Day 1 :
Lenox Hill Hospital, USA
Time : 09:30-10:10
Michael F Michelis has been Director of the Division of Nephrology at Lenox Hill Hospital for more than three decades. He is Clinical Professor of Medicine at the New York University, School of Medicine. He received a BA at Columbia College, Columbia University in New York City, and his MD Degree at George Washington School of Medicine in Washington DC. He received his Nephrology Training at the University of Pittsburgh, School of Medicine. He has been selected for inclusion in the listing of Top Doctors in New York for the past several years. He is the co-Editor of several medical textbooks, and he has published dozens of articles in the area of general nephrology, electrolyte disorders, hypertension, and geriatric renal disease. He has lectured extensively throughout the United States, Hawaii, Japan, and in various European cities. He has served on the Editorial Board of several medical journals, and he also reviews articles for established journals in Nephrology. He has received many awards and lectureships for his work in nephrology.
As patients with advanced renal disease become more complicated with time, due to factors such as complex associated conditions, aging, increasing numbers of available pharmacologic agents and improvement in renal replacement therapies, decision making has become more challenging. Subjects to be evaluated will include proper approaches to blood pressure therapy in patients with pre, inter or intra dialysis blood pressure abnormalities. Medication characteristics will be outlined and the effects of various drugs as they relate to the dialysis procedure will be described. Also metabolic issues such as approaches to hyperuricemia and hyperphophatemia will be reviewed and discussed. New agents and their benefits and limitations will be noted and present goals of therapy will be reviewed. Furthermore the effects of increased body mass and glucose intolerance on survival as well as possible corrective measures will be elucidated. Recent concerns regarding enzymatic predispositions to obesity will be described and possible solutions to these newly recognized abnormalities will be offered. Finally, current approaches to renal replacement therapy will be reviewed and the importance of the timing of interventions and the choice of access and modality will receive consideration. These issues apply particularly to patients of advanced age. Current standards as proposed by various nephrologic entities may not be appropriate for particular age groups with serious comorbidities. Factors influencing such decisions will be presented and critically evaluated.
Vanderbilt University, USA
Time : 10:10-10:50
Ghodrat Siami is MD, PhD, Fellow of American College of Physician, and Fellow of American Society of Nephrology, Professor of Medicine and Nephrology at Vanderbilt School of Medicine and was promoted to Professor Emeritus. He served as the President of International Society for Apheresis, and Vice President of Word Apheresis Association. He published more than 100 original papers, book chapters, editorials and abstracts. He presented his original works in more than 160 National and International Scientific Meetings. He is on the Editorial Board of several journals and Reviewer for FDA. He is a winner of several professional awards including 50 Year Service Award from AMA. He chaired the celebration of 100 years of Plasmapheresis in St. Petersburg, Russia. He is still an invited Keynote Speaker around the world.
Introduction: Combination Therapy is for dialysis patients requiring another extracorporeal therapy such as plasmapheresis.
Purpose: of study was to evaluate the safety and efficacy of both procedures.
Methods: We performed Cryofiltration Apheresis which I created 30 years ago, to treat patients with cryoglobulinemia to remove cryoglobulin from blood, LDL- Pheresis for dialysis patients with cardiovascular and coronary artery diseases which can be done by 8 different methods; Immunoadsorptiom to remove immune complex; and dialysis patients may need Plasma Purification and Whole Blood Purification for toxicology. We have developed procedures to do combination therapy safely and effectively.
Result: show all above procedures are safe and effective. Hemodialysis takes 4 hours and Apheresis 3.5 hours if they perform separately with total of 7.5 hours. But the Combination Therapy, if done together takes only 4 hours.
Conclusions: Both procedures take only 4 hours not 7.5 hours, Patients and Dialysis Nurse does not need to be on the machine/working almost all day. This will be less tiring and more acceptable for Patients and Nurses. The cost will be lower compared to doing them separately.
