NKF 2014 Spring Clinical Meetings Abstracts

ERYTHROPOEITIN AND IRON CONTROL IN HEMODIALYSIS PATIENTS BY ADVANCED PRATICIONERS IMPROVES ANEMIA CONTROL Kathryn McComb, Cassie Kolstad, R.Allan Jhagroo, University of Wisconsin, Madison, WI Management of Anemia in ESRD hemodialysis patients remains a

major function in dialysis units. As with many other reportable measures, anemia has now being tied into payment for dialysis services. Failure to reach goals will result in poor patient care as well as not reaching network goals. With the current proposed reduction of 10% for ESRD services by CMS, the margin for financial variation has grown thinner. All patients receiving hemodialysis at our dialysis unit (Wisconsin

Dialysis Incorporated) were included in a chart review to examine anemia parameters commonly used for a specific 12 months of time. During the first 6 months our patients were receiving management of Erythropoietin (EPO) and Iron based on a protocol that was used by a RN with a focus in anemia management. The second 6 months examined were after a 3 months of the anemia management under control by our APs. Results were taken from data selected using the criteria for which

monitoring takes place in CROWN web which is required by all dialysis units for quality monitoring. Thus, data was not included if the patients had been on dialysis less than 3 months or if they were not on Erythropoietin. The primary goal was to identify hemoglobin (Hbg) over 12 mg/dl as this is this number has been established by the Quality Incentive Program(QIP). Based on the last checked Hbg for those months the percent of patients over 12 mg/dl was 6.8 % when managed by protocol with RN as opposed to 1.8 % with individual management with our AP. No significant differences in Iron or EPO were noted. Using AP’s to individually manage anemia in our ESRD patient we

were able to keep the percentage of Hbg > 12mg/dl down to 1.8% as opposed to 6.8% percent seen with the use of a specialized RN in combination with a protocol. To ensure better clinical outcomes as well as meet the requirements of the QIP which is less than 2 % this year and is expected to be 0 % next payer year this approach may be very helpful for dialysis units.

INITIATION OF DIALYSIS VIA SLOW LOW EFFICIENT DIALYSIS IS SAFE AND COULD REDUCE LENGTH OF

HOSPITALIZATION Mohammad Mataria, MD, MSCR, Talal Mahmood, MD, Youshay Humayun, MD, Tibor Fülöp, MD University of Mississippi Medical Center, Jackson, Mississippi Hemodialysis is the most utilized dialysis modality among end stage renal disease patients (ESRD) in the United States. USRDS 2009 report stated that 94 percent of ESRD patients were started on hemodialysis1. Dialysis disequilibrium syndrome (DDS) is a potential complication among patients’ initial session of dialysis. DDS signs and symptoms vary from mild self-limited symptoms that may progress to sever complications2. A fundamental safeguard in preventing the development of DDS is to limit the drop of blood urea nitrogen (BUN) during initial dialysis sessions. Escalating daily dialysis sessions have been the common adopted practice. These sessions lead to prolonged hospitalization and increased health cost. Slow low efficient dialysis modality (SLED) is a valid, understudied, and underutilized modality for initiation of dialysis that potentially can eliminate the risk of DDS and shorten the length of hospitalization. We are reporting two cases where SLED was the modality employed to initiate dialysis. Patient A has BUN/Cr of 105/5.01 mg/dl upon presentation. The patient was dialyzed using blood flow rate of 200 ml/min and dialysate flow rate of 100 ml/min for 8 hours. Pre and post dialysis serum osmolality levels were 309 mOsm/kg and 284 mOsm/kg, respectively. Patient B has BUN/Cr of 117/8.2 mg/dl. Again, patient B was dialyzed using SLED with identical blood and dialysate flow rates. Patient B pre and post dialysis osmolality levels were 360 and 293 mOsm/kg. Neither patient A nor patient B had any symptoms following SLED. SLED is a potential alternative modality to initiate hemodialysis. Shorter hospital stay has always shown to have a significant impact on health care cost and application of SLED modality clearly has great advantage. 1-USRDS 2009 annual data report 2-Dialysis Disequilibrium Syndrome: current concepts on pathogenesis and prevention; Arieff Al; Kidney Int. 1994;45(3):629

