Term Dialysis Research Articles

Abstract 3143: Computational Modeling Of Non-homeostatic Changes Within An Arterial-venous Fistula System Using In Vivo Validation To Understand Mechanical Causes Of Fistula Failure

Introduction: Arteriovenous fistula (AVF) failure is a clinical problem for end stage renal patients seeking durable long term dialysis access. AVF failure is not fully understood, but linked to neointimal hyperplasia (NH). Understanding the hemodynamic factors that may trigger NH response is important for minimizing this clinical problem. Methods: A validated murine AVF model defined the geometry and boundary conditions for the computational model. Anesthetized mice underwent laparotomy and aorta-IVC puncture. Ultrasound specified blood flow velocity within the vessels. In vivo CT angiography scans were segmented using 3D software (Simpleware ScanIP) to establish global geometry which was imported into Xflow, a fluid dynamics simulation software. Velocity, static pressure, and turbulence were averaged along the length of the vein above and below the fistula in this model, a stenotic vein model, and a stenotic fistula model. Results: Velocity and turbulence significantly increases in the peri-fistula vein and dramatically increases in systole phase. Velocity, turbulence, and static pressure peak in the stenotic vein. When the fistula is stenosed, native flow is restored. Conclusions: The presence of AVF dramatically changes the hemodynamics of the native vein. Increased velocity and turbulence in the peri-fistula vein are significant and peak in systole. Venous stenosis substantially strains the system, demonstrated by the high static pressures proximal to the stenosis. The gradients of high turbulence directly correlate with in vivo histology measurements of neointimal hyperplasia thickness changes that have been previously reported. These results may be used to predict how the underlying hemodynamics within a fistula system preclude biological responses from the tissue. We conclude that non-homeostatic hemodynamics, namely increased venous velocity, turbulence, and static pressure may be a potential trigger for NH and ultimately fistula failure.

Resting strain analysis to identify myocardial ischemia in patients with advanced chronic kidney disease

Abstract Background Chronic kidney disease (CKD) is associated with a higher incidence of cardiovascular death, particularly as the disease progresses and patients are on long term dialysis treatment. Screening for coronary artery disease in asymptomatic or mildly symptomatic patients is challenging and controversial. Objective The aim of this study was to investigate the incremental value of resting deformation analysis with speckle tracking echocardiography in predicting positive results on stress transthoracic echocardiography in patients with end-stage renal disease on dialysis (stage 5 CKD). Methods Our cohort consisted of 61 consecutive patients (mean age 62.3±11.8, 65.7% men) with stage 5 CKD. Patients with a confirmed diagnosis of pre-existing cardiac diseases, such as obstructive coronary artery disease, heart failure, severe arrhythmias or severe valvular disease were excluded. Patients underwent a resting transthoracic echocardiogram and a dobutamine stress contrast echo (DSCE) protocol. Positive results of DSCE were defined as stress-induced LV wall motion abnormalities (new or worsening preexisting abnormalities). Results The study cohort had normal or mildly impaired systolic function with mean LV ejection fraction (EF) of 49.17% (±10.41) and a mean LV GLS of 14.35% (±4.49) (Figure 1). In addition, half of our population had impaired LA strain: mean LA reservoir, LA conduit, and LA contractile reserve were 24.11% (±12.61), 10.56% (±5.88), and 13.60% (±9.15), respectively. DSCE was positive for ischemia in 55.7%. Age, gender, and history of diabetes were significantly correlated with positive result in DSCE (p=0.027, p=0.022 and p=0.039, respectively). Additionally, a significant negative association with DSCE results was found for the echocardiographic parameters LV EF, LV GLS, the conduit phase of LA strain, LV end diastolic volume as well as LA dimensions (p=0.002, p=0.002, p=0.004, p= 0.002 and p=0.048, respectively). Logistic regression analysis showed that LV global longitudinal strain was independently associated with DSCE outcome (p=0.007), after controlling for covariates. The area under the curve (AUC) to predict positive results for LV GLS was 0.92 with with a sensitivity of 96%, a specificity of 56% and an overall diagnostic accuracy of 84% (Fig 2). Conclusion The present findings demonstrate that resting LV deformation is associated with the presence of coronary ischemia and may be useful to better identify patients with advanced CKD who might benefit from coronary artery screening.LV GLSAUC

Effect of low-calcium and standard-calcium dialysate on serum calcium, phosphorus and full-segment parathyroid hormone in patients on peritoneal dialysis: A retrospective observational study.

