NKF 2014 Spring Clinical Meetings Abstracts

WARFARIN RELATED NEPHROPATHY Sumendra Joshi, Rahul Bhardwaj, Sonal Kamalia. Warfarin Related Nephropathy (WRN) is a recently described disease entity, in which excessive anticoagulation (INR>3) causes acute kidney injury (AKI). Recent studies show that it can develop in as much as 19.3% of patients having supra-therapeutic INR. We are presenting a case of WRN in a patient with Marfan syndrome, who needed anticoagulation for aortic valve replacement. A 57 year old Caucasian male with Marfan syndrome with aortic valve replacement, on warfarin, presented with 2-3 weeks history of hemoptysis and AKI with creatinine of 2.6mg/dL. INR at presentation was 4. Pulmonary renal syndromes were considered in the differential diagnosis. However, work up including antinuclear antibody, Anti-Glomerular basement membrane antibody, anti-Proteinase 3 antibody, anti-Myeloperoxidase antibody cryoglobulins and Hepatitis B surface antigen was negative. Complement levels (C3 and C4) were normal. Cystoscopy showed no evidence of bleeding from lower urinary tract. A renal biopsy was performed which showed “large number of red cell casts occluding tubules in the absence of necrotizing or proliferative lesions in glomeruli” suggestive of warfarin induced nephropathy. With optimization of anticoagulation and supportive management for AKI, renal function along with hematuria and hemoptysis resolved over next few days. Renal replacement therapy was not needed. With limited options for anticoagulation, he was discharged on warfarin albeit on a lower therapeutic target range of INR (2-2.5) with close follow up. WRN is common and frequently overlooked as a cause of acute kidney injury in the absence of overt hematuria. WRN occurs in patients with or without chronic kidney disease (CKD) and it is associated with an increased mortality rate as well as accelerated progression of CKD. Based on renal biopsy findings, AKI is caused by glomerular hemorrhage and renal tubular obstruction by red blood cell casts. It should be kept as a differential of AKI in all patients on warfarin with an INR >3.

EVALUATION OF AIR MICRO BUBBLES IN DIALYSIS SYSTEMS IN VITRO. Per Jonsson, Ulf Forsberg, Bernd Stegmayr Umeå University dep. of Medicin and public helth and County council of Västerbotten dep. of biomedical engineering & Medicin Umeå / Skellefteå, Sweden. Introduction: During haemodialysis air infusion may occur. In Sweden incidents occurred using different systems. Air could be introduced into the blood stream from couplings where i.e., a negative pressure is present besides residual air. The aim was to find a method that could be used to verify presence and size of air contamination, such as micro bubbles in dialysis extra corporal circuit. Aim: Find a method that could be used to verify presence and size of air micro bubbles contamination. Method, mimic blood: Mixtures of Dextrane compared with blood. Brookfield Digital Viscometer, Model LVTDV-IICP was used with cone CP-40, angle 0.8 degrees. Viscosity measurements at: shear rates 90, 225 and 450 s-1 The normal value vas compared: blood at 37oC vs. dextrane at 25oC. Quantitative: Bubble detectors Hatteland CMD10 were used to count and verify size of bubbles. A set of blood lines was connected to a container with dextran-albumin solution that was re-circulated in the system. A bubble detector probe was attached to the system. One variable at a time was changed; such as flow or venous chamber. Statistic: paired nonparametric statistics were used. Results: Mixture of 1l Dextrane 40g/l +50ml albumine 20% mimic blood viscosity dynamics. Visual inspection verified presence of micro bubbles in venous lines. In vitro tests showed that the micro bubble distribution correlate to flow, dialysator and shape of venous chamber. Conclusions: The method using a D-A-solution is a fast qualitative method to get a view of bubble distribution in extra corporal systems. Together with a bubble detector and paired non parametric statistics it is a robust and effective method for in vitro testing to evaluate and compare bubble exposure in extra corporal systems.

