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Mandt SR, Thadathil N, Klem C, Russ C, McNamee PL, Stigge K, Cheng D. Apixaban Use in Patients with Kidney Impairment: A Review of Pharmacokinetic, Interventional, and Observational Study Data. Am J Cardiovasc Drugs 2024; 24:603-624. [PMID: 39102124 PMCID: PMC11344734 DOI: 10.1007/s40256-024-00664-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/26/2024] [Indexed: 08/06/2024]
Abstract
Chronic kidney disease (CKD) remains a significant global health issue and is a leading cause of mortality worldwide. Patients with CKD have an increased risk of developing atrial fibrillation (AF) and venous thromboembolism (VTE). While direct oral anticoagulants (DOACs) have become a standard of care for anticoagulation (AC) in patients with AF and VTE, the appropriate use of these agents in comorbid kidney impairment warrants detailed discussion. This scientific narrative review summarizes the effectiveness and safety of apixaban use in patients with renal dysfunction by assessing the current published pharmacokinetic, interventional, observational, and guideline data. Apixaban is a highly selective, orally active, direct inhibitor of factor Xa, with well-established pharmacokinetics and consistent clinical outcomes across a broad range of patient populations, including those with kidney impairment. Overall, the scientific literature has shown that apixaban has a favorable clinical efficacy and safety profile compared with vitamin K antagonists for patients with AF or VTE and comorbid kidney impairment. These data support the approved label dosing strategy of apixaban in reducing the risk of stroke/systemic embolism in patients with nonvalvular AF and in treating VTE across all ranges of kidney function. Both clinician experience and knowledge of patient-specific factors may be required in the management of comorbid patients with advanced CKD or those requiring dialysis, as data on these patients are limited.
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Affiliation(s)
| | | | | | | | | | | | - Dong Cheng
- Bristol Myers Squibb, Lawrenceville, NJ, USA
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2
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Nguyen AT, Curtis KM, Tepper NK, Kortsmit K, Brittain AW, Snyder EM, Cohen MA, Zapata LB, Whiteman MK. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep 2024; 73:1-126. [PMID: 39106314 PMCID: PMC11315372 DOI: 10.15585/mmwr.rr7304a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2024] Open
Abstract
The 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of specific contraceptive methods by persons who have certain characteristics or medical conditions. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. MEC (CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR 2016:65[No. RR-3]:1-103). Notable updates include 1) the addition of recommendations for persons with chronic kidney disease; 2) revisions to the recommendations for persons with certain characteristics or medical conditions (i.e., breastfeeding, postpartum, postabortion, obesity, surgery, deep venous thrombosis or pulmonary embolism with or without anticoagulant therapy, thrombophilia, superficial venous thrombosis, valvular heart disease, peripartum cardiomyopathy, systemic lupus erythematosus, high risk for HIV infection, cirrhosis, liver tumor, sickle cell disease, solid organ transplantation, and drug interactions with antiretrovirals used for prevention or treatment of HIV infection); and 3) inclusion of new contraceptive methods, including new doses or formulations of combined oral contraceptives, contraceptive patches, vaginal rings, progestin-only pills, levonorgestrel intrauterine devices, and vaginal pH modulator. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.
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Affiliation(s)
- Antoinette T. Nguyen
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Kathryn M. Curtis
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Naomi K. Tepper
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Katherine Kortsmit
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Anna W. Brittain
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Emily M. Snyder
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Megan A. Cohen
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Lauren B. Zapata
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Maura K. Whiteman
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
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3
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Jones A, Swan D, Lisman T, Barnes GD, Thachil J. Anticoagulation in chronic kidney disease: current status and future perspectives. J Thromb Haemost 2024; 22:323-336. [PMID: 37778512 DOI: 10.1016/j.jtha.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/14/2023] [Accepted: 09/21/2023] [Indexed: 10/03/2023]
Abstract
Chronic kidney disease (CKD) is being diagnosed increasingly worldwide. It is often identified in individuals with comorbidities, which may increase the already heightened risk of thrombosis and hemorrhage associated with CKD. Oral anticoagulation is an effective means of reducing rates of ischemic stroke and systemic embolism in patients with atrial fibrillation and minimizes the morbidity and mortality caused by venous thromboembolic disease. Despite the proven benefits in the majority of patients, these have not been so clearly realized in patients with CKD due to the precarious balance between bleeding and thromboembolic complications. In this review, the current status of anticoagulant utilization in CKD is examined, and some practical recommendations are put forward to assist in the decision-making process of safely anticoagulating patients with CKD diagnosed with atrial fibrillation and venous thromboembolism.
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Affiliation(s)
- Alfred Jones
- Department of Haematology, Beaumont Hospital, Dublin, Ireland
| | - Dawn Swan
- Department of Haematology, Beaumont Hospital, Dublin, Ireland.
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Geoffrey D Barnes
- Division of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Oxford Road, Manchester, United Kingdom
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4
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Dicks AB, Moussallem E, Stanbro M, Walls J, Gandhi S, Gray BH. A Comprehensive Review of Risk Factors and Thrombophilia Evaluation in Venous Thromboembolism. J Clin Med 2024; 13:362. [PMID: 38256496 PMCID: PMC10816375 DOI: 10.3390/jcm13020362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 12/29/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Venous thromboembolism (VTE), which encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE), is a significant cause of morbidity and mortality worldwide. There are many factors, both acquired and inherited, known to increase the risk of VTE. Most of these result in increased risk via several common mechanisms including circulatory stasis, endothelial damage, or increased hypercoagulability. Overall, a risk factor can be identified in the majority of patients with VTE; however, not all risk factors carry the same predictive value. It is important for clinicians to understand the potency of each individual risk factor when managing patients who have a VTE or are at risk of developing VTE. With this, many providers consider performing a thrombophilia evaluation to further define a patient's risk. However, guidance on who to test and when to test is controversial and not always clear. This comprehensive review attempts to address these aspects/concerns by providing an overview of the multifaceted risk factors associated with VTE as well as examining the role of performing a thrombophilia evaluation, including the indications and timing of performing such an evaluation.