To investigate the effects of low-calcium and standard-calcium dialysate in patients with chronic kidney disease on peritoneal dialysis, and find out which dialysate has less vascular calcification effect. A total of 141 patients who had undergone peritoneal dialysis (PD) for 2 years in the PD centre from January 2012 to December 2017 were included and divided into two groups according to the calcium concentration of the PD fluid used. There were 79 cases in the low-calcium group, with a dialysate calcium concentration of 1.25 mmol/L and 62 cases in the standard-calcium group, with a dialysate calcium concentration of 1.75 mmol/L. The demographic characteristics and clinical information before initiation of PD were collected and compared between the two groups. Information on the serum calcium, phosphorus and PTH, systolic and diastolic blood pressures and the use of antihypertensive and phosphate-lowering drugs in the second year of dialysis was also collected and compared between the two groups. Vascular calcification was assessed in patients on PD treatment. The mean serum calcium concentrations before initiation of PD in the low- and standard-calcium groups were 1.94 ± 0.27 and 1.89 ± 0.28 mmol/L, respectively. The serum calcium concentrations after PD were 2.30 ± 0.21 and 2.41 ± 0.23 mmol/L, respectively. After PD, the serum calcium concentration in both groups was significantly increased (p < 0.05). The serum calcium concentration in the low-calcium group after PD treatment was lower than that in the standard-calcium group, and the difference was statistically significant (p < 0.05). Compared with the standard-calcium group, patients in the low-calcium group had significantly higher parathyroid hormone concentrations (p < 0.05). More types of phosphate-lowering drugs were used (59.49%) in the low-calcium group than that in the standard-calcium group (35.48%; p < 0.05). The number of antihypertensive drug usage were also higher in the low-calcium group, and the difference was statistically significant (p < 0.05). As for the vascular calcification effect, the two groups have shown no statistical difference in abdominal aortic calcification rate, carotid arteriosclerosis rate and aortic arch calcification rate (p < 0.05). We found that low-calcium PD fluid may increase the PTH level and the proportion of CKD patients using antihypertensive drug and phosphorus-lowering drug, but the vascular calcification effect of the low and standard calcium PD fluid needs further exploration. This paper provides new evidence for the choice of dialysate for PD, low-calcium dialysate has no outstanding advantages for long term dialysis.

Hip Arthroplasty Outcomes in the Presence of Kidney Failure: A National Data Linkage Study

BackgroundPatients who have kidney failure are at higher risk of requiring total hip arthroplasty (THA) and are at higher risk of complications. This study compared the rate of revision surgery and mortality following THA between patients who have kidney failure receiving long term dialysis or who had a kidney transplant and those who did not have kidney failure. MethodsA data linkage study was performed using data from 2 national registries: a registry of dialysis and kidney transplant patients and a registry of THA procedures. Both registries had coverage of almost all procedures or treatments in Australia. Data from September 1999 to December 2016 were used. Mortality and revision surgery were compared between patients receiving dialysis, those who had a functioning kidney transplant, and patients who did not have kidney failure using Cox and Fine-Gray (competing risk) regression models. A total of 383,478 primary THA procedures were identified as people receiving dialysis (n = 490), who had a functioning kidney transplant (n = 459), or who did not have kidney failure (n = 382,529). ResultsThere was no significant difference in the overall rate of revision surgery between the groups (dialysis versus no kidney failure HR = 1.20; 95% CI 0.76, 1.88, transplant versus no kidney failure (hazard ratio) HR = 1.01; 95% (confidence interval) CI 0.66, 1.53). The risk for death after surgery was significantly higher in the dialysis group compared to both the functioning transplant group (HR = 3.44; 95%CI 1.58, 7.5), and in those without kidney failure (HR = 4.13; 95%CI 3.25, 5.25). ConclusionThe rate of mortality after THA in patients on dialysis is higher than in patients who have a functioning transplant or those who do not have kidney failure, but there is no early excess mortality to suggest a difference in this metric due to the surgery.

