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Hypoalbuminemia Severity Predicts Intradialytic Parenteral Nutrition (IDPN) Effectiveness in Hemodialysis Patients Arezu Dezfuli, MD1, Michelle Ricker, RD2; Deborah Scholl, RD2; Stanley M Lindenfeld, MD2; and Kamyar Kalantar-Zadeh, MD PhD1,2 1Harold Simmons Center for Kidney Disease Research& Epidemiology, Harbor-UCLA, Torrance, CA; and 2Pentec Health, Boothwyn, PA Background: Intradialytic parenteral nutrition (IDPN) is currently used infrequently to correct hypoalbuminemia in maintenance hemodialysis (MHD) patients (pts). Correcting hypoalbuminemia may significantly improve survival in MHD pts (Kalantar-Zadeh et al, NDT 2005; 20:1880-8). We hypothesized that IDPN responders, i.e., those whose baseline serum albumin [S-albumin] increased persistently during IDPN, have unique characteristics. Methods: In a recent cohort of MHD pts who had received IDPN through Pentec Health, predictors of IDPN response were examined using multivariate logistic regression. Results: A total of 196 MHD patients underwent IDPN for 5.8±2.4 mo between 2002 and 2006. Baseline serum albumin (2.68±0.47 g/dL) was lower in the IDPN responders than the non-responders (see table):

MHD patients’ characteristics

Responder (n=142)

Nonresponder (n=54)

p-value

Age (yrs) 64±15 65±14 0.81 Diabetes mellitus 53% 57% 0.59 Gender (% women) 54% 50% 0.57 IDPN time (months) 5.7±2.2 6.1±2.8 0.27 S-albumin (mg/dL) 2.62±0.47 2.85±0.44 0.002 S-albumin <3 mg/dL 74% 54% 0.006 � albumin≥0.5 mg/dL 59% n/a n/a

In multivariate logistic regression analyses adjusted for age, gender, diabetes, and IDPN time, the presence of severe hypoalbuminemia (S-albumin <3.0 g/dL, n=134) at baseline was associated with 2.5 time higher chance of responding to IDPN (95% confidence interval [CI]: 1.3-4.9, p=0.006). The same severe hypoalbuminemia was associated with 3.8 times (95% CI: 1.9-7.5, p<0.001) increased likelihood of serum albumin correction by at least 0.5 g/dL. Conclusions: In most hypoalbuminemic MHD pts who undergo IDPN an increase in serum albumin is observed, and the likelihood and magnitude of response is associated with the severity of baseline hypoalbuminemia.

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NEPHROGENIC FIBROSING DERMOPATHY (NFD) IN A PATIENT WITH ACUTE KIDNEY IN JURY (AKI). Ashish Dhungel ,Rakesh Lattupalli, Mohammed El Ghoroury, Robert Provenzano, Joel Topf, Division of Nephrology, St John Hospital and Medical Center, MI. Introduction NFD is an acquired, idiopathic skin disorder, reported with increasing frequency in dialysis patients. A more widespread variant with involvement of other organs is described as Nephrogenic Systemic Fibrosis (NSF). Cutaneous manifestations include thickening, and induration of skin over the distal extremities and trunk with sparing of the face. Renal failure and gadolinium exposure continue to be the predominant common denominators. Only five cases of NFD are reported in literature in patients with acute renal failure not on maintenance dialysis. We report a case of NFD after gadolinium exposure with AKI from cresentic glomerulonephritis in renal allograft. Case report: A 60-year-old African American female, recipient of living related renal allograft, admitted with AKI from biopsy proven cresentic glomerulonephritis unresponsive to therapy. Maintenance hemodialysis was initiated after tunneled catheter placement. Patient underwent MRI of abdomen and pelvis with gadolinium during this admission. One month later patient noticed tightening of skin over ankle area, which slowly progressed to involve the entire lower extremity. Stiff knee and ankle joints with limited range of motion restricted her mobility. Similar skin changes were noticed in both forearms. Circumferential thickening and induration of skin with plaques and contractures of knee and ankle joints were noted on physical examination. Skin biopsy findings were consistent with NFD. Discussion Awareness of NFD among radiologists and nephrologists has increased substantially in the recent times. Caution is being exercised to minimize gadolinium exposure in patients on dialysis. Acute renal insufficiency with GFR < 30 ml/min is also listed in Federal Drug Administration (FDA) black box warning as risk for NFD. Over emphasis on dialysis as a risk factor may lead to a patterned behavior and result in under recognition of AKI as an equally important risk. Since GFR can be calculated only in a steady state with a stable renal function any rise in serum creatinine should be treated as risk for NFD with gadolinium exposure.

