A Description of Advanced Chronic Kidney Disease Patients in a Major Urban Center Receiving Conservative Care.

BACKGROUND: Conservative/palliative (nondialysis) management is an option for some individuals for treatment of stage 5 chronic kidney disease (CKD). Little is known about these individuals treated with conservative care in the Canadian setting. OBJECTIVE: To describe the characteristics of patients treated with conservative care for category G5 non-dialysis CKD in a Canadian context. DESIGN: Retrospective chart review. SETTING: Urban nephrology center. PATIENTS: Patients with G5 non-dialysis CKD (estimated glomerular filtration rate <15 mL/min/1.73 m2). MEASUREMENTS: Baseline patient demographic and clinical characteristics of conservative care follow-up, advanced care planning, and death. METHODS: We undertook a descriptive analysis of individuals enrolled in a conservative care program between January 1, 2009, and June 30, 2015. RESULTS: One hundred fifty-four patients were enrolled in the conservative care program. The mean age and standard deviation was 81.4 ± 9.0 years. The mean modified Charlson Comorbidity Index score was 3.4 ± 2.8. The median duration of conservative care participation was 11.5 months (interquartile range: 4-25). Six (3.9%) patients changed their modality to dialysis. One hundred three (66.9%) patients died during the study period. Within the deceased cohort, most (88.2%) patients completed at least some advanced care planning before death, and most (81.7%) of them died at their preferred place. Twenty-seven (26.7%) individuals died in hospital. LIMITATIONS: Single-center study with biases inherent to a retrospective study. Generalizability to non-Canadian settings may be limited. CONCLUSIONS: We found that individuals who chose conservative care were very old and did not have high levels of comorbidity. Few individuals who chose conservative care changed modality and accepted dialysis. The proportions of engagement in advanced care planning and of death in place of choice were high in this population. Death in hospital was uncommon in this population.

CONTEXTE: Les traitements conservateurs ou soins palliatifs (sans dialyse) constituent une option thérapeutique pour certaines personnes atteintes 'd'insuffisance rénale chronique non-dialyse de catégorie 5 (IRC-ND). Toutefois, nous en savons peu au sujet des personnes inscrites à un programme de traitement conservateur dans le contexte canadien. OBJECTIF DE L'ÉTUDE: Faire le portrait des patients atteints d'IRC-ND G5, sous traitement conservateur dans un contexte canadien. TYPE D'ÉTUDE: Examen rétrospectif des dossiers médicaux. CADRE DE L'ÉTUDE: Un centre de néphrologie en milieu urbain. PATIENTS: Des patients atteints d'IRC-ND G5 (débit de filtration glomérulaire estimé à moins de 15 ml/min/1,73 m2). MESURES: Les données démographiques initiales des patients, de même que les données cliniques de suivi du traitement conservateur, de planification des soins avancés et du décès. MÉTHODOLOGIE: Nous avons entrepris l'analyse descriptive des individus inscrits à un programme de traitement conservateur pour la période s'échelonnant du 1er janvier 2009 au 30 juin 2015. RÉSULTATS: Au total, 154 patients ont été inscrits dans un programme de traitement conservateur au cours de la période étudiée. L'âge moyen des patients était de 81,4 ans avec un écart-type de ± 9,0 ans. Le score moyen à l'index de comorbidité de Charlson modifié était de 3,4 ± 2,8 et la durée médiane de participation à un programme de traitement conservateur était de 11,5 mois (écart interquartile de 4,25). Au cours de la période étudiée, six patients (3,9%) sont passés du traitement conservateur à la dialyse et 103 patients (66,9%) sont décédés. Au sein de la cohorte de patients décédés, la grande majorité (88,2%) avait complété une partie des soins avancés planifiés avant le décès. De cette même cohorte, la plupart (81,7%) sont décédés où ils l'avaient choisi alors que 27 personnes (26,7%) sont décédées à l'hôpital. LIMITES DE L'ÉTUDE: L'étude s'est tenue au sein d'un seul centre hospitalier et comporte des biais inhérents attribuables à son modèle rétrospectif. De plus, la généralisation des résultats à des paramètres non canadiens peut être limitée. CONCLUSIONS: Nous avons constaté que les personnes qui avaient opté pour un traitement conservateur étaient très âgées et présentaient peu de comorbidités. Au cours de la période étudiée, quelques patients qui avaient choisi un traitement conservateur ont changé de modalité et accepté de passer à la dialyse. Nous avons également observé que l'engagement dans la planification des soins avancés et dans le choix de l'endroit où mourir était élevé au sein de cette population, alors que le décès à l'hôpital a été plutôt rare.

Sudden onset of parathyroid hormone-independent severe hypercalcemia from reversal of tumoral calcinosis in a dialysis patient.

BACKGROUND: Tumoral calcinosis is a rare manifestation of extraskeletal calcification, featuring large calcified cystic masses in the periarticular regions of large joints. In chronic kidney disease (CKD), this disorder is thought to evolve through a chronically elevated calcium-phosphorus solubility product leading to calcium precipitation in soft tissue. Treating tumoral calcinosis in these patients involves interventions to lower the calcium-phosphorus product such as reduction in vitamin D therapy and intensive hemodialysis regimens. CASE PRESENTATION: We report the case of a 54-year old woman with polycystic kidney disease on peritoneal dialysis with widespread tumoral calcinosis in the context of hypercalcemic tertiary hyperparathyroidism who had been on long-term alfacalcidol therapy. After withdrawal of the vitamin D analogue and initiation of daily hemodialysis, there was rapid dissolution of her tumoral calcium deposits with the abrupt onset of parathyroid hormone (PTH)-independent transient hypercalcemia that resolved once the soft tissue deposits disappeared. CONCLUSIONS: Resorption of soft tissue calcific deposits may result in transient parathyroid hormone (PTH)-independent hypercalcemia. In CKD patients, this hypercalcemia causes a decrease in the PTH level, distinguishing it from tertiary hyperparathyroidism, though PTH may not be totally suppressed, the way it is seen in PTH-independent hypercalcemia in non-CKD patients.

Antineutrophil Cytoplasmic Antibody Induction due to Infection: A Patient with Infective Endocarditis and Chronic Hepatitis C.

While antineutrophil cytoplasmic antibody (ANCA) is often used as a diagnostic marker for certain vasculitides, ANCA induction in the setting of infection is much less common. In the case of infective endocarditis, patients may present with multisystem disturbances resembling an autoimmune process, cases that may be rendered even trickier to diagnose in the face of a positive ANCA. Though not always straightforward, distinguishing an infective from an inflammatory process is pivotal in order to guide appropriate therapy. We describe an encounter with a 43-year-old male with chronically untreated hepatitis C virus infection who featured ANCA positivity while hospitalized with acute bacterial endocarditis. His case serves as a reminder of two of the few infections known to uncommonly generate ANCA positivity. We also summarize previously reported cases of ANCA positivity in the context of endocarditis and hepatitis C infections.

Hyperchloremic Metabolic Acidosis due to Cholestyramine: A Case Report and Literature Review.

Cholestyramine is a bile acid sequestrant that has been used in the treatment of hypercholesterolemia, pruritus due to elevated bile acid levels, and diarrhea due to bile acid malabsorption. This medication can rarely cause hyperchloremic nonanion gap metabolic acidosis, a complication featured in this report of an adult male with concomitant acute kidney injury. This case emphasizes the caution that must be taken in prescribing cholestyramine to patients who may also be volume depleted, in renal failure, or taking spironolactone.