Clinical experience of REcanalisation and balloon-oriented puncture for Re-insertion of long- term dialysis catheter in nonpatent central veins

It is difficult to insert long-term dialysis catheters after severe stenosis or occlusion of the internal jugular vein and innominate vein. We used REcanalisation and balloon-oriented puncture for Re-insertion of dialysis catheter in nonpatent central veins (REBORN) in seven patients with severe central venous lesions, and all patients were inserted with long-term dialysis catheters successfully. None had severe complications such as pneumothorax, hemothorax, or pulmonary embolism during operation. All catheters functioned well after postoperative follow-up of 2 months. REBORN provides a novel approach to establish difficult dialysis pathways.

EDITORIAL COMMENT

In the 22 years of this study, much has been learned about renal tumors and their management including their oncological diversity, the critical importance of renal functional preservation whenever possible, vast improvements in radiological imaging techniques and nephrometry scoring, evolving minimally invasive (MIS) and thermal ablative approaches, and the selective use of renal mass biopsy (RMB). The authors effectively incorporated these advances into their management of challenging renal tumors in horseshoe kidneys (HK) (RENAL scores 8-10) in which 19 (44%) patients had the more potentially malignant clear cell RCC, 24 (57%) patients had partial nephrectomy (PN), 2 patients underwent thermal ablation, and long term dialysis was required in only 3 patients.

A 33-year-old Male with End-stage Renal Disease

&lt;p&gt;本篇個案是位33歲的年輕男性，因喘及水腫而住院。經抽血檢驗、尿液分析及腎臟超音波檢查， 發現是末期腎臟病患者合併高血壓與嚴重的蛋白尿，須長期接受透析治療。在排除可能的相關鑑別診斷後，經由酵素檢驗、基因分析及腎臟切片檢查，個案確診為法布瑞氏症。本文之目的在強調慢性腎臟病除了常見病因如糖尿病、高血壓及慢性腎絲球腎炎外，若為原因不明的早發性腎臟病變，尤其是發生在年輕男性，須考慮法布瑞氏症的可能性，並及早的接受酵素替代治療，以預防進一步的心臟及腦部病變。此外，也藉由基因篩檢，確診家族中其它法布瑞氏症患者，積極接受早期治療。因此，藉由這篇病例報告，希望醫護人員對法布瑞氏症有進一步的了解，以早期診斷、早期治療，及減少併發症與殘疾的發生。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;The 33-years-old young male was hospitalized due to dyspnea and edema. The patient was diagnosed with end-stage renal disease, hypertension and heavy proteinuria requiring long term dialysis treat&amp;shy;ment. Other possible differential diagnosis were excluded and eventually Fabry disease was confirmed through enzyme assay, genetic analysis and kidney biopsy. The purpose of this study emphasizes on the need to consider the possibility of Fabry disease on young male with unknown reason younger-on&amp;shy;set kidney disease in addition to other causes of chronic kidney disease, such as DM, hypertension or chronic glomerulonephritis. Enzyme replacement therapy was administered as soon as possible to pre&amp;shy;vent pathological development of heart or brain. Furthermore, we also diagnosed other cases of Fabry disease in his family through Genetic Test and early treatments were provided. Therefore, we expected that Fabry disease will not be considered in clinical practice and early diagnosis with treatment could be provided to decrease the complication and disability rates.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

24 IS POOR ADHERENCE TO HYPERTENSIVE TREATMENT ASSOCIATED WITH THE RISK OF OBSTRUCTIVE SLEEP APNEA IN LONG TERM DIALYSIS PATIENTS?

