Emerging Nephropathy

45 %
55 %
Information about Emerging Nephropathy
Science-Technology

Published on October 9, 2009

Author: llimchiu

Source: authorstream.com

Emerging Nephropathies : Emerging Nephropathies Luis V. Limchiu, Jr. October 15, 2009 PSN Midyear Convention, Tagaytay Emerging Nephropathies : Emerging Nephropathies Gadolinium Acute phosphate nephropathy Star fruit Nephropathy Orlistat Nephropathy Pattern : Pattern level of evidence Risk populations Clinical Picture Diagnosis Treatment Prognosis Prevention Oral Phosphate Base Bowel Prep (Fleet) : Oral Phosphate Base Bowel Prep (Fleet) Acute Renal Injury (Acute phophate nephropathy) Acute Acid-base electrolyte abnormalities Chronic Renal Failure and Nephrocalcinosis Seen more commonly in patients with CKI but has also been noted in patients with normal kidney function seen also with sodium phosphate enema Oral Bowel Prep Choice : Oral Bowel Prep Choice GoLytely: Gold Standard of Bowel Preparation 4L of volume, 5-15 % of pts do not complete NaP: low-volume hyperosmotic solution that contains 48 g or 400 mmol of monobasic NaP and 18 g (130 mmol) of dibasic NaP per 100 ml Bowel prep of choice among most patients AM Report Emily Jenkins 7.28.08 Acute Phosphate Nephropathy : Acute Phosphate Nephropathy Increasing use of colonoscopy, as indicated for colonic cancer prevention and early detection, has brought about increase use of oral bowel prep drugs particularly the sodium phosphate preparation more commonly known as fleet. Which is more commonly use because it is better tolerated and more effective than the Golytely and the Nu-Lytely OSP increasing use has been associated with reports of serious and sometimes fatal complication in the kidney and acid-base electrolyte abnormalities. Fleets Phosphate Soda : Fleets Phosphate Soda Osmotic Purgatives Each 45 ml of Fleet’s phosphate soda contain 5 gm sodium and 17.8 gm phosphate yielding a solution with 16,622 mmol/L containing 11.5 gms elemental phospate (usual daily load is 1-1.5 gm/day) 2 OSP - visicol with similar content to Fleet and osmoprep which has 20% less phosphate Each 100 ml of the OSP will obligate 4 L of stools Acute Metabolic Disturbance NaP : Acute Metabolic Disturbance NaP Hyponatremia- if water taken in is retained Hypernatremia- excessive water loss Severe hyperphosphatemia and hypocalcemia- can lead to tetany, seizures, coma, and acute phosphate nephropathy and nephrocalcinosis CKD- calcinosis Kidney Injury in Sodium Phosphate Bowel PreP : Kidney Injury in Sodium Phosphate Bowel PreP Desmueles et al reported in a letter to NEJM in 2003 about a 71 year female whose creatinine went up from 1 to 4.5 in a 10 week period after a bowel prep using OSP. Biopsy using light microscopy, scanning electron and x-ray microanalysis confirm the presence of calcium phosphate tubular deposits in the form of hydroxyapatite Markowitz of Columbia University reviewed 7349 biopsies and reported on 21 biopsies showing Phosphate nephropathy. Mean age was 64. 2/3 had normal baseline renal function of less than 1.2 mg/dl. Many presented with AKI with in 3 days to 2 weeks (38.1%) or 2 month (85%) after the bowel prep with mean creatinine of 3.4 mg/dl. Many left with CKD average creatinine after 10 months was 2.4 and 4 ended in chronic dialysis. Renal Biopsy findings in APN : Renal Biopsy findings in APN Glen S. Markowitz,* M. Barry Stokes,* Jai Radhakrishnan,† and Vivette D.D’Agati*J Am Soc Nephrol 16: 3389 –3396, 2005 Slide 13: Biopsy in a 69 year patient with menbranous GN initially (B) developed APN after OSP bowel Prep 4 months after (C) Acute Phosphate Nephropathy : Acute Phosphate Nephropathy Biopsy Acute Phosphate Nephropathy Note Nephrocalcinosis in OSP use detected by Biopsy only : Biopsy Acute Phosphate Nephropathy Note Nephrocalcinosis in OSP use detected by Biopsy only Slide 17: at at Task Force Guidelines for NaP preparation Agents of American Society of Colon and Rectal Surgeons, American Society of Gastrointestinal Endoscopy and The Society of Gastrointestinal and Endoscopic Surgeons Wexner SD, Beck DE, Baron TH, et al.Gastrointest Endosc 2006; 63:894–909 Absolute Contraindication to OSP : Absolute Contraindication to OSP Relative Contraindication : Relative Contraindication Acute Phosphate Nephropathy : Acute Phosphate Nephropathy level of evidence: clinical report with biopsy, case series, and