Tele-Nephrology: A Feasible Way to Improve Access to Care for Patients with Kidney Disease Who Reside in Underserved Areas.

BACKGROUND: The Miami VA Healthcare System serves veterans in three South Florida counties: Miami-Dade, Broward, and Monroe, with an estimated veteran population of 175,000. To overcome geographical barriers and facilitate the access to nephrology clinics, we implemented provider-patient tele-nephrology using secured videoconferencing. METHODS: A retrospective and descriptive study design was used to evaluate the effect of the tele-nephrology clinic intervention. Multiple clinical indicators were included in the analysis: blood pressure (BP) control, stabilization of the renal function, and electrolyte/metabolic control. One hundred one patients who were evaluated in the clinic between 2013 and 2015 were included in the analysis, and the indicators were collected retrospectively. RESULTS: One hundred one patients were included in the analysis, with 95% of patients being male (n = 96) and 5% female (n = 5). The mean age was 65.5 years. Fifty patients had chronic kidney disease (CKD) stage III (49.5%), 14 patients had CKD stage IV (13%), and 8 patients had CKD stage II (7.9%). A one-way analysis of variance between subjects was conducted and showed that the effect of the tele-nephrology clinic intervention on reducing BP was statistically significant (systolic BP less than 140 p value <0.0001). Renal function stabilized but the creatinine changes over time were not statistically significant (p value: 0.50). Potassium showed a significant improvement in this sample (p value: 0.0076). Phosphorous and bicarbonate did not show a statistically significant improvement (p value 0.79 and 0.91, respectively). CONCLUSION: With the tele-nephrology clinic intervention, we were able to effectively improve BP and stabilize renal function in patients with kidney disease who reside in underserved areas.

ESKD, Transplantation, and Dialysis in Lupus Nephritis.

Kidney disease resulting from systemic lupus erythematosus accounts for 1.9% of the end-stage kidney disease (ESKD) population in the United States. Systemic lupus erythematosus patients with lupus nephritis (LN) who progress to ESKD in the United States are mostly female (81%) and of African ancestry (49%), with a mean age of 41 years at initiation of renal replacement therapy (RRT). The incidence of ESKD in patients with LN steadily increased between 1982 and 1998 because RRT was offered more readily to LN patients in the United States. However, it appears to have plateaued in the early 2000s, and recently decreased, with approximately 3.26 incident cases per million patient-years during the biennium period of 2009 to 2010. When LN patients approach ESKD, patients and providers must choose among the RRT options available. The trend of the RRT used to support LN ESKD patients is not guided by the lower mortality seen with the use of kidney transplantation compared with dialysis (>85% versus 73% survival during 5 years of follow-up evaluation, respectively). Less than 4% of LN ESKD patients have pre-emptive kidney transplantation. Although the survival of LN ESKD patients who begin with hemodialysis and peritoneal dialysis are similar (77% versus 79% during 3 years of follow-up evaluation, respectively), more than 80% of patients begin with hemodialysis and less than 15% begin with peritoneal dialysis in the United States.

Atypical sarcoidosis diagnosed by bone marrow biopsy during renal workup for possible multiple myeloma.

Sarcoidosis is a multi-organ disease of unknown etiology characterized by non-caseating granulomas. Here we report the case of a 78-year-old white male with a past medical history of diabetes mellitus, hypertension, and chronic kidney disease stage III with a baseline serum creatinine of 2.5 mg/dl. The patient had a prior admission history for acute kidney injury (AKI) attributed to dehydration and medication-induced nephro-toxicities. He presented to the renal clinic for follow-up with acute worsening of chronic kidney failure with a serum creatinine level of 3.5 mg/dl. Examination revealed that he was anemic and mildly hypercalcemic with suppressed parathyroid hormone and had proteinuria of 1.3 g per day. The computed tomography scan of the abdomen revealed right renal pelvic non-obstructing calculi. Serum protein electrophoresis revealed gammopathy with two distinct monoclonal peaks consisting of immunoglobulin G (IgG) kappa and IgG lambda, respectively. The kappa/lambda ratio was within normal limits, and urine protein electrophoresis showed no evidence of a monoclonal peak or Bence Jones proteins. Further workup for multiple myeloma, including bone marrow (BM) biopsy, revealed polyclonal plasma cells and B cells with no clonality. No morphological and immune-phenotypic evidence of plasma cell dyscrasia was found, but BM biopsy did show numerous non-caseating granulomas consistent with sarcoidosis. Skin biopsy from non-scaly 6-mm skin colored papule also showed non-caseating granulomas. The patient had elevated angiotensin-converting enzyme levels (165 ug/l) and an erythrocyte sedimentation rate of 27 mm/h. Kidney biopsy did not show granulomas. The hypercalcemia, proteinuria, and AKI responded well after 2 weeks of 60 mg oral prednisone daily.

