241ASSOCIATION BETWEEN LOWER GRAFT SURVIVAL AND KIDNEYS FROM DONORS AGED 40-49 YEARS WITH CO-MORBIDITIESAnita Patel, Mohamad Al-Abed, Mariella Goggins, Lauren Malinzak, Vanji Karthikeyan, Department of Internal Medicine and Transplant Institute, Henry Ford Hospital, Detroit, MI, United States

Several recipient (R) and donor (D) risk factors are associated with inferior graft survival (GS). Outcomes of recipients (R) receiving kidneys from standard criteria donors (SCD) aged 40-49 years with risk factors of ECD criteria coined compromised SCD donors (CSCD) were compared with SCDR using UNOS data from1995 to 2010. Patient survival (PS) and GS were studied. Median follow up was 4 years. On Kaplan Meier survival analysis, both PS and GS appeared to be significantly superior for SCDR compared to CSCDR. However, on Cox regression analysis, there appeared to be a marginally significant decrease in PS (Hazard ratio [HR] 1.089 [95% confidence interval 1.010-1.174]); p=0.02) in CSCDR. In this group, GS was significantly lower (HR:1.109 [CI 1.031-1.192]; p=0.0053). However, patient survival was not significantly different. In conclusion, GS appears to be strongly influenced by donor risk factors in age group 40-49 years. It is possible that duration and severity of co-morbidities and effective renal reserve influence graft outcomes in this age group of standard criteria donors. Whether the same influence exists in donors less than 40 years of age or healthy donors over age 50 years is being invested. Influence of other risk factors including components of the metabolic syndrome is also being studied.

242COCAINE USE AND CHRONIC KIDNEY DISEASE: FINDINGS FROM THE NATIONAL HEALTH AND NUTRITION EXAMINATION SURVEY S.Akkina. University of Illinois at Chicago, Chicago, IL. A. Patel. University of Illinois at Chicago, Chicago, IL. M. Fischer. University of Illinois at Chicago, Chicago, IL. J. Lash. University of Illinois at Chicago, Chicago, IL. Purpose: Studies have reported a possible link between cocaine use and chronic kidney disease (CKD). The purpose of this study was to specifically examine this relationship in a nationally representative sample. Methods: We performed a cross-sectional analysis of data from the National Health and Nutrition Examination Survey 2005-2008. The sample included 6,168 participants who completed the drug use survey and were between the ages of 20-59 years. CKD was defined as an MDRD estimated glomerular filtration rate (eGFR) ≤60 mL/min/1.73m2 or the presence of microalbuminuria (>20mg/g). We compared non-cocaine users to those who used any form of cocaine, recently used cocaine (defined as within the last 30 days), and also examined the number of times used (<5, 5 times or more). Using logistic regression models, we estimated odds ratios for CKD with cocaine use adjusted for demographic factors and medical history. Results: Between cocaine and non-cocaine users, there was no significant difference in eGFR (90.3±0.87mL/min/1.732 vs 91.4±0.73 mL/min/1.732, p = 0.268) and albumin/creatinine ratio (23.7±5.8mg/g vs 28.8±4.9mg/g, p = 0.519). There was also no significant difference in eGFR and albumin/creatinine ratio between recent cocaine users or those that had used cocaine 5 times or more compared to non-users and those with a history of distant cocaine use or < 5 times used (p>0.05). Unadjusted and adjusted logistic regression analysis revealed no significant association between cocaine use and prevalent CKD Discussion: In a representative sample of the U.S. population, there was no substantial difference in kidney function or albuminuria between non-drug users and those who used cocaine.

243UNSUSUAL CASE OF AGRANULOCYTOCIS WITH VALACYCLOVIR IN A KIDNEY TRANSPLANT PATIENT H Patni, A Chawla,& R Barnett:Hofstra North Shore LIJ School of Medicine, NY Although Valacyclovir (VAL) has been shown to cause leukopenia; agranulocytosis has not been reported. Solid organ transplants may be particularly at risk. A 55 year-old male with cadaveric renal transplant was maintained on mycophenolate mofetil (MMF), tacrolimus (FK) and prednisone for 12 years without significant complications. Ten days prior to admission he developed painful oral ulcers. Prescribed VAL 1 gm twice daily for a presumed herpes infection but a week later presented with high grade fever and worsening malaise. Denied cough, diarrhea, nausea, vomiting or dysuria. Exam was notable for oral ulcers with erythematous base. Laboratory tests revealed a WBC of 300/μl with no granulocytes, hemoglobin 9.8gm/dl & platelet count of 118K/μl. Chemistries were unremarkable. FK trough was 7.2ng/ml and MMF levels were 0.7mcg/ml. Tests were negative for cytomegalovirus, HIV, BK virus, Parvovirus, mycoplasma, ehrlichia and acute EBV infection. Patient was treated empirically with cefepime, however his blood and urine cultures were negative. FK and prednisone were continued while MMF & VAL held. Agranulocytocis persisted despite 3 doses granulocyte macrophage colony stimulating agent (GM-CSF). Bone marrow biopsy revealed normal cellularity with early myeloid precursors. Studies for myelodysplastic syndrome were negative. After the 5th dose GM-CSF, WBC count rose to 4000/μl & neutrophils rose to 800/μl by day 6. His out patient follow up revealed normal WBC count and stable allograft function. This case illustrates a rare but severe complication of VAL. Even though agranulocytocis has not been previously reported, recent literature suggests an interaction between VAL and MMF, leading to marrow suppression. Further studies are needed to determine the mechanism of synergistic toxicities and to suggest possible dose adjustments in transplant patients.

244COST-EFFECTIVE MANAGEMENT OF IRON DEFICIENCY AMONG PATIENTS WITH ANEMIA AND NON-DIALYSIS DEPENDENT CHRONIC KIDNEY DISEASE Robert Perkins, Ion D. Bucaloiu, Matthew Bailey, Nirav Shah, James Pitcavage, Michael Schultz, James E. Hartle Geisinger Medical Center, Danville, PA. The optimal treatment of iron-deficiency among anemic patients with stage 3 or 4 chronic kidney disease has not been determined. We designed a Markov, state-transition model exploring oral vs. IV iron as initial therapy for newly anemic (hgb < 10 g/dL), iron deficient patients with non-dialysis dependent chronic kidney disease (NDD-CKD). The perspective was that of a health care system. Probabilities of state transitions, cardiovascular events and blood transfusions, as well as direct health care costs incorporating hematologic response and downstream ESA use, were derived from a retrospective cohort (2004—2009) of adult patients with iron deficiency, incident anemia, and stage 3 or 4 chronic kidney disease at Geisinger. The timeframe and analytic horizon were median life-expectancy. Outcomes assessed included costs, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER). Sensitivity analyses across subgroups with varying responsiveness to oral iron and across a range of healthcare resource utilization and IV iron dosing regimens were conducted. Over the course of 4.0 years follow-up, for average and robust responders to oral iron therapy (as measured by probability of achieving a hemoglobin of 11.0 g/dL or greater), an initial strategy of oral vs. intravenous iron was associated with modestly higher effectiveness (0-80 quality-adjusted life-days) and lower costs (cost savings range $2500-$12,000). Among those with the poorest early hematologic response to oral iron therapy, intravenous iron was modestly more effective (18 quality-adjusted life days) and cost-saving ($300), but sensitive to background health care resource utilization Oral iron is the optimal first treatment strategy for the majority of iron-deficient, anemic NDD-CKD patients.

NKF 2011 Spring Clinical Meetings Abstracts

Am J Kidney Dis. 2011;57(4):A1-A108 A77