleukin administration and was successfully treated with 25 mg of meperidine. Later, he experienced renal dysfunction that was also linked to aldesleukin therapy and developed normeperidine-induced neurotoxicity requiring discontinuation of meperidine therapy. The rigors were treated with intravenous dantrolene sodium 20 mg every 4 hours, with complete resolution of symptoms. Several antineoplastic agents can cause rigors; many of these agents can also lead to renal failure. Several agents have been investigated for their use in the management of rigors but can cause adverse effects or are unsuitable in the setting of renal insufficiency or failure. Although meperidine remains the mainstay for the treatment and prevention of rigors, it can be associated with neurotoxicity in some patients, particularly those with impaired renal function. Given that dantrolene has been shown to be effective against rigors, it may be a useful alternative for patients who can not tolerate meperidine. Drugs with a more favorable adverse effect profile that are not eliminated through the kidneys are needed. In the oncology setting, severe rigors can result in the interruption of a patient's cancer therapy, which can increase the risk of treatment failure. Dantrolene may be a useful alternative for patients experiencing rigors who can not tolerate meperidine.

Use of Argatroban as a Procedural and Bridging Anticoagulant in a Patient Undergoing Carotid Endarterectomy with Concomitant Atrial Fibrillation

To describe the use of argatroban as a procedural and bridging anticoagulant in a patient with a previous history of heparin allergy and atrial fibrillation undergoing carotid endarterectomy. A 78-year-old female with a history of heparin-induced thrombocytopenia (HIT) and multiple medical comorbidities, including atrial fibrillation requiring chronic anticoagulation with warfarin, was found to have greater than 70% stenosis of her left carotid artery by standard duplex imaging. Her warfarin therapy was discontinued as an outpatient approximately 48 hours prior to an elective left carotid endarterectomy and she was started on argatroban 2 μg/kg/min for bridging therapy. The endarterectomy was successfully performed while the patient was maintained on a continuous argatroban infusion. The dose was adjusted by 0.25-μg/kg/min intervals to achieve and maintain an activated clotting time of greater than 200 seconds during the procedure. Her postoperative course was unremarkable and she was transitioned back to warfarin and subsequently discharged home. HIT poses a challenge for patients in need of vascular surgery. Optimally, one would postpone any surgical intervention until the heparin antibodies are cleared from circulation, which on average takes about 100 days. In theory, it is safe to reexpose these patients to heparin products upon clearance of the antibody; however, there is scant literature available to show its safety. Current guidelines recommend limiting heparin exposure in any patients with a history of HIT, but the optimal alternative anticoagulant in this setting is unclear. There are several direct thrombin inhibitors available, but argatroban seemed to be a logical choice for our patient, especially in the setting of renal insufficiency, given its favorable pharmacokinetics and ease of monitoring with readily available coagulation tests. To our knowledge, this is the second reported case of the systemic use of argatroban in carotid endarterectomy in a patient with a previous history of HIT. Argatroban may be an effective anticoagulant during carotid endarterectomy in patients with underlying chronic renal disease and a history of HIT. Additional research is needed to determine the ideal anticoagulant in vascular surgery when heparin cannot be utilized.

Gemcitabine, paclitaxel, and doxorubicin for patients (pts) with urothelial carcinoma (UC) and renal insufficiency: Preliminary results of a multicenter phase II study.

246 Background: The role of cisplatin-based chemotherapy for the treatment of locally advanced or metastatic UC is well established. Pts with impaired renal function cannot receive cisplatin, however, and substitution with carboplatin yielded inferior results. We initiated a phase II study to assess the efficacy of gemcitabine, paclitaxel, and doxorubicin (GTA) treatment for UC in pts with renal insufficiency. Methods: Eligible pts had metastatic or unresectable UC of bladder, urethra, or upper tract, no prior chemotherapy, glomerular filtration rate &lt; 60 ml/min, ECOG performance status ≤ 2, left ventricular ejection fraction &gt; 40%, and adequate hematopoietic and hepatic function. Pts were excluded if they had brain metastasis, peripheral neuropathy ≥ grade 2, significant heart disease within 6 months of enrollment, or required hemodialysis. Outpatient treatment consisted of 900 mg/m2 gemcitabine, 135 mg/m2 paclitaxel, and 40 mg/m2 doxorubicin on day 1 every 2 weeks. Pegfilgrastim 6 mg sc was given immediately after GTA on day 1, or on day 2 if requested by the pt. Tumor evaluation was repeated every 3 cycles (6 weeks); treatment duration was limited to 9 cycles. A Simon 2-stage design was chosen to detect a target overall response rate of 40% and to reject a response rate of 25% or less. Results: Twenty-five pts enrolled and 21 could be assessed for response. Median (range) age was 72.8 years (53.4, 89.3) and 8 pts (32.0%) were female. RECIST responses occurred in 12 pts (4 complete; 8 partial), for an overall response rate of 57.1% (95% CI 34.0-78.2). Notable grade 3 and 4 toxicities were anemia (9 pts), thrombocytopenia (3 pts), neutropenia (2 pts), dyspnea (1 pt), mucositis (1 pt), and sepsis (1 pt). No adverse events were attributed to same-day pegfilgrastim and there were no treatment-related deaths. Eleven pts (44.0%) died of progressive disease; the median (range) follow-up time for 14 surviving pts was 5.5 months (2.3, 17.5). Conclusions: GTA has been well-tolerated in the setting of renal insufficiency, with an observed response rate in advanced UC exceeding the targeted response. The study will continue to a maximum of 72 pts. [Table: see text]