therapy early in the disease process. With the utility of MARS together with the CVVHDF, we could break the vicious cycle of perpetuating metabolic acidosis ...
1ST ASIA PACIFIC AKI CRRT 2017 therapy (CRRT) in these kinds of patients with acute liver injury and concomitant acute kidney injury. Objective: To highlight the utility and rationale of MARS therapy in the setting of acute liver failure with acute kidney injury and highlighting the possibility of predicting success by considering certain factors influencing the use of MARS therapy early in the organ support process. Case Series: This case series highlights 3 cases that was on MARS therapy as well as concomitant CRRT for hepatorenal support. The cases were two severe dengue infection with decompensated shock and one leptospirosis infection, both complicated by acute kidney injury and acute liver failure. All 3 cases were intubated and suffered from severe metabolic acidosis and hyperlactatemia. All patients required varying degree of vasopressors or inotropic support to maintain adequate hemodynamics. Patients had persistently elevated worsening trend of liver function, coagulopathy as well as Grade 2 hepatic encephalopathy. We used these parameters as a tool to decide the commencement of MARS therapy early in the disease process. With the utility of MARS together with the CVVHDF, we could break the vicious cycle of perpetuating metabolic acidosis, restore hemodynamic stability and indirectly prevent further extrahepatic complications including but not limited to acute kidney injury. All patients made good progress with the weaning of inotropes and vasopressors as early as Day 1 into MARS therapy. By the 2nd or 3rd cycle of MARS, we could see vast improvement in the liver function, the reduction of metabolic acidosis as well as improvement in clinical stability. All patients were extubated and discharged home well. Conclusion: We conclude that there is utility of MARS therapy in patients with concomitant acute liver failure and acute kidney injury. The case series brings forth a signal in terms of success if certain parameters are considered early in the disease to be able to start MARS therapy early on.
085 VANCOMYCIN REMOVAL IN PATIENTS ON HIGH-FLUX INTERMITTENT HEMODIALYSIS VARELI Yong, ZY1, Chan, JYM1, Tan, RYT1, Chew, SP1, Chua, WWC1, Tan, CHH2 1
2
Department of Pharmacy, Sarawak General Hospital, Nephrology Unit, Medical Department, Sarawak General Hospital
Category: Other Presenter: Mr ZAI YANG YONG Keywords: hemodialysis, vancomycin, high-flux Introduction: High-flux dialysis membrane is commonly used
nowadays and studies have shown that vancomycin is significant removed with high-flux hemodialysis (HD). Furthermore, there is a rebound of vancomycin level 3-6 hours after HD due to redistribution. In our hospital, vancomycin dosing is currently based on pre HD serum concentration of less than 20 mg/mL but this may result in under-dosing due to drug removal during high-flux HD. Objectives: To determine the extent of vancomycin removal with highflux intermittent HD. Methodology: This is a prospective, observational study performed at Sarawak General Hospital, Kuching from June 2016 to May 2017. All patients on high-flux HD who received vancomycin with a trough level of more than 20 mg/mL pre HD were recruited into this study. Vancomycin levels were measured pre HD, at completion of 4 hours of HD and 6 hours after HD. The serum concentrations of vancomycin were determined by Enzyme Multiplied Immunoassay Technique (EMIT) using SIEMENS VIVA E. Data were analysed using descriptive statistics. Results: A total of 8 patients were recruited into this study. The mean (SD) vancomycin serum concentrations pre HD, upon completion of 4-hour HD, and 6 hours post HD were 28.89 (5.03) mg/mL, 16.18 (4.35) mg/mL and 22.31 (4.97) mg/mL respectively. The extent of vancomycin removal with 4-hour high-flux HD was 44.31%, but the actual removal of vancomycin taking into consideration of rebound was 22.49% at 6 hours post HD. Three out of eight (37.5%) patients had vancomycin concentration of less than 20 mg/mL 6 hours post HD.
