NKF 2014 Spring Clinical Meetings Abstracts

ACUTE OXALATE NEPHROPATHY ASSOCIATED WITH ORLISTAT: Youshay Humayun, Talal Mahmood, Mohammad Mataria, Jack R Lewin, Tibor Fülöp University of Mississippi Medical Center, Jackson, Mississippi Acute oxalate nephropathy (AON) may be an under-reported yet important complication of malabsorption induced by weight loss supplements. We are reporting on a patient taking orlistat, a lipase inhibitor, who presented with acute kidney injury due to oxalate deposition. A 76 year-old white female with Chronic Kidney Disease (baseline creatinine 1.5 mg/dL), hypertension, gout and psoriatic arthritis, admitted for evaluation of elevated creatinine, peaking at 4.83 mg/dL. Notably, she was taking vitamin C supplementation, orlistat, calcium carbonate and monthly infliximab infusions. A renal ultrasound showed multiple non-obstructing stones. Urinalysis was remarkable for 5 WBCs/high power fields with no crystals. A 24 hour urine collection detected increased oxalate excretion. Thereafter, a kidney biopsy showed calcium oxalate crystals within tubular lumens with associated interstitial inflammation. AON is defined as renal insufficiency in the presence of calcium oxalate crystal deposition in the renal interstitium and renal tubular cells. Due to the low solubility of oxalate, increased concentrations of oxalate in the body can lead to deposition of calcium oxalate in the kidney tissue resulting in nephrocalcinosis, nephrolithiasis, and ultimately renal insufficiency. Orlistat is a gastrointestinal lipase inhibitor used as an adjunct treatment of obesity and type 2 diabetes mellitus, to induce fat malabsorption. Malabsorption could lead to increased oxalate absorption via the binding of calcium by free fatty acids in the colon. The amount of calcium available to bind oxalate in the gastrointestinal tract leads to excessive oxalate absorption, tissues deposition and subsequent organ injury. Another potential cause of oxalate deposition in this case was the intake of vitamin-C, a known precursor of oxalate. AON is an important entity to recognize in patients taking weight loss supplements. If recognized early, acute oxalate nephropathy can be prevented and may even be reversible with the discontinuation of the offending agent and dietary modifications.

EVALUATION OF A PHARMACY MANAGED ESA PRESCRIBING PROTOCOL IN THE INPATIENT SETTING Joanna Q. Hudson, and Chris K. Finch, The University of Tennessee Department of Clinical Pharmacy and Methodist University Hospital, Memphis, TN, USA Safety concerns with erythropoiesis-stimulating agents (ESAs) have prompted the FDA to recommend conservative dosing in oncology and chronic kidney disease (CKD) patients. The cost of ESAs is also significant. The purpose of this study was to evaluate the effect of an ESA prescribing protocol on ESA use and costs in the inpatient setting. An ESA ordering process was developed requiring the prescriber to specify the FDA approved indication and to verify the following: adequate iron indices [transferrin saturation (TSat) and serum ferritin], length of stay (LOS) of at least 3 days, no contraindications [uncontrolled hypertension, hemoglobin (Hb) > 12 g/dL in CKD or ≥ 10 g/dL in oncology patients, active bleeding, or curative cancer]. Pharmacists verified compliance with the prescribing criteria prior to dispensing the ESA. Orders initiated using this process were evaluated over a one month period to assess the patient population, Hb, compliance with the ordering process, and ESA costs. During the one month evaluation period epoetin alfa was prescribed for 43 patients: 35 (81%) end-stage renal disease, 3 (7%) CKD not requiring dialysis, 2 (5%) oncology, and 3 (7%) other indication. The mean (± SE) admission and discharge Hb was 9.6 ± 0.3 and 9.0 ± 0.2 g/dL, respectively. The average time until the start of an ESA was 7.9 ± 1.3 days. There were 37 instances of noncompliance with ordering: LOS < 3 days (6), LOS incorrectly identified (4), TSat and/or ferritin inadequate (20), TSat and/or ferritin incorrectly documented (7). Compared to previous ESA usage, there was a 70% reduction in ESA doses prescribed. The cost avoidance per 1000 patient days was $2726. Annually, the cost savings is expected to exceed $225,000. A pharmacy managed ESA prescribing protocol may promote more prudent use of ESAs and reduce medication costs in the inpatient setting.

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MORTALITY OF PATIENTS WITH SIGNIFICANT LIVER DYSFUNCTION INITIATED ON DIALYSIS Gina Iacovella, Neelja Kumar and Lloyd Cantley Yale University New Haven, CT, USA Acute kidney injury (AKI) in patients with significant liver dysfunction is frequently accompanied by a high morbidity and mortality. We asked whether dialysis would benefit patients with liver dysfunction who are not listed for orthotopic liver transplant(OLTx). We performed a retrospective, observational study at a single tertiary care center over 31 months from 2010-2013. Of 892 patients followed by the Hepatology service, a cohort of 57 patients were identified with a MELD score >15, never listed for OLTx, and Stage III AKI who required initiation of dialysis during hospitalization. Etiology for AKI was determined as ATN (25/57), HRS (18/57), or other (14/57). Of those 57 patients, 8(14%) were eventually listed for OLTx and 49(86%) were not listed. Of those listed, 3/8(37.5%) were discharged with on-going dialysis needs, 5/8 (62.5%) underwent OLTx, of which 3 remain alive. Among patients not listed, 47/49(95.9%) died and 2/49(4.1%) recovered without on-going dialysis needs. Survival in patients who were not listed was 2/49(4%) as compared to those who were listed 6/8(75%)(p<0.05). Neither the diagnosis of AKI nor initial dialysis modality (IHD 22/57 and CVVHDF 35/57)impacted survival. This small cohort of patients calls into question initiation of dialysis in patients who have no chance of being listed for OLTx during hospitalization.

SPONTANEOUS RENAL HEMORRHAGE (WUNDERLICH SYNDROME) IN BIOPSY-PROVEN ANCA VASCULITIS: A CASE REPORT AND REVIEW OF THE LITERATURE: Muzzaffar Hussain, Daniel Landry, Baystate Medical Center, Springfield, MA, USA Spontaneous renal hemorrhage (SRH) is a rare but life-threatening

entity. It has most frequently been attributed to underlying malignant or benign tumors, medium vessel vascular disorders (i.e. polyarteritis nodosa) and infection. We describe a case of 42 year-old male with acute glomerulonephritis

who developed SRH 13 days following a biopsy of the contralateral kidney revealing c-ANCA/anti-PR3 positive (granulomatosis with polyangiitis) vasculitis. An unenhanced CT scan did not show any evidence of renal mass, cystic lesion or abscess, and serologic testing was negative for systemic lupus erythematosis and hepatitis B. He was successfully managed with a non-surgical approach and had good outcome. Upon review of the world-wide literature we found 4 other cases of

small-vessel vasculitis causing SRH - of which one was a dialysis patient with late presentation. Our report is the first biopsy-proven case of a small vessel vasculitis causing SRH and now clearly identifies this group of patients as being at potential risk for a disorder previously attributed to diseases of medium and large arteries. Possible underlying mechanisms of ANCA vasculitis-induced SRH include rupture of microaneurysms and immunosuppression-(i.e. corticosteroid) induced vascular reactivity.

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