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Affiliation(s)
- Andrew B. Dicks
- Department of Vascular Surgery, Prisma Health, University of South Carolina School of Medicine—Greenville, Greenville, SC 29601, USA; (E.M.); (M.S.); (S.G.); (B.H.G.)
| | - Elie Moussallem
- Department of Vascular Surgery, Prisma Health, University of South Carolina School of Medicine—Greenville, Greenville, SC 29601, USA; (E.M.); (M.S.); (S.G.); (B.H.G.)
| | - Marcus Stanbro
- Department of Vascular Surgery, Prisma Health, University of South Carolina School of Medicine—Greenville, Greenville, SC 29601, USA; (E.M.); (M.S.); (S.G.); (B.H.G.)
| | - Jay Walls
- Department of Hematology, Prisma Health, University of South Carolina School of Medicine—Greenville, Greenville, SC 29601, USA;
| | - Sagar Gandhi
- Department of Vascular Surgery, Prisma Health, University of South Carolina School of Medicine—Greenville, Greenville, SC 29601, USA; (E.M.); (M.S.); (S.G.); (B.H.G.)
| | - Bruce H. Gray
- Department of Vascular Surgery, Prisma Health, University of South Carolina School of Medicine—Greenville, Greenville, SC 29601, USA; (E.M.); (M.S.); (S.G.); (B.H.G.)
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5
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Rønnow Sand J, Troelsen FS, Nagy D, Farkas DK, Erichsen R, Christiansen CF, Sørensen HT. Increased Cancer Risk in Patients with Kidney Disease and Venous Thromboembolism: A Population-Based Cohort Study. Thromb Haemost 2023; 123:1165-1176. [PMID: 36574778 DOI: 10.1055/s-0042-1759879] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) may be a harbinger of cancer in the general population. Patients with kidney disease have an a priori increased VTE risk. However, it remains unknown how a VTE affects subsequent cancer risk in these patients. OBJECTIVES To examine the cancer risk in patients with kidney disease following a VTE. METHODS We conducted a nationwide population-based cohort study in Denmark (1996-2017), including all VTE patients with a diagnosis of kidney disease. We calculated absolute risks of cancer (accounting for competing risk of death) and age-, sex-, and calendar-period standardized incidence ratios (SIRs) comparing the observed cancer incidence with national cancer incidence rates and cancer incidence rates of VTE patients without kidney disease. RESULTS We followed 3,362 VTE patients with kidney disease (45.9% females) for a median follow-up time of 2.4 years (interquartile range: 0.6-5.4). During follow-up, 464 patients were diagnosed with cancer, of whom 169 (36.4%) were diagnosed within the first year. The 1-year absolute risk of any cancer was 5.0% (95% confidence interval [CI]: 4.3-5.8), with a SIR of 2.9 (95% CI: 2.5-3.4) when compared with the general population, and 2.0 (95% CI: 1.8-2.4) when compared with VTE patients without kidney disease. During subsequent years of follow-up, the SIRs declined to 1.5 (95% CI: 1.3-1.6) when compared with the general population, and 1.1 (95% CI: 0.9-1.2) compared with VTE patients without kidney disease. CONCLUSION Patients with hospital-diagnosed kidney disease have increased cancer risk after VTE, especially within the first year following the VTE diagnosis.
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Affiliation(s)
- Jakob Rønnow Sand
- Department of Clinical Epidemiology, Aarhus University Hospital and Clinical Institute of Arhus University, Aarhus N, Denmark
| | - Frederikke Schønfeldt Troelsen
- Department of Clinical Epidemiology, Aarhus University Hospital and Clinical Institute of Arhus University, Aarhus N, Denmark
| | - Dávid Nagy
- Department of Clinical Epidemiology, Aarhus University Hospital and Clinical Institute of Arhus University, Aarhus N, Denmark
| | - Dóra Körmendiné Farkas
- Department of Clinical Epidemiology, Aarhus University Hospital and Clinical Institute of Arhus University, Aarhus N, Denmark
| | - Rune Erichsen
- Department of Clinical Epidemiology, Aarhus University Hospital and Clinical Institute of Arhus University, Aarhus N, Denmark
- Department of Surgery, Randers Regional Hospital, Randers NØ, Denmark
| | - Christian Fynbo Christiansen
- Department of Clinical Epidemiology, Aarhus University Hospital and Clinical Institute of Arhus University, Aarhus N, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital and Clinical Institute of Arhus University, Aarhus N, Denmark
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Liao YC, Chang CC, Chen CY, Liu CC, Liao CC, Shih YRV, Lin CS. Preoperative renal insufficiency predicts postoperative adverse outcomes in a mixed surgical population: a retrospective matched cohort study using the NSQIP database. Int J Surg 2023; 109:752-759. [PMID: 36974714 PMCID: PMC10389524 DOI: 10.1097/js9.0000000000000278] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 01/27/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND The incidence of chronic kidney disease is increasing, but most cases are not diagnosed until the accidental finding of abnormal laboratory data or the presentation of severe symptoms. Patients with chronic kidney disease are reported to have an increased risk of postoperative mortality and morbidities, but previous studies mainly targeted populations undergoing cardiovascular surgery. The authors aimed to evaluate the risk of postoperative mortality and complications in a surgical population with preoperative renal insufficiency (RI). MATERIALS AND METHODS This retrospective cohort study used data from the National Surgical Quality Improvement Program database between 2013 and 2018 to evaluate the risk of postoperative morbidity and mortality in the surgical population. Patients with estimated glomerular filtration rate less than 60 ml/min/1.73 m 2 were defined as the RI group. Propensity score matching methods and multivariate logistic regression were used to calculate the risk of postoperative morbidity and mortality. RESULTS After propensity score matching, 502 281 patients were included in the RI and non-RI groups. The RI group had a higher risk of 30-day in-hospital mortality (odds ratio: 1.54, 95% CI: 1.49-1.58) than the non-RI group. The RI group was associated with a higher risk of postoperative complications, including myocardial infarction, stroke, pneumonia, septic shock, and postoperative bleeding. The RI group was also associated with an increased risk of prolonged ventilator use for over 48 h, readmission, and reoperation. CONCLUSION Patients with preoperative RI have an increased risk of postoperative 30-day mortality and complications. RI group patients with current dialysis, estimated glomerular filtration rate less than or equal to 30 ml/min/1.73 m 2 or concomitant anemia had an elevated risk of postoperative mortality.
