Paul Taylor

Multi-intervention Management of Calciphylaxis: A Report of 7 Cases

Calcific uremic arteriolopathy (calciphylaxis) is a devastating but rare complication seen predominantly in dialysis patients that often is fatal. Because of the rarity of the disease and the multifactorial nature of its cause, no clinical trials have been conducted to date to determine the best therapy for the condition. We report a case series of 7 patients at a single institution in whom a systematic multi-interventional treatment strategy was implemented, consisting of trigger-agent cessation (calcium-based phosphate binders, alphacalcidol, and warfarin), wound management, and antibiotic therapy, supplemented by intensified hemodialysis (4 hours daily for 7 days followed by 5-6 times weekly), intravenous sodium thiosulfate (12.5-25 g intravenously 3 times a week), and attempted oxygen therapy (given through a face mask or hyperbaric chamber as tolerated by patient circumstance). Treatments selected were based on literature review, consensus discussion, and attempts to address the physiologic disturbances that underlie the condition. All 7 patients identified with biopsy-proven calcific uremic arteriolopathy were treated with this regimen in 2007-2010, with 6 of 7 showing complete recovery. We suggest that consistent implementation of a multi-interventional approach may alter the course of this devastating disease. Further studies are needed to confirm and extend these findings.

CLINICAL PRACTICE GUIDELINES AND RECOMMENDATIONS ON PERITONEAL DIALYSIS ADEQUACY 2011

Division of Nephrology,1 University of Western Ontario, London, Ontario; Division of Nephrology,2 University of Toronto, Toronto, Ontario; Division of Nephrology,3 McMaster University, Hamilton, Ontario; Division of Nephrology and Transplant Immunology,4 University of Alberta, Edmonton, Alberta; Division of Nephrology,5 Dalhousie University, Halifax, Nova Scotia; Division of Nephrology,6 University of Ottawa, Ottawa, Ontario; Division of Nephrology,7 University of British Columbia, Vancouver, British Columbia, Canada

Conservative outpatient renoprotective protocol in patients with low GFR undergoing contrast angiography: a case series

BackgroundThe correct strategy to prevent radiocontrast-induced nephropathy (CIN) in high-risk patients going for cardiac angiography is widely debated in the literature. It is well known that chronic kidney disease (CKD) patients with lower estimated glomerular filtration rates (eGFRs) at baseline are at the greatest risk for a significant loss in kidney function, or even dialysis after a contrast load. For this reason potentially life-saving procedures such as angiography are sometimes withheld or delayed.MethodsWe describe a case series of 31 well-characterized patients with CKD who underwent cardiac or peripheral vessel angiography, and patients with renal artery stenosis (RAS) who underwent angioplasty and stenting. All were treated with a standardized outpatient protocol of withholding their diuretics and angiotensin-converting enzyme (ACE) inhibitors (ACEs)/angiotensin receptor blockers (ARBs) the day prior to and 2 days after the procedure, restarting the diuretic the day after the procedure and the ACE inhibitor/ARB after 2 days. Calcium channel blockers were prescribed for the 2 days prior to and 2 days after the procedure. Patients had bloodwork on days 2–3 and days 7–10 post-procedure.ResultsThe patients had a mean baseline creatinine of 214 µmol/l (SD = 123), ranging from 87 to 535 µmol/l. This corresponded to a mean baseline eGFR of 34 ml/min (SD = 15.8), ranging from a minimum of 12–59 ml/min. The mean age was 64 ± 13.8 years; 48% were male and 11 (35.5%) were diabetic. All patients enrolled had a baseline eGFR of less than 60 ml/min as calculated by the Modification of Diet in Renal Disease (MDRD) formula. Based on pre-procedure CKD stage, 21 (68%) were stage 3 (eGFR 30–60 ml/min), 5 (16%) were stage 4 (eGFR 15–30 ml/min), and 6 (19%) were stage 5 (eGFR < 15 ml/min). No patient required urgent hemodialysis following their angiography. All patients have had a longitudinal follow up of 26 months, and none developed any change in the rate of progression from prior to procedure.ConclusionsThis case series provides data in support of a conservative, outpatient-based approach for high-risk CKD patients going for cardiac angiography. This protocol warrants further study in randomized control trials.

Incidental atherosclerotic renal artery stenosis diagnosed at cardiac catheterization: no difference in kidney function with or without stenting.

