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HIGH RENAL RECOVERY RATE FROM CAST NEPHROPATHY FOLLOWING FREE LIGHT CHAIN REMOVAL HEMODIALYSIS Colin A Hutchison,1 Kolitha Basnayake,1 Mark Cook,2 Paul Cockwell,1

Arthur R. Bradwell.3 Departments of 1Renal Medicine and 3Hematology, Queen Elizabeth Hospital, QEMC, Birmingham, UK; 2Division of Immunity and Infection, Medical School, University of Birmingham, Birmingham, UK. This study assessed the efficacy of high cut-off hemodialysis (HCO-HD), using the Gambro HCO 1100TM dialyser, to result in sustained reductions in serum free light chain (FLC) concentrations in patients with cast nephropathy. Renal recovery rates and survival in 17 patients treated with HCO-HD were compared with a case matched control population treated with standard high flux dialysis (n=17). Standard induction chemotherapy regimens were initiated in all patients. HCO-HD was undertaken for 8 hours daily for the first 5 days and then 8 hours alternate days through to 21 days. Extended HCO-HD was supported by the replacement of human albumin solution, magnesium and calcium per protocol. HCO-HD resulted in sustained reductions in serum FLC concentrations in 12 of 17 patients (median 86% (range 50-93)). These 12 patients became independent of dialysis at a median of 27 days (range 13-50). With an estimated GFR three months following the commencement of treatment of 44mls/min/1.73m2 (range 29-60). Five patients had chemotherapy stopped because of early infective complications and did not achieve sustained reductions in serum FLCs. These patients did not recover renal function and had a significantly reduced survival (P<0.002). On an intention to treat basis FLC removal HD increased the rate of renal recovery from two of 18 (11%) patients in the control population to 12 of 17 (70%) in the study population (P<0.0001). In both groups, patients with cast nephropathy who recovered renal function had a significantly improved survival, P<0.012. In conclusion, extended HCO-HD resulted in sustained reductions in serum FLC concentrations in patients with cast nephropathy. This was associated with an increased rate of renal recovery compared with a historical control group and improved survival.

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PLATELET FUNCTION ANAL YSER-100 (PFA-100) MONITORING DOES NOT PREDICT BLEEDING AFTER PERCUTANEOUS KIDNEY BIOPSY.

Benahili Iboaya, Nahid Islam, Frederick Lee, Eric Miller, Christopher Mire, Darren Schmidt, Tibor Fulop. University of Mississippi Medical Center, Jackson, MS. Severe chronic kidney disease (CKD) patients have acquired platelet dysfunction and are at increased risk of bleeding during invasive procedures. Objective was to determine the clinical utility of Platelet Function Analyser-100 (PFA-100) during native and transplant percutaneous kidney biopsies (PKB). A prospective blinded study enrolled 56 participants. Data was collected on baseline variables and procedure-related outcomes. Baseline data included age, sex, BMI, blood pressure(BP), BMP, CBC, urine studies and PT/PTT. PFA-100 was drawn before each biopsy. Desmopressin acetate (DDAVP) wa s given routinely for MDRD predicted GFR < 30 mL/min/1.73m2. Real-time ultrasound (US) guidance PKB were performed. Procedure related outcomes included hematuria, need for transfusion and hematoma formation. Post biopsy monitoring included repeat vital signs, CBC and renal US. Data was analyzed using SPSS-13 for ANOVA. Baseline characteristics: age 43.7 ±15, BMI 26.9 ±4.9, SBP 138±14.6, DBP 80.3 ± 11.3, serum creatinine (SeCr) 3.3 ± 2.28mg/dl, MDRD GFR 33.4 ± 19.1cc/min/1.73 m2, random urine Alb/Cr ratio 6 ±5.6, hemoglobin(Hb) 11.2 ± 2.16. Fifty-one (91%) participants had valid PFA-100 values. Average number of passes 3.34 ± 1.13. Eleven patients had post-biopsy hematoma, 5 had hematuria, and 4 required transfusion. There were no deaths, renal loss, or need for surgical intervention. Little association between bleeding risk and baseline characteristics. SeCr predicted risk of transfusion (p=0.011), with a corresponding trend for lower MDRD GFR (p=0.099). There was an association between number of passes and post biopsy transfusion (p=0.008), as well as, between post-PKB Hb at 4 hour (p=0.006), with a trend for lower mean arterial pressure (p=0.167). PFA-100 monitoring does not predict bleeding after PKB. Abnormal PFA-100 did not predict any of the main outcomes. Most complications became evident within 8 hours post-procedure.