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Affiliation(s)
| | - Chuen-Chau Chang
- Department of Anesthesiology
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chien-Yu Chen
- Department of Anesthesiology
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chih-Chung Liu
- Department of Anesthesiology
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chien-Chang Liao
- Department of Anesthesiology
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Ru Vernon Shih
- Department of Orthopedic Surgery, Duke University, Durham, North Carolina, USA
| | - Chao-Shun Lin
- Department of Anesthesiology
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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7
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Wong M, Parsi K, Myers K, De Maeseneer M, Caprini J, Cavezzi A, Connor DE, Davies AH, Gianesini S, Gillet JL, Grondin L, Guex JJ, Hamel-Desnos C, Morrison N, Mosti G, Orrego A, Partsch H, Rabe E, Raymond-Martimbeau P, Schadeck M, Simkin R, Tessari L, Thibault PK, Ulloa JH, Whiteley M, Yamaki T, Zimmet S, Kang M, Vuong S, Yang A, Zhang L. Sclerotherapy of lower limb veins: Indications, contraindications and treatment strategies to prevent complications - A consensus document of the International Union of Phlebology-2023. Phlebology 2023; 38:205-258. [PMID: 36916540 DOI: 10.1177/02683555231151350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Sclerotherapy is a non-invasive procedure commonly used to treat superficial venous disease, vascular malformations and other ectatic vascular lesions. While extremely rare, sclerotherapy may be complicated by serious adverse events. OBJECTIVES To categorise contraindications to sclerotherapy based on the available scientific evidence. METHODS An international, multi-disciplinary panel of phlebologists reviewed the available scientific evidence and developed consensus where evidence was lacking or limited. RESULTS Absolute Contraindications to sclerotherapy where the risk of harm would outweigh any benefits include known hypersensitivity to sclerosing agents; acute venous thromboembolism (VTE); severe neurological or cardiac adverse events complicating a previous sclerotherapy treatment; severe acute systemic illness or infection; and critical limb ischaemia. Relative Contraindications to sclerotherapy where the potential benefits of the proposed treatment would outweigh the risk of harm or the risks may be mitigated by other measures include pregnancy, postpartum and breastfeeding; hypercoagulable states with risk of VTE; risk of neurological adverse events; risk of cardiac adverse events and poorly controlled chronic systemic illness. Conditions and circumstances where Warnings and Precautions should be considered before proceeding with sclerotherapy include risk of cutaneous necrosis or cosmetic complications such as pigmentation and telangiectatic matting; intake of medications such as the oral contraceptive and other exogenous oestrogens, disulfiram and minocycline; and psychosocial factors and psychiatric comorbidities that may increase the risk of adverse events or compromise optimal treatment outcomes. CONCLUSIONS Sclerotherapy can achieve safe clinical outcomes provided that (1) patient-related risk factors and in particular all material risks are (1a) adequately identified and the risk benefit ratio is clearly and openly discussed with treatment candidates within a reasonable timeframe prior to the actual procedure; (1b) when an individual is not a suitable candidate for the proposed intervention, conservative treatment options including the option of 'no intervention as a treatment option' are discussed; (1c) complex cases are referred for treatment in controlled and standardised settings and by practitioners with more expertise in the field; (1d) only suitable individuals with no absolute contraindications or those with relative contraindications where the benefits outweigh the risks are offered intervention; (1e) if proceeding with intervention, appropriate prophylactic measures and other risk-mitigating strategies are adopted and appropriate follow-up is organised; and (2) procedure-related risk factors are minimised by ensuring the treating physicians (2a) have adequate training in general phlebology with additional training in duplex ultrasound, procedural phlebology and in particular sclerotherapy; (2b) maintain their knowledge and competency over time and (2c) review and optimise their treatment strategies and techniques on a regular basis to keep up with the ongoing progress in medical technology and contemporary scientific evidence.
