NKF 2014 Spring Clinical Meetings Abstracts

OUTCOMES IN PATIENTS WITH ACUTE KIDNEY INJURY IN AN INNER CITY TEACHING HOSPITAL ICU: Shivakanth Burugu1, Elizabeth Ann Phipps1, Oriade Adeoye1, Siddhartha Yedla1 , Anjali Acharya1, Ravindra L Mehta2. 1Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, 2University of California, San Diego, USA. Acute kidney injury (AKI) even if transient is associated with bad outcomes in critically ill patients. The aim of the study was to compare outcomes of patients who developed AKI in an inner city intensive care unit (ICU) with other centers that participated in an AKI registry study. Our cohort consists of 847 of the 880 eligible patients admitted to the medical intensive care unit (MICU) at Jacobi Medical Center between April 2009 and October 2013. 173 of 847 critically ill patients (20.4%) had AKI within seven days of ICU admission. Results: Eighty four percent of our patients were non Caucasian. Sepsis was seen in 59% of our patients with AKI. Eighty two percent of patients had exposure to multiple AKI risk factors in the preceding 4 weeks. Mortality rate was higher in our center at 33% compared to 21% at other centers despite similar Sequential Organ Failure Assessment score (SOFA) and Acute Physiology, Age, Chronic Health Evaluation III (APACHE III) scores. Table 1: Characteristics Jacobi Medical

Center Remaining centers

Multifactorial AKI, %

66 38

History of renal insult, %

82 55

Sepsis, % 59 34 The decreased likelihood of discharge to home in our cohort of non-Caucasian patients was possibly related to a higher percentage of patients with sepsis. Higher rate of exposure to other AKI risk factors may have contributed to the AKI development. Identifying and appropriately managing the risk factors in the ICU is crucial for better outcomes. Role of genetic predisposition to AKI needs exploration.

ARE CURRENT CDC GUIDELINES FOR HEPATITIS B TESTING IN PATIENTS WITH ESRD ADEQUATE? Shivakanth Burugu, Kisra Anis, Jacobi Medical Center, Bronx, NY, USA. In the United States, the current prevalence of hepatitis B surface antigen (HBsAg) positivity in hemodialysis (HD) patients is 1%; the annual incidence of positive seroconversion is 0.12%. Current CDC guidelines recommend dialyzing HBsAg positive patients in isolation rooms, with no specific guidelines for their serological surveillance. Monthly serological testing is recommended for patients who are negative for hepatitis B surface antibody (HBsAb). For patients positive for both HBsAb and hepatitis B core antibody (HBcAb) no further serological testing is required. We describe two patients where the seroconversion in the hepatitis B status would have been overlooked if surveillance was performed according to the present guidelines. The first patient is a 37 year old African American male with history of hypertension, HIV with undetectable viral load and ESRD on HD, who was initially positive for HBsAg and negative for HBsAb in 2010. He was found to have converted to HBsAg negative status, while his HBsAb and HBcAb serologies became positive when evaluated at a transplant center in 2011. The second patient is a 60 year old Hispanic male with history of diabetes, hypertension, HIV with undetectable viral load and end stage renal disease on HD, who had been positive for HBsAb and negative for HBsAg annually since 2011. He was subsequently found to be HBsAg positive, HBsAb negative and HBcAb positive when tested at a transplant center in 2013. It is known that immunocompromised patients can harbor low levels hepatitis B virus in the liver despite being HBsAg negative. We highlight the fact that hepatitis B serologic status of HD patients is subject to change. These two cases illustrate the need to revisit CDC guidelines for hepatitis B testing for HD patients, especially for those who are immunodeficient with HIV.

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Am J Kidney Dis. 2014;63(5):A1-A121

TREATMENT-REFRACTORY HISTOLOGIC TIP-VARIANT FSGS IN A PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS Kristin Meliambro, Shuchita Sharma and Kirk N. Campbell, Icahn School of Medicine at Mount Sinai, New York, NY USA Here we present a case of FSGS with a tip lesion in a patient with systemic lupus erythematosus (SLE) lacking the classic features of lupus nephritis. This is a 60 year old female with established and long-standing SLE (20+ years) who presented to nephrology with proteinuria. At the time of initial evaluation she had a blood pressure of 159/86. Her physical exam was notable for a malar rash and 1+ bilateral lower extremity edema. She had a urine protein/creatinine (P/C) ratio of 3.06 mg/mg with an eGFR of 42 cc/min. Urinalysis revealed 11-25 RBCs/hpf. Mycophenolate Mofetil 500 mg BID had been initiated by rheumatology 4 weeks prior for extrarenal lupus manifestations including arthralgias and the malar rash. She had also been taking Captopril 12.5 mg TID. She did not tolerate hydroxychloroquine due to retinal toxicity. A kidney biopsy was performed that revealed 22 glomeruli, one with segmental sclerosis, tip variant. Electron microscopy (EM) revealed diffuse podocyte foot process effacement. There were no basement membrane or immune deposits by EM or immunofluorescence. With a serum albumin of 2.9 g/dl her urine P/C ratio peaked at 14.6, averaging 5-7 g urinary protein per day. The MMF was discontinued due to the development of herpes zoster which was treated with acyclovir. The patient completed 6 month courses of Prednisone 60 mg daily then cyclosporine 2 mg/kg/day with persistent proteinuria of 7-8 grams per day and an eGFR of 30 cc/min. Acthar gel was started at 80 units subcutaneously twice weekly. After 12 months on Acthar her urine protein excretion is approximately 3 grams per day with a stable GFR ~ 30 cc/min. This patient's clinical course highlights the potential refractory course of non-canonical lupus-associated renal disease even in the presence of seemingly favorable histologic features. Further studies will be needed to determine the optimal treatment regimen for these patients.

IS C1q BINDING DONOR-SPECIFIC ANTI-HLA ANTIBODIES STILL CLINICALLY RELEVANT MORE THAN 10 YEARS AFTER KIDNEY TRANSPLANTATION? S. Calp,-Inal, A. Colavai, M.Melamed, E. Akalin. Background: We aimed to investigate the prevalence and clinical significance of C1q binding DSA in patients with functioning allografts more than 10 years post-transplantation. Method: All recipients had negative CDC cross-match at the time of transplantation. HLA antibody identification was performed using Luminex SAB assay. The capacity of serum HLA antibodies to fix complement was tested using the C1q assay. Results: Of the 176 patients studied, %23 had DSA, and %20 of the DSA+ patients had C1q binding capacity. MFI values of DSAs were higher in DSA+/C1q+ group. Comparing to DSA- and DSA+/C1q- patients, DSA+/C1q+ patients had more history of previous kidney transplantation, higher class II PRA levels, acute antibody-mediated rejection (AMR) and transplant glomerulopathy. There was no difference in terms of allograft function and the degree of proteinuria between the groups. Conclusion: Positive C1q assay was seen in 20% of the DSA+ patients 10 years after transplantation and it is significantly associated with AMR and transplant glomerulopathy.

DSA(-) (n=135)

DSA+C1q+ (n=8)

DSA+C1q- (n=33)

P value

MeanCr 1.8±1.08 2.2±0.99 2.0±1.12 0.36 ACR,% 8 13 15 0.45 AMR,% 3 50 3 <0.001 TGP, % 8 37 24 0.004 Class I PRA

11± 22 9±12 34±34 <0.001

Class II PRA

13±25 60±41 44±26 <0.001

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