Identification of anionic supramolecular complexes of sulfonamide receptors with Cl-, NO3-, Br-, and I- by APCI-MS.

As part of a mass spectrometric investigation of the binding properties of sulfonamide anion receptors, an atmospheric pressure chemical ionization mass spectrometric (APCI-MS) method involving direct infusion followed by thermal desorption was employed for identification of anionic supramolecular complexes in dichloromethane (CH2Cl2). Specifically, the dansylamide derivative of tris(2-aminoethyl)amine (tren) (1), the chiral 1,3-benzenesulfonamide derivatives of (1R,2S)-(+)-cis-1-amino-2-indanol (2), and (R)-(+)-bornylamine, (3), were shown to bind halide and nitrate ions in the presence of (n-Bu)4N+X- (X- = Cl-, NO3-, Br-, I-). Solutions of receptors and anions in CH2Cl2 were combined to form the anionic supramolecular complexes, which were subsequently introduced into the mass spectrometer via direct infusion followed by thermal desorption. The anionic supramolecular complexes [M + X]-, (M = 1-3, X- = Cl-, NO3-, Br-, I-) were observed in negative mode APCI-MS along with the deprotonated receptors [M - H]-. Full ionization energy of the APCI corona pin (4.5 kV) was necessary for obtaining mass spectra with the best signal-to-noise ratios.

Extractionless GC/MS analysis of gamma-hydroxybutyrate and gamma-butyrolactone with trifluoroacetic anhydride and heptafluoro-1-butanol from aqueous samples.

gamma-Hydroxybutyrate (GHB) is a DEA Schedule I drug of abuse commonly spiked into beverages to incapacitate victims of sexual assault. GHB is a challenging drug for analysis by GC/MS because of its small size, charged nature, low volatility, and intramolecular esterification leading to gamma-butyrolactone (GBL). In this work an extractionless technique has been developed that allows for the use of an aqueous sample for direct derivatization. The technique uses a solution of trifluoroacetic anhydride (TFAA) and 2,2,3,3,4,4,4-heptafluoro-1-butanol (HFB) to derivatize the active hydrogens of GHB. The conversion of GBL into GHB can be forced under alkaline conditions by diluting the sample in 10 mM borate buffer, pH 12. GBL found in beverages intended for human consumption is treated as a Schedule I control substance analogue. Spikes of the two compounds into several beverage matrices gave quantitative recovery of GHB by GC/MS. The derivatization produces higher molecular mass products whose fragmentation pattern provides multiple peaks for confirmation and quantification. The concentration of GBL can also be indirectly determined by the method developed. Therefore, this extractionless technique is rapid, sensitive, and selective for the confirmation of the presence of GHB and GBL in commercial beverages.

Estimation of postmortem interval using the protein marker cardiac Troponin I.

The importance of determining the time since death is crucial to criminal, civil and forensic cases. A technique exploiting the degradation of a protein, cardiac Troponin I (cTnI), to estimate the postmortem interval (PMI) was investigated. Cardiac Troponin I is a basic regulatory protein found as part of a ternary complex responsible for calcium dependent muscle contraction. An efficient extraction protocol to analyze the banding pattern of cTnI in postmortem tissue was developed. The analysis involves extraction of the protein, separation by denaturing gel electrophoresis (SDS-PAGE) and visualization by Western blot using cTnI specific monoclonal antibodies. A bovine model was used to develop and optimize the protocol. The homology of cTnI amongst mammalian species allows for the cross-reaction of human anti-cTnI antibodies with bovine cTnI. The results indicate a characteristic banding pattern amongst human cadavers (n=6), a pseudo-linear relationship between percent cTnI degraded and the log of the time since death (r>0.95), and a qualitative degradation band pattern that in a simple comparative analysis with a standard human heart (known time since death) can be used to estimate the postmortem interval. The degradation-banding pattern of tissue cTnI is useful in the determination of the early postmortem (pm) interval (0-5 days). Overall, this technique offers advantages such a wide postmortem interval, measurable degradation pattern, a temporal semiquantitative relationship and manageable temperature dependence over direct temperature methods.