IRON INFUSION AND HYPOPHOSPHATEMIA

V KHELGI1,2, D VARDESH1,3, J FRAZIER1
1Queensland Health, Brisbane, Australia, 2Rural Clinical School, Brisbane, Australia, 3Griffith University, Brisbane, Australia

Background: Parenteral iron supplementation for iron deficiency anaemia (IDA) has become more common over the last decade due to ease of administration and reduced GI side effects. Iron infusion is well known to cause mild allergic-type reactions. Herein we report a case of severe hypophosphatemia post ferric carboxymaltose (FCM) infusion.
Case Report: A 35-year-old Caucasian female presented to our Emergency Department with severe lethargy and abdominal pain of 2 days’ duration. She had received FCM infusion 5 days prior to presentation at another hospital for IDA. She denied taking any diuretics or over the counter medications. Her serum biochemistry showed severe hypophosphataemia (0.22 mmol/L) with normal calcium, electrolytes and renal function. Her Vitamin D level was low 37 nmol/L with normal parathormone level (6.6 pmol/L). Urinary phosphate excretion was high at 24.7 mmol/L and fractional excretion of phosphate was more than 20% indicating hypophosphataemia secondary to renal phosphate wasting. There was no evidence of Fanconi’s syndrome. We treated her with 0.25mcg calcitriol BD and her phosphate levels normalised on follow up.
Conclusion: While parenteral iron-induced hypophosphataemia is increasingly reported in the medical literature, there is limited physician awareness about this.
FCM is more frequently associated with hypophosphataemia than other formulations and underlying Vitamin D deficiency exacerbates the condition. FCM reduces breakdown of FGF23 levels resulting in renal phosphate wasting and reduced 1- alpha-hydroxylation of Vitamin D. This case highlights the importance of monitoring serum phosphate levels before and after iron infusion particularly in patients at risk of vitamin D deficiency.

PREVALENCE OF MALNUTRITION, NUTRITIONAL PROFILE AND LENGTH OF STAY IN RENAL INPATIENTS

S BAHCECI1, M CHAN1, K EVANS2
1St George Hospital , Sydney, Australia, 2The Sutherland Hospital, Sydney, Australia

Aim: This study aimed to examine the relationship between the clinical profile, prevalence of malnutrition, and length of stay (LOS) in a cohort of renal patients admitted to an acute tertiary hospital.
Background: Malnutrition is common among renal patients, and is associated with morbidity, mortality, and hospitalisation including increased LOS.
Methods: A retrospective audit was conducted on data routinely collected for patients admitted under the renal medicine team over 11 months. Data collected included demographics, clinical presentation, LOS, nutritional profile including Subjective Global Assessment (SGA) score, history of dietitian involvement and the need for dietitian follow up post discharge.
Results: Records of 218 patients were reviewed. The average number of renal admissions was 12.8±3.9 per day, with 45.4±15.9% of patients under the care of the dietitian, either referred or automatic referral as per department policy.
The mean age of patients was 68.0±14.3 years. The prevalence of malnutrition was 63.6% (SGA=B and C). The LOS period between well nourished (SGA=A) vs. malnourished (SGA=B and C) was 12.2±11.5 vs. 16.5±22.6 days respectively, p=0.09 and was considered clinically significant. All malnourished patients required ongoing nutrition support by dietetics post discharge.
Conclusions: Malnourished renal inpatients tended to have longer LOS which has implications for clinical practice. Malnutrition management prior to, during, and after hospital discharge is likely to make a difference to LOS. Therefore, a multidisciplinary team approach to early identification of malnutrition for dietetic referral is vital to ensure continuum of care.


Biography:
Su Bahceci is a clinical dietitian working at St George Hospital, Sydney with extensive experience in a number of medical and surgical areas and has been specialising for over four years in the renal acute inpatient and chronic outpatient areas. She has undertaken post-graduate training in renal nutrition. Su has a vested interest in research, particularly in nutrition support for malnourished renal patients and examining the role of intradialytic parenteral nutrition on nutritional outcomes. She is also enthusiastic about mentoring fellow dietitians and students in the area of renal nutrition.