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Am J Kidney Dis. 2014;63(5):A1-A121

HIGH PREVALENCE OF CHRONIC KIDNEY DISEASE IN PATIENTS WHO ARE SUPER-USERS OF HEALTH RESOURCES Claudine Jurkovitz, Zugui Zhang, James Bowen, Simone Lavin, Eric Jackson, Heather Bittner-Fagan. Value Institute, Christiana Care Health System, Newark DE, United States A small number of patients account for a large percentage of healthcare system utilization and cost. Use of emergency and inpatient services by this group, referred to as “super-users”, results in expensive and ineffective care. Only few studies report the prevalence of chronic kidney disease (CKD) in these patients. The objective of this study was to compare the characteristics of super-users with and without CKD.

Our study population included patients who had at least 2 inpatient visits in any 6 months period between 2003 and 2013. We used data from our hospital electronic health records to determine patients’ characteristics at the first hospital stay of a high utilization period. To understand the life-cycle of these patients, we restricted the population to those for whom there were at least 5 years-worth of records and who became super-user after at least a 3 year-period of less frequent hospital visits. Glomerular filtration rate (GFR) was calculated using the CKD-Epi equation. CKD was defined as GFR<60 ml/min/1.72m2.

Of 6330 patients who met our inclusion criteria, 23.3% had GFR 30-59, 6.6% had GFR 15-29 and 5.5% had GFR<15. Compared with those without CKD, patients with CKD were as likely to be male (40.0% versus 39.7%), were older (71.4 years versus 56.2, p<0.0001) more likely to be white (71.4% versus 65.4%, p<0.0001), more likely to have Medicare (77.7% versus 44.0%), less likely to have Medicaid (6.3% versus 18.3%) or to be without insurance (2.0% versus 5.6%), p<0.001. The prevalence of comorbidities was high among the CKD patients. A total of 35.3% versus 14.2% had congestive heart failure, 45.7% versus 30.4% had diabetes, 89.4% versus 63.9% had hypertension, 18.9% versus 7.9% had some peripheral vascular disorder (all p<0.0001). Patients with CKD were more likely to have 2 or more high utilization episodes (23.3% versus 19.1%, p=0.003).

The prevalence of CKD is high among patients who frequently use hospital services even though most of them have insurance. Early identification of these patients and focused management after discharge may be the key for reducing the number of rehospitalizations.

MULTI-PRONG APPROACH TO IMPROVE PHOSPHORUS CONTROL IN A HEMODIALYSIS POPULATION Cherriday Joson, Sue Kim, Stephanie Tovar, Mandy Cheung, Prajakta Parab, Antoine C. Abcar, John J. Sim, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA Reasons for poor phosphorus control in the dialysis population are multifactorial. We sought to evaluate whether a multi-prong implementation strategy focused on health literacy, medication adherence, and peer support group would lead to improved phosphorus control. Based on survey results from the same population, interventions targeted towards patient health literacy, medication adherence, and peer group support were initiated in a single dialysis unit. These interventions included a two day educational fair about phosphorus control, the creation of a phosphorus group social, and staff education on phosphate binders. The survey itself reinforced the importance of phosphorus control to dialysis patients. Comparisons of phosphorus levels and control at baseline and at 6 months were performed. The mean serum phosphorus levels at baseline was 4.92 mg/dL compared to 5.07 mg/dL at 6 months (p = 0.19). The serum phosphorus percent controlled (serum phosphorus level <= 5.5 mg/dL) for the same population was 72.4% at baseline compared to 72.5% after 6 months (p=0.8). The insignificant difference of percentages and phosphorus levels in the two time points may be too early to assess the impact of the implementation strategies. Seasonal variations in phosphorus levels also indicate a potential confounding. We will continue to follow and assess for the impact of whether the implementation programs lead to meaningful improvements in CKD BMD outcomes.

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