Background: Obstructive Sleep Apnea (OSA) is one of the causes of secondary hypertension. Vast majority of secondary hypertensive patients have uncontrolled blood pressure due to poor adherence to treatment. However, the association between adherence to hypertensive treatment and the risk of OSA in long term dialysis patients remains unclear. Objective: This study aimed to investigate the association between adherence to hypertensive treatment and the risk of OSA in long term dialysis patients. Method: A cross-sectional study was conducted on eighty-nine hypertensive patients at the Rasyida Kidney Hospital, Medan, North Sumatera. Adherence to hypertensive treatment was measured using the Morisky Medication Adherence Scale (MMAS) questionnaire while the risk of OSA was assessed utilizing the STOP-Bang questionnaire (a tool used to help diagnose OSA). Patients' age, gender, history of smoking, and body mass index (BMI) were also analyzed as possible associated factors. The Chi-Square test and multivariate analysis were used to analyze the association between study variables. Results: Multivariate analysis showed that older age (&gt;50 years old) and higher BMI (&gt;25 kg/m2) were significantly associated with high risk of OSA (OR=6.449; 95% CI= 2.246-18.520; p=0.001 and OR=6.130; 95% CI= 2.105-17.849; p=0.001, respectively). In contrary, we found no significant association between adherence to hypertensive treatment and the risk of OSA (p=0.679). Conclusion: No association between adherence to hypertensive treatment and the risk of OSA was found in long term dialysis patients. However, being older and having higher BMI were significantly associated with higher risk of OSA in long term dialysis patients.

The prognostic value of left atrial strain in patients with end stage renal disease on dialysis

Abstract Funding Acknowledgements Type of funding sources: None. Background Chronic kidney disease (CKD) is associated with higher incidence of cardiovascular death especially as the disease progresses and the patients undergo long term dialysis treatment (1). Left ventricular (LV) dysfunction evaluated by cardiac deformation measurements with speckle tracking echocardiography seems to have an important prognostic role in several different specific populations (2-4). Purpose Τhe prognostic value of strain analysis measurements, including the novel diastolic parameters such as left atrial (LA) strain, in patients with end-stage renal disease on dialysis (stage 5 CKD). Methods 67 patients (mean age 62.3 ± 11.8, 65.7% men) with stage 5 CKD (45 on hemodialysis and 22 on peritoneal dialysis) were enrolled in the study protocol. The mean duration of dialysis was 102.48 ± 84.98 months. Patients were submitted to a transthoracic echocardiogram at rest and dobutamine stress contrast echo (DSCE) protocol. Mean follow-up lasted five years. Results The majority of the study population had normal or mildly impaired systolic function with a mean LV ejection fraction 49.17% (±10.41) while 70% of the patients had impaired LV global longitudinal strain, (mean 14.35%, ±4.49). Regarding LA strain parameters the mean LA reservoir, LA conduit, and LA contractile reserve were 24.11%(±12.61), 10.56% (±5.88) and 13.60% (±9.15) respectively. Thus 50% of the population had impaired LA strain. DSCE was positive for ischemia in 55.7%. The 5-year cumulative event-free survival was 58.2% (±6.7), while 30% of major events happened during the first 2 years after DSCE (see Figure). Logistic regression analysis showed that of the various echocardiographic parameters LV ejection fraction, LV global longitudinal strain, and the conduit phase of LA strain were significantly associated with DSCE result and total prognosis (p = 0.009, p = 0.007, p = 0.05, and p = 0.005, p = 0.049, p = 0.043, respectively). The conduit element of LA strain notably was the strongest predictor among them(OR = 0.76 p = 0.05 and OR = 0.72 p = 0.043, respectively). Conclusion Left ventricular diastolic dysfunction is an important prognostic factor among patients with advanced CKD under long-term dialysis. The novel echocardiographic parameters such as LA strain couldadd valuable information to the overall cardiac evaluation of this specific population. Abstract Figure.

