NKF 2014 Spring Clinical Meetings Abstracts

IMPROVEMENT OF CALCIPHYLAXIS AFTER INTRAVENOUS PAMIDRONATE THERAPY IN PATIENTS WITH ESRD. N. Varothai, E. Sarac. St. Elizabeth Health Center, Youngstown, Ohio. Calcific uremic arteriolopathy (also known as calciphylaxis) is a rare disease characterized by calcium-phosphorus deposition in small vessels leading to necrosis tissue. The prognosis of calciphylaxis is poor. Suggested supportive treatment includes wound care, control infection, non calcium-phosphate binder, low-calcium dialysis. One of experimental therapies included the use of IV and oral bisphosphonates. We describe three patient cases where the use of IV pamidronate was successful in the management of calciphylaxis. Case 1 A 51-year old Caucasian obese ESRD female hospitalized with lower abdomen and both thigh painful ulcers from calciphylaxis for 2-3 months on June 2005. Treated with daily dialysis for 10 days follow by 4 h dialysis three times a week and Pamidronate 30mg IV once daily for 5 days with significant clinical improve. Case 2 A 56-year old Caucasian obese ESRD male hospitalized with bilateral lower extremity painful ulcers from calciphylaxis on June 2005. Treated with daily hemodialysis for 10 days follow by 4 h dialysis three times a week and pamidronate 30mg IV once daily for 4 days The leg ulcers improved significantly. Case 3 A 51-year old Caucasian ESRD hospitalized with multiple necrotic ulcers on left leg from calciphylaxis for 3 wks on June 2013. Treated with daily hemodialysis for 7 days follow by 4 h dialysis three times a week and Pamidronate 30 mg IV once daily for 2 days. with improve within 1 month Discussion :Although the pathogenesis of calciphylaxis remains uncertain, inflammatory changes may play a role. Besides, inhibition of osteoclastic bone resorption, Bisphosphanate suppress an inflammatory syndrome through inhibition of macrophage activity and the release of proinflammatory cytokines. This cellular effect may play an important role in rapid healing of necrotic ulcer. According to the cases, bisphosphanates may be an effective alternative for treatment of calciphylaxis.

ROLE OF ENDOTHELIAL AND PLATELET-DERIVED MICROPARTICLES IN HEMODIALYSIS ACCESS COMPLICATIONS: Helga Vamenta-Morris, Angie Nishio-Lucar, Christine Rudy, Kambiz Kalantari, Uta Erdbruegger, University of Virginia Health System, Charlottesville, VA, USA

Failure of hemodialysis vascular access (HVA) produces high morbidity and mortality in end-stage renal disease patients and represents an economic burden. At present there is no tool to identify those at high risk for HVA complications. Microparticles (MP) are intact vesicles derived from eukaryotic cell membrane that constitute markers of cell activation, injury and apoptosis.

We designed a cross-sectional study to measure endothelial and platelet-derived MP (activated and non-activated) in patients with HVA complications (n=10) and those without complications (n=8). We used flow cytometry in platelet-poor plasma to detect and quantify MP using surface markers of endothelial cells and platelets. MP pellets were stained with Annexin V.

Endothelial-derived microparticles (activated CD 62E) and non-activated (CD 144, CD 105) were elevated in HVA complications (CD62E p=0.07, CD144 p=0.07, CD 105 p=0.08). Annexin V positive MP were higher in patients with HVA complications, whereas levels of platelet derived MP did not differ in both groups.

Higher levels of endothelial-derived MP might reflect endothelial damage in patients with vascular access complications and identify those at high risk for complications. This observation needs to be confirmed in a larger cohort.

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

EVALUATION OF ACUTE KIDNEY INJURY (AKI) IN AN ORTHOPEDIC POPULATION IN A COMMUNITY HOSPITAL Myriam Vela-Ortiz, Elnaz Rakhshan, Mohammad Umar Farooq, Sukhminder Singh Richard Snyder . Easton Hospital, Department of Internal Medicine and Nephrology, Easton, Pennsylvania, USA Common metabolic complications in patients undergoing orthopedic procedures may include the development of Acute Kidney Injury (AKI) and hyponatremia (HNA). The purpose of this retrospective study is twofold: first, to identify those risk factors that may contribute to the development AKI (AKI) and HNA in this patient population. Second, to develop a protocol checklist that identifies these risk factors and employs measures to try and prevent these metabolic derangements from occurring. We reviewed the records of 40 patients who had undergone elective orthopedic procedures. Of these, 29 were female and 11 were male with a mean age of 60. We reviewed comorbidities, the type of orthopedic procedure, medications, and pertinent laboratory values at baseline, pre and post-surgery including Hgb and Cr levels. Eighteen out of fifty patients developed AKI. The highest risk of AKI was found in patients who underwent knee and hip surgery; interestingly the risk of AKI was higher for knee-focused procedures in our patient population. The risk of AKI and HNA presenting simultaneously was primarily seen in patients that underwent knee surgery; hyperkalemia was also demonstrated in this patient population. Risk factors for AKI were CKD, post-operative decrease in Hgb, advanced age, ACE inhibitor and NSAID use. Risk for AKI and HNA included those already mentioned above with the addition of diuretic use and knee surgery. Note that AKI and low Hgb levels were seen in patients that also developed hyperkalemia. In summary, this retrospective analysis shows that in evaluating patients who will undergo orthopedic procedures, there are factors that should be considered that increase the risk of developing ARF and HNA.. The next step will be the creation of a protocol that can be used to not only prevent metabolic complications but increase quality of care and decrease length of stay due to prevention of these complications.

C3 GLOMERULONEPHRITIS MANIFESTING AS RECURRENT EPISODES OF ACUTE KIDNEY INJURY DURING TIMES OF INFECTION Myriam Vela-Ortiz, Shawn Hazlett, Sharif Ali, Easton Hospital Affiliated with Drexel Unniversity, Department of Internal Medicine and Nephrology, Easton, Pennsylvania, USA 41 year old male presented with decreased urinary output and cola colored urine following a presumed viral gastroenteritis. Initial creatinine was 9.8 mg/dL with hematuria and proteinuria. Serologic evaluation included low C3 and C4 (49 and 4.5 mg/dl, respectively) high C5 (19.2 mg/dL), and negative hepatitis and autoimmune serologies. Kidney function improved with supportive treatment alone and the patient was discharged home with a creatinine of 1.0. The patient returned a day later with oliguria and creatinine at 2.1 mg/dL. A biopsy was performed showing diffuse membranoproliferative glomerulonephritis with diffuse capillary wall staining for C3 deposits, corresponding with very electron dense membranous deposits. No necrotizing or crescentic, but focal podocyte foot process effacement noted. Kidney function again normalized with supportive therapy alone. Two years later, the patient presented with cola colored urine while receiving antibiotic treatment for Lyme disease. He was again noted to have proteinuria and hematuria and creatinine of 4.5. His kidney function again normalized after several days without therapy. After five years of follow up since presentation, the patient remains well with stable kidney function and normal complement levels. C3 glomerulonephritis is an increasingly recognized entity associated with hypocomplementemia and nephritic like presentation, characterized by a mesangial and endocapillary proliferative lesions by light microscopy associated and C3-limited deposits along glomerular capillary walls that have very electron dense appearance along glomerular basement membrane by electron miscopy. This case demonstrates a patient with C3 glomerulonephritis, manifesting as recurrent episodes of severe acute kidney injury during times of infectious illness with normalization of kidney function and complement levels between episodes. It also highlights the fact that glomerular deposits can be focal and sampling variability may interfere with electron microscopic diagnosis.

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