biochemical derangement, FDA warnings, Risk population factors: Elderly, ESRD, CKD, KT, Diabetic, slow bowel motility Clinical Picture ARF, Hypocalcemia, CKD, non-polarizing tubular deposits {von kossa staining} -Nephrocalcinosis Diagnosis: History, hyperphosphatemia, hypercalcemia, kidney biopsy Treatment: Dialysis Prognosis ARF recovery but some with CKD and ESRD Prevention Gadolinium : Gadolinium Nephogenic Systemic Sclerosis Acute Renal Failure associated with Gadolinium Level of Evidence- Animal studies and clinical case reports Case Report : Case Report A 56-year-old woman was admitted with a hypertensive crisis (blood pressure, 250/120 mm Hg), for which she was treated with valsartan (160 mg/d) and hydrochlorothiazide (12.5 mg;cld). The serum creatinine 2 months previously was 1 mg/dL and the urine protein-creatinine ratio was 0.02. Four days after the hypertensive crisis, her serum creatinine was 1.0 mg/dL. Because of persistent headache, magnetic resonance imaging of the head with intravenous injection of 17 mL (8.5 mM, 0.10 mM/kg body weight) gadolinium–diethylenetriaminepentaacetic acid (DTPA) The MRI showed findings consistent with meningioma Archives of Pathology and Laboratory Medicine: Vol. 130, No. 9, pp. 1354–1357 March 2006 Case Report : Case Report For the workup of the hypertensive crisis, magnetic resonance imaging of the abdomen was also performed the next day with a bolus intravenous injection of 30 mL (15 mM, 0.19 mM/kg body weight) of gadolinium–DTPA-BMA. Her serum creatinine started to increase and 6, 7, and 9 days after the last magnetic resonance imaging reached levels of 1.5, 2.8, and 3.4 mg/dL, respectively. Physical examination was unremarkable. Urinalysis showed no protein, glucose, ketones, or bilirubin. A renal biopsy, performed 10 days after the last magnetic resonance imaging, showed features of acute tubular necrosis consistent with gadolinium nephrotoxicity. Patient was managed conservatively with gradual recovery of renal function. Discharge serum creatinine was 1.6 mg/dl. Kidney Biopsy- ATN Gadolinium : Kidney Biopsy- ATN Gadolinium Gadolinium : Gadolinium With the documented increase risk of AKI with iodinated contrast media used. gadolinium-based contrast media were originally introduced as an alternative to the iodinated media for magnetic resonance imaging studies. Some early studies suggested that gadolinium-based contrast media are not nephrotoxic, even in patients with preexisting renal insufficiency. They are distributed in the extracellular space and are eliminated almost exclusively by the kidney through glomerular filtration. In patients with normal renal function, about 98% of gadolinium chelates are excreted within 24 hour Animal Studies : Animal Studies Sekido et al and Spencer et al In the former, a single dose of gadolinium chelates to dogs caused diffuse vacuolization of renal cortical tubular cells. In the latter, intravenous injection of gadolinium in mice or rats caused mineral deposits in glomerular and peritubular capillaries at the renal papillae, which contained both gadolinium by x-ray diffraction studies and calcium by a weak alizarin red stain Clinical Reports : Clinical Reports Sam et al comprehensively studied 260 patients (195 with chronic renal insufficiency and 65 without) subjected to gadolinium angiography and found that acute renal failure developed in 7 patients (3.5%) in the chronic renal insufficiency group but was not encountered in the other group. The serum creatinine returned to baseline within 4 to 12 days in 5 patients, but end-stage renal disease developed in 2 Gadolinium Chelates : Gadolinium Chelates Distinct from, but closely related to, the problem of gadolinium-based contrast nephrotoxicity is the recent introduction of gadolinium chelates as a radiosentitizer for radiation therapy Rosenthal et al reported that 4 of 41 patients who received a single intravenous dose of gadolinium texaphyrin in conjunction with radiation therapy for advanced cancers developed acute renal failure from the background of normal renal function, but the condition was reversible in all within 4 days The safety of gadolinium in patients with stage 3 and 4 renal failure : The safety of gadolinium in patients with stage 3 and 4 renal failure 91 patients with stage 3 and 4 exposed to gadolinium dose was 0.2 ml/kg and ARF defined as an increase