49EMPHYSEMATOUS PYELONEPHRITIS IN RENAL ALLOGRAFT SUCCESSFULLY TREATED WITH MEDICAL MANAGEMENT Guillermo Carnero, Susmitha Dhanyamraju, Junu Bhattarai, Rajesh Govindasamy, Michael Schultz. Geisinger Medical Center, Danville, PA Emphysematous pyelonephritis (EPN) is rare and life-threatening necrotizing bacterial infection of the kidney caused by gas-forming organism, mostly in diabetic patients and often requires nephrectomy. We report the case of EPN in renal allograft successfully treated with medical therapy. A 51 year old woman with history of cadaveric kidney transplant 1.5 years back presents to the emergency department with fever, hypotension and vomiting. On admission she appeared acutely ill and dry on physical examination; she had no graft tenderness. She was noted to have diabetic keto-acidosis. Blood urea nitrogen and creatinine level of 67 mg/dl and 4.3 mg/dL respectively from baseline of 20 mg/dl and 1.2 mg/dl. Her white cell count was elevated with bandemia of 16% and her serum tacrolimus level was 5.2 ng/mL. Urine analysis showed numerous WBC and bacteria. Patient was treated with intravenous hydration, insulin infusion and broad spectrum antibiotics. Prograf and Cellcept were held and patient was started on stress dose steroid. Kidney transplant doppler ultrasound showed echogenic foci which likely represented a gas forming infection. CT scan without contrast showed an enlarged and heterogeneous attenuation in right lower quadrant transplant with several pockets of parenchymal gas most consistent with emphysematous pyelonephritis. Two non-obstructive renal calculi in the transplanted kidney were found. Blood and urine cultures grew pan sensitive Escherichia coli responding to intravenous Ceftriaxone. Her general condition improved and sepsis and ketoacidosis resolved. Her allograft function improved and her BUN and creatinine were 27 mg/dl and 1.4 mg/dL at discharge. This is a rare presentation of EPN in a renal allograft associated with calculi. No real consensus exists on the optimal treatment of EPN in kidney transplant recipients and some debate on need for nephrectomy. In conclusion, this case demonstrates successful non-operative therapy of EPN with aggressive medical management in a kidney transplant recipient who presents with urosepsis, shock and renal failure.

50RENAL FUNCTION IN MORBIDY OBESE PATIENTS AT THE TIME OF REFERRAL TO A WEIGHT MANAGEMENT CLINIC G. Carnero, D. Bucaloiu, C. Wood, E. Norfolk, C. Still, R. Perkins Geisinger Medical Center, Danville, PA Morbid obesity (BMI >40 kg/m²) is associated with proteinuria and glomerular hyperfiltration, and is a risk factor for chronic kidney disease. We retrospectively characterized renal function across a referred population of morbidly obese patients at a single tertiary care center in Central Pennsylvania. Subjects were stratified by Cockcroft/Gault creatinine clearance (low = <97 and <88 ml/min; normal = 97-137 and 88-128 ml/min; high = >137 and 128 ml/min, for males and females, respectively) using a previously validated lean body weight estimating formula. Table. Characteristics of referred patients (n=1265, 82% female) with morbid obesity, by creatinine clearance and gender

Low CrCl Normal CrCl High CrCl MN=58

Fn=514

Mn=90

Fn=441

Mn=83

Fn=79

Age, y; mean (sd) 56.3(8.1)

49.2(9.5)

47.0(8.5)

39.7(8.8)

39.1(10.6)

33.6(8.8)

BMI, kg/m2; mean (sd) 48.9(8.1)

48.3(6.8)

50.2(8.5)

49.9(7.8)

56.2(10.7)

55.1(9.4)

Hypertension, n (%) 49(85)

298(58)

64(71)

179(41)

52(63)

34(43)

Diabetes, n (%) 42(72)

199(39)

49(54)

138(31)

31(37)

30(38)

S. creatinine at referral, mg/dL; mean (sd)

1.4(1.2)

0.9(0.3)

0.9(0.1)

0.7(0.1)

0.8(0.1)

0.6(0.1)

25% of men and 50% of women referred for weight management had reduced creatinine clearance, while nearly 40% of men presented with an elevated creatinine clearance. Among both men and women, those presenting with elevated creatinine clearance tended to be younger and have a higher BMI, relative to those with normal kidney function (p< 0.001 for both comparisons). Abnormal kidney function is highly prevalent in this referred population of morbidly obese patients. The identification of factors associated with impaired kidney function in this growing segment of the population should be further investigated.