RENAL RECOVERY IN A DIALYSIS-DEPENDENT PATIENT WITH END-STAGE KIDNEY DISEASE SECONDARY TO ANALGESIC NEPHROPATHY

Y PARK1, G HARRIS2, D DEGEN3
1University of Melbourne Department of Medicine, Royal Melbourne Hospital, Parkville, Australia, 2Department of Renal Medicine, Bendigo Health, Bendigo, Australia, 3Department of Renal Medicine, Alfred Health, Melbourne, Australia

Background: Renal recovery has been reported in specific aetiologies of kidney failure such as autoimmune disease, haemolytic uraemic syndrome and renovascular nephrosclerosis, but is less likely in analgesic nephropathy. To the best of our knowledge, there is limited literature regarding reversible dialysis-dependent ESKD secondary to analgesic nephropathy.
Case Report: A 31-year-old male presented to the hospital with renal failure thought to be secondary to chronic analgesic abuse of ibuprofen/codeine combination tablets for three years, which peaked at approximately 100 tablets per day, equivalent to 20g ibuprofen and 1.3g codeine. Following admission, he was noted to be oligo-anuric requiring haemofiltration and required ongoing dialysis for end-stage kidney disease (ESKD) with an estimated glomerular filtration rate (eGFR) under 10mL/min/1.73m2. A renal biopsy was performed demonstrating global sclerosis in 100% of the 21 glomeruli sampled and severe diffuse cortical interstitial fibrosis with widespread tubular atrophy.2 years and 7 months later, his renal function improved enabling cessation of dialysis. The mechanism for this recovery is not clearly understood. The patient has remained dialysis-free for two years and is clinically well with stable chronic kidney disease with a serum creatinine of 276mol/l corresponding to an eGFR of 25mL/min/1.73m2.
Conclusion: Although rare, our case demonstrates that renal recovery in dialysis-dependent ESKD secondary to analgesic nephropathy is possible despite poor prognostic features on biopsy and a relatively long period of regular dialysis.


Biography:
Yeung-Ae has completed her Doctor of Medicine with Honours at the age of 24 years from the University of Melbourne, Australia following her completion of Bachelor of Biomedicine with Honours at the same institution. Yeung-Ae is currently working as a hospital medical officer at the Royal Melbounre Hospital, Victoria, Australia.

PURTSCHER-LIKE RETINOPATHY IN SYSTEMIC VASCULITIS AND CLASS IV LUPUS NEPHRITIS: 2 CASE REPORTS

P TAN1, D LANGSFORD1, T PIANTA1, J SAVIGE1
1Northern Health, Epping, Australia

Background: Purtscher-like retinopathy is a rare and severe angiopathy mediated by retinal microembolisation and complement activation. We report two cases of Purtscher-like retinopathy in context of systemic vasculitis and lupus nephritis. The condition was demonstrated with retinal imaging using a Canon non-mydriatic retinal camera.
Case Report: A 68-year-old male presented with hypertension and acute kidney injury requiring dialysis. Lower limb palpable purpuric rash was noted. Renal biopsy demonstrated cortical infarction, which was proven to be bilateral despite patent renal arteries on angiogram. Autoimmune, vasculitic and pro-thrombotic screens found no abnormalities. Skin biopsy demonstrated leucocytoclastic vasculitis. Severe lower limb ischemia developed despite patent lower limb arteries on angiogram. He then developed increasing confusion, cardiac instability and painless visual loss. Retinal imaging found Purtscher-like retinopathy. He was treated with prednisolone, cyclophosphamide and plasma exchange. At 9 months, whilst dialysis dependent, he has made an otherwise good recovery including now normal retinal findings with restored vision.
A 47-year-old female presented with nephrotic syndrome, hypertension, a malar rash. She was found to have class IV lupus nephritis associated with low complement factors (C3 and C4). Antiphospholipid screen was normal. She was treated with prednisolone, hydroxychloroquine and mycophenolate. At 3 months she achieved partial remission but reported blurred vision. Retinal imaging demonstrated Purtscher-like retinopathy.
Conclusion: Purtscher-like retinopathy is a rare microvascular occlusive retinal disease that can cause painless visual loss. It is associated with complement-mediated disorders including lupus and atypical haemolytic uremic syndrome. The pathogenesis is believed to be microembolic or thrombotic with complement activation and reflects the underlying systemic disease. It may improve with successful treatment of the systemic disease.


Biography:
Pek Ghe Tan is a renal advanced trainee in Victoria, Australia. She is currently in her final year training in the Northern Hospital.