Peter Edward Cadman has received his MD from Columbia University, College of Physicians and Surgeons and completed his Internal Medicine Residency and Nephrology Fellowship at the University of California, San Diego (UCSD). As an Associate Clinical Professor of Medicine at UCSD, he holds a dual appointment with both the Division of Nephrology and Hypertension and the Division of Hospital Medicine. He works as a Staff Nephrologist and Hospitalist, acting as a Clinical Educator for medical students, residents and nephrology fellows. To date, he has authored or contributed to 12 different publications.
Cannabis has been legalized for medical and recreational use in several states, making physicians more aware of the drug’s potential toxicities. First described in 2004, the cannabinoid hyperemesis syndrome (CHS) has been recognized as a significant cause of hospitalization among drug users. Relatively little, however, has been written about electrolyte or acid-base disturbances in CHS. Between 2011 and 2014, six men were treated for CHS at the VA Medical Center in San Diego, CA and found to have significant hypophosphatemia (range <1 to 1.3 mg/dL). The six cases will be presented and possible causes of hypophosphatemia discussed. In half of the patients, serum phosphate levels normalized spontaneously within hours, suggesting redistribution of phosphate as a potential mechanism. Hyperventilation, which can lead to phosphate redistribution was observed in two-thirds of the patients and may have contributed. Hypophosphatemia is a feature of CHS in some patients.
University of Toledo, USA
Time : 11:40-12:10
Jorge Ortiz has completed his Residency in General Surgery at North Shore University Hospital. He did his Fellowship at the University of Miami Jackson Memorial Hospital. He is currently an Associate Professor of Surgery at the University of Toledo, College of Medicine and Life Sciences. He has published dozens of papers in reputed journals.
Background & Aim: Obesity can be a barrier to live donor selection and there are reports of obese live kidney donors (OLKDs) undergoing bariatric surgery prior to donation. While this practice has potential promise, the risks associated with it are unclear. Thus, our aim was to evaluate the advantages and disadvantages of this practice.
Design: Risks and benefits were ascertained from the literature. Analysis of costs and benefits was performed to provide objective data for each scenario.
Results: Live kidney donation is associated with superior outcomes compared to deceased donation. However, live donors are at risk of complications that could be exacerbated by obesity. Higher donor body mass index (BMI) has been associated with inferior recipient outcomes. Bariatric surgery (BS) results in decreased mortality and can induce sustained weight loss. Our cost-benefit analysis revealed a benefit-to-cost ratio of 3.64 for BS prior to live donation by OLKDs. We found ratios of 3.19 and 0.97 for live donation with an obese donor and a deceased donor, respectively.
Conclusions: Our results suggest that BS for an OLKD has the potential to increase the number of live donors and improve outcomes. However, more data is required; thus we recommend a registry of patients who have undergone both procedures.
Fresenius Medical Care, Germany
Time : 12:10-12:40
Maria Teresa Parisotto has obtained Nursing Diploma in 1974 and the Nursing Management Diploma in 1976 at the Nursing School Ospedale San Carlo, Milan, Italy. She has worked as a Nurse Manager in a Dialysis Unit, Ospedale San Paolo, Milan, Italy. In 1980, she left the hospital and started working as an Application Specialist and Marketing Director Peritoneal Dialysis afterwards in Fresenius Medical Care, Italy. In 1999 she moved to Fresenius Medical Care headquarters at Bad Homburg, Germany, as Director Peritoneal Dialysis for Europe, Middle East and Africa. From 2006 to 2016 she has worked in Fresenius Medical Care Deutschland GmbH, NephroCare Coordination as Director Nursing Care Management for Europe, Middle East and Africa. Currently she is working at Fresenius Medical Care Deutschland GmbH, Care Value Management as Chief Nurse Advisor. Her main areas of interest and experience are vascular access cannulation and care, hygiene and infection control, dialysis processes analysis, safety in dialysis. Her publications focused on peritoneal dialysis, hemodialysis safety and quality and vascular access cannulation and care.