POS-576 OUTCOMES OF GERIATRIC PATIENTS WITH CHRONIC KIDNEY DISEASE STAGE 5 : SINGLE CENTRE EXPERIENCE

Globally, the number of elderly persons with stage 5 chronic kidney disease (CKD) is rising. It's still unclear whether dialysis will benefit geriatric patients with advanced CKD. The decision to start dialysis or to follow a non-dialysis treatment plan is complex and difficult. This study aims to investigate how modality selection affects geriatric patient survival and to explore the associated risk factors. The pre-dialysis clinic database was used to identify geriatric patients (age > 65 years) with an eGFR of 15 mls/min/1.73m2 who were followed up in the nephrology clinic from January 1 to December 31 2016. Demographics, comorbidities, dialysis modality, clinical outcome, and laboratory data were obtained from hospital electronic medical reports. Patients were then followed up till 31stDecember 2018. Survival was calculated from the time when eGFR was <15 mls/min/1.73m2 until death or the end of the study. A total of 97 patients were identified during this study period. Sixty-one (62.9%) patients opted for long term dialysis (LTD) whilst the remaining 37.1% (n=36) opted for non-dialysis (ND) pathway. Patients in the ND group were older with median(IQR) age of 74.5(8) years compared to LTD patients with median age of 70.0(6) (P<0.001). One and two-year survival rates were 67.2% and 62.2% in the LTD group and 66.7% and 60.7% in the ND (p =0.815). Further analysis of patients who chose LTD found that 47.5% (n=29) started dialysis in a timely manner, with mean eGFR of 7.4ml/min/1.73m2, while 52.4% (n=32) crashed-landed with mean eGFR of 5.9ml/min/1.73m2. Patients who crash-landed had the lowest survival rate when compared to patients who started dialysis in a timely manner and those who chose the ND course, as shown in the table below. Mean time of decline in eGFR 15mls/min/ 1.73m2to death or study end was 22.5±12.7 months for those on LTD and 20.8±11.9 months for those managed conservatively (P=0.303). Comorbidities and age did not have a significant impact on survival. Tabled 1No. of patientsNo. of events1 Year Survival %2 Years Survival %P-valueLTD with timelyinitiated dialysis29589.786.10.002LTD butcrash-landed321946.940.6Non-dialysis treatment361566.760.7 Open table in a new tab In this study, geriatric patients who chose dialysis had similar survival to those who chose non-dialysis treatment. If opted for long-term dialysis treatment, it must be started in a timely manner to maximize the survival advantage as crash-lander had the lowest survival rate.

POS-593 STUDY OF 2 YEAR OUTCOMES OF HUB AND SPOKE MODEL OF DIALYSIS

ESRD is a major health problem worldwide particularly in developing countries. The economic, human, technical resources required for long term dialysis makes it a major economic and political challenge. Most countries do not have well formed policies for providing renal care. Dialysis facilities are grossly inadequate and pose a huge economic burden in resource poor countries. Dialysis programs should be decentralized and all the available resources should be used at its maximum. Hub and Spoke model is an innovative model of dialysis to cater the needs of dialysis and providing adequate renal care to patients.

Acute kidney injury due to deposition disease

Acute kidney injury presenting without obvious cause is a diagnostic dilemma. One condition to be considered is monoclonal gammopathy. A case of light chain deposition disease was detected as a cause, involving kidney and extra renal site. It is a part of monoclonal immunoglobulin deposition disease, and may or may not be related to multiple myeloma. Delayed diagnosis can lead to end stage kidney disease, requiring long term dialysis, with its vascular access problems, preventing the treatment by autologous stem cell transplant. The case is presented with review of literature.

‘Kidney Health for All’ - Implications for India

‘Kidney Health for All’ - Implications for India

Upper thigh loop prosthetic arterio-venous grafts (AVG) for dialysis access: An Indian perspective.