of 0.5 mg/dl in creatinine over baseline Results: 11/91 (12%) developed ARF Risk factors were: lower eGFR, older age, diabetic nephropathy, lower albumin, and lower HB. Multivariate analysis was significant only for diabetic nephropathy and lower eGFR Ihsan Ergu¨n1, Kenan Keven1, Irfan Uruc¸1, Yakup Ekmekc¸i1, et al. Department of Nephrology and Department of Radiology, Ankara University School of Medicine, NDT 2006 Gadolinium AKI : Gadolinium AKI level of evidence- Animal and Clinical Reports Risk population factors- Diabetic, Multiple frequent exposure, azotemia, Use of Gadolinium Chelates Clinical Picture Develops a few days after exposure as ATN Diagnosis Clinical Treatment Conservative Prognosis Most will recover, few with ESRD Prevention Prevention : Prevention It is recommended that the dose should not be more than 0.3 mM/kg and, in patients with renal insufficiency, even lower doses should be used. Avoid in diabetic, azotemic patients Avoid closely repeated exposure MR angiography less risky than MR digital subtraction angiography Avoid gadolinium chelates as a radiosentitizer for radiation therapy even in those with normal kidney function. Nephrogenic Systemic Fibrosis from Gadolinium : Nephrogenic Systemic Fibrosis from Gadolinium NSF is a debilitating systemic disease developing exclusively in patients with renal failure Etiology is unknown but recent reports suggest exposure to Gadolinium may play a role. Nephrol Dial Transplant (2007) 1 of 7 doi:10.1093/ndt/gfm584 Nephrogenic systemic fibrosis after exposure to gadolinium in patients with renal failure : Nephrogenic systemic fibrosis after exposure to gadolinium in patients with renal failure Reviewed 849 patients on RRT over 5 years 2001 to 2006. 4 of the 261 exposure to gadolinium developed clinically apparent disease, while none of the 588 not exposed developed the diseased. The OR for single exposure was 6.67 [(CI) 1.537–53.97] and for multiple exposure was 44.5 (95% CI 2.362–2913) Among 592 patients on stage 3 and stage 4 CKD with exposure to Gadolinium none developed clinically apparrent disease Othersen B. Jennifer, John C. Maize, et. al.NDT 2007 Clinical Manifestation : Clinical Manifestation Skin- reddened or darkened patches, papules or plaques. Textures maybe woody and resemble peel of an orange. Patients feel burning, itching, or sharp pains in the involved areas. The lesions most commonly involved the areas between the ankle and the thigh and between the wrist and the upper arm, typically sparing the face. In some patients the internal organs maybe involved as well- skeletal muscle, myocardium, pericardium, lungs and pleura. Biopsy reveals proliferation of elongated spindle-shaped fibroblast with CD 34 markers, and thickened collagen bundles. 10% of cases have never been dialysed Occurs 2-3 months after exposure and dose was 7.5 to 10 mmol In 1 patient skin lesions improved after LKT Skin Biopsy NSF : Skin Biopsy NSF Management : Management Hemodialysis/Plasmapheresis immediately after exposure Kidney Transplantation Prevention Avoid Gadolinium in ESRD- do iodinated contrast instead, reserved Gadolinium for stage 3 and 4 Avoid repeated exposure Warning! : Warning! Balimbing Toxicity Aka Star Fruit, Carambola Toxicity : Balimbing Toxicity Aka Star Fruit, Carambola Toxicity Evidence : Evidence Several case reports pathology animal studies Intoxication by star fruit (Averrhoa carambola) in 32 uraemic patients: treatment and outcome : Intoxication by star fruit (Averrhoa carambola) in 32 uraemic patients: treatment and outcome 32 uremic patients who had ingested star fruit 20 patients were in regular HD, 8 in PD, 4 not on dialysis Most common symptoms: persistent intractable hiccups (93.75%), vomiting (68.7 %), varying degrees of disturbed consciousness -confusion, aggitation (65.6%), seizures (21.8%), muscles weakness, numbness, paresthesia, and insomnia (40.6%) Miguel Moyses Neto Jose´ Abrano Cardeal da Costa et al. Nephrol Dial Transplant (2003) 18: 120–125 Treatment Outcomes : Treatment Outcomes Patients that were treated promptly with hemodialysis including those with severe toxicity recovered without sequelae Patients that were not treated or treated with peritoneal dialysis did not survive- 7 deaths. Daily dialysis or CRRT maybe the treatment of choice because of rebound toxicity Acute oxalate nephropathy after ingestion of