BACKGROUND The long-term kidney function of patients with atherosclerotic renal artery stenosis (ARAS) diagnosed incidentally at the time of cardiac catheterization is not well described despite the increasingly common practice of assessing these vessels at the time of cardiac investigation. METHODS This is a retrospective analysis of a cohort identified prospectively at the time of non-emergent coronary angiography. Those with >or=50% ARAS were managed medically and underwent stenting if recommended by their nephrologist and/or cardiologist. Longitudinal regression analysis was used to compare the annualized change in estimated glomerular filtration rate (GFR) in stented and unstented patients. Cox regression analysis was used to determine the predictors of a decline in GFR by >or=25%. RESULTS Of 140 patients, 67 (48%) were stented, mostly for preservation of kidney function (70.1%) and/or resistant hypertension (53.7%). Median follow-up time was 943 days. Stented patients were younger, had higher systolic blood pressure and more severe ARAS. The adjusted rate of change in GFR was -1.49 (95% CI -2.33 to -0.65) ml/min/1.73 m(2)/year in the unstented group, and -1.48 (95% CI -2.34 to -0.62) ml/min/1.73 m(2)/year in the stented group (p = 0.99). A decline of GFR >or=25% occurred in 42 (30%) patients; no patient required dialysis. Only the presence of cereberovascular disease was associated with this outcome (hazard ratio 2.52, 95% CI 1.56-5.41). CONCLUSION We were unable to demonstrate a benefit or harm of renal artery stenting for ARAS, thus further increasing the uncertainty of the significance of these lesions and how they are best managed.

Implementing a home haemodialysis programme without adversely affecting a peritoneal dialysis programme

BACKGROUND As the population with stage 5 CKD grows, the associated costs of providing dialysis care increase. Due to the high costs of these therapies, home haemodialysis is enjoying a renaissance in many jurisdictions. However, concerns persist as to whether home haemodialysis programmes grow at the expense of other home therapies such as peritoneal dialysis. This study attempts to look at the impact of a new home haemodialysis programme on an existing peritoneal dialysis programme in the province of British Columbia. METHODS Using the provincial renal database in British Columbia (PROMIS), all patients receiving dialysis were tracked over the years preceding the implementation of a home haemodialysis programme and following its implementation. Rate of growth by specific dialysis modality (hospital haemodialysis, community haemodialysis, home haemodialysis, and peritoneal dialysis) were tracked. RESULTS When comparing the provincial growth rates in the peritoneal dialysis programme, using the 4 years before and following the introduction of the home haemodialysis programme, they were unchanged both annually (7.84% versus 7.34%) and overall (25.27% versus 23.62%). The growth within the home haemodialysis programme appears to have come from the community haemodialysis programme (annual growth rate 12.28% versus 5.87%) and in-hospital haemodialysis (annual growth rate 4.61% versus 1.3%). Incident rates of dialysis were similar both prior to and following the introduction of the home haemodialysis programme.Finally, only 6.4% of the total patients entering the home haemodialysis programme had discontinued peritoneal dialysis within the 6 months preceding home haemodialysis training, indicating a low frequency of movement from peritoneal dialysis to home haemodialysis. CONCLUSIONS Successful implementation of a home haemodialysis programme can be done at a provincial level without having an adverse impact on the growth rate of existing peritoneal dialysis programmes.

Incidental Atherosclerotic Renal Artery Stenosis in Patients Undergoing Elective Coronary Angiography: Are These Lesions Significant?

Background: Cardiologists often identify atherosclerotic renal artery stenosis (ARAS) during cardiac angiography. The importance of such ‘incidental’ ARAS (iARAS) is not known. The present study sought to describe renal perfusion using non-captopril (baseline) nuclear renograms in patients with iARAS, and to determine characteristics associated with a positive captopril renogram. Methods: Patients presenting for non-emergent coronary angiography between June 2001 and February 2006 were angiographically screened for iARAS. Those with >50% stenosis of one or both renal arteries were referred to nephrology and underwent nuclear renography. Results: 131 patients had renograms. The mean age was 73.2 ±8.1 and median eGFR was 51.2 (40.0, 66.6) ml/min/1.73 m2. 51% had evidence of reduced perfusion to one kidney, of which 13% were discordant with the angiographic lesion. 9% had positive captopril renograms. Captopril renogram positivity was associated with severe unilateral stenosis (p = 0.02). Conclusions: In cardiac patients diagnosed with iARAS, the presence of known anatomic lesions did not correlate with captopril renogram positivity. Uncertainty remains as to whether nuclear renography is a poor functional test in this population, or the lesions are not functionally significant. These results lead us to question both the significance of such lesions, and the utility of conducting renograms in this population.