Hemodialysis forms the most common replacement therapy for majority of Indians suffering from chronic kidney disease (CKD). Multiple access failure and central vein stenosis has become commonplace in Indian dialysis access patients and there is a burgeoning need for more advanced hemodialysis (HD) access options. Upper thigh arterio-venous grafts (AVG) are seldom inserted due to fear of infection and limb ischemia. This is a single institutional, retrospective, descriptive case study of consecutive patients who underwent upper thigh prosthetic AVG over a period of 7 years. All these patients had exhausted options of upper limb access and or had central vein stenosis. AVG from the proximal superficial femoral artery (SFA) to the proximal great saphenous vein (GSV) in a loop configuration using polytetrafluoroethylene (PTFE) was carried out in the upper thigh. A total of 24 patients had undergone upper thigh loop AVG. Their age varied from 24 to 77 years. The median follow-up period was 3 years. Five of these grafts developed infection (21%) which led to primary failure. A primary patency of 71% (17/24 patients) was achieved at 1 year. Thrombosis developed at a mean of 16.7 months after the primary procedure. Adjunctive procedures such as thrombectomy, segmental replacement of graft, patch angioplasty, balloon angioplasty, and stenting were required in 75% of patients to achieve a secondary patency of 86% at 1 year. Three grafts were explanted without limb loss. Upper thigh loop AVG forms a reliable alternate dialysis access option for patients with failed upper limb access sites or central vein occlusion. Adjunctive procedures are key to maintaining patency in these grafts. Good secondary patency is achievable, and the infection rates are similar to arm AVG. Close follow-up and timely intervention are key to long term dialysis through these grafts.

Secondary hyperparathyroidism, weight loss, and longer term mortality in haemodialysis patients: results from the DOPPS.

BackgroundWasting is a common complication of kidney failure that leads to weight loss and poor outcomes. Recent experimental data identified parathyroid hormone (PTH) as a driver of adipose tissue browning and wasting, but little is known about the relations among secondary hyperparathyroidism, weight loss, and risk of mortality in dialysis patients.MethodsWe included 42,319 chronic in‐centre haemodialysis patients from the Dialysis Outcomes and Practice Patterns Study phases 2–6 (2002–2018). Linear mixed models were used to estimate the association between baseline PTH and percent weight change over 12 months, adjusting for country, demographics, comorbidities, and labs. Accelerated failure time models were used to assess 12 month weight loss as a mediator between baseline high PTH and mortality after 12 months.ResultsBaseline PTH was inversely associated with 12 month weight change: 12 month weight loss >5% was observed in 21%, 18%, 18%, 17%, 15%, and 14% of patients for PTH ≥600 pg/mL, 450–600, 300–450, 150–300, 50–150, and <50 pg/mL, respectively. In adjusted analyses, 12 month weight change compared with PTH 150–299 pg/mL was −0.60%, −0.12%, −0.10%, +0.15%, and +0.35% for PTH ≥600, 450–600, 300–450, 50–150, and <50 pg/mL, respectively. This relationship was robust regardless of recent hospitalization and was more pronounced in persons with preserved appetite. During follow‐up after the 12 month weight measure [median, 1.0 (interquartile range, 0.6–1.7) years; 6125 deaths], patients with baseline PTH ≥600 pg/mL had 11% [95% confidence interval (CI), 9–13%] shorter lifespan, and 18% (95% CI, 14–23%) of this effect was mediated through weight loss ≥2.5%.ConclusionsSecondary hyperparathyroidism may be a novel mechanism of wasting, corroborating experimental data, and, among chronic dialysis patients, this pathway may be a mediator between elevated PTH levels and mortality. Future research should determine whether PTH‐lowering therapy can limit weight loss and improve longer term dialysis outcomes.

Comparable survival outcome between acquired cystic disease associated renal cell carcinoma and clear cell carcinoma in patients with end-stage renal disease: a multi-institutional central pathology study.

