Faculty Bibliography
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336
Use of tablo hemodialysis systems to extend dialytic capabilities for the COVID-19-associated surge of AKI [Meeting Abstract]
Background: The COVID-19 pandemic was associated with a greater incidence of AKI than expected. At the NY Harbor VA we faced an overwhelming number of AKI patients who were critically ill with multi-organ failure. We needed to invoke new mechanisms of providing kidney replacement therapy (KRT).
Method(s): We obtained 3 Tablo systems in late March, 2019. The machines have selfcontained reverse osmosis capabilities and so do not require other equipment to operate. They can make dialysate from concentrate and tap water and so do not require special plumbing adaptation. Their self-contained step-by-step procedures are relatively simple to follow and allow rapid training of previously unskilled personnel. Tablo generates 300 ml dialysate per minute, and blood flow was increased to up to 400 ml/min as tolerated.
Result(s): Training was completed by 2 nephrologists and 2 RNs without previous dialysis experience. We used the Tablo Hemodialysis System to provide KRT to critically ill patients. In the first week we demonstrated that water cultures and endotoxin testing were negative, and that AAMI water tests were acceptable. We used the machines to provide KRT for ICU patients with double-lumen dialysis catheters. In addition we used the machines on hospital wards where KRT had not been provided before because of a lack of the plumbing needs of conventional HD machines. We provided multiple treatments 3-6 times per week for 15 AKI patients, mean age 65 years. The mean of the best urea reduction ratio achieved in the first 1-4 treatments, if available, was 41% (often limited by hypotension and fulfillment of ultrafiltration, UF, needs). Most treatments were successful and were slowed for hypotension or tachycardia. Some were aborted because of water pressure alarms if sediment filters needed replacement, or lines clotted due to hypercoagulability associated with COVID-19. Personnel availability dictated that most treatments were 3-4 hours (and up to 8h), and generally achieved UF goals. Later HD nurses cannulated arteriovenous fistulas in ESKD patients and left treatment to non-HD nurses to complete.
Conclusion(s): By incorporating a user-friendly platform and an accelerated training program including nephrologists and RNs without previous dialysis experience, we were able to nearly double our capacity to deliver KRT during the surge
Method(s): We obtained 3 Tablo systems in late March, 2019. The machines have selfcontained reverse osmosis capabilities and so do not require other equipment to operate. They can make dialysate from concentrate and tap water and so do not require special plumbing adaptation. Their self-contained step-by-step procedures are relatively simple to follow and allow rapid training of previously unskilled personnel. Tablo generates 300 ml dialysate per minute, and blood flow was increased to up to 400 ml/min as tolerated.
Result(s): Training was completed by 2 nephrologists and 2 RNs without previous dialysis experience. We used the Tablo Hemodialysis System to provide KRT to critically ill patients. In the first week we demonstrated that water cultures and endotoxin testing were negative, and that AAMI water tests were acceptable. We used the machines to provide KRT for ICU patients with double-lumen dialysis catheters. In addition we used the machines on hospital wards where KRT had not been provided before because of a lack of the plumbing needs of conventional HD machines. We provided multiple treatments 3-6 times per week for 15 AKI patients, mean age 65 years. The mean of the best urea reduction ratio achieved in the first 1-4 treatments, if available, was 41% (often limited by hypotension and fulfillment of ultrafiltration, UF, needs). Most treatments were successful and were slowed for hypotension or tachycardia. Some were aborted because of water pressure alarms if sediment filters needed replacement, or lines clotted due to hypercoagulability associated with COVID-19. Personnel availability dictated that most treatments were 3-4 hours (and up to 8h), and generally achieved UF goals. Later HD nurses cannulated arteriovenous fistulas in ESKD patients and left treatment to non-HD nurses to complete.
Conclusion(s): By incorporating a user-friendly platform and an accelerated training program including nephrologists and RNs without previous dialysis experience, we were able to nearly double our capacity to deliver KRT during the surge
EMBASE:633704127
ISSN: 1533-3450
CID: 4750162
Evaluation and Medical Management of Patients with Cystine Nephrolithiasis: A Consensus Statement
PMID: 32066273
ISSN: 1557-900x
CID: 4683692
Jornal brasileiro de nefrologia : 'orgao oficial de Sociedades Brasileira e Latino-Americana de Nefrologia. 2020:42(2):133-135.DOI: 10.1590/2175-8239-JBN-2020-0062
Effects of ambient temperature and humidity on kidney stone admissions in Brazil
PMID: 32495818
ISSN: 2175-8239
CID: 4517832
Are conventional stone analysis techniques reliable for the identification of 2,8-dihydroxyadenine kidney stones? A case series
We have recently encountered patients incorrectly diagnosed with adenine phosphoribosyltransferase (APRT) deficiency due to misidentification of kidney stones as 2,8-dihydroxyadenine (DHA) stones. The objective of this study was to examine the accuracy of stone analysis for identification of DHA. Medical records of patients referred to the APRT Deficiency Research Program of the Rare Kidney Stone Consortium in 2010-2018 with a diagnosis of APRT deficiency based on kidney stone analysis were reviewed. The diagnosis was verified by measurement of APRT enzyme activity or genetic testing. Attenuated total reflection-Fourier transform infrared (ATR-FTIR) spectra of pure crystalline DHA and a kidney stone obtained from one of the confirmed APRT deficiency cases were generated. The ATR-FTIR spectrum of the kidney stone matched the crystalline DHA spectrum and was used for comparison with available infrared spectra of stone samples from the patients. Of 17 patients referred, 14 had sufficient data available to be included in the study. In all 14 cases, the stone analysis had been performed by FTIR spectroscopy. The diagnosis of APRT deficiency was confirmed in seven cases and rejected in the remaining seven cases. Comparison of the ATR-FTIR spectrum of the DHA stone with the FTIR spectra from three patients who did not have APRT deficiency showed no indication of DHA as a stone component. Misidentification of DHA as a kidney stone component by clinical laboratories appears common among patients referred to our program. Since current clinical protocols used to interpret infrared spectra for stone analysis cannot be considered reliable for the identification of DHA stones, the diagnosis of APRT deficiency must be confirmed by other methods.
