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73 UNDERREPORTING OF NON-COMPLIANCE WITH PHOSPHORUS BINDERS MAY CONTRIBUTE TO POOR PHOSPHORUS CONTROL IN DIALYSIS POPULATION Nischala Dhanekula, Roopa Yarlagadda, Wei Wang, Virginia Lyons, Vijay Jain, Wajid Choudhry Unity Health System, Rochester, New York Dialysis Outcomes and Practice Patterns Study annual report in 2010 reported that only 58% of the dialysis patients have phosphorus levels in the target range. Our aim is to evaluate the factors possibly contributing to the poor phosphorus control in dialysis population. We interviewed 60 adult dialysis patients with mean phosphorus levels ≥5.5mg/dl using a questionnaire and compared with the control group patients (40 patients with mean phosphorus levels <5.5mg/dl). Both groups had minimal or no residual renal function. Twenty five point four percent of the uncontrolled patients admitted that they missed their medications on a daily basis, which was significantly higher than that of the control group (2.5%, p<0.001). However, pharmacy records indicated that 41.7% of the uncontrolled patients were not filling their prescriptions regularly, indicating that about 16% of this group underreported their noncompliance. Patient’s knowledge about high phosphorus diet did not differ significantly between the groups. Interestingly, the uncontrolled patients were better able to identify the health risks associated with a high phosphorus (p<0.001). Drug dispensing information from pharmacy may play a role in controlling hyperphosphatemia. 74 LONG-TERM SURVIVAL OF AV GRAFTS COMPARABLE TO THAT OF NON-TRANSPOSED AND TRANSPOSED AV FISTULAE IN THE ARM Peter Van, Renu Gupta and Neville R. Dossabhoy Nephrology Se on, LSUHSC and VA Medical Center, Shreveport, LA The Fistula First Breakthrough Ini a ve has increased the placement of arteriovenous fistulae (AVF) for vascular access. The purpose of this study was to compare the overall survival of transposed brachial- basilic fistulae (TBBF), non-transposed (NT) AVF and AV Gra s (AVG) placed in the upper extremity (UE) in the era of Fistula First. Our prospe ve, computerized clinical database was queried retrospe vely to iden the outcomes of all upper extremity fistulae and gra s placed at our center over a 6-year period (2005-10). The primary end point was failure of the access. Kaplan-Meier curves were plo ed for comparison of access survival. 268 UE accesses were placed: 93 were TBBF, 139 were NT AVF, and 36 were AVG. The figure shows that there was no difference in the Kaplan-Meier survival curves for the three groups (P=0.37). In conclusion, overall survival was similar for TBBF, NT AVF and AV in our study, even with primary failures excluded (P=0.45). This study confirms that both types of fistulae have a high primary failure rate. In the era of Fistula First, these findings ques on the wisdom of pushing fistula placement indiscriminately in all ESRD pa ents. 75 GROSS HEMATURIA HERALDING DISSEMINATED MUCORMYCOSIS Angelina Edwards, Aneel Kumar, Abdulla Salahudeen, Patricia Troncoso. University of Texas MD Anderson Cancer Center, Houston, TX A 53-year-old man with acute myeloid leukemia experienced the sudden onset of left-sided flank pain with gross hematuria. On examination, he had a mobile, 5-cm in diameter fluctuant sternal mass and a 2-cm in diameter right shin mass without overlying skin changes. Laboratory studies showed a serum creatinine value of 1.8 mg/dL (baseline creatinine of 1.2 mg/dL) and grossly bloody urine. Chest CT showed a 7.5 cm sternal mass, extending to the mediastinum. Abdominal CT showed changes suggestive of left renal infarction and left renal vein thrombosis, associated with several hypodensities in the right kidney. An aspirate of the sternal mass and biopsy specimen of the right kidney demonstrated extensive necrosis and broad, non- septate hyphae, consistent with mucormycosis (see GMS stain to the right). Accordingly, the patient received systemic antifungal therapy, debridement of the sternum, and left nephrectomy. The patient is currently in remission. Mucormycosis is a rare and often fatal invasive fungal infection. Its angiophilic properties lead to mycotic thrombosis of arteries and veins. Specific involvement of the renal artery presents as flank pain and hematuria. Disseminated forms are common in patients who are immunosuppressed. Prompt diagnosis, antifungal therapy, and, at times, surgical intervention can lead to better outcomes. 76 A Cause Analysis of Absence of Functional Arterio-Venous (AV) Mireille El Ters, Andrew Rule, Bonnie Jensen, Scott Nyberg ,Sandra Taler , Amy Williams, Robert Albright, Marie C. Hogan, Mayo Clinic, Rochester, MN. Failure to achieve a functional AV access remains a major problem in the ESRD population with negative implications on survival, outcome and cost of hemodialysis. We evaluated causes behind the lack of functional Included were 295 prevalent hemodialysis patients in Mayo Clinic Dialysis Network (as of Jan 31, 2011). Mean age was 68.6 y, 58% male, 56% diabetics and 88 % were caucasian. Of these, 168 (56.9%) had a functioning AV fistula (AVF), 12 (4.2%) a functioning AV graft and 115 (38.9%) a tunneled dialysis catheter (TDC). Of the 115 patients using TDCs, 54 (47%) had a prior failed AVF, 17 (14.8 %) had an immature AV fistula and 44 (38.2%) never underwent AV access placement. Of the 44 with no prior AV access, 15 (34%) refused AV access placement, 17 (38.6%) were not considered suitable candidates and 12 (27.2%) did not undergo evaluation for unknown reasons. Reviewing prior failed AVF cases, we observed a trend toward more radio-cephalic AVFs amongst the failed AVF group (n=11, 20.4%) than amongst the functional AVF group (n=23, 13.7%); this difference was not statistically significant (p=0.27, Fisher’s test). Wrist cephalic vein and radial artery diameters tended to be smaller in the failed AVF group then in the patent AVF group, however this difference was not statistically significant in our limited subgroup (failed vs patent mean cephalic vein at wrist: 2.5 vs 2.8 mm (p=0.56); radial artery: 2.1 vs 2.7 mm,(p=0.1), Wilcoxon test). In conclusion, amongst hemodialysis patients with TDC access, we identified failed AVF and patient refusal to undergo AVF placement as major factors leading to that outcome. In this study, most causes of absence of functioning AVF were recognizable and potentially remediable. Improved patient education about the importance and timing of AVF placement as well as interdisciplinary approach to vein preservation even after achieving a successful AV access are crucial to successful AV access long term. NKF 2012 Spring Clinical Meetings Abstracts Am J Kidney Dis. 2012;59(4):A1-A92 A33