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ABDOMINAL AORTIC ANEURYSM: A RARE CAUSE OF BILATERAL URETERAL OBSTRUCTION. Swati Mehta1, Kisra Anis21Bronx VA hospital, NY 2Jacobi Medical Center, Bronx, NY Obstructive uropathy refers to the functional or anatomical obstruction of urinary flow at any level of the urinary tract. Abdominal aortic aneurysm is one of the rare causes of obstructive uropathy. Only few such cases have been reported in literature. 72 year old male former smoker with history of coronary artery disease presented to Jacobi Medical Center with generalized weakness, fatigue, oliguria and decreased appetite for 2 months. On laboratory analysis patient was found to have serum creatinine of 7.8 mg/dl (baseline creatinine 1.1 mg/dl six months prior) and serum potassium of 5.8 meq/L. Workup with ultrasonography of abdomen revealed presence of 6.2 cm large atherosclerotic infra-renal abdominal aortic aneurysm (AAA) with bilateral hydronephrosis (left >right) . Computed tomography confirmed the 8 cm large infra-renal AAA extending to common iliac artery bilaterally with element of retroperitoneal fibrosis accounting for bilateral hydronephrosis. Patient underwent left sided nephrostomy tube placement and subsequently bilateral ureteral stent placement for decompression , however the renal function did not show any improvement. AAA was repaired with endovascular approach with no impact on renal function and the patient eventually became dialysis dependent. AAA is associated with peri aneurysmal fibrosis which can involve surrounding structures and cause ureteral entrapment. Exact mechanism of peri aneurysmal fibrosis is unknown. Parums et al. hypothesized that peri aneurysmal fibrosis is due to immunological response to leakage of lipid from atherosclerotic plaque. We are reporting the case of large AAA with peri aneurysmal fibrosis causing severe obstructive uropathy which did not improve after urinary drainage and AAA repair. This can be explained by the delayed presentation and diagnosis.

ANTIBIOTIC IMPREGNATED SPACERS AND HA-AKI- A RETROSPECTIVE STUDY: Jagdeep K.Mehr, H.Lester Kirchner,James E Hartle,Geisinger Health System, Danville,PA,USA. Antibiotic-laden cement spacers are a standard of care for late chronic infections at the site of total joint replacement. The incidence of hospital acquired acute kidney injury (HA-AKI) after these procedures has not been defined, although cases of such have been reported. We performed a retrospective study on all patients between the age of 18-88 years undergoing prosthetic hip, or knee revision, or prosthesis removal. All patients had utilization of bone cement. There were a total of 533 hip/knee procedures meeting study criteria. The incidence of AKI after these procedures with or without spacer and/or with or without antibiotic use was determined. There was a total of 204 (38.3%) procedures where antibiotics were used and 160 (30.0%) where a spacer was implanted. Among the 533 admissions, the incidence of HA-AKI was 12.4% (95% CI: 9.8%, 15.7%). Both antibiotic and spacer use was significantly associated with developing AKI (p=0.0012, p=0.0071, respectively). The unadjusted odds ratio (OR) was 2.52 (95% CI: 1.44, 4.42) for antibiotics and 2.17 (95% CI: 1.23, 3.81) for spacers. After controlling for other co-morbid conditions, only antibiotic use remained as a significant risk factor (OR=2.22, 95% CI: 1.16, 4.24). Our study defines another setting of surgical procedure with an increased risk of developing HA-AKI. The risk appears to be higher with antibiotic use. Clearer guidelines for antibiotic use and dosing in joint revisions, as well as more precise implementation may be warranted to prevent HA-AKI in this population.

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