ASSOCIATION OF CIRCULATING ZINC WITH NEUTROPHIL TO LYMPHOCYTE RATIO AS NOVEL INFLAMMATION MARKER IN CKD PATIENTS

M KIM1,  E KOH1, S SHIN1, C PARK1, S CHUNG1
1Department of Internal Medicine, College of Medicine, The Catholic University Of Korea , Seoul, Republic of Korea

Background and Aims: Zinc (Zn) is an essential trace element regarding cellular metabolism, tissue repair and inflammation. Neutrophil to lymphocyte ratio (NLR) has been reported as measure of systemic inflammation. The purpose of this study is to analyze the association between serum zinc level and NLR as novel inflammation marker in CKD patients.
Methods: Serum zinc concentration and inflammation markers including neutrophil to lymphocyte ratio (NLR) were evaluated in 348 patients with CKD under conservative treatment.
Results: Mean age of all participants was 59.94 year-old. 171 patients of the participants were male (49.1%). Median levels of serum Zn and eGFR were 68.3 ug/L (Interquqrtile range (IQR): 56.93-77.17 ug/L) and 35.20 ml/min/1.73m2 (IQR: 12.56-81.64 ml/min/1.73m2), respectively. According to median value of serum Zn, lower Zn group showed lower eGFR, more albuminuria, higher hs-CRP, NLR and monocyte to lymphocyte ratio (MLR). Serum Zn level showed positive correlation eGFR (r=0.235, P<0.001). On the other hands, serum Zn level negatively correlated with NLR (r=-0.289, P<0.001) and also MLR (r=-0.244, P<0.001). Higher serum zinc level (per 1 µg/L increase) was associated with higher NLR level after adjustment for age, sex, hypertension, diabetes, smoking, serum albumin and eGFR in multivariate binary logistic regression analysis. (HR 0.979, 95% CI: 0.953 to 0.995, P = 0.012).
Conclusions: Serum zinc was independently associated with NLR, a novel inflammation marker. It might be important to maintain optimal serum zinc level to delay progression of CKD with regard to inflammation.


Biography:
Clinical Fellow, Division of Nephrology
Department of Internal Medicine,
College of Medicine The Catholic University of Korea

OUTCOME OF NUTRITIONAL INTERVENTION IN PATIENTS WITH END STAGE RENAL DISEASE ON MAINTENANCE DIALYSIS

A RANDALL1,2, B BOSE2,3, K SUD2,3
1Department of Nutrition & Dietetics , Nepean Hospital, Kingswood, Australia, 2Department of Renal Medicine , Nepean Hospital, Kingswood, Australia, 3Nepean Clinical School, The University of Sydney, Kingswood, Australia

Aim: To evaluate change in nutritional status after six months of individualised dietetic intervention and counselling in patients receiving dialysis.
Background: Malnutrition is a strong and independent predictor of morbidity and mortality and is common in patients on dialysis. Clinical guidelines consistently recommend multi-parameter nutritional assessments and interventions as an essential component of care for dialysis patients.
Methods: We assessed nutritional status in maintenance haemodialysis and peritoneal dialysis patients at a single centre who had not received any dietetic intervention for over 3 years. Based on this initial assessment, patients were provided individualised dietetic intervention and counselling and the effect of this intervention was assessed prospectively after 6 months. Data collected included demographics; nutritional assessment including the Patient-Generated Subjective Global Assessment (SGA) and handgrip strength (HGS); anthropometric and biochemical parameters.
Results: One-hundred and three patients were studied (male, 60.2%; age, 62.9±15.1 years; diabetic, 51.5%; haemodialysis, 75.7%). Prevalence of malnutrition (SGA B and C) at baseline was 35%. Eighty-three patients (80.5%) were followed-up 6 months after nutritional intervention. Forty-nine patients (59%) had an improved SGA score; 25 (30.1%) remained nutritionally stable with no change to SGA score; while 9 (10.8%) had a decline in SGA score. Thirty-five (50.7%) patients had an improved HGS; 19 (27.5%) remained stable and maintained HGS; 15 (21.7%) had a decline in HGS. In those who were underweight on initial assessment, 60% had an increase and 9% maintained dry body weight.
Conclusions: One third of patients on maintenance dialysis were malnourished at baseline. Implementation of nutrition interventions by a dietitian was associated with improvement or maintenance of nutritional status and handgrip strength, with 60% of underweight patients gaining weight within 6 months.


Biography:
Ann-Maree is currently working as the Senior Dietitian for Renal and Renal Supportive Care at Nepean Hospital. She has worked as a dietitian for 8 years with the past 4 years specialising in renal nutrition and has experience in working with patients across all stages of CKD.