star fruit- Cheng CL et al : Acute oxalate nephropathy after ingestion of star fruit- Cheng CL et al 2 cases not on dialysis consuming large quantities of fresh carambola juice with in hours presented with nausea, vomiting, abdominal pain and back pain followed by ARF pathology compatible with acute oxalate nephropathy Hemodialysis done, renal function recovered 4 weeks later. Am J Kidney Dis. 2001 Feb;37(2):418-22 Fatal outcome after ingestion of star fruit (Averrhoa carambola) in uremic patients : Fatal outcome after ingestion of star fruit (Averrhoa carambola) in uremic patients 20 patients, 8 mortalities (including 1 not yet on dialysis) Their initial presentations included sudden-onset limb numbness, muscle weakness, intractable hiccups, consciousness disturbance of various degrees, and seizure. Death occured within 5 days, Chang JM, Hwang SJ, Kuo HT, Tsai JC et al ,Am J Kidney Dis. 2000 Feb;35(2):189-93 Balimbing Toxicity : Balimbing Toxicity Calcium Oxalate Crystal : Calcium Oxalate Crystal Pathophysiology: Neurotoxic effects of carambola in rats: the role of oxalate : Pathophysiology: Neurotoxic effects of carambola in rats: the role of oxalate The effects on barbiturate-induced sleeping time and death caused by intraperitoneal administration of carambola juice were observed in Sprague-Dawley rats serial amounts of pure carambola juice diluted with normal saline in a volume of 1:1. Either 5.33 g/kg carambola after oxalate removal or 5.33 g/kg of pure carambola juice diluted with normal saline were administered intraperitoneally, while the control group was given normal saline before pentobarbital injection To assess the lethal effect of oxalate in carambola, we gave rats chemical oxalate at comparable concentrations to the oxalate content of carambola Chen CL, Chou KJ, Wang JS, Yeh JH, Fang HC, Chung HM. J Formos Med Assoc. 2002 May;101(5):337-41 Results : Results The sleeping time of rats that received normal saline and 1.33 g/kg, 2.67 g/kg, 5.33 g/kg, and 10.67 g/kg of carambola juice were 66 +/- 16.6, 93.7 +/- 13.4, 113.3+/- 11.4, 117.5 +/- 29.0, and 172.5 +/- 38.8 minutes, respectively. The 3 higher dose were statically significant compared to saline alone. This effect was eliminated after the removal of oxalate from carambola juice. Four of eight rats in the 10.67-g/kg group and all rats in the 21.33 g/kg and chemical oxalate groups died after seizure. Lethal doses of carambola juice were rendered harmless by the oxalate removal procedure. Pattern : Pattern level of evidence - case reports and case series, animal studies Risk population factors: CKD, ESRD, some none CKD, 1-3 fruits and 150-250 ml pure juice Clinical Picture- hiccups, sensorial changes, seizures Diagnosis: calcium oxalates in biopsies Treatment increase hemodialysis, CRRT, Prognosis Recovery with prompt hemodialysis or CRRT Prevention: Public Warning Warning! : Warning! Slide 56: Orlistat- Pancreatic Lipase Inhibitor Bile Acids and Fatty Acids not absorbed BA and FA Bind Calcium Calcium Oxalate Stool Stool Oxalate Blood Urine Ca X O Orlistat and Oxalate Nephropathy : Orlistat and Oxalate Nephropathy Orlistat is a gastrointestinal and pancreatic lipase inhibitor used in the treatment of obesity Acute oxalate nephropathy describes the development of calcium oxalate crystalluria, causing tubular obstruction and tubular injury [1]. Calcium oxalate crystal deposition occurs in both primary and secondary hyperoxaluria. Our audit does not directly support an association between the use of orlistat, oxalate crystalluria and ATN. However, the retrospective use of biopsy reports is a limitation in drawing Patients with pre-existing renal disease, undiagnosed mild forms of primary hyperoxaluria or secondary hyperoxaluria, who also take orlistat, may be predisposed to developing acute oxalate crystalluria. Nephrol Dial Transplant (2007) 0: 1 Orlistat Nephropathy : Orlistat Nephropathy However, calcium oxalate crystals are found frequently in the kidneys, and in particular in association with acute tubular necrosis The identif ication of high risk patients treated with orlistat and the regular monitoring of their renal function might reduce the theoretical risk of renal failure due to acute oxalate nephropathy. Nephrol Dial Transplant (2007) 0: 1 The End : The End Indinavir Nephropathy : Indinavir Nephropathy Slide 62: Exenatide Nephropathy