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Conclusion: A considerable amount of vancomycin is eliminated with
high-flux HD. This should be taken into consideration if using pre HD vancomycin level to guide dosing. If feasible, vancomycin concentration 6 hours post HD would be a more accurate guide to prevent under-dosing.
086 ACUTE KIDNEY INJURY SECONDARY TO AVERRHOA BILIMBI INGESTION Men, Leong Chong1, Chang, Eason2 1 Department of Nephrology, Hospital Kulim, Kedah, Malaysia, 2Department of Medicine, Hospital Sultan Abdul Halim, Sungai Petani, Kedah, Malaysia
Category: Other Presenter: Dr CHONG MEN LEONG Keywords: Averrhoa bilimbi, acute
kidney injury, oxalate nephropathy Averrhoa bilimbi(locally called as Belimbing Buluh) is generally accepted as an ingredient in local culinary and may potentially have medicinal properties, including lowering blood sugar and cholesterol. However, ingestion of excessive amount of the fruit may cause gastrointestinal tract discomfort, neurological side effects, cardiovascular collapse and acute kidney injury (AKI). Averrhoa bilimbi is known to cause AKI due to calcium oxalate crystal deposition in renal tubules, acute tubular necrosis, acute interstitial nephritis and chronically may cause interstitial fibrosis. Treatments of Averrhoa belimbipoisoning mainly include discontinuation of the fruit, adequate hydration and temporary dialysis if indicated clinically. We describe a case of AKI following ingestion of Averrhoa bilimbi which was referred by a district hospital in the state of Kedah, Malaysia.
091 SEVERE METFORMIN ASSOCIATED LACTIC ACIDOSIS: A NOT SO RARE AND POTENTIALLY FATAL COMPLICATION Lai, KH1, Ngu, LS Laura2, Chew, KF2, Lawrence Hii, WS2, Lee, J2, Clare Tan, HH2 1 Department of Medicine, UNIMAS, 2Nephrology Unit, Sarawak General Hospital
Category: Other Presenter: Dr KEE HOE LAI Introduction: Metformin has been used increasingly in diabetics as
newer evidence showed that it is beneficial and safe in mild to moderate chronic kidney disease (CKD). Severe metformin-associated lactic acidosis (MALA) is a rare but potentially fatal side effect. Objective: To assess the prevalence of MALA admitted to Sarawak General Hospital and identify potential associated factors. Methods: This is a prospective study of patients admitted from March 2016 to March 2017 with a high anion-gap metabolic acidosis and hyperlactatemia associated with metformin use. Results: Of the 16 patients admitted with MALA, 5 patients (31.2%) had CKD stage 1 or 2, 6 patients (37.5%) had CKD Stage 3 and only 2 (12.5%) had CKD stage 4. Most patients (81.25%) were on metformin dose of $ 1.5g daily. Concomitant therapy with angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptors blockers (ARB) (75%) and diuretics (37.5%) were common. Most patients had preceding history of vomiting (75%) or diarrhea (68.75%), and presented with Kussmaul breathing (68.75%), hypotension (81.25%), dehydration (87.5%) and oliguria (68.75%). Majority of the patient needed fluid resuscitation (87.5%), sodium bicarbonate infusion (68.75%) and inotropic support (87.5%). More than 50% of the patients were admitted to intensive care unit with mechanical ventilations. All patients were treated with dialysis. The majority of patients needed only 1 or 2 dialysis session. Acidosis was corrected in most of the patient after dialysis (81.25%). The mortality rate was 18.75% (N¼3). Conclusions: Our study showed that MALA is not such a rare event and has a high mortality rate of 18.75%. It can occur even in patients with mild stage 1- 3 CKD. It is often associated with preceding diarrhea or vomiting in patients taking metformin dose of $ 1.5g daily and ACEI/ARB/diuretics concomitantly. The dose of metformin should be reduced in CKD and patients should be educated to withhold metformin, ACEI/ARB, and diuretics during acute illness that can lead to dehydration or hypotension, and seek medical attention promptly.
Kidney International Reports (2017) 2, S1–S41