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THE MANAGEMENT OF LEFT VENTRICULAR SYSTOLIC DYSFUNCTION IN PATIENTS WITH ADVANCED CHRONIC KIDNEY DISEASE. Vera Dounaevskaia 1, DiMeglio1, Ron Wald1 1 St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada. Left ventricular systolic dysfunction (LVSD) is frequently observed in patients with advanced chronic kidney disease (CKD) and its presence is associated with a poor prognosis. In the general population, renin-angiotensin system inhibition and beta-blockade are the cornerstones of medical management in patients with LVSD. Although the high quality trials that contributed to this evidence base generally excluded patients with significant CKD, current guidelines advocate that CKD patients with advanced LVSD should be treated with agents that have shown benefit in the general population. The extent to which these recommendations are followed needs further clarification. We conducted a retrospective study of all patients with advanced CKD followed in our centre as of June 1, 2007. These included chronic dialysis patients (n=299) and those with advanced pre-dialysis CKD actively followed in our multi-disciplinary pre-dialysis clinic (n=177). Echocardiographic, and pharmacotherapy data were sought for each patient. We defined optimal therapy for LVSD as the receipt of both a beta-blocker and either an angiotensin converting enzyme inhibitor (ACEi) or an angiotensin II receptor blocker (ARB). 388 (82%) patients had at least one echocardiogram performed, and 35 (9.0%) had moderate-severe LVSD (ejection fraction < 40%). Of those with moderate-severe LVSD, 22 (62.9%) were receiving optimal therapy; the rate was 66.7% and 60.9 % among pre-dialysis and dialysis patients, respectively. Beta-blockers were more frequently prescribed to patients receiving dialysis (91.3% versus 66.7% among pre-dialysis patients), whereas, pre-dialysis patients were more likely to receive ACEi or ARB, 83.3% versus 65.2 % of the dialysis population. The non-receipt of optimal therapy could not be explained by a tendency to hypotension, hyperkalemia, drug sensitivities or pill burden. Nearly 40% of patients with advanced CKD and significant LVSD were not receiving evidence-based therapies for LVSD management. Overcoming the barriers to care will be crucial in order to optimize the cardiovascular management of this high-risk population.

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0.8

0.9

1

1.1

1.2

1996 1997 1998 1999 2000 2001 2002 2003 2004

Calendar Year

Dea

th H

azar

d R

atio

Fresenius DaVita

Gambro RCG

DCI

MORTALITY TREND OF HEMODIALYSIS CHAINS IN THE USA: 1996-2004Uyen Duong, MD MPH1,2, Kamyar Kalantar-Zadeh, MD PhD1,2, Csaba Kovesdy, MD3. Rajnish Mehrotra, MD2. 1Harold Simmons Center for Kidney Disease Research & Epidemiology, 2Division of Nephrology, LABioMed at Harbor-UCLA, Torrance, CA; and 3VA, Salem, VA Background: Discrepancies in mortality rates of maintenance hemodialysis (MHD) patients (pts) across diverse dialysis organizations in the USA have been reported. Methods: Annual relative death hazard ratios of MHD pts in 5 major US dialysis chains were examined in the United Stated Renal Data System (USRDS) database between 1996 to 2004 using Cox proportional hazard models, adjusted for age, gender, race, ethnicity, network, employment, insurance, comorbid states, GFR, albumin and hemoglobin. Results: Compared to non-chain facilities, Gambro and RCG

showed worsening death hazard ratios (HR) of MHD pts over 9 yrs, whereas DCI exhibited the strongest survival improvement (1.00% per yr) followed by DaVita (0.26% per yr)(Figure). Over the last 4 yrs of the study

period, DCI, DaVita and Fresenius showed HR improvement, whereas Gambro and RCG showed worsening trends compared to nonchain facilities (Table).

Conclusions: US dialysis chains show different relative mortality trends over time. Identifying and understanding the potential factors that contribute to these trends may help improve longevity of MHD pts.

HR change per yr (beta) Chain 1996-04 2001-04 Fresenius 0.09% -0.53% DaVita -0.26% -1.24% Gambro 1.08% 3.10% RCG 0.85% 0.41% DCI -1.00% -2.45%

NKF 2008 Spring Clinical Meetings AbstractsA42