Add a comment

Related presentations

Related pages

Diabetic nephropathy[mdash]emerging epigenetic mechanisms ...

Diabetic nephropathy (DN), a severe microvascular complication frequently associated with both type 1 and type 2 diabetes mellitus, is a leading cause of ...
Read more

Glomerular Diseases: Emerging Tests and Therapies for IgA ...

Introduction. In 1968, Berger and Hinglais published the first modern report of IgA nephropathy (IgAN) . Using immunofluorescence microscopy, the authors ...
Read more

Autophagy: emerging therapeutic target for diabetic ...

Autophagy: emerging therapeutic target for diabetic nephropathy. Kume S, Yamahara K, Yasuda M, Maegawa H, Koya D.
Read more

Emerging therapies in immunoglobulin A nephropathy - Yeo ...

How to Cite. Yeo, S. C., Liew, A. and Barratt, J. (2015), Emerging therapies in immunoglobulin A nephropathy. Nephrology, 20: 788–800. doi: 10.1111/nep.12527
Read more

This Article - Glomerular Diseases: Emerging Tests and ...

Email this article to a colleague; Alert me when this article is cited; Alert me if a correction is posted; Similar articles in this journal;
Read more

Rituximab Emerging as New Option for Membranous Nephropathy

SAN DIEGO — For patients with idiopathic membranous nephropathy, the addition of rituximab to nonimmunosuppressive antiproteinuric therapy leads to ...
Read more

Diabetic Nephropathy: Emerging Biomarkers for Risk Assessment

Progression of diabetic nephropathy (DN) is commonly defined by an increase in albuminuria from normoalbuminuria to microalbuminuria and ...
Read more

Emerging molecular mechanisms of diabetic nephropathy ...

Figure 1: Emerging molecular mechanisms of diabetic nephropathy. From Diabetic nephropathy—emerging epigenetic mechanisms. Mitsuo Kato 1, Rama Natarajan 1,
Read more

Emerging biomarkers and metabolomics for assessing toxic ...

1. Biomed Res Int. 2014;2014:602526. doi: 10.1155/2014/602526. Epub 2014 Jun 11. Emerging biomarkers and metabolomics for assessing toxic nephropathy and ...
Read more