TENOFOVIR INDCUED REVERSIBLE NEPHROGENIC DIABETES INSIPIDUS WITHOUT FANCONI SYNDROME IN A PATIENT WITH HEPATITIS B

Z THET1,2, S MALALASEKERA3, N AL-SAFFFI3,T HAN1,2, C HAN1,  Y HEIN1, R HASELL1
1Department of Nephrology, Central Queensland Hospital and Health Service, Rockhampton, Australia, 2University of Queensland, Rural Clinical School, Rockhampton, Australia, 3Department of General Medicine, Central Queensland Hospital and Health Service, Rockhampton, Australia

Background: In patients with Hepatitis B Virus, there are approximately 10 cases of Tenofovir related Fanconi Syndrome but no report of nephrogenic diabetes insipidus.
Case report: A 54 year old female with hepatitis B virus on tenofovir for 1 year presented with polyuria and acute urinary retnetion. There was no history of diabetes, thyroid, kidney and intracranial pathology. The patient had acute transverse meyelitis that was treated successfully with steroid and plasmapharesis, however polyuria (10L/day) persisted beyond an accepted time frame. As HBV-PCR was negative, tenofovir was ceased. Her full blood count, inflammatory makers, blood sugar, thyroid, kidney and liver function tests were normal. Urine didn’t show haematuria or protienuria. Renal imaging showed no evidence of obstructive uropathy or chronic kidney disease. MRI brain excluded any intracranial lesions.Primary polydipsia was excluded as urine osmolality was not elevated > 500 mosmol/kg during 8 hour water deprivation and the patient responded to DDAVP significantly. Submaximal response to DDAVP at 30% excluded complete nephrogenic DI and complete central DI. Normal ADH result and resolution of polyuria after cessation of an offending drug suggested both complete and partial central DI was unlikely. A submaximal rise in urine osmolality (358mmol/kg) with DDAVP producing elevation of urine osmolality of approximately 30% suggested a diagnosis of partial nephrogenic DI. Polyuria resolved 6 weeks after tenofvoir therapy alone was discontinued.
Conclusion: Patients receiving tenofovir must be monitored closely even several months after initiation of treatment as the drug can cause nephrogenic DI. Combinging plasma ADH assay with water deprivation testing can lead to greater accuracy in differentiating the different forms of DI.


Biography:
Dr Zaw Thet is a full time Nephrologist from Central QLD Renal Service. He is also a Director of Physician Education and a member of Central QLD Clinical Senate. He is a leading investigator of local and state research projects.

EXPRESSION OF MMPS AND TIMPS ARE DIFFERENTIALLY REGULATED IN CATARACT TISSUE OF PATIENTS WITH CKD AND DIABETES OR BOTH

C CHONG1, I FRANCIS1, Z ENDRE1, M CORONEO1, J ERLICH1
1Renal Research Laboratory, Department of Nephrology, and Department of Opthalmology Prince of Wales Hospital and Prince of Wales Clinical School, Faculty of Medicine, UNSW Sydney, Randwick, Australia

Aim: To investigate the effect of diabetes and CKD on the expression of MMPs and TIMPs from patients undergoing routine cataract surgery.
Background: Cataract is common preventable cause of blindness. It is common amongst patients with diabetes with some recent reports suggesting an increased incidence in patients with chronic kidney disease (CKD). Matrix metalloproteinases MMPs and their inhibitors tissue inhibitors of MMPs (TIMPs) are variably expressed in lens tissue and have been suggested to play a role in the genesis of cataract formation.
Methods: This prospective study comprised 123 patients (age range, 46-93 years; mean, 71 years) who had phacoemulsification cataract surgery with intraocular lens implantation. Patients were categorised according to presence or absence of a diagnosis of diabetes mellitus and the presence or absence of CKD. mRNA was extracted, and real time PCR (RT-PCR) performed for MMPs 1,2,3,9,14 and 15 and TIMPs 1,2,3 and 4. All samples were corrected for the housekeeping gene 18S.
Results: MMPs 1,3,14 and TIMPs 1,2,3 were readily quantifiable by RT-PCR. Levels of MMP2 and 9 were low and could only be detected as present or not. MMP15 and TIMP 4 were not detectable. Non-diabetic patients with CKD EGFR < 60 ml/ml had relatively increased expression of MMPs 1,3,14 and TIMPs 1,2,3. There were no detectable differences in MMP2 and 9. The presence of DMII abrogated many of these differences with MMPs 1,3 and 14 and TIMPs 2 and 3 being higher in patients without CKD compared to the with CKD and DMII.
Conclusion: CKD and diabetes differentially regulate the expression of MMPs and TIMPs in cataracts and this may be important in the pathogenesis of the cataracts.


