269: Renal Artery Stenting Works−In the Right Patient
1
269 RENAL ARTERY STENTING WORKS - IN THE RIGHT PATIENT Aastha Sethi , Ralph Daher, Sumeska Thavarajah, Mahmoud Malas, John Anderson Johns Hopkins University, Baltimore, MD, USA Atherosclerotic renal artery stenosis (RAS) accounts for approximately 90% of all cases of RAS. It classically manifests after the age of 50 years and its presence carries significant morbidity and mortality. We present the case of a woman with significant bilateral RAS who had a favorable response to renal artery intervention (RAI). A 74-year-old female with hypertension, and coronary artery disease was admitted to our hospital with a blood pressure of 200/100 mm Hg. Her serum creatinine was elevated at 2.5 mg/dl compared to a normal baseline. Her hospital course was complicated by multiple episodes of flash pulmonary edema. An MRA revealed bilateral 90% ostial renal artery stenosis. She underwent left renal artery angioplasty and stent placement. However, she continued to have episodes of flash pulmonary edema. A repeat angiogram performed revealed a 50% stenosis and dissection distal to the left renal artery stent with a failed attempt at revascularization. She developed another episode of pulmonary edema, became anuric and her creatnine increased to 5.6 mg/dl. A third attempt at revascularization, albeit considered very challenging, was offered to the patient. Both renal arteries were successfully stented using a brachial artery approach. Her urine output improved immediately after the procedure with decline in her serum creatinine to 1.2 mg/dl over the next 3 weeks. Despite significant advances in techniques of RAI, the indication for renal artery stenting remains controversial due to an unproven benefit of RAI compared to best medical therapy. Furthermore, consistent and reliable predictors of a favorable response to RAI in terms of renal function remain unknown making it very challenging to select the right patients for RAI. Our patient had a favorable response to the RAI as suggested by significantly lowered requirement of antihypertensive medications and rapid improvement in renal function after the procedure. This case illustrates that careful patient selection and an adequately skilled interventionist are of paramount importance in managing renal artery stenosis by a vascular intervention. 270 OUTCOMES IN PATIENTS WITH AND WITHOUT PROTEINURIA IN A SINGLE CENTER HIV COHORT Rehan Shafique ; Robert B. Canada, Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA. We sought to examine prevalence and incidence of proteinuria and outcomes of patients with and without proteinuria in a single center HIV cohort. In a retrospective chart review analysis, data were collected from all patients who were referred to HIV clinic in the year 2005. Urinalyses on the initial HIV visit were used to determine the prevalence of proteinuria. Patients with trace proteinuria were not included as having proteinuria. Other data gathered included age, initial CD 4 count, and serum creatinine. In November 2009, charts of these patients were again reviewed. Study outcomes included development of ESRD and death. Total number of patients was 203. 50 patients had proteinuria on initial visit. 22 patients developed proteinuria subsequently who did not have proteinuria on the initial visit. 6 patients had doubling of creatinine. Four developed ESRD. There were total of 27 deaths. Proteinuria was found to be associated with higher mortality and development of ESRD in an unadjusted model. After adjustment with age, serum creatinine, and CD 4 count, association of proteinuria with mortality was found not to be significant although there was a trend towards higher mortality. Low CD 4 count was independently associated with higher mortality after adjustment with age, serum creatinine, and proteinuria. Adjusted Odds Ratios for mortality: Variable Odds Ratios Confidence Limits Proteinuria on initial visit 1.446 0.569-3.677 Creatinine 1.127 0.895-1.420 Age 1.026 0.987-1.067 CD 4 count 0.997 0.995-0.999 In summary, proteinuria is highly prevalent in HIV population, and it may be associated with worse outcomes including development of ESRD and Death. Further study is warranted in examining outcomes in patients with HIV with proteinuria to determine best interventions to prevent or slow progression of renal damage. 271 EFFECT OF MEDICAID COVERAGE IN DIALYSIS Simi Shahabdeen , Prasanna Srinagesh, Nauman Shaheed, Muhammed Rahman, Mohit Gupta, Ziauddin Ahmed Drexel University College of Medicine, Philadelphia, PA, USA Medicaid reimbursement by different HMOʼs is adversely impacting the dialysis units. In the absence of good monitoring system it is not uncommon to discover that frequently prescribed medications are not covered. Denial of home medications are usually reported by the patients but the denial of medications that are given intravenously during dialysis may get unnoticed. Most Medicaid payers do not pay for the intravenous dialysis medications and the routine monthly blood work. This can be a burden when numbers of patients on Medicaid is increased in any unit. We decided to look for the unsuspected loss of revenue by giving uncovered medications to Medicaid patients in an inner city Philadelphia dialysis unit which is managed by a national chain and run by University Physicians. The unit has 139 patients and 40 (28.7%) of them have Medicaid coverage and 19 of them have only Medicaid without any secondary coverage. The vitamin D analog administration during dialysis is reviewed in 19 (13.6%) patients who have primary Medicaid. The Cost of blood work also reviewed In just one month the unit lost $4300 for all 19 Medicaid patients for only Vitamin D analog and loss of $7200 per month for blood work for all uncovered Medicaid patients. The alternate choices to avoid loss of revenue may be giving generic medications & or converting them to oral form. The loss of revenue from monthly blood work may be more difficult to resolve but contracting competitive local laboratory may provide some relief. 