PMID: 32399606
ISSN: 2194-7236
CID: 4438082
Clinical journal of the American Society of Nephrology : CJASN. 2020:15(6):880-882.DOI: 10.2215/CJN.05180420
Impending Shortages of Kidney Replacement Therapy for COVID-19 Patients
PMID: 32345750
ISSN: 1555-905x
CID: 4412262
The Association of Mesalamine With Kidney Disease
The package inserts for products containing 5-aminosalicylic acid, or mesalamine, include the following language regarding the risk of adverse kidney effects: "renal impairment, including minimal change nephropathy, acute and chronic interstitial nephritis, and rarely renal failure, has been reported in patients given products such as mesalamine delayed-release tablets that contain mesalamine or are converted to mesalamine." In this article, we review the data regarding this nephrotoxicity and the recommendations regarding appropriate monitoring. Chronic interstitial nephritis is a rare occurrence in patients treated with these drugs for Crohn disease and ulcerative colitis. Patients often present with asymptomatic reductions in glomerular filtration rate, without accompanying pyuria, skin lesions, or eosinophilia, unlike cases of acute interstitial nephritis. Drug cessation is usually associated with improved kidney function. However, if left undetected, more prolonged exposure to the drug can lead to irreversible kidney failure and end-stage kidney disease. No convincing studies demonstrate efficacy of treatment with corticosteroids. Frequent monitoring of serum creatinine, especially in the first years after initiation of therapy, is recommended.
PMID: 32147005
ISSN: 1548-5609
CID: 4349582
Vitamin D and Kidney Stones
This review explores the relationship between vitamin D supplementation and lithogenesis. A causal relationship has been assumed despite myriad studies demonstrating that therapeutic doses of vitamin D do not increase lithogenic risk. Select stone formers may be at increased risk for recurrence with vitamin D supplementation, possibly from CYP24A1 gene mutations. Additionally, the evidence for who is vitamin D deficient, and the benefits of supplementation in those not at risk for rickets, is sparse. Concerns may be avoidable as vitamin D screening appears unnecessary in most patients, and superior pharmacology is available which increases bone density, while decreasing stone formation.
PMID: 32032687
ISSN: 1527-9995
CID: 4300922
Occupational kidney stones
PURPOSE OF REVIEW/OBJECTIVE:Kidney stones are a common and preventable disorder. Certain occupations may increase risk for stone disease which will be discussed in this review. Few observational studies have examined this association. RECENT FINDINGS/RESULTS:Some occupations prevent individuals from drinking enough fluids to maintain a dilute urine or to void when they need to. People may have poor access to fluids or to bathroom facilities. These issues pose a risk for stone disease and are exacerbated by those who work in warmer climates. Individuals who do more activity while working, especially outdoors, perspire more, leading to more concentrated urine. In more sedentary jobs, individuals are at a higher risk of metabolic syndrome and therefore have a higher risk for stones. Astronauts, who work in environments without gravity, mobilize calcium from bone, leading to a higher risk of stone disease. SUMMARY/CONCLUSIONS:Proper fluid intake, more access to restrooms and increased use of potassium citrate may be the best options for those who encounter greater risk for stones because of their occupation.
PMID: 31895162
ISSN: 1473-6543
CID: 4252452
Uronephrology: a new nephrology subspecialty
PMID: 31895164
ISSN: 1473-6543
CID: 4252462
Assessment of health-related quality of life in patients with cystinuria on tiopronin therapy
Cystinuria comprises less than 1% of kidney stones and is associated with impaired health-related quality of life (HRQOL). Limited evidence is available regarding HRQOL of patients with cystinuria treated with tiopronin (Thiola®). The objective of this study was to assess the HRQOL of patients with or without tiopronin treatment. For this cross-sectional survey, patients on tiopronin treatment were recruited through the "Thiola® Total Care Hub," a specialty pharmacy used to dispense tiopronin, and compared with patients not taking tiopronin (non-tiopronin group) who were identified from the Cystinuria Contact Registry at New York University School of Medicine. Consented patients responded to a survey that included questions about their experiences with kidney stones, the Wisconsin stone quality of life (WISQOL) (disease-specific) questionnaire, and the short form-36 version 2 (SF-36v2) (generic) HRQOL questionnaire. Statistical analyses included independent-sample t tests, one-way analysis of variance (ANOVA), and correlations. The survey was completed by 312 patients: 267 in the tiopronin group (144 male, 123 female; mean 49 years) and 45 in the non-tiopronin group (10 male, 35 female; mean 48 years). Both groups utilized pain medications similarly (24% overall). Patients on tiopronin had a significantly better HRQOL than patients not on tiopronin for all WISQOL domains (p < 0.001) and all but the physical functioning SF-36v2 domain (p < 0.001), where both groups approached the US normative mean, when controlling for the last stone event. Compared with patients in the non-tiopronin group, patients taking tiopronin reported better HRQOL on both the WISQOL and SF-36v2.
PMID: 31834425
ISSN: 2194-7236
CID: 4235042