Introduction & Aim: There is a close link between the availability of a well-functioning vascular access and patient survival on hemodialysis. Every effort should be made to maintain the functionality of the vascular access for long-term use. Practices of access cannulation vary from clinic to clinic, mainly for historical reasons. The aim of this study is to investigate the impact of cannulation technique on the survival of the arteriovenous fistula (AVF) and grafts (AVG).
Methods: In April 2009, a cross sectional survey was conducted in 171 dialysis units located in Europe, Middle East and Africa to collect details on vascular access cannulation practices. On the basis of this survey, a cohort of patients was selected for follow-up, inclusion being dependent on the availability of corresponding access survival/intervention data in the clinical database. Access survival was analyzed using the Cox regression model (adjusted for within country effects) defining as events the need for first surgical access survival intervention. Patients were censored for transplantation, death, loss of follow-up or end of the study period (March 31, 2012). Results were adjusted for age, gender and diabetes mellitus.
Results: Out of the 10,807 patients enrolled for the original survey, access survival data was available for 7,058 (65%) of patients, these residing in Portugal, UK, Italy, Turkey, Romania, Slovenia, Poland and Spain. Mean age was 63.5±15.0 years; 38.5% were female; 27.1% were diabetics; 90.6% had a native fistula and 9.4% had a graft. Access location was distal for 51.2% of patients. During the follow-up, 51.1% were treated with antiaggregants and 2.8% with anti-coagulants. Prevalent needle sizes were 15 G and 16 G for 63.7% and 32.2% of the patients, respectively (14 G: 2.7%, 17 G: 1.4%). Cannulation technique was area for 65.8% and rope-ladder for 28.2% and the direction of puncture was antegrade for 57.3%. Median blood flow was 350-400 mL/min.
Conclusions: The study revealed that area cannulation technique, despite being the most commonly used was inferior to both rope-ladder and buttonhole for the maintenance of vascular access functionality. With regard to the effect of needle and bevel direction, the combination of antegrade position of arterial needle with bevel up or down was significantly associated with better access survival than retrograde positioning with bevel down. There was an increased risk of access failure for graft versus fistula, proximal vs. distal location, right arm vs. left arm and the presence of a venous pressure greater than 150 mmHg. The higher HR associated with a venous pressure greater than 150 mmHg should open a discussion on currently accepted limits.
Sanofi Cambridge, United States
Title: Graft survival following deceased donor kidney transplantation with ratg vs basiliximab (bas) induction therapy in recipients at risk of delayed graft function and/or acute rejection
Time : 12:40-13:10
Edward Drea completed his residency in Internal Medicine, and Nephrology fellowship, at Saint Barnabas Medical Center and Morristown Memorial Hospital and is currently the Chief of Barnabas Health Kidney/Pancreas Transplant Division. He has led clinical trials using novel immunosuppressants and has published over 70 scientific papers in peer review journals. He is a member of the American Society of Transplantation, American Society of Nephrology, the American Medical Association, the Renal Physicians Association, the Transplant Society of New Jersey, and the United Network for Organ Sharing. He is a member of the advisory board of the New Jersey Organ and Tissue Sharing Network.
Introduction: Studies show conflicting results regarding the long-term impact of induction therapies on kidney graft survival. The srtr database was analyzed for patients transplanted 01/2000–12/2009 who met the inclusion criteria of a prior multicenter study (risk of delayed graft function and/or acute rejection; nejm 2006;355:1967) and received ratg (thymoglobulin®) or bas induction therapy.
Methods: Registry analysis identified 90,851 deceased donor kidney graft recipients; 51,561 had risk factor status entries and met the increased risk inclusion criteria used in the prior study (nejm 2006; cold ischemia time [cit] > 24h, additional risk factors if cit < 24h). Graft survival was compared for patients with and without each risk factor; patients with functioning grafts lost to follow-up were excluded. Adjusted kaplan-meier survival curves were generated for each risk factor, with other covariates fixed at population means. Hazards models included ratg vs bas induction.
