ANCA Associated Vasculitis Secondary to Levamisole-Adultered Cocaine with Associated Membranous Nephropathy: A Case Series.

BACKGROUND: Cocaine is a risk factor for acute kidney injury and chronic kidney disease with progression to end-stage renal disease. Levamisole is an adulterant that is added to cocaine to enhance its euphoric effects. Levamisole-adulterated cocaine (LAC) is associated with the distinct clinical syndromes of agranulocytosis, leukocytoclastic vasculitis, cocaine-induced midline destructive lesions (CIMDL), and ANCA-associated vasculitis (AAV) with pauci-immune necrotizing glomerulonephritis. METHODS: We reviewed all cases of AAV secondary to LAC at our institution. RESULTS: We report 3 cases of AAV secondary to LAC and associated membranous nephropathy (MN). The first and second cases are concurrent AAV secondary to LAC and associated MN while the third case involves the development of MN after AAV secondary to LAC. CONCLUSIONS: Clinicians should be aware of this novel association of LAC with MN.

Determination of the optimal case definition for the diagnosis of end-stage renal disease from administrative claims data in Manitoba, Canada.

INTRODUCTION: End-stage renal disease (ESRD) is a major public health problem with increasing prevalence and costs. An understanding of the long-term trends in dialysis rates and outcomes can help inform health policy. We determined the optimal case definition for the diagnosis of ESRD using administrative claims data in the province of Manitoba over a 7-year period. METHODS: We determined the sensitivity, specificity, predictive value and overall accuracy of 4 administrative case definitions for the diagnosis of ESRD requiring chronic dialysis over different time horizons from Jan. 1, 2004, to Mar. 31, 2011. The Manitoba Renal Program Database served as the gold standard for confirming dialysis status. RESULTS: During the study period, 2562 patients were registered as recipients of chronic dialysis in the Manitoba Renal Program Database. Over a 1-year period (2010), the optimal case definition was any 2 claims for outpatient dialysis, and it was 74.6% sensitive (95% confidence interval [CI] 72.3%-76.9%) and 94.4% specific (95% CI 93.6%-95.2%) for the diagnosis of ESRD. In contrast, a case definition of at least 2 claims for dialysis treatment more than 90 days apart was 64.8% sensitive (95% CI 62.2%-67.3%) and 97.1% specific (95% CI 96.5%-97.7%). Extending the period to 5 years greatly improved sensitivity for all case definitions, with minimal change to specificity; for example, for the optimal case definition of any 2 claims for dialysis treatment, sensitivity increased to 86.0% (95% CI 84.7%-87.4%) at 5 years. CONCLUSION: Accurate case definitions for the diagnosis of ESRD requiring dialysis can be derived from administrative claims data. The optimal definition required any 2 claims for outpatient dialysis. Extending the claims period to 5 years greatly improved sensitivity with minimal effects on specificity for all case definitions.

Secular trends in end-stage renal disease requiring dialysis in Manitoba, Canada: a population-based study.

BACKGROUND: End-stage renal disease (ESRD) requiring dialysis is expensive and is associated with disproportionately poor health outcomes and quality of life. Understanding regional long-term secular trends in the incidence and prevalence of dialysis will allow for the alignment of appropriate and efficient delivery of care. The primary objective of this study was to describe long-term secular and geographic trends in ESRD over a 22-year period in a single-provider Canadian health care setting. METHODS: Using a previously validated case definition, we described the annual incidence and prevalence of ESRD in Manitoba from 1989 to 2010, stratified by age, sex and geographic location within the province. RESULTS: We searched more than 1.2 million records within the Manitoba Health repository. We identified 9489 patients in the Manitoba Health Physician Claims database with at least 1 claim for dialysis from 1989 through Mar. 31, 2010. Using the case definition of any 2 dialysis treatment claims, the total annual incidence of ESRD increased 2.5-fold from 15.8 to 40.2 per 100 000 during the study period. Of note, the northern rural portions of the province saw a 12-fold unadjusted increase in ESRD, from 8.1 per 100 000 in 1989 to 96.3 per 100 000 in 2009. INTERPRETATION: The incidence and prevalence of ESRD is increasing in Manitoba, most notably in the north of the province. Innovative interventions, such as primary screening and treatment initiatives, should specially target northern rural regions.

Alteplase for blood flow restoration in hemodialysis catheters: a multicenter, randomized, prospective study comparing "dwell" versus "push" administration.

