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UNCOMMON ETIOLOGY OF CRYOGLOBULINEMIC RENAL VASCULITIS Hilana H Hatoum 1, Fadi S Rzouq 2. 1: Internal Medicine Department/McLaren Regional Medical Center, Flint, MI. 2: Internal Medicine Department, University of Washington, Seattle, WA Background: West Nile (WN) virus is increasingly recognized as an important human pathogen in the North America with meningitis being the most clinical manifestations. Aim: to report a rare complication of WN virus infection. Clinical vignette: A 67-year-old gentleman with history of recurrent urinary tract infections presented to the emergency room complaining of fever and headache for two days. Upon presentation, his T was 102 F with otherwise normal physical and neurological exam. His WBC was 9.5 cells/ml with mildly elevated serum creatinine of 1.4 mg/dL from a normal baseline. Lumbar puncture was performed revealing aseptic meningitis with negative cultures but positive WN PCR so WN meningitis was diagnosed. While in the hospital, the patient continued to spike fevers with gradual worsening of serum creatinine so urinalysis was repeated showing 4+ proteinuria followed by 24 hour urine protein measurement that was 1.8 g/24 hours. At that point, complete rheumatologic work-up was performed including ANA, ANCA, C3, and C4 levels and returned negative but serum cryoglobulins were positive. Cryoglobulinemic vasculitis was the presumed etiology for the worsening in kidney function so HCV, HBV, and HIV tests were sent and came back negative so renal biopsy was performed revealing pauci-immune crescentic glomerulonephritis. WN induced cryoglobulinemic vasculitis was the presumed diagnosis and prednisone 60mg daily was started with gradual improvement in symptoms and kidney function. Two weeks later, the patient was free of symptoms with normal kidney function so he was discharged home on prednisone therapy. Conclusion: Most WN virus infections in humans are subclinical but overt disease can occur. Rare manifestations include myocarditis, pancreatitis and fulminant hepatitis where the involved organs are sites of high viral replication. Some evidence has accumulated recently suggesting renal tropism of WN virus. As far as our current knowledge extend, this is the first reported case of WN virus induced cryoglobulinemic vasculitis with classical renal affection.

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HEMOPERFUSION (HP) VS HEMODIALYSIS (HD) IN A CASE OF COMBINED OVERDOSE (OD) WITH ACETAMINOPHEN AND VALPROIC ACID (VPA): IMPLICATIONS OF OUR FINDINGS Suiwen He, Stephen I. Rifkin, and Jacques A. Durr. Division of Nephrology and Hypertension, University of South Florida, College of Medicine, Tampa, Florida, USA Acetaminophen (N-acetyl-p-aminophenol) or APAP ODs are frequent, as it is the most widely used analgesic/antipyretic drug sold as a single medication or in drug combinations. In the U.S. APAP OD is the major cause of acute liver failure and second leading cause of hepatic failure requiring liver transplantation. Although HD clears APAP, its benefit is questionable in single APAP ODs, where N-acetyl-cysteine (NAC) is the antidote of choice, as it foils the toxic metabolites. VPA ODs have recently increased, in part because of its expanding clinical use. For mild to moderate VPA ODs, supportive care is the sole treatment. Guidelines lack as to whether more aggressive approaches should be used in severe VPA ODs. In severe cases with coma and impending cardiovascular compromise, HD, HP, and continuous renal replacement therapies (CRRT), or combinations thereof, have been used. In severe combined VPA/APAP ODs, extracorporeal therapies may be indicated, since both drugs can be cleared and are metabolized by the liver, but in turn, become hepatotoxic at OD levels. Herein we report such a case. Because of co-ingestion of ibuprofen, four psychiatric medications, and illicit drugs, we offered first charcoal HP, followed by HD, in addition to the usual NAC protocol. Both HP and HD decreased the half life of VPA from > 30, to 3.03 and 3.60 hours, respectively, and improved the patientʼs condition. While VPA, a fatty acid (pKa~ 5), has limited water solubility, the valproate anion (VP–),its circulating form, is soluble in plasma (pH > 7), and displays saturable protein binding. The free VPA fractions (54.4 ± 1.1%) were identical at initiation of HP and HD. The similar clearances with HP or HD suggest that the equilibrium between bound and free VPA is not rate limiting. Thus extra-corporal modalities such as the molecular adsorbent recirculating system (MARS), HP, or HD with albumin supplemented dialysate, are unlikely to perform any better than HD alone in treating a single, severe VPA OD. However, in severe VPA ODs complicated by other drug ODs, including APAP, a clear hepatotoxin, an initial HP, followed by HD, is a logical strategy.