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73UNDERREPORTING OF NON-COMPLIANCE WITH PHOSPHORUS BINDERS MAY CONTRIBUTE TO POOR PHOSPHORUS CONTROL IN DIALYSIS POPULATION Nischala Dhanekula, Roopa Yarlagadda, Wei Wang, Virginia Lyons, Vijay Jain, Wajid Choudhry Unity Health System, Rochester, New York Dialysis Outcomes and Practice Patterns Study annual report in 2010 reported that only 58% of the dialysis patients have phosphorus levels in the target range. Our aim is to evaluate the factors possibly contributing to the poor phosphorus control in dialysis population. We interviewed 60 adult dialysis patients with mean phosphorus levels ≥5.5mg/dl using a questionnaire and compared with the control group patients (40 patients with mean phosphorus levels <5.5mg/dl). Both groups had minimal or no residual renal function. Twenty five point four percent of the uncontrolled patients admitted that they missed their medications on a daily basis, which was significantly higher than that of the control group (2.5%, p<0.001). However, pharmacy records indicated that 41.7% of the uncontrolled patients were not filling their prescriptions regularly, indicating that about 16% of this group underreported their noncompliance. Patient’s knowledge about high phosphorus diet did not differ significantly between the groups. Interestingly, the uncontrolled patients were better able to identify the health risks associated with a high phosphorus (p<0.001). Drug dispensing information from pharmacy may play a role in controlling hyperphosphatemia.

74LONG-TERM SURVIVAL OF AV GRAFTS COMPARABLE TO THAT OF NON-TRANSPOSED AND TRANSPOSED AV FISTULAE IN THE ARM Peter Van, Renu Gupta and Neville R. Dossabhoy Nephrology Se on, LSUHSC and VA Medical Center, Shreveport, LA The Fistula First Breakthrough Ini a ve has increased the placement of arteriovenous fistulae (AVF) for vascular access. The purpose of this study was to compare the overall survival of transposed brachial-basilic fistulae (TBBF), non-transposed (NT) AVF and AV Gra s (AVG) placed in the upper extremity (UE) in the era of Fistula First. Our prospe ve, computerized clinical database was queried retrospe vely to iden the outcomes of all upper extremity fistulae and gra s placed at our center over a 6-year period (2005-10). The primary end point was failure of the access. Kaplan-Meier curves were plo ed for comparison of access survival. 268 UE accesses were placed: 93 were TBBF, 139 were NT AVF, and 36 were AVG. The figure shows that there was no difference in the Kaplan-Meier survival curves for the three groups (P=0.37). In conclusion, overall survival was similar for TBBF, NT AVF and AV

in our study, even with primary failures excluded (P=0.45). This study confirms that both types of fistulae have a high primary failure rate. In the era of Fistula First, these findings ques on the wisdom of pushing fistula placement indiscriminately in all ESRD pa ents.

