237 Ganciclovir Resistant Cytomegalovirus in a Renal Transplant Recipient: A Medical Challenge

NKF 2011 Spring Clinical Meetings Abstracts

237 GANCICLOVIR RESISTANT CYTOMEGALOVIRUS IN A RENAL TRANSPLANT RECIPIENT: A MEDICAL CHALLENGE Aashish K Pandey, David B. Butcher Department of Nephrology and Hypertension St. John Hospital & Medical Center, Detroit, Michigan The PV 16000 study reported ganciclovir resistant cytomegalovirus (CMV) in 1.9% renal transplant recipients. The resistant strain may present amino acid deletions or substitutions in conserved regions of the UL97 protein, point mutation in the DNA polymerase (UL54) or both. We describe a case of a 54 year old African American female, who received a deceased donor renal allograft in August, 2009. CMV serology status was seronegative for the recipient and seropositive for donor. Patient had intermittent lapses in CMV prophylaxis due to missing medication followed by leucopenia. Her Immunosuppressant medications included Tacrolimus, Mycophenolate Mofetil and prednisone. One month post transplant, patient developed Acute Antibody- Mediated rejection, and received treatment with Plasmapheresis, IV Immunoglobulin and Rituximab. A week later she developed CMV pneumonitis, and was started on Valganciclovir. A viral load of 381,000 was detected that progressively decreased to 44,800 over a period of 4 months. Patient continued to feel lethargic and was admitted again in the hospital. Her viral load had increased to 80,300. A genotypic testing for drug resistance was performed, and patient found to have a UL97 mutation with resistance at site L595S. Treatment was initiated on a combination synergistic regimen of one half dose of ganciclovir and one half dose of Foscarnet, which helped bring the viral load down to 17,300 in 3 weeks. Renal function remained stable with IV hydration. The intensity of immunosuppression, CMV seronegative status and intermittent CMV prophylactic treatment contributed to the development of ganciclovir resistant CMV infection in our renal transplant patient.

238 METABOLIC SYNDROME, INSULIN RESISTANCE, AND KIDNEY FUNCTION IN NONDIABETIC INDIVIDUALS Barry Johns, Alan Pao, Sun Kim, Stanford University School of Medicine, Stanford, CA The metabolic syndrome has been recently identified as a risk factor for chronic kidney disease (CKD). Since components of the metabolic syndrome have been individually identified as risk factors for CKD, the metabolic syndrome diagnosis may represent an aggregate of CKD risk factors. On the other hand, the components of the metabolic syndrome have also been associated with insulin resistance, which may directly mediate the increased CKD risk. In a cross-sectional study, we evaluated the relationship among the metabolic syndrome, insulin resistance and estimated glomerular filtration rate (eGFR) in 574 nondiabetic volunteers. Insulin resistance was directly quantified using the insulin suppression test, and the metabolic syndrome components were measured. eGFR was calculated using three validated estimation equations: the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, the Mayo quadratic equation, and the Modification of Diet in Renal Disease (MDRD) study equation. Statistical analysis was performed using SPSS, version 17. Comparisons of clinical and laboratory characteristics were performed using analysis of variance (ANOVA) or chi-square tests for categorical variables. A linear model was used to evaluate the relationship between insulin resistance (SSPG) and eGFR adjusted for age, gender, and ethnicity. While CKD prevalence was higher and mean eGFR was lower in individuals who met the metabolic syndrome criteria compared with those who did not, we did not observe a significant relationship between the degree of insulin resistance and eGFR. Out of all of the components of the metabolic syndrome, only hypertension was significantly associated with CKD prevalence (OR (95% CI), 3.5 (1.210.1), p=0.02). In conclusion, while CKD is more common among subjects with the metabolic syndrome, insulin resistance does not appear to be a common associated factor.

A76

239 OSMOLAR GAP METABOLIC ACIDOSIS ASSOCIATED WITH LACTIC ACIDOSIS IN PATIENT TAKING METFORMIN: A CASE REPORT Ninad Parekh, Sunil Soi, Conemaugh Valley Memorial Medical Center Johnstown, PA. A 43 year old male with past medical history of type 2 diabetes, hypertension, hypothyroidism and dyslipidemia who was taking metformin presented with acute renal failure and anion gap metabolic acidosis (table). Further work up showed lactic acidosis (>14.9 mmol/L) without any evidence of acute bowel ischemia. Calculation of osmolar gap showed elevated osmolar gap 31.2 mOsm/L, but work up for any detectable levels of toxic alcohols typically associated with osmolar gap was negative. Sodium 145 mEq/L Chloride 94 mEq/L Bicarbonate 5 mEq/L BUN 74 mg/dl Creatinine 10.9 mg/dl He was also found to have methicillin-sensitive staphylococcal pneumonia which was initially treated with piperacillin/tazobactam and subsequently tapered to cafazolin based on culture reports. The patient required brief admission to intensive care unit and vasopressors administration for hypotension. Patient had worsening renal failure with development of hyperkalemia which required hemodialis during hospitalization. Extensive work up to identify the etiology of acute renal failure was negative. Patient recovered subsequently and was able discharged in stable condition. One week later, his renal function improved and dialysis was stopped. Metformin use has been associated with lactic acidosis especially in patients with chronic renal insufficiency or congestive heart failure. However, lactic acidosis causing elevated osmolar gap is rarely reported. Here, we present a case of elevated osmolar gap without any detectable levels of toxic alcohols in presence of lactic acidosis in patient taking metformin. We conclude that lactic acidosis is an osmolar substance and if present at very high concentration, can possibly cause high osmolar gap.

240 IS VITAMIN D DEFICIENT IN THE SUNSHINE STATE OF FLORIDA? Umabala Pasupala, Noelle Barrera, Mihail Soare, Mauro Braun, Beth L Fromkin, Rute Paixao, Dianne Sandy, Cleveland Clinic Florida, Weston, FL, United States. Vitamin D has an import role in skeletal and extra skeletal functions. The high prevalence of vitamin D deficiency has been increasingly recognized as an important public health problem. One of the major risk factors for vitamin D deficiency is Chronic Kidney Disease (CKD). Recent studies have been challenging the assumption that vitamin D deficiency may be less prevalent in people living in sunny climate; however limited data is available so far. To verify the prevalence of Vitamin D deficiency in sunny areas and its association with other co morbidities, we conducted a cross sectional descriptive study at Cleveland Clinic Florida on patients with CKD stage III to V from spring 2008 to winter 2009. Over 2000 patients admitted to Internal Medicine and its subspecialties were screened, from those 84 patients with eGFR < 60 (MDRD equation) met the inclusion criteria, and were checked for vitamin D levsl. 25-OH vitamin D levels below 30 ng/ml were considered to be insufficient, and below 15 ng/ml as deficient. Hypovitaminosis D was prevalent in 70% of the study group (52% vitamin D insufficient and 18% vitamin D deficient). The majority of patients were CKD stage 3, and 75% of those were vitamin D deficient. Also hypovitaminosis D showed significant association with Diabetes Mellitus (p= 0.03), and some association with anemia (p 0.437), and with cancer (p 0.221). In conclusion, Vit D deficiency is highly prevalent in CKD patients admitted to a South Florida Hospital and is significantly correlated with Diabetes Mellitus. Routine monitoring of vitamin D levels in early stages CKD and in diabetes can be beneficial even in sunny areas. Larger multi-center population-based studies are needed to verify the prevalence and outcomes of vitamin D deficiency.

Am J Kidney Dis. 2011;57(4):A1-A108