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OUTCOMES OF CULTURAL COMPETENCY BASED PATIENT EMPOWERMENT DURING IMPLEMENTATION OF CKD CLINIC MODEL OF DIABETES MANAGEMENT Vipin Jain, J. Sevilla, T. Zollinger, Indianapolis, Indiana, USAPoor health literacy is related to worse glycemic levels and kidney failure among underserved. The Agency for Healthcare Research and Quality (AHRQ) stated in its 87th report that low reading skills and poor health are clearly related. A cultural competency and literacy based patient centered diabetes management (PCDM) program was implemented on modeling concepts formulated by the Brigham Chronic Kidney Disease (CKD) initiative with emphasis on patient empowerment. OBJECTIVES: 1. Implement AHRQ studied and other available health literacy tools using culturally appropriate health communications. 2. Aggressively manage all the comorbidities among diabetics with reduced renal function. A prospective non-randomized open study with comparative clinical outcomes analysis 18 months after the initiative was performed. Diabetic patients received CKD related care based on Brigham CKD Initiative. AHRQ studied and other commonly available literacy promoting tools were employed as applicable with cultural appropriateness. Total of 206 patients age > 40 were included in the study. 63.5% were females. Reduction in renal function was found in 27.1% of patients. 24.8% had mild reduction in GFR. 26.1% had HbA1c < 8 and only 10.1% had HbA1c < 7 before initiation of the CKD clinic compared to 82.3% and 54.7% respectively after the clinic initiation (p<0.0005 using McNemar test).72.4% had SBP <130 and 61.7% had diastolic < 80 compared to 20.7% and 21.4% respectively with desired control before. Lipid functions were improved after the CKD clinic approach with an average 44.5 point improvement in LDL levels (p<0.0005 using paired t-test). 59.7% had BMI >= 25 and 31.7% of them had >= 5% of weight loss after receiving periodic lifestyle modification counseling. 46.6% were smokers & 57.2% of them were heavy nicotine dependent on the Fagerstorm test. Readiness to Change on Lairson's modified CAGE was positive for 67.2% of them with 16.3% who quit. CONCLUSIONS: PCDM approach modeled on the Brigham CKD clinic concepts and delivered by a culturally competent provider team led to improved outcomes among diabetic patients with reduced renal function.

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PERCUTANEOUS THROMBECTOMY OF ARTERIOVENOUS FISTULAS IN HEMODIALYSIS PATIENTS: A SINGLE-CENTER EXPERIENCE Gaurav Jain, Ivan D. Maya, Michael Allon, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama. Thrombosis of arteriovenous fistulas usually occurs in the setting of underlying stenosis in the venous outlet, arterial anastomosis, or central vein. Percutaneous mechanical thrombectomy, in conjunction with angioplasty of the underlying lesion, may restore fistula patency. There are relatively few published reports of the outcomes of this approach. We evaluated the success rate of percutaneous thrombectomy of fistulas at our medical center. Using a prospective, computerized vascular access database, we identified 42 patients with thrombosed fistulas treated percutaneously, including 21 in the forearm and 21 in the upper arm. As compared with patients with thrombosed upper arm fistulas, those with thrombosed forearm fistulas were more likely to be male (86 vs 47%, P=0.02) and black (95 vs 67%, P=0.04), but were similar in terms of age, diabetic status, hypertension, peripheral, coronary and cerebral vascular disease. Percutaneous thrombectomy of fistulas was technically successful (restored patency) in 26 of 42 patients (60%). The technical success rate was 57% (12 of 21) for forearm fistulas and 67% (14 of 21) for upper arm fistulas (P = 0.75). Two procedures were aborted. Among the remaining 40 fistulas, an underlying stenotic lesion was present in the venous outlet in 37 patients (92%), at the arterial anastomosis in 11 (28%), and in the central vein in 4 (10%). Twelve patients (30%) had concurrent stenoses at 2 anatomic locations. For the subset of patients with a successful thrombectomy, the median primary patency (time from thrombectomy to the next intervention) was 167 days. In conclusion, percutaneous treatment of thrombosed fistulas can restore fistula patency in 60% of patients, with a comparable success rate for fistulas in the forearm and upper arm. However, the primary fistula patency after successful thrombectomy is fairly short-lived (about 6 months). This approach may be useful in a subset of dialysis patients with thrombosed fistulas.

NKF 2008 Spring Clinical Meetings Abstracts A53