75GROSS HEMATURIA HERALDING DISSEMINATED MUCORMYCOSIS Angelina Edwards, Aneel Kumar, Abdulla Salahudeen, Patricia Troncoso. University of Texas MD Anderson Cancer Center, Houston, TX A 53-year-old man with acute myeloid leukemia experienced the sudden onset of left-sided flank pain with gross hematuria. On examination, he had a mobile, 5-cm in diameter fluctuant sternal mass and a 2-cm in diameter right shin mass without overlying skin changes. Laboratory studies showed a serum creatinine value of 1.8 mg/dL (baseline creatinine of 1.2 mg/dL) and grossly bloody urine. Chest CT showed a 7.5 cm sternal mass, extending to the mediastinum. Abdominal CT showed changes suggestive of left renal infarction and left renal vein thrombosis, associated with several hypodensities in the right kidney. An aspirate of the sternal mass and biopsy specimen of the right kidney demonstrated extensive necrosis and broad, non-septate hyphae, consistent with mucormycosis (see GMS stain to the right). Accordingly, the patient received systemic antifungal therapy, debridement of the sternum, and left nephrectomy. The patient is currently in remission. Mucormycosis is a rare and often fatal invasive fungal infection. Its angiophilic properties lead to mycotic thrombosis of arteries and veins. Specific involvement of the renal artery presents as flank pain and hematuria. Disseminated forms are common in patients who are immunosuppressed. Prompt diagnosis, antifungal therapy, and, at times, surgical intervention can lead to better outcomes.

76A Cause Analysis of Absence of Functional Arterio-Venous (AV)

Mireille El Ters, Andrew Rule, Bonnie Jensen, Scott Nyberg ,Sandra Taler , Amy Williams, Robert Albright, Marie C. Hogan, Mayo Clinic, Rochester, MN. Failure to achieve a functional AV access remains a major problem in the ESRD population with negative implications on survival, outcome and cost of hemodialysis. We evaluated causes behind the lack of functional Included were 295 prevalent hemodialysis patients in Mayo Clinic Dialysis Network (as of Jan 31, 2011). Mean age was 68.6 y, 58% male, 56% diabetics and 88 % were caucasian. Of these, 168 (56.9%) had a functioning AV fistula (AVF), 12 (4.2%) a functioning AV graft and 115 (38.9%) a tunneled dialysis catheter (TDC). Of the 115 patients using TDCs, 54 (47%) had a prior failed AVF, 17 (14.8 %) had an immature AV fistula and 44 (38.2%) never underwent AV access placement. Of the 44 with no prior AV access, 15 (34%) refused AV access placement, 17 (38.6%) were not considered suitable candidates and 12 (27.2%) did not undergo evaluation for unknown reasons. Reviewing prior failed AVF cases, we observed a trend toward more radio-cephalic AVFs amongst the failed AVF group (n=11, 20.4%) than amongst the functional AVF group (n=23, 13.7%); this difference was not statistically significant (p=0.27, Fisher’s test). Wrist cephalic vein and radial artery diameters tended to be smaller in the failed AVF group then in the patent AVF group, however this difference was not statistically significant in our limited subgroup (failed vs patent mean cephalic vein at wrist: 2.5 vs 2.8 mm (p=0.56); radial artery: 2.1 vs 2.7 mm,(p=0.1), Wilcoxon test). In conclusion, amongst hemodialysis patients with TDC access, we identified failed AVF and patient refusal to undergo AVF placement as major factors leading to that outcome. In this study, most causes of absence of functioning AVF were recognizable and potentially remediable. Improved patient education about the importance and timing of AVF placement as well as interdisciplinary approach to vein preservation even after achieving a successful AV access are crucial to successful AV access long term.

NKF 2012 Spring Clinical Meetings Abstracts

Am J Kidney Dis. 2012;59(4):A1-A92 A33