Results: Of 51,561 patients receiving induction therapy, 35.7% received rATG and 17.4% received BAS. The proportion of patients receiving rATG increased from 14.2% (2000) to 53.3% (2009) ; The proportion receiving BAS declined from 30.2% (2000) to 14.5% (2009). One-year graft survival was 90.7% vs 89.9% for rATG vs BAS, respectively (p = 0.02); 5-year graft survival was 69.3% vs 66.7% for rATG vs BAS, respectively (p < 0.001). Improved survival for rATG vs BAS was maintained at longer follow-up.
Conclusion: Analyses suggest improved graft survival for rATG vs BAS induction therapy in transplant patients at risk of delayed graft function/rejection. Sanofi funded.
Fortis Superspeciality Hospital, India
Time : 14:10-14:40
Rajinder Yadav had completed his MCh in Urology from AIIMS in 1980. He Joined as Sr. Lecturer at PGI Medical College, Rohtak. He had established and developed many departments of Urology and MIS in various hospitals in Delhi. He was Chairman of Urology & Renal Transplant in BLK and Max Hospital. He is the Director of Urology & Kidney Transplant at Fortis Healthcare, a premier healthcare organization. He had performed more than 30,000 surgeries including endoscopic, laparoscopic/retroperitoneoscopic surgeries, kidney transplants, more than 1,000 RIRS and around 1,500 laser prostatectomies (Holmium, KTP, Thulium & Diode)
Objective Retrograde intra-renal surgery (RIRS) is considered as a minimally invasive procedure for management of renal stones with minimal morbidity. Our objective is to demonstrate its effectiveness in management of large, multiple and staghorn stones in our institution.
Methods A prospective study was done of 274 patients who presented to us with renal and upper ureteric stones and were managed with RIRS. Pre-operatively, stone size and laterality were assessed on NCCT KUB and X-ray KUB. Intra-operative parameters were assessed such as; operative time, need for ureteric dilatation and intra-operative complications. Post operatively, X-ray KUB/USG KUB was done before stent removal.
Results: Out of 274 patients, 185 patients were male and 89 were female. 83 patients had single stone and 191 patients had multiple stones. 25 patients were pre stented in view of septicemia or renal impairment. 47 patients had renal impairment at the time of presentation, which improved in all patients and returned to normal value in 36 patients. 85 patients underwent bilateral RIRS and 189 underwent unilateral RIRS. 175 patients had more than 2 cm sized stones. Six patients had residual stones out of which, three patients underwent URS, two patients underwent RIRS and one patient underwent ESWL.
Conclusion RIRS is feasible in case of large stone burden, like partial and complete staghorn stones along with multiple stones. Our study demonstrates its effectiveness in large stone burden with additional procedure required in < 3% patients.
Ana Fernandes has completed her Master from Faculdade de Ciências Médicas da Universidade Nova de Lisboa, Portugal. She is a 5th year Resident in Nephrology, at Centro Hospitalar de Setúbal. She has published five papers in reputed journals and is a Reviewer at International Journal of STD & AIDS
Coxiella burnetii (C. burnetii) causes a zoonotic disease – Q fever. This bacterium is highly resistant to harsh environmental conditions and causes an uncharacteristic clinical syndrome. Q fever may be acute or chronic and renal manifestations of the disease are more common in the chronic forms. There is a few reports of acute kidney injury due to C. Burnetti and most of them were reported in chronic forms of the disease. We are going through renal manifestations of the disease and we are going to review a case of acute Q fever manifested by recurrent fever and acute kidney injury with nephrotic syndrome.