272 POSTERIOR REVERSIBLE ENCEPHALOPATHY (PRES) RELATED TO TACROLIMUS (TAC): A CASE REPORT Simi Shahabdeen , Mohit Gupta, Nauman Shahid, Alden Doyle Dept of Nephrology and Transplantation, Drexel University, PA 43 year old white female post heart transplant in 2001 secondary to postpartum cardiomyopathy on immunosuppression with TAC and history of calcineurin inhibitor induced End Stage Renal disease presented with sudden onset of agitation and generalized tonic-clonic seizures occurring within 1 hour after dialysis. Review of systems positive for high fever, vomiting and recent admission for line sepsis. Past history is also significant for insulin-dependent diabetes and hypertension controlled with Labetalol, Clonidine. Physical examination revealed temp 103, BP 170/90mm Hg and HR 117/mt. Patient appeared somnolent, confused and hence intubated. Air entry reduced bilaterally and reflexes were brisk. Left internal jugular permacath was intact with clean exit site. Labs showed WBC 11.1, Hb 10.1, platelet count 121, sodium 141, K 4.1, bicarbonate 21, BUN 17, Cr 3.4, prograf level 6.3. Treatment initiated with loading dose of dilantin, broad spectrum antibiotics and antivirals. Permacath was removed suspecting line sepsis. CSF studies, CT head, Echo and USS liver were unremarkable. Patient continued to remain somnolent, febrile and markedly hypertensive for next 2 days requiring labetalol drip, but was seizure free. Blood and CSF cultures were negative. Due to absence of clinical improvement, non-contrast MRI brain was done that demonstrated subcortical white matter lesions in right posterior lobe and pons suggesting the diagnosis of PRES. Intravenous TAC was immediately discontinued and cyclosporine started, to which a remarkable response was noticed. Patient became more awake and alert within few hours and was extubated the next day. This case aims to draw attention to consider PRES as differential diagnosis in solid organ transplant recipient on TAC or cyclosporine presenting with following symptoms: headache, mental status changes, focal neurological deficits, and/or hypertension. PRES can occur with therapeutic levels of these drugs. Mostly, PRES is reversible by reducing the dosage or withholding the drug for a few days. Early recognition is of paramount importance for prompt control of blood pressure or removal of precipitating factors and treatment of seizures. NKF 2010 Spring Clinical Meetings Abstracts A99
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Transcript of 269: Renal Artery Stenting Works−In the Right Patient
269
RENAL ARTERY STENTING WORKS - IN THE RIGHT PATIENT Aastha Sethi, Ralph Daher, Sumeska Thavarajah, Mahmoud Malas, John Anderson Johns Hopkins University, Baltimore, MD, USA Atherosclerotic renal artery stenosis (RAS) accounts for approximately 90% of all cases of RAS. It classically manifests after the age of 50 years and its presence carries significant morbidity and mortality. We present the case of a woman with significant bilateral RAS who had a favorable response to renal artery intervention (RAI). A 74-year-old female with hypertension, and coronary artery disease was admitted to our hospital with a blood pressure of 200/100 mm Hg. Her serum creatinine was elevated at 2.5 mg/dl compared to a normal baseline. Her hospital course was complicated by multiple episodes of flash pulmonary edema. An MRA revealed bilateral 90% ostial renal artery stenosis. She underwent left renal artery angioplasty and stent placement. However, she continued to have episodes of flash pulmonary edema. A repeat angiogram performed revealed a 50% stenosis and dissection distal to the left renal artery stent with a failed attempt at revascularization. She developed another episode of pulmonary edema, became anuric and her creatnine increased to 5.6 mg/dl. A third attempt at revascularization, albeit considered very challenging, was offered to the patient. Both renal arteries were successfully stented using a brachial artery approach. Her urine output improved immediately after the procedure with decline in her serum creatinine to 1.2 mg/dl over the next 3 weeks. Despite significant advances in techniques of RAI, the indication for renal artery stenting remains controversial due to an unproven benefit of RAI compared to best medical therapy. Furthermore, consistent and reliable predictors of a favorable response to RAI in terms of renal function remain unknown making it very challenging to select the right patients for RAI. Our patient had a favorable response to the RAI as suggested by significantly lowered requirement of antihypertensive medications and rapid improvement in renal function after the procedure. This case illustrates that careful patient selection and an adequately skilled interventionist are of paramount importance in managing renal artery stenosis by a vascular intervention.
270
OUTCOMES IN PATIENTS WITH AND WITHOUT PROTEINURIA IN A SINGLE CENTER HIV COHORT Rehan Shafique; Robert B. Canada, Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.