Acquired cystic disease (ACD) associated renal cell carcinoma (RCC) is designated as a new subtype unique to patients with end-stage renal disease (ESRD) according to the 2016 World Health Organization (WHO) classification. However, the oncological outcomes of the prognostic factors for patients with this subtype are not fully understood. In the present study, we compared the survival of ACD associated RCC patients who underwent nephrectomy with that of patients with other histological subtypes who developed ESRD. Over 378 patients who underwent nephrectomy at three Japanese institutes between 1987 and 2016 were included in this study. A central pathologist reviewed the sections from all patients according to the 2016 WHO classification. The central pathological review showed a clear cell subtype in 165 patients (43.6%), ACD associated RCC in 112 (29.6%), papillary in 61 (16.1%), and others in 40 (10.7%). The proportion of patients with pathological stage 1 was extremely high in both clear cell and ACD associated RCC cohorts (86.6%, 85.7%). The cancer specific survival (CSS) and recurrence free survival rates of patients with ACD associated RCC were comparable with those with clear cell carcinoma and significantly better than those with the papillary subtype. The factors predictive of unfavourable outcomes were long dialysis duration, tumour size, pathological stage, grade 4 tumour, and the presence of lymphovascular invasion or a sarcomatoid component. Patients with a pre-operative dialysis duration of 20 years or longer showed a significantly worse CSS than other patients, probably owing to sarcomatoid differentiation and stage migration during the advanced stages. In conclusion, this study included the largest number of patients with ACD associated RCC, showing a survival similar to that of clear cell histology patients with ESRD, except for the rarity of late recurrence. ACD associated RCC was not as indolent as initially recognised when patients were on long term dialysis.

Acquired Cystic Disease-Associated Renal Cell Carcinoma: An Unusual Case in the Absence of Acquired Cystic Disease or Dialysis

Abstract Casestudy: Acquired cystic disease-associated renal cell carcinoma (ACD-RCC) is a relatively recently recognized subtype of RCC. Although much less common than clear cell RCC and papillary RCC, it is the most common tumor occurring in patients with end-stage renal disease (ESRD) and acquired cystic disease (ACD). The tumor is said to occur exclusively in patients with acquired cystic disease, most commonly in patients undergoing long- term dialysis. We report a case of a 67-year-old male with stage IV chronic kidney disease due to membranous glomerulonephritis for 6 years with no history of dialysis and without a history of acquired cystic disease. The patient presented with left lower quadrant pain. On imaging, an enhancing exophytic mass was noted in the left kidney. Partial nephrectomy was performed, demonstrating a unifocal 2.2 cm nodular mass diagnosed as ACD-RCC. Microscopically, the tumor revealed intracystic papillary growth, focal cytoplasmic vacuoles (sieve-like growth) with involvement of perinephric adipose tissue by the tumoral cysts. Immunohistochemical staining revealed tumor cells positive for CD10, MIT/113, MPAX8, AMACR, and negative for CK7 and CD117. This immunophenotype supports the diagnosis of ACD-RCC (although itis not specific). Although the patient lacks a clinical history of dialysis and no intratumoral oxalate crystals were noted, the morphological findings and immunohistochemistry support the diagnosis of ACD-RCC, with concurrence by outside expert opinion. In summary, we present this unusual case of ACD-RCC to emphasize the awareness of this entity when considering the differential diagnosis of RCC in adult patients with chronic kidney disease, and specifically distinguish it from the close differential of papillary renal cell carcinoma.

An extra year of Onco-Nephrology fellowship training is required for the subspecialty: PRO

Recent advances in the fields of hematology and oncology over the past decades are truly astounding. Higher response rates have increased the overall and progression free survival, and for certain cancers, have brought the possibility of a cure within reach. While this represents great news for many cancer patients, their longer survival is creating new challenges. Cancer patients can now live long enough to develop chronic kidney disease (CKD), receive long term dialysis, and even a kidney transplantation. There are important and significant knowledge gaps in the care of the cancer patient with CKD or end stage renal disease (ESRD). The subspecialty of Onco-Nephrology was created with the goal of optimizing the care of cancer patients with CKD or ESRD by (1) identifying crucial knowledge gaps in the proper care of these patients by (2) engaging in basic science and clinical research independently and in partnership with cancer specialists to attenuate these gaps, and (3) by educating future onco-nephrologists.