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Affiliation(s)
- Mandy Wong
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kurosh Parsi
- Department of Dermatology, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia.,Faculty of Medicine, 7800University of New South Wales, Sydney, NSW, Australia.,Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia.,Australasian College of Phlebology, Chatswood, NSW, Australia
| | - Kenneth Myers
- Australasian College of Phlebology, Chatswood, NSW, Australia
| | | | - Joseph Caprini
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | | | - David E Connor
- Department of Dermatology, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia.,Faculty of Medicine, 7800University of New South Wales, Sydney, NSW, Australia.,Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | - Alun H Davies
- 4615Department of Surgery & Cancer, Imperial College London, UK
| | - Sergio Gianesini
- Department of Translational Medicine, University of Ferrara, Italy
| | | | | | | | - Claudine Hamel-Desnos
- Department of Vascular Medicine, Saint Martin Private Hospital Ramsay GdS, Caen,France and Paris Saint Joseph Hospital Group, France
| | | | | | | | | | - Eberhard Rabe
- Emeritus, Department of Dermatology, University of Bonn, Germany
| | | | | | - Roberto Simkin
- Faculty of Medicine, 28196University of Buenos Aires, Argentina
| | | | - Paul K Thibault
- Australasian College of Phlebology, Chatswood, NSW, Australia.,Central Vein and Cosmetic Medical Centre, Newcastle, Australia
| | - Jorge H Ulloa
- Hospital Universitario Fundación Santa Fé - Universidad de los Andes, Bogotá, Colombia
| | | | - Takashi Yamaki
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University Adachi Medical Center, Japan
| | | | - Mina Kang
- Department of Dermatology, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia.,Faculty of Medicine, 7800University of New South Wales, Sydney, NSW, Australia.,Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | - Selene Vuong
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | - Anes Yang
- Department of Dermatology, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia.,Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | - Lois Zhang
- Department of Dermatology, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia.,Faculty of Medicine, 7800University of New South Wales, Sydney, NSW, Australia.,Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
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8
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Parker K, Choudhuri S, Lewis P, Thachil J, Mitra S. UK prescribing practice of anticoagulants in patients with chronic kidney disease: a nephrology and haematology-based survey. BMC Nephrol 2023; 24:9. [PMID: 36635661 PMCID: PMC9837988 DOI: 10.1186/s12882-022-03041-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/15/2022] [Indexed: 01/14/2023] Open
Abstract
A survey to gain insight into anticoagulant prescribing practice in the setting of chronic kidney disease (CKD) across the UK was disseminated via renal and haematology networks. Areas of anticoagulant use included patients with venous thromboembolism (VTE), requiring thromboprophylaxis for VTE, Atrial Fibrillation (AF) and nephrotic syndrome.An online-survey was disseminated via British Haematology Society, UK Kidney Association, and Renal Pharmacy Group over a five month period. All responses were voluntary and anonymous.Among 117 responses there were 49 nephrology doctors, 47 renal pharmacists and 20 haematology clinicians. A specialist multidisciplinary team to discuss the specific anticoagulant management of these patients was only available to 3% (4/117) respondents. Renal function estimate used for anticoagulant dosing was mainly Cockcroft-Gault for pharmacists and haematology but lab-based estimates were used by nephrology doctors. Therapeutic dose of Low Molecular Weight Heparin was mostly likely to be reduced by one-third when used for VTE treatment, with the majority of units undertaking anti-Xa monitoring in CKD stage 5 and dialysis. Direct-acting Oral Anticoagulants are being used in patients with nephrotic syndrome, those with CKD stage 5 and on dialysis for VTE and AF in the absence of license in these indications.This survey highlighted the significant differences between anticoagulant prescribing in CKD between two professional specialties and marked variation between centres in anticoagulant management strategies employed for these patients. With gaps still existing in the evidence base and answers to these not expected within the next few years, development of a best-practice guideline would be warranted to support clinicians in this field.
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Affiliation(s)
- Kathrine Parker
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Oxford Road, M13 9WL, Manchester, UK.
- Division of pharmacy and optometry, School of health sciences, Manchester Academic Health Science Centre, The University of Manchester, University of Manchester, M13 9PT, Manchester, UK.
| | - Satarupa Choudhuri
- Department of Haematology, Northern Care Alliance NHS Foundation Trust, Royal Oldham hospital, Rochdale Rd, OL1 2JH, Oldham, UK
| | - Penny Lewis
- Division of pharmacy and optometry, School of health sciences, Manchester Academic Health Science Centre, The University of Manchester, University of Manchester, M13 9PT, Manchester, UK
| | - Jecko Thachil
- Department of Haematology, Manchester University NHS Foundation Trust, Oxford Road, M13 9WL, Manchester, UK
| | - Sandip Mitra
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Oxford Road, M13 9WL, Manchester, UK
- Division of cardiovascular sciences, School of medical sciences, The University of Manchester, M13 9NT, Manchester, UK
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9
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A systematic review of the efficacy and safety of anticoagulants in advanced chronic kidney disease. J Nephrol 2022; 35:2015-2033. [PMID: 36006608 PMCID: PMC9584987 DOI: 10.1007/s40620-022-01413-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/19/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) have an increased risk of venous thromboembolism (VTE) and atrial fibrillation (AF). Anticoagulants have not been studied in randomised controlled trials with CrCl < 30 ml/min. The objective of this review was to identify the impact of different anticoagulant strategies in patients with advanced CKD including dialysis. METHODS We conducted a systematic review of randomized controlled trials and cohort studies, searching electronic databases from 1946 to 2022. Studies that evaluated both thrombotic and bleeding outcomes with anticoagulant use in CrCl < 50 ml/min were included. RESULTS Our initial search yielded 14,503 papers with 53 suitable for inclusion. RCTs comparing direct oral anticoagulants (DOACs) versus warfarin for patients with VTE and CrCl 30-50 ml/min found no difference in recurrent VTE events (RR 0.68(95% CI 0.42-1.11)) with reduced bleeding (RR 0.65 (95% CI 0.45-0.94)). Observational data in haemodialysis suggest lower risk of recurrent VTE and major bleeding with apixaban versus warfarin. Very few studies examining outcomes were available for therapeutic and prophylactic dose low molecular weight heparin for CrCl < 30 ml/min. Findings for patients with AF on dialysis were that warfarin or DOACs had a similar or higher risk of stroke compared to no anticoagulation. For patients with AF and CrCl < 30 ml/min not on dialysis, anticoagulation should be considered on an individual basis, with limited studies suggesting DOACs may have a preferable safety profile. CONCLUSION Further studies are still required, some ongoing, in patients with advanced CKD (CrCl < 30 ml/min) to identify the safest and most effective treatment options for VTE and AF.