We sought to examine prevalence and incidence of proteinuria and outcomes of patients with and without proteinuria in a single center HIV cohort. In a retrospective chart review analysis, data were collected from all patients who were referred to HIV clinic in the year 2005. Urinalyses on the initial HIV visit were used to determine the prevalence of proteinuria. Patients with trace proteinuria were not included as having proteinuria. Other data gathered included age, initial CD 4 count, and serum creatinine. In November 2009, charts of these patients were again reviewed. Study outcomes included development of ESRD and death. Total number of patients was 203. 50 patients had proteinuria on initial visit. 22 patients developed proteinuria subsequently who did not have proteinuria on the initial visit. 6 patients had doubling of creatinine. Four developed ESRD. There were total of 27 deaths. Proteinuria was found to be associated with higher mortality and development of ESRD in an unadjusted model. After adjustment with age, serum creatinine, and CD 4 count, association of proteinuria with mortality was found not to be significant although there was a trend towards higher mortality. Low CD 4 count was independently associated with higher mortality after adjustment with age, serum creatinine, and proteinuria. Adjusted Odds Ratios for mortality:
Variable Odds Ratios Confidence Limits Proteinuria on initial visit 1.446 0.569-3.677 Creatinine 1.127 0.895-1.420 Age 1.026 0.987-1.067 CD 4 count 0.997 0.995-0.999
In summary, proteinuria is highly prevalent in HIV population, and it may be associated with worse outcomes including development of ESRD and Death. Further study is warranted in examining outcomes in patients with HIV with proteinuria to determine best interventions to prevent or slow progression of renal damage.
271
EFFECT OF MEDICAID COVERAGE IN DIALYSIS Simi Shahabdeen, Prasanna Srinagesh, Nauman Shaheed, Muhammed Rahman, Mohit Gupta, Ziauddin Ahmed Drexel University College of Medicine, Philadelphia, PA, USA Medicaid reimbursement by different HMOʼs is adversely impacting the dialysis units. In the absence of good monitoring system it is not uncommon to discover that frequently prescribed medications are not covered. Denial of home medications are usually reported by the patients but the denial of medications that are given intravenously during dialysis may get unnoticed. Most Medicaid payers do not pay for the intravenous dialysis medications and the routine monthly blood work. This can be a burden when numbers of patients on Medicaid is increased in any unit. We decided to look for the unsuspected loss of revenue by giving uncovered medications to Medicaid patients in an inner city Philadelphia dialysis unit which is managed by a national chain and run by University Physicians. The unit has 139 patients and 40 (28.7%) of them have Medicaid coverage and 19 of them have only Medicaid without any secondary coverage. The vitamin D analog administration during dialysis is reviewed in 19 (13.6%) patients who have primary Medicaid. The Cost of blood work also reviewed In just one month the unit lost $4300 for all 19 Medicaid patients for only Vitamin D analog and loss of $7200 per month for blood work for all uncovered Medicaid patients. The alternate choices to avoid loss of revenue may be giving generic medications & or converting them to oral form. The loss of revenue from monthly blood work may be more difficult to resolve but contracting competitive local laboratory may provide some relief.
272
POSTERIOR REVERSIBLE ENCEPHALOPATHY (PRES) RELATED TO TACROLIMUS (TAC): A CASE REPORT Simi Shahabdeen, Mohit Gupta, Nauman Shahid, Alden Doyle Dept of Nephrology and Transplantation, Drexel University, PA 43 year old white female post heart transplant in 2001 secondary to postpartum cardiomyopathy on immunosuppression with TAC and history of calcineurin inhibitor induced End Stage Renal disease presented with sudden onset of agitation and generalized tonic-clonic seizures occurring within 1 hour after dialysis. Review of systems positive for high fever, vomiting and recent admission for line sepsis. Past history is also significant for insulin-dependent diabetes and hypertension controlled with Labetalol, Clonidine. Physical examination revealed temp 103, BP 170/90mm Hg and HR 117/mt. Patient appeared somnolent, confused and hence intubated. Air entry reduced bilaterally and reflexes were brisk. Left internal jugular permacath was intact with clean exit site. Labs showed WBC 11.1, Hb 10.1, platelet count 121, sodium 141, K 4.1, bicarbonate 21, BUN 17, Cr 3.4, prograf level 6.3. Treatment initiated with loading dose of dilantin, broad spectrum antibiotics and antivirals. Permacath was removed suspecting line sepsis. CSF studies, CT head, Echo and USS liver were unremarkable. Patient continued to remain somnolent, febrile and markedly hypertensive for next 2 days requiring labetalol drip, but was seizure free. Blood and CSF cultures were negative. Due to absence of clinical improvement, non-contrast MRI brain was done that demonstrated subcortical white matter lesions in right posterior lobe and pons suggesting the diagnosis of PRES. Intravenous TAC was immediately discontinued and cyclosporine started, to which a remarkable response was noticed. Patient became more awake and alert within few hours and was extubated the next day. This case aims to draw attention to consider PRES as differential diagnosis in solid organ transplant recipient on TAC or cyclosporine presenting with following symptoms: headache, mental status changes, focal neurological deficits, and/or hypertension. PRES can occur with therapeutic levels of these drugs. Mostly, PRES is reversible by reducing the dosage or withholding the drug for a few days. Early recognition is of paramount importance for prompt control of blood pressure or removal of precipitating factors and treatment of seizures.
NKF 2010 Spring Clinical Meetings Abstracts A99