Renal leukocyte chemotactic factor 2 (LECT2) amyloidosis in First Nations people in Northern British Columbia, Canada: a report of 4 cases.

Leukocyte chemotactic factor 2 (LECT2) amyloidosis is a recently identified type of amyloidosis that may represent an underdiagnosed cause of chronic kidney disease. LECT2 amyloidosis typically is reported as being renal limited and, in the United States, more prevalent in Hispanic patients. We add to the epidemiologic data of this condition by describing 4 First Nations people from Northern British Columbia, Canada, who presented with slowly progressive chronic kidney disease that was found to be due to LECT2 amyloidosis.

Collapsing glomerulopathy coexisting with membranous glomerulonephritis in native kidney biopsies: a report of 3 HIV-negative patients.

Collapsing glomerulopathy (CG), a variant of idiopathic focal segmental glomerulosclerosis (FSGS), can occur in both human immunodeficiency virus (HIV)-positive and HIV-negative patients. Idiopathic membranous glomerulonephritis (MGN) has been reported to coexist with FSGS, but rarely with CG. We report 3 HIV-negative patients (2 men, 1 woman) who developed nephrotic syndrome secondary to MGN complicated by CG, with relatively rapid disease progression despite aggressive therapy.

Progressive kidney disease in three sisters with elevated lipoprotein(a)

Lipoprotein(a) [Lp(a)] is an atherogenic, LDL-like particle of unknown physiologic function. Elevated serum concentrations of Lp(a) have been linked conceptually and epidemiologically to cardiovascular disease [1–3], but their relationship to the progression of renal disease remains much less clear, despite several hypothesized mechanisms by which this could occur [4–12]. We present a unique case of three sisters with profound elevations in serum Lp(a), progressive but unexplained impairment of kidney function, and renal biopsies demonstrating benign nephrosclerosis and apolipoprotein(a) [apo(a)] deposition.

Elimination of BNP by peritoneal dialysis: investigation of analytical issues.

1. Zareie M, hekking l, Welten AG, Driesprong BA, Schadeeeestermans Il, Faict D, et al. Contribution of lactate buffer, glucose and glucose degradation products to peritoneal injury in vivo. Nephrol Dial Transplant 2003; 18:2629–37. 2. rippe B, Simonsen o, heimburger o, Christensson A, haraldsson B, Stelin G, et al. long-term clinical effects of a peritoneal dialysis fluid with less glucose degradation products. Kidney Int 2001; 59:348–57. 3. Jones S, holmes CJ, Krediet rT, Mackenzie r, Faict D, Tranæus A, et al. Bicarbonate/lactate-based peritoneal dialysis solution increases cancer antigen 125 and decreases hyaluronic acid levels. Kidney Int 2001; 59: 1529–38. 4. Zweers MM, de Waart Dr, Smit W, Struijk DG, Krediet rT. Growth factors VeGF and TGF-beta1 in peritoneal dialysis. J lab clin med 1999; 134:124–32. 5. Cooker lA, luneburg P, holmes CJ, Jones S, Topley n; the Bicarbonate/lactate Study Group. Interleukin-6 levels decrease in effluent from patients dialyzed with bicarbonate/lactate-based peritoneal dialysis solutions. Perit Dial Int 2001; 21(Suppl 3):S102–7. 6. Mortier S, Faict D, Schalkwijk CG, lameire nh, De Vriese AS. long-term exposure to new peritoneal dialysis solutions: effects on the peritoneal membrane. Kidney Int 2004; 66:1257–65. 7. ho-dac-Pannekeet MM, hiralall JK, Struijk DG, Krediet rT. longitudinal follow-up of CA125 in peritoneal effluent. Kidney Int 1997; 51:888–93. 8. Topley n. Membrane longevity in peritoneal dialysis: impact of infection and bio-incompatible solutions. adv ren replace Ther 1998; 5:179–84. 9. ho-dac-Pannekeet MM, Krediet rT. Inflammatory changes in vivo during CAPD: what can the effluent tell us? Kidney Int Suppl 1996; (56):S12–16. 10. McIntyre CW. Update on peritoneal dialysis solutions. Kidney Int 2007; 71:486–90. doi:10.3747/pdi.2009.00139