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10
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Fan G, Wang D, Zhang M, Luo X, Zhai Z, Wu S. Anticoagulant for treatment and prophylaxis of venous thromboembolism patients with renal dysfunction: A systematic review and network meta-analysis. Front Med (Lausanne) 2022; 9:979911. [PMID: 36226154 PMCID: PMC9548609 DOI: 10.3389/fmed.2022.979911] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
Objective The aim of this study was to compare the efficacy and safety for particular regimen and dosage in venous thromboembolism (VTE) patients with renal insufficiency. Methods English language searches of PubMed, Embase, and Web of Science (inception to May 2021). RCTs evaluating anticoagulants for VTE treatment at acute phase, extension phase, and VTE prophylaxis in patients with renal insufficiency and reporting efficacy (death, recurrence, or occurrence of VTE) and safety (bleeding) outcomes were selected. The methodological quality of each study included was assessed at the outcome level using the risk-of-bias assessment tool developed by the Cochrane Bias Methods Group. Results Twenty-one trials that involved 76,574 participants and 8,972 (11.7%) patients with renal insufficiency were enrolled, including 10 trials on VTE treatment in acute phase (3–12 months), four trials on VTE treatment in extension phase (6–36 months), and seven trials for VTE prophylaxis. For acute VTE treatment, compared with dabigatran etexilate, apixaban (RR 5.90, 95%CI 1.00–34.60) and rivaroxaban (RR 6.18, 95%CI 1.17–32.75) were significantly associated with increased risk of death or recurrence. For extension treatment of VTE, aspirin had the highest probability of the most effective and safest treatment, followed by apixaban. For VTE prophylaxis, compared with enoxaparin, desirudin was associated with lower risk of VTE occurrence (RR 0.56, 95% CI 0.34–0.91), but had higher risk of bleeding than dabigatran etexilate. Conclusion The network meta-analysis informs the optimal choice of anticoagulants and their particular dosage for treatment and prophylaxis of VTE patients comorbid renal insufficiency. Systematic review registration www.crd.york.ac.uk/prospero/, identifier: CRD42021254086.
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Affiliation(s)
- Guohui Fan
- Department of Clinical Research and Data Management, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Disease, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
- Institute of Respiratory Medicine, Chinses Academy of Medical Sciences, Beijing, China
| | - Dingyi Wang
- Department of Clinical Research and Data Management, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Disease, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
- Institute of Respiratory Medicine, Chinses Academy of Medical Sciences, Beijing, China
| | - Meng Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xufei Luo
- School of Public Health, Lanzhou University, Lanzhou, China
| | - Zhenguo Zhai
- National Center for Respiratory Disease, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
- Institute of Respiratory Medicine, Chinses Academy of Medical Sciences, Beijing, China
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Sinan Wu
- Department of Clinical Research and Data Management, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Disease, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
- Institute of Respiratory Medicine, Chinses Academy of Medical Sciences, Beijing, China
- *Correspondence: Sinan Wu
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11
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Roetker NS, Guo H, Ramey, ABD DR, McMullan CJ, Atkins GB, Wetmore JB. Hemodialysis Vascular Access and Risk of Major Bleeding, Thrombosis, and Cardiovascular Events: A Cohort Study. Kidney Med 2022; 4:100456. [PMID: 35706716 PMCID: PMC9189779 DOI: 10.1016/j.xkme.2022.100456] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Rationale & Objective The risks of major bleeding, thrombosis, and cardiovascular events are elevated in patients receiving maintenance hemodialysis (HD). Our objective was to compare the risk of these outcomes in HD according to the permanent vascular access type. Study Design Observational cohort study. Setting & Participants Using data from the United States Renal Data System (2010-2015), we included patients with kidney failure who were greater than 18 years, had Medicare as the primary payer, were not using an oral anticoagulant, and were newly using an arteriovenous (AV) access for HD. Exposure AV graft (AVG) or AV fistula (AVF). Outcomes Major bleeding, venous thromboembolism, ischemic stroke, myocardial infarction, cardiovascular death, and critical limb ischemia. Analytical Approach Comparing 17,763 AVG and 60,329 AVF users, we estimated the 3-year incidence rates and incidence rate ratios (IRRs) of each outcome using Poisson regression. IRRs were adjusted for sociodemographic and clinical covariates. Results The use of an AVG, compared with that of an AVF, was associated with an increased risk of venous thromboembolism (10.8 vs 5.3 events per 100 person-years; adjusted IRR, 1.74; 95% CI, 1.63-1.85) but not with the risk of major bleeding (IRR, 1.04; 95% CI, 0.93-1.17). The use of an AVG was also potentially associated with a slightly increased risk of cardiovascular death (IRR, 1.09; 95% CI, 1.01-1.16). Limitations This analysis focused on patients with a functioning AV access; adverse events that may occur during access maturation should also be considered when selecting a vascular access. Conclusions The use of an AVG, relative to an AVF, in HD is associated with an increased risk of venous thromboembolism. Given recent guidelines emphasizing selection of the “right access” for the “right patient,” the results of this study should potentially be considered as one additional factor when selecting the optimal access for HD.