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COMPARISON OF MORTALITY OF INCIDENT PERITONEAL DIALYSIS (PD) AND HEMODIALYSIS (HD) PATIENTS BY AGEAND DIABETES IN A NATIONAL COHORTRulin Hechter, Kamyar Kalantar-Zadeh, Csaba P Kovesdy, Jennie Jing, Allen R Nissenson, Rajnish Mehrotra. Harold Simmons Center, Harbor-UCLA, Torrance, CA; VA Salem; DaVita, El Segundo, CA.

Background: Comparing patient (pt) survival between HD and PD may relate to four statistical interactions including dialysis vintage, age, diabetic status, and co-morbid conditions. We examined a large national cohort that enables these subgroup analyses.

Methods: We compared the death risk of PD vs. HD in DaVita pts over 5 yrs (7/2001-6/2006) after 1:1 matching via “propensity score”, created using logistic regression that included age, gender, race, diabetes, dialysis vintage, calendar quarter, and location (State) to predict the probability that a pt would be assigned to PD vs. HD. We then separately examined survival of pts who were on PD or HD for 3 to 24 mo (n=9,277) by age (>=60 vs. <60 yrs old) and diabetic status.

Results: Cox models, adjusted for case-mix and laboratory measures of “malnutrition-inflammation-cachexia syndrome” (MICS) showed that PD pts had consistent survivalsuperiority compared to HD in all subgroups, although the said survivaladvantage was somewhat mitigated among the diabetic PD pts (see Figure).

Follow-up Year1-year cohort 2-year cohort 3-year cohort 4-year cohort 5-year cohort

0.2

0.4

0.6

0.8

1.0

1.2Diabetic and Age>=60 (N=2171)Diabetic and Age<60 (N=2387)Non-Diabetic and Age>=60 (N=1911)Non-Diabetic and Age<60 (N=2808)

1 2 3 4 5

Conclusions: Compared to incident HD pts, incident PD pts, esp. those who were non-diabetic, show a robust and consistent survival advantage up to 5 yrs. Additional studies to identify subgroups that benefit the most from modality selection are indicated.

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CMV NEPHRITIS IN NATIVE KIDNEYS OF A PATIENT WITH MYCOSIS FUNGOIDES Amanda Hernandez, Kanwardeep Sachdeva, Charles Nguyen, Amber Podoll. Department of Renal Disease and Hypertension. University of Texas Health Science Center, Houston, TX, USA. CMV is a common infection seen in transplant recipients and immunosuppressed patients. Prior studies have reported CMV-associated renal injury limited to allograft recipients and autopsy samples. There have not been any reports of CMV nephritis in native kidneys. We present a case of CMV nephritis in the native kidneys of a woman with newly diagnosed Mycosis Fungoides (MF). A 48 year old woman with psoriasis refractory to immunosuppressive therapy was admitted to the hospital with failure to thrive and acute renal failure. Because of the worsening rash and overall clinical condition, MF was suspected and confirmed by a repeat skin biopsy. The patientʼs renal function continued to decline despite adequate fluid resuscitation. Given her active urine sediment and 1.8 grams of proteinuria, a kidney biopsy was done which showed acute tubulointerstitial nephritis with CMV viral inclusions. The patient was treated with IV Gancyclovir and her creatinine stabilized. However, due to other comorbidities she continued to deteriorate and eventually died of septic shock. CMV is one of the most common infectious complications seen in renal allograft recipients. Its role as a causative agent for direct renal injury remains controversial because CMV viral inclusions are seen in only 1% of biopsies. There have been no proven cases of CMV causing direct injury in native kidneys even in immunocompromised patients. We present for the first time a patient with newly diagnosed MF who had previously been on immunosuppressive therapy and subsequently developed acute renal failure secondary to CMV nephritis. Previous reports suggest that over 97% of MF patients are seropositive for CMV compared to only 57% of healthy controls. Patients with MF develop severe immunodeficiency and CD8+ T cell depletion as their disease progresses. The combination of immunosuppressive therapy and immunodeficiency associated with MF likely led to reactivation of CMV infection in this patient.

NKF 2010 Spring Clinical Meetings AbstractsA64