S1573 Case Report and Literature Review of Acute Pancreatitis in COVID-19 Patient

INTRODUCTION: Recently subset of patients with COVID-19 has been presenting with complication of acute pancreatitis (AP). Although exact mechanism of how SARS-CoV-2 causes AP is unclear but different mechanism have been hypothesized. CASE DESCRIPTION/METHODS: We are presenting two cases. First case of 94 year old female who presented with nausea, vomiting, diarrhea, abdominal pain, weakness for 5 days. In the ED she was found hypoxic with SPO2 88% on room air. COVID-19 test result was positive. Blood investigations (Table 1) showed normal LFT and triglyceride, lipase level was high1846. CT abdomen showed AP with trace fluid collection. She was diagnosed with AP in the setting of acute COVID-19 infection and was treated supportively with good response. In second case of 58 year old female who was recently tested COVID-19 positive 2 weeks ago presented with abdominal pain, nausea and nonbilious vomiting since 2 weeks with poor oral intake. In the ED she was found to be afebrile, hypotensive with B.P of 97/81mmHg. Blood investigations showed (Table 1) high creatinine 8.1, high BUN 66, high lipase 685, high amylase 173, normal triglyceride. CT abdomen showed AP without any fluid collection. Diagnosis of AP in the setting of COVID-19 with renal failure was made after ruling out other causes and patient was treated supportively with intravenous fluids. Patient required dialysis for worsening renal function and uremia induced encephalopathy. She subsequently improved was discharged on long term dialysis. DISCUSSION: In both cases all the causes of AP were ruled out, making the diagnosis of COVID-19 induced AP more likely. To further evaluate this topic, we conducted an extensive literature search which resulted in identifying total of 6 published case studies (Table 2) with mean age of 50.5 years who were diagnosed with AP due to COVID-19 infection. It has been hypothesized that SARS-CoV-2 causes AP either due to its direct cytopathic effect by attacking ACE-2 receptors on pancreas or due to dysregulated immune response or cytokine storm leading to multi organ failure.Table 1.: Laboratory findings of cases on admissionTable 2.: Published Studies in the Literature (Acute Pancreatitis complication in COVID-19 infection)

Depression among Chronic Kidney Diseases Patients Receiving Hemodialysis

Background: Chronic Kidney Disease (CKD) is a progressive irreversible loss of renal function over a period of months or years. When kidney disease progresses, it may eventually lead to kidney failure, which requires dialysis or a kidney transplant to maintains life. Hemodialysis is used for patients who require short term dialysis (days to weeks) and for patients with advanced CKD and End Stage renal Disease (ESRD) who require long term or permanent renal replacement therapy. Hemodialysis significantly and adversely affects the lives of patients, both physically and psychologically. Depression is the most common psychological condition among patients with ESRD. Depression in dialysis patients not only effect mortality, but increased rate of hospitalizations and dialysis withdrawal is also very common.&#x0D; Methods: A descriptive cross sectional research design was carried out to identify the depression level of chronic kidney disease patients receiving Hemodialysis in Western Regional Hospital, Pokhara using Beck Depression Inventory among forty six patients.&#x0D; Results: The study findings revealed that majority of the patients (84.8%) has various degree of depression i.e. mild (21.7%), moderate (30.8%) and severe (32.6%). Only fifteen percent of patient has no depression. There was no statistical association between the level of depression and socio-demographic variables. It can be concluded that the prevalence of depression is high among patients receiving Hemodialysis.&#x0D; Conclusion: The prevalence of depression is high among patients receiving Hemodialysis. It is effective to provide mental health services to the CKD patients receiving Hemodialysis which help them better psychologically adaptation to their disease and improve their quality of life.