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12
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Su X, Yan B, Wang L, Cheng H, Chen Y. Comparative efficacy and safety of oral anticoagulants for the treatment of venous thromboembolism in the patients with different renal functions: a systematic review, pairwise and network meta-analysis. BMJ Open 2022; 12:e048619. [PMID: 35190410 PMCID: PMC8862458 DOI: 10.1136/bmjopen-2021-048619] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 01/24/2022] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES To compare the efficacy and safety of direct oral anticoagulants (DOACs) in patients with venous thromboembolism (VTE) and different renal functions. DESIGN Systematic review containing pairwise and Bayesian network meta-analysis of randomised controlled trials (RCTs). DATA SOURCES MEDLINE, EMBASE and Cochrane Library. ELIGIBILITY CRITERIA RCTs reporting the efficacy and safety outcomes of DOACs in different creatinine clearance (CrCl) subgroups. DATA EXTRACTION AND SYNTHESIS Data extraction and quality assessment were undertaken by two independent reviewers. Data were pooled using the DerSimonian-Laird method in pairwise meta-analysis. Network meta-analysis within a Bayesian framework was conducted. RESULTS Data from 10 RCTs were included. In the treatment of acute VTE, DOACs did not significantly reduce recurrent VTE or VTE-related death (OR, 0.96; 95% CI, 0.82 to 1.11) but significantly reduced bleeding events (0.76, 0.68 to 0.90) compared with warfarin. In the extended treatment of VTE, DOACs produced significant benefits in recurrent VTE or VTE-related death (0.23, 0.16 to 0.29), but significantly increased bleeding events (1.86, 1.04 to 3.33) compared with placebo/aspirin. There were no significant differences in efficacy and safety of DOACs among the three CrCl stratified subgroups in acute and extended treatment of VTE (p for subgroup heterogeneity >0.1). Bayesian network meta-analysis suggested that apixaban 2.5 mg and 5 mg two times per day were associated with a lower risk of bleeding than dabigatran, rivaroxaban, warfarin and aspirin in the subgroup with CrCl >80 mL/min. CONCLUSIONS For the treatment of acute VTE, DOACs are similar to warfarin in reducing recurrent VTE and VTE-related death but are significantly superior to warfarin in reducing the risk of bleeding. For the efficacy and safety of DOACs across different CrCl stratifications (30-50, 50-80 and more than 80 mL/min), no significant difference was found. In light of minimal evidence, apixaban might be associated with a lower risk of bleeding in patients with VTE and CrCl >80 mL/min. PROSPERO REGISTRATION NUMBER CRD42018090896.
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Affiliation(s)
- Xiaole Su
- Department of Nephrology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang District, Beijing, China
- Department of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, China
| | - Bingjuan Yan
- Department of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, China
| | - Lihua Wang
- Department of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, China
| | - Hong Cheng
- Department of Nephrology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang District, Beijing, China
| | - Yipu Chen
- Department of Nephrology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang District, Beijing, China
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13
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Outcome of Elderly Patients with Venous Thromboembolism Treated with Direct Oral Anticoagulants-A Retrospective Cohort Study. J Clin Med 2021; 10:jcm10235673. [PMID: 34884375 PMCID: PMC8658344 DOI: 10.3390/jcm10235673] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/26/2021] [Accepted: 11/27/2021] [Indexed: 01/07/2023] Open
Abstract
Introduction: Randomized controlled trials that compared direct oral anticoagulants (DOACs) to vitamin K antagonists (VKA) for the treatment of venous thromboembolism (VTE), demonstrated both efficacy and safety of DOACs. The aim of the current study was to compare DOACs to VKA for the treatment of VTE in the elderly, in a real-life setting. Methods: A retrospective cohort study was performed in Rabin Medical Center encompassing a 7-year period. Hospitalized patients >65 years, with a diagnosis of VTE discharged with DOACs or VKA were included. The primary outcome was a composite of all-cause mortality, major bleeding, recurrent VTEs and hospitalizations throughout the follow-up period of one year. Results: A total of 603 patients were included in the final analysis. The mean age was 79.6 ± 8.5 years. The primary composite outcome occurred in 74.6% and 56.7% of the patients in the VKA group and DOACs group, respectively, hazard ratio 0.59, 95% confidence interval 0.46 to 0.76, in favor of the DOACs group. In a matched cohort analysis, the results were the same as the original analysis. Conclusion: In the elderly population, treatment of VTE with DOACs was associated with a lower rate of the composite outcome. DOACs are safe and effective for elderly patients with VTE.
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14
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Eikelboom J, Floege J, Thadhani R, Weitz JI, Winkelmayer WC. Anticoagulation in patients with kidney failure on dialysis: factor XI as a therapeutic target. Kidney Int 2021; 100:1199-1207. [PMID: 34600964 DOI: 10.1016/j.kint.2021.08.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 12/18/2022]
Abstract
Chronic kidney disease is present in almost 10% of the world population and is associated with excess mortality and morbidity. Reduced glomerular filtration rate and the presence and extent of proteinuria, key domains of chronic kidney disease, have both been shown to be strong and independent risk factors for cardiovascular disease. Patients with kidney failure requiring dialysis are at highest risk for cardiovascular events (e.g., stroke or myocardial infarction), and of developing chronic cardiovascular conditions, such as heart failure. Despite the high burden of cardiovascular disease, there is a paucity of evidence supporting therapies to reduce this risk. Although long-term anticoagulant treatment has the potential to prevent thromboembolism in persons with kidney failure on dialysis, this possibility remains understudied. The limited data available on anticoagulation in patients with kidney failure has focused on vitamin K antagonists or direct oral anticoagulants that inhibit thrombin or factor (F) Xa. The risk of bleeding is a major concern with these agents. However, FXI is emerging as a potential safer target for new anticoagulants because FXI plays a greater part in thrombosis than in hemostasis. In this article, we (i) explain the rationale for considering anticoagulation therapy in patients with kidney failure to reduce atherothrombotic events, (ii) highlight the limitations of current anticoagulants in this patient population, (iii) explain the potential benefits of FXI inhibitors, and (iv) summarize ongoing studies investigating FXI inhibition in patients with kidney failure on dialysis.