Al Wakra Hospital, Qatar
Time : 15:10-15:40
Morshed Salah has completed his MD in 1992 from University Medical School of Pecs, Hungary and his Postgraduate studies on Urology in 1996 and PhD studies from University of Debrecen, Hungary in 2001. He has received his Master’s degree in Health Services Management from University of Debrecen, Hungary in 2007. He has worked as an Assistant Professor and Consultant Urologist in University of Debrecen, Hungary from 2002-2012. From 2012 to 2016, he has worked as a Consultant in Hamad Medical Corporation, Qatar and from 2016 to till date as a Senior Consultant. He is also an Assistant Professor of Clinical Urology in Weill Cornell of Medical College, Qatar from 2013 to till date.
Percutaneous Nephrolithotomy (PCNL) is the first-line treatment modality for the management of kidney stones larger than 2 cm in diameter. The creation of a percutaneous renal access is the most important step in PCNL and the adequacy of the access directly influences the success and complication rates of this procedure. Several techniques have been used for guidance for entrance to the collecting system, including fluoroscopy, computed tomography (CT) and ultrasonography (US), however access under fluoroscopy is the most commonly used. The aim of this presentation is to emphasize the importance of the renal access, mainly the monoplanar technique, during PCNL. The access under fluoroscopy control can be performed either under biplanar or monoplanar guidance. Biplanar access is based on the cephalad-caudad and mediolateral movements of the needle; the depth of the needle is adjusted with using fluoroscopic imaging in 30 degree and vertical positions. Monoplanar access is based on the intensive movement of the kidney and the retraction of the targeted calyx under fluoroscopy on a vertical plane only. The monoplanar access technique is a safe method, it decreases puncture and radiation time, it minimizes the patient's, the surgeon's and stuff's direct exposure time to radiation and it has similar success rates as the biplanar access technique.
Universidad Central del Ecuador, Ecuador
Time : 15:40-16:10
Darío Jiménez MD has completed his medical graduate at the age of 24 years from Universidad Central del Ecuador and postdoctoral studies from Eugenio Espejo hospital. Nephrology mini fellowship at University of Colorado at Denver. He is head of nephrology department at Enrique Garcés Hospital, medical director of Dialnef critical care nephrology and medicine professor at Universidad Central del Ecuador.
Introduction: Acute intoxication is an important cause of admission to intensive care unit in Ecuador; 8% of patients who needed renal replacement therapy developed by DIALNEF group since 2014 were by acute poisoning. The haemoperfusion with macro adsorbent resin offers advantages to clear toxins with medium molecular weight, high bound proteins and lipophilic characteristics.
Objective: To evaluate the role of early haemoperfusion as a therapy in severe acute intoxication. Mortality was primary outcome.
Methodology: A case and controls study was delivery in poisoning patients with neurologic deterioration by drugs with high bound proteins. Group 1 (n: 25 patients) were in haemoperfusion by 3 hours with MG-150- 250 macro adsorbent resin cartridge after general treatment for detoxifications versus group 2 (n: 25 patients) patients without access to haemoperfusion treatment. APACHE and SOFA scores were used to severity evaluation.
Results: Severity score APACHE II was G1:19 and G2: 15 (p: 0.03) and SOFA G1: 8.9 and G2: 6 (p: 0.02). UCI stay was G1: 3.5 and G2: 5.4 days (p: 0.11). Mortality in G1: 0 and G2: 5 (p=0,018).
Conclusions: The present study shows benefits of haemoperfusion in patients with severe acute intoxications. In addition, it shows how dramatically decreases the mortality in patients with high APACHE 2 score. Also, it was effective because decrease the permanence either in intensive care unit and hospitalization, therefore the cost is reduced. Haemoperfusion is a suitable technic for effective treatment in poisoning patients and clearance of high bound protein drugs.
Pontifical Catholic University of São Paulo, Brazil
Title: Evaluation of arterial hypertension in chronic kidney patients on hemodialysis and peritoneal dialysis
Time : 16:30-17:00
Rodrigo de Oliveira Pierami is currently a Medical student at Pontifical Catholic University of São Paulo, Brazil. He is a Former Member of Vital Brazil Student Council and Organizer of the XVI International Journey of Geriatric and Gerontology (2015). He did Internship at Hôpital Saint Vincent de Paul, Université Catholique de Lille, France (2016).