51SEVERE METHANOL POISONING REQUIRING RECURRENT HEMODIALYSIS AND FOMEPIZOLE Guillermo Carnero, Manish Nepal, James Hartle. Geisinger Medical Center, Danville, PA Diagnosing methanol poisoning requires both clinical and laboratory data and high index of clinical suspicion. Fomepizole is the first-line agent treatment; ethanol combined with hemodialysis remains the most appropriate alternative for treatment of ethylene glycol or methanol poisoning when Fomepizole is not available. We present the case of a young man with methanol poisoning requiring double treatment with an extremely high serum methanol level. A 21 year old man with history of depression and alcohol abuse was admitted after drinking wind-shield wiper. He was drinking vodka and 12 beers daily for the previous 3 days. On admission he was alert and oriented, hemodynamically stable, had a calculated and measured serum osmolality of 291 and 549 mOsm/Kg respectively, with an osmolar gap of 258 mOsm/Kg and a methanol level of 745 mg/dL. Given the extremely elevated methanol level, he was given Fomepizole 15 mg/Kg loading dose, followed by 10 mg/kg every 4 hours. Patient was also treated with hemodialysis (HD) with dose calculated based on molecular weight of methanol (32.04 g/mol) with a large optiflux membrane size (200) and with a blood flow rate of 300 ml/min for 5.5 hours. Towards the end of dialysis the methanol level was 204 mg/dL and was 171 mg/dL after 4 hours. Despite Fomepizole treatment his level continued to be high so we decided to give a second dialysis treatment for 4 hours with the same HD dose. After second treatment his methanol level was 43 mg/dL. He was continued with Fomepizole 10 mg/Kg every 12 hours until methanol was not detectable. Patient improved and was transferred to the psychiatry facility for continuation of care. Although treatment with Fomepizole eliminates the need for hemodialysis in many cases of ethylene glycol poisoning, this is not always clear with methanol poisoning. The literature documents a mean elimination half-time of methanol when alcohol dehydrogenase was inhibited with Fomepizole at 52 hours. This case argues for use of hemodialysis with Fomepizole therapy in patients with methanol poisoning with very elevated levels.

52PREVALENCE OF CVD RISK FACTORS AND THEIR TREATMENT IN CHRONIC, STABLE KIDNEY TRANSPLANT RECIPIENTS IN THE FOLIC ACID FOR VASCULAR OUTCOME REDUCTION IN TRANSPLANTATION (FAVORIT) TRIAL Myra A. Carpenter, 1, Andrew Bostom2, John W. Kusek3, Deborah Adey4, Edward Cole5, Andrew House6, and Matthew Weir7 for the FAVORIT Trial Investigators; 1University of North Carolina, Chapel Hill, NC; 2Rhode Island Hospital, Providence, RI; 3NIDDK, NIH, Bethesda, MD; 4UVM/Fletcher Allen Health Care, Burlington, VT; 5University of Toronto, Toronto, ONT, Canada; 6London Health Sciences Center, London, ONT, Canada; 7University of Maryland, Baltimore, MD. Kidney transplant recipients (KTRs) are at increased risk for CVD. We describe the baseline prevalence of CVD risk factors and use of CVD risk factor lowering medications in participants of the FAVORIT Study, a randomized double-blind trial of homocysteine (Hcy)-lowering therapy on cardiovascular and renal outcomes. KTRs (n=4110) with elevated Hcy and stable graft function were enrolled in the US (n=3000), Canada (n=498) and Brazil (n=612). All results are unadjusted. At study entry, 89% of participants were taking a blood pressure- (BP) lowering medication, 54% a lipid-lowering agent, and 29% used medications for diabetes. History of CVD was self-reported by 802 (20%) participants. Among these, the proportion prescribed a BP-lowering drug, a lipid-lowering agent or an anti-platelet medication was 93%, 64% and 69%, respectively. Elevated LDL ( ≥ 160 mg/dL) was identified in 205 participants, of which only 83 (40%) were taking a lipid-lowering agent. The association between graft vintage and use of CVD risk factor lowering medications appears inconsistent and is unrelated to use of BP-lowering medications, whereas lipid-lowering agent use is less prevalent and anti-platelet use, particularly aspirin, is more prevalent among those with grafts in place less than 2 years than in participants with older vintage grafts. Our results suggest the rate of treatment of CVD risk factors in stable kidney transplant recipients can be increased.

NKF 2011 Spring Clinical Meetings Abstracts

Am J Kidney Dis. 2011;57(4):A1-A108 A29