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Affiliation(s)
- John Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jürgen Floege
- Department of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - Ravi Thadhani
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Wolfgang C Winkelmayer
- Department of Medicine, Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas, USA.
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15
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Singh J, Khadka S, Solanki D, Kichloo A, Shah H, Vyas MJ, Chugh S, Patel N, Solanki S. Pulmonary embolism in chronic kidney disease and end-stage renal disease hospitalizations: Trends, outcomes, and predictors of mortality in the United States. SAGE Open Med 2021; 9:20503121211022996. [PMID: 34158942 PMCID: PMC8182212 DOI: 10.1177/20503121211022996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/18/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND It is well-known that patients with chronic kidney disease and end-stage renal disease are at increased risk of pulmonary embolism than patients with normal kidney function. However, the data on trends, outcomes, and predictors of mortality in pulmonary embolism patients with chronic kidney disease and end-stage renal disease in the United States are limited. METHODS We queried the National Inpatient Sample database from 2010 to 2014. International Classification of Diseases-Ninth Revision-Clinical Modification codes were used to identify patients with normal kidney function, chronic kidney disease, and end-stage renal disease. The frequency of pulmonary embolism, complications, in-hospital mortality, and length of stay were calculated for each cohort. Multivariable logistic regression models were constructed to determine the predictors of mortality. RESULTS In the study population (2010-2014), there were 766,176 pulmonary embolism hospitalizations with normal kidney function, 79,824 with chronic kidney disease, and 9147 with end-stage renal disease. Among the study cohorts, the mortality rate was 2.7% in normal kidney function, 4.5% in chronic kidney disease, and 6.8% in end-stage renal disease hospitalizations. Median length of stay was highest in the end-stage renal disease cohort and lowest in the normal kidney function cohort. After adjusting for confounders, pulmonary embolism patients with chronic kidney disease died 1.15 times more often than those with normal kidney function and pulmonary embolism patients with end-stage renal disease died 4.2 times more often than those with normal kidney function. CONCLUSION The mortality rate and length of stay in pulmonary embolism patients with chronic kidney disease and end-stage renal disease were significantly higher than those in pulmonary embolism patients with normal kidney function. Also, pulmonary embolism patients with chronic kidney disease and end-stage renal disease were at higher risk of in-hospital mortality than those with normal kidney function. There was statistically significant higher risk of mortality in elderly and Black patients with pulmonary embolism and concurrent chronic kidney disease or end-stage renal disease.
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Affiliation(s)
- Jagmeet Singh
- Department of Medicine, Geisinger
Commonwealth School of Medicine, Scranton, PA, USA
| | - Sushmita Khadka
- Department of Medicine, Guthrie Robert
Packer Hospital, Sayre, PA, USA
| | | | - Asim Kichloo
- College of Medicine, Central Michigan
University, Saginaw, MI, USA
| | - Harshil Shah
- Hospitalist Department, Guthrie Corning
Hospital, Corning, NY, USA
| | - Manasee J Vyas
- Mahatma Gandhi Medical Institute of
Health Sciences, Navi Mumbai, India
| | - Savneek Chugh
- Department of Nephrology, Westchester
Medical Center, Valhalla, NY, USA
| | - Neil Patel
- Division of Cardiology, The Wright
Center for Graduate Medical Education, Scranton, PA, USA
| | - Shantanu Solanki
- Department of Medicine, Geisinger
Commonwealth School of Medicine, Scranton, PA, USA
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16
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DeBiase C, Giuliano CA, Doshi M, Ganoff M, Alexander Paxton R. Enoxaparin versus unfractionated heparin for venous thromboembolism prophylaxis in renally impaired ICU patients. Pharmacotherapy 2021; 41:424-429. [PMID: 33641194 DOI: 10.1002/phar.2518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/25/2021] [Accepted: 02/13/2021] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Intensive care unit (ICU) patients with renal insufficiency are more likely to develop venous thromboembolism and are at an increased risk for bleeding. There is conflicting data on whether enoxaparin or unfractionated heparin (UFH) is preferred for preventing thromboembolism in this population. Therefore, the purpose of this study was to evaluate the safety of prophylactic enoxaparin versus UFH in ICU patients with renal impairment. METHODS We conducted a single-center, retrospective cohort study of ICU patients with renal impairment who received venous thromboembolism prophylaxis with either enoxaparin or UFH. Patients were included if they were at least 18 years of age, had renal impairment (acute kidney injury, severely decreased renal function, or end-stage renal disease), and an ICU length of stay ≥72 h. The primary outcome was the proportion of patients experiencing a major bleeding event, including fatal bleed, symptomatic bleed in a critical area, or bleeding causing a ≥2 g/dl decrease in hemoglobin leading to a transfusion of ≥2 units of packed red blood cells. RESULTS A total of 460 patients were included in the study. Of these, 231 received enoxaparin and 229 received UFH. In the unadjusted analysis, there was no difference in major bleeding events observed with enoxaparin compared to UFH (29.4% vs. 22.3%; p = 0.08) or rates of venous thromboembolism (4.3% vs. 3.5%; p = 0.64), respectively. After adjusting for confounding factors, enoxaparin showed a significant increase in major bleeding (OR: 1.84; 95% CI: 1.11 - 3.04; p = 0.02). CONCLUSION Thromboprophylaxis with enoxaparin in critically ill patients with renal impairment was associated with an increased risk of major bleeding compared to UFH.