High Blood Pressure (HBP) is a common finding in patients with chronic kidney disease on dialyses. This research analyzed the relation between blood pressure (BP) and hydration status (HS) in chronic kidney patients under hemodialysis (HD) and peritoneal dialysis (PD) in a Brazilian Dialysis Center. Demographic data, BP, number of antihypertensive drugs (NAD) and HS by bioimpendance exam were collected from 89 patients (69 in HD; 20 in PD). There were findings of 55.1% of men, age between 57.6±16.4 years old, Caucasian ethnicity (80.9%), usage of 2.4±1.2 hypotension drugs in HD, 1.7±1.4 in PD. Systolic Blood Pressure (SBP)<140 mmHg in 27.5% patients before HD, in 40.6% after HD and in 55% under PD. Diastolic Blood Pressure <90 mmHg in 81.2%, 79.7% and 85% respectively. 43.8% with mean blood pressure (MBP)>100 mmHg (86.9±9.9 mmHg) and OH 0.5±2.5 liters. 56.2% with MBP>100 mmHg (114.7±11.9 mmHg; p=0.0001) and OH of 1.5±2.7 liters (p=0.06 between the groups). When pre-dialysis SBP and HS were combined, the patients were stratified in 4 groups: Group-1; 40.4% HBP can relate to hyperhydration; Group-2; 24.71%, HBP is independent of hyperhydration; Group-3; 19.1%, in which 9% are hypohydrated and low blood pressure; Group-4; 15.7%, in which 12.3% are normohydrated and normotensive and 3.4% are hyperhydrated, though normotensive or arterial hypotension. HS was normal in 22.5%. In this research, there was noted the difficulty of controlling BP in these patients despite the use of expressive NAD and no relation between HS and MBP.
Federal University of Piaui, Brazil
Title: A rare case of association between fabry's nephropathy and membranous glomerulonephritis: new perspectives on pathophysiology and follow-up of fabry's disease
Time : 17:00-17:30
Daniel Santos Rocha Sobral Filho is a Medical Student at Federal University of Piauí, Teresina - Piauí - Brazil. Scholarship of the Program of Scientific Initiation of the Federal University of Piauí, participates in researches in nephrology, focusing on genetic nephropathies.
Fabry disease (FD) is a rare X-linked disorder resulting from the deficiency of alpha-galactosidaseA enzyme. Microalbuminuria is the initial manifestation of renal involvement, progressing to end-stage renal disease. From one case, we followed the patient's response to enzyme replacement therapy (ERT) and the evolution of its manifestations. A 61 years old male was referred to nephrologist to investigate generalized edema and massive proteinuria. He referred a previous diagnosis of cardiomyopathy and heart failure treatment. Physical examination revealed widespread edema. Complementary tests showed nephrotic proteinuria, hypoalbuminemia and dyslipidemia. Renal biopsy revealed membranous glomerulonephritis (MN) and FD association. Anti-phospholipase-A2-Receptor autoantibodies were positive, revealing the unprecedented association between idiopathic MN and Fabry nephropathy, reinforces the hypothesis that Fabry's nephropathy may modify podocyte antigens, leading to idiopathic MN. Others FD manifestations were found: cornea verticillata, hypertrophic cardiomyopathy and supratentorial microangiopathy. The α-Gal activity was reduced, associated with lyso-Gb3 accumulation. Genetic analysis identified an unreported hemizygous mutation in exon 7 of the GLA gene. The patient experienced decreased edema and clinical stabilization with the institution of fortnightly ERT with agalsidase alfa, with complementary exams showing preservation of renal function with reduction in proteinuria and increased serum albumin. Family screening identified six close relatives with FD on oligosymptomatic stage. This study recognized an unknown association between MN and FD and an unreported genetic mutation. It’s also serving as the basis for the development of a database that aims to allow the follow-up of these patients, making possible the analysis of clinical data and of its evolution.