AIMS: Catheter-related thrombosis is a frequent complication of providing hemodialysis via central venous catheters. The primary aim of this study was to compare the efficacy of an alteplase "dwell" protocol over 30 minutes (with an additional 90 minutes where necessary) to a new 30 minute "push" protocol in restoring function to occluded hemodialysis catheters. METHODS: This was a prospective, randomized, parallel arm, multicenter study. Participants included hemodialysis patients using central venous catheters for vascular access. A new alteplase push protocol was the intervention and was compared to an alteplase dwell protocol. The primary outcome of this study was the proportion of patients with pre-thrombolytic blood flows less than 200 ml/min achieving a post thrombolytic blood flow ≥ 300 ml/ min. Secondary outcomes included recovery of Kt/V and liters processed per hour at the hemodialysis session following the intervention, time from thrombolytic to future catheter interventions, and the presence of serious adverse events. RESULTS: 82 patients were included in the intention-to-treat analysis. 65% (28/43) of catheters receiving the dwell protocol achieved blood flow ≥ 300 ml/min compared to 82% (32/39) in the push protocol. The difference was not statistically significant despite a 17% separation in the point estimates, p = 0.84. A non-significant result may have been associated with an inability to enrol the required a priori sample size. Kt/V, liters processed per hour and time to next catheter event were not significantly different. There were no serious adverse events attributed to the study medication. CONCLUSIONS: The alteplase push protocol was effective and safe for managing dysfunctional hemodialysis catheters and was more practical than a 2 h dwell.

Home hemodialysis in the remote Canadian north: treatment in Manitoba fly-in communities.

Manitoba has the highest prevalence of ESRD in Canada. Northern Manitoba is a very sparsely settled area with a high proportion of aboriginal ESRD patients. Relocating to urban areas for dialysis is psychosocially and culturally stressful to patients. Delivering dialysis care in a home setting has demonstrated advantages in both clinical, economic, and health related quality of life domains. Establishing home hemodialysis in very remote communities has significant challenges, including poor and inadequate housing, unreliable water supply, limited community medical backup, and poor road access to communities especially for delivery of supplies. These challenges necessitate the development of strong community partnerships, and well documented processes for contingencies. A dedicated interdisciplinary support and training team at the urban hub is essential.

Model for equitable care and outcomes for remote full care hemodialysis units.

BACKGROUND AND OBJECTIVES: Remotely located patients not living close to a nephrologist present major challenges for providing care. Various models of remotely delivered care have been developed, with a gap in knowledge regarding the outcomes of these heterogeneous models. This report describes a satellite care model for remote full-care hemodialysis units managed homogenously in the province of Manitoba, Canada, without onsite nephrologists. Survival in remotely located full-care units is compared with a large, urban full-care center with onsite nephrologists. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Data from a Canadian provincial dialysis registry were extracted on 2663 patients between 1990 and 2005. All-cause mortality after initiation of chronic hemodialysis was assessed with Cox proportional hazards regression. Both short-term (1 year) and long-term (2 to 5 years) survival were analyzed. RESULTS: Survival for patients receiving remotely delivered care was shown to be better than for those receiving care in the urban care center with this particular Canadian model of care. Furthermore, there was no difference when assessing short- and long-term survival. This was independent of distance from the urban center. CONCLUSIONS: Chronic hemodialysis patients receiving remotely delivered care in a specialized facility attain comparable, if not better survival outcomes than their urban counterparts with direct onsite nephrology care. This model can potentially be adapted to other underserviced areas, including increasingly larger urban centers.

Are CSN and NKF-K/DOQI mineral metabolism guidelines for hemodialysis patients achievable? Results from a provincial renal program.

BACKGROUND: The calcium, phosphorus, and parathyroid hormone targets recommended by the Canadian Society of Nephrology (CSN) encompass a wider range of values as compared to the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) guidelines. We sought to compare mineral metabolism parameters within the Manitoba Renal Program (MRP) to the CSN and NKF-K/DOQI guidelines. Medication use was also examined. METHODS: All hemodialysis patients in Manitoba were evaluated. Values for serum albumin, phosphorus, calcium, intact parathyroid hormone (PTH) and pertinent medications were collected. RESULTS: Five hundred and forty-six patients were included in the analysis. Fifty-three per cent to 81% of MRP patients met individual CSN targets. However, only 26% of patients achieved all targets, despite high usage of phosphate (85.5% calcium carbonate, 16.1% sevelamer, 1.3% aluminum) and PTH-lowering drug therapies (30.2% calcitriol, 2.7% cinacalcet). CONCLUSION: Only a small proportion of patients were able to achieve all three CSN mineral metabolism targets simultaneously. The majority of outliers presented with hyperphosphatemia or hypoparathyroidism.

Conversion from epoetin alfa to darbepoetin alfa within the Manitoba Renal Program: evaluation of dose ratios.