Biography:
Senior Lecturer in Medicine, Prince of Wales Clinical School, UNSW

ASSOCIATION BETWEEN SCLEROSTIN WITH CALCIUM AND ORGANIC PHOSPHORUS LEVELS IN PREDIALYTIC CHRONIC KIDNEY DISEASE

D SUKMANA1
1Pernefri Indonesia, Bandung, Indonesia

Aim: The objective of this study is to associate between sclerostin and calcium and organic phosphorus levels in predialytic chronic kidney disease patients
Background: Sclerostin is a 190-amino-glycoprotein plays a role in decreasing bone formation by inhibiting osteoblastic differentiation through Wnt signaling pathways and enhancing apoptosis. In patients with chronic kidney disease (CKD), sclerostin is a biomarker Chronic Kidney Disease-Mineral Bone Disorder (CKD-MBD) and contributors to cardiovascular disease, through increased vascular calcification.
Method: This is a cross-sectional design using secondary data of previous sclerostin linkage to vascular calcification study.
Result: The results showed that mean levels of calcium and organic phosphorus between stage 3, 4, and 5 CKD, consecutively were 8.71, 8.74 and 8.24 (significantly different, p = 0.027) for calcium and 3.42, 3.47 and 4.08 (significantly different, p = 0.006) for organic phosphorus. There were no significant difference of CaP product among patients with stage 3,4, and 5 of CKD (p> 0,05). There was significant correlation between calcium and sclerostin (r = 0.254; p <0.05), however, there were no significant correlation between phosphorus and sclerostin (r = 0.069; p = 0.274) and between CaP product and sclerostin (r = 0.170; p = 0.068 ).
Conclusion: There is a positive correlation between calcium levels and sclerostin and the decline in kidney function affects bone mineral homeostasis.


Biography:
Dr. Dede Satia Sukmana. Born in Garut City, Indonesia, December, 25th, 1966. General doctor graduated in 1991 and Internal medicine graduated in 2004 from Medical Faculty Padjadjaran University Bandung Indonesia. Now traine nephrologist at the Medical Faculty Padjadjaran University and working as staff at the Naval Hospital Tanjungpinang Indonesia.

A CASE OF TUBULOINTERSITIAL NEPHRITIS AND ANTERIOR UVEITIS (TINU SYNDROME) IN A YOUNG MALE.

V SRINIVASA1, G KAN1, V MANICKAM1, V SRIVASTAVA1
1Townsville Hospital, Douglas, Australia

Background: Tubulointerstitial nephritis and anterior uveitis syndrome (TINU) is a rare disorder. It was first described in 1975 by Dobrin, and since then more than 250 cases have been recorded. Although reported in adolescents and females, it may present in all ages and in both sexes with a incidence rate of 0.1 to 2% worldwide. It has been suggested that it is underdiagnosed due to lack of recognition.
Case Report: We present a case of an 18 year old male who was admitted to hospital with bilateral anterior uveitis. Urinary beta 2 microglobulin was high at a value of 5802 ug/L and serum creatinine was raised at 110 micromol/l.  Urine protein excretion rate was approximately 1.9 grams per day. Sarcoidosis was initially suspected, but serum ACE levels was negative and imaging of the chest was not suggestive. Additionally, MRI Brain and lumbar puncture were both negative. Renal biopsy was performed and revealed tubulointerstitial nephritis. Based on exclusion, a diagnosis of TINU was made. He was commenced on a course of oral steroids and following this his creatinine improved to 75 micromol/l. His proteinuria resolved and urinary beta 2 microglobulin has decreased to a value of 1563ug/L. The bilateral uveitis has disappeared.
Conclusions: TINU syndrome is a underdiagnosed disorder that should be considered in the differential diagnosis, for any patient presenting with anterior uveitis with associated renal impairment and high urinary beta 2 microglobulin. Urinary protein studies may be used in the workup of a patient with bilateral uveitis as this may increase detection of TINU. Renal involvement in TINU is responsive to steroids and portends a good prognosis.


Biography:
Dr. Vinay Srinivasa is a advanced trainee currently working at the Townsville hospital.
He is in his final year of advanced training for general medicine and is currently doing his first year of renal advanced training at Townsville hospital. He is aiming to be a dual specialist in both nephrology and general medicine
He has a special interest in Glomerulonephritis and hypertension

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