We sought to describe dose conversion ratios between epoetin alfa and darbepoetin alfa for patients with anemia of chronic kidney disease (CKD) in a large provincial renal program. Hemodialysis (HD), peritoneal dialysis (PD) and pre-dialysis patients with CKD were included. Laboratory parameters and darbepoetin alfa doses were compared to epoetin alfa doses (same route). In 2005, 857 patients received darbepoetin alfa and were compared to 746 patients who received epoetin alfa in 2003-2004. Mean dose conversion ratios were 12,939 IU, 53.1 microg, 244:1 for HD; 9,273 IU, 41.8 microg, 222:1 for PD; and 5,516 IU, 25.2 microg and 219:1 for CKD patients. The mean hemoglobin and iron parameters were within K/DOQI targets on both drugs. Conversion ratios in HD, PD and CKD patients using erythropoietic therapies was greater than 200:1 with both intravenous and subcutaneous dosing. Renal programs across Canada should consider dosage conversion ratios in addition to drug acquisition costs when considering a formulary decision about erythropoiesis stimulating agents.

Type I Gaucher disease following chemotherapy for light chain multiple myeloma.

Although plasma cell disorders, such as hypergammaglobulinemia and monoclonal gammopathy of undetermined significance (MGUS), are reported to occur at higher incidences in patients with Type I Gaucher disease (GD) than in the normal population, pure light chain multiple myeloma (LCMM) has never been described in this context. Our case is the first to highlight a patient with LCMM who developed clinically apparent GD only following chemotherapy and hematopoietic stem cell transplantation. Renal complications are also exceedingly rare in GD, but nephrotic syndrome is one of the presenting features in this patient. The findings from this case will have important screening and diagnostic implications for both clinicians and patients.

Erythropoietin-alpha dosage requirements in a provincial hemodialysis population: effect of switching from subcutaneous to intravenous administration.

BACKGROUND: The purpose of this initiative was to compare erythropoietin-alpha doses in hemodialysis patients who changed from subcutaneous to intravenous administration. The Manitoba Renal Program switched routes due to concern about erythropoietin-associated pure red cell aplasia. METHODS: We compared the erythropoietin-alpha dosage requirements during subcutaneous administration (3 months pre-switch) and intravenous administration (months 4-6 post-switch). We also compared: hemoglobin, transferrin saturation (Tsat%), ferritin, and percent of patients receiving intravenous iron. The same erythropoietin-alpha regimen was initially used when patients were switched. RESULTS: Of the 628 patients receiving erythropoietin-alpha, the data were complete for 400. The dose increased 26% (mean +/- SD, 10,425 +/- 7,330 vs. 13,125 +/- 8,638 IU/week; p < 0.0001), despite similar hemoglobin, (mean +/- SD, 11.5 +/- 1.1g/dl (114.9 +/- 11.2 g/l) vs. 11.3 +/- 1.0 g/dl (113.5 +/- 10.4 g/l); p = 0.0450) and iron parameters (Tsat 30.9%, ferritin 464 ng/ml (microg/l) vs. Tsat 28.7%, ferritin 538 ng/ml (microg/l)). For the subgroup of 84 patients who maintained target hemoglobin (10-11 g/dl or 110-120 g/l) for both periods, the dose increased 26% (mean +/- SD, 8,393 +/- 6,242 vs. 10,589 +/- 7,049 IU/week; p < 0.0001) without a change in hemoglobin, (mean +/- SD, 11.5 +/- 0.3 g/dl (115.2 +/- 3.0 g/l) vs. 11.5 +/- 0.3 g/dl (114.9 +/- 3.3 g/l); p = 0.5789). When stratified by subcutaneous dose, patients with the lowest dose (<5,000 IU/week) demonstrated the greatest increase (89%), and those with the highest dose (>20,000 IU/week) experienced no increase (-3%). CONCLUSION: Overall, erythropoietin-alpha doses increased by 26% when patients were converted from subcutaneous to intravenous administration.

An in vitro evaluation of the antibiotic/heparin lock to sterilize central venous haemodialysis catheters.

This in vitro study investigated the ability of antibiotic/heparin locks to sterilize central venous haemodialysis catheters (CVCs) inoculated with methicillin-resistant Staphylococcus epidermidis (MRSE). Isolates of MRSE were incubated in broth inside CVCs. The catheters were then drained and filled with either vancomycin/gentamicin/heparin (VGH), cefazolin/gentamicin/ heparin (CGH) or control locks for 48 h. The catheters were drained, filled with fresh broth and again incubated. The final catheter solutions were sampled and the remaining volumes filtered. The samples, filters and catheter segments were examined for growth. For two isolates, both the VGH and CGH locks sterilized the catheters. Bacterial counts of the remaining two isolates were significantly reduced by >99%, but the catheters were not sterilized after the instillation of a single-antibiotic/heparin lock.