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Affiliation(s)
| | - Christopher A Giuliano
- Ascension St. John Hospital, Detroit, MI, USA.,Eugene Applebaum College of Pharmacy, Wayne State University, Detroit, MI, USA
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17
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Zhan X, Yang M, Chen Y, Zhang L, Yan C, Wang Y. Comparison of risk of stroke in patients treated with peritoneal dialysis and hemodialysis: a systematic review and meta-analysis. Ren Fail 2020; 41:650-656. [PMID: 31296101 PMCID: PMC6691832 DOI: 10.1080/0886022x.2019.1632210] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objective: Accumulating evidence has demonstrated that dialysis patients are at increased risk for stroke. However, the impact of dialysis modalities on stroke risk remains controversial. We conducted a systematic review and meta-analysis to determine the effect of peritoneal dialysis (PD) and hemodialysis (HD) on stroke risk. Methods: A systematic search of PubMed, EMBASE, and Web of Science was performed to identify articles comparing the stroke outcomes of dialysis patients. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) were extracted and synthesized to examine stroke outcomes, including ischemic stroke, hemorrhagic stroke, and overall stroke. Results: The search yielded five studies composed of 1,219,245 patients that were evaluated in the final analysis. The results showed that PD was associated with a lower risk for hemorrhagic stroke compared with HD (HR = 0.78; 95% CI: 0.69-0.88; p < 0.001). For ischemic stroke, the results showed that PD was associated with a higher risk compared with HD among the non-Asian patients (HR = 1.13; 95% CI: 1.05-1.23; p = 0.002), but there were no significant differences between PD and HD for the Asian patients. Similarly, there were no significant differences between the effects of the PD and HD approaches on overall stroke risk. Conclusions: We observed that PD patients were less likely to develop hemorrhagic stroke than HD patients, and the risk for ischemic stroke was significantly higher for PD patients than for HD patients among the non-Asian patients. However, our findings could be biased due to the heterogeneity of the included studies.
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Affiliation(s)
- Xiaojiang Zhan
- a Department of Nephrology , The First Affiliated Hospital of Nanchang University , Nanchang , Jiangxi , China
| | - Mei Yang
- a Department of Nephrology , The First Affiliated Hospital of Nanchang University , Nanchang , Jiangxi , China
| | - Yanbing Chen
- a Department of Nephrology , The First Affiliated Hospital of Nanchang University , Nanchang , Jiangxi , China
| | - Li Zhang
- a Department of Nephrology , The First Affiliated Hospital of Nanchang University , Nanchang , Jiangxi , China
| | - Caixia Yan
- a Department of Nephrology , The First Affiliated Hospital of Nanchang University , Nanchang , Jiangxi , China
| | - Yu Wang
- a Department of Nephrology , The First Affiliated Hospital of Nanchang University , Nanchang , Jiangxi , China
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18
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Molnar AO, Bota SE, McArthur E, Lam NN, Garg AX, Wald R, Zimmerman D, Sood MM. Risk and complications of venous thromboembolism in dialysis patients. Nephrol Dial Transplant 2019; 33:874-880. [PMID: 28992258 DOI: 10.1093/ndt/gfx212] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/10/2017] [Indexed: 11/12/2022] Open
Abstract
Background Contemporary data on venous thromboembolism (VTE) risk in dialysis patients are limited. Our objective was to determine the risk and complications of VTE among incident maintenance dialysis patients. Methods We performed a retrospective cohort study using administrative databases. We included adult incident dialysis patients from 2004 to 2010 (n = 13 315). Dialysis patients were age- and sex-matched to individuals of the general population using a 1:4 ratio (n = 53 260). We determined the 3-year cumulative incidence and incidence rate (IR) of VTE, pulmonary embolism (PE) and deep venous thrombosis (DVT). We examined outcomes of bleeding and all-cause mortality following a VTE event among matched dialysis patients who did and did not experience a VTE. We used Cox proportional hazards regression models, stratified on matched sets, to calculate the hazard ratios (HRs) for all outcomes of interest. Results VTE occurred in 1114 (8.4%) dialysis patients compared with 1233 (2.3%) individuals in the general population {IR 37.1 versus 8.1 per 1000 person-years; HR 4.5 [95% confidence interval (CI) 4.1-4.9]; adjusted HR 2.9 (95% CI 2.6-3.4)}. Both components of VTE [PE and DVT; adjusted HR 4.0 (95% CI 2.9-5.6) and HR 2.8 (95% CI 2.4-3.2), respectively] occurred more frequently in dialysis patients. Compared with dialysis patients without a VTE, those with a VTE had a higher risk of bleeding [adjusted HR 2.0 (95% CI 1.3-2.9)] and all-cause mortality [adjusted HR 2.4 (95% CI 2.0-2.8)]. Conclusions VTE is common in dialysis patients and confers a high risk of major bleeding and all-cause mortality. Thromboprophylaxis and VTE treatment studies in dialysis patients are needed.
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Affiliation(s)
- Amber O Molnar
- Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada.,Department of Medicine, Division of Nephrology, McMaster University, Hamilton, Ontario, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Sarah E Bota
- Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada
| | - Ngan N Lam
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada.,Department of Medicine, Division of Nephrology, Western University, London, Ontario, Canada
| | - Ron Wald
- Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada.,Department of Medicine, Division of Nephrology, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Deborah Zimmerman
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada
| | - Manish M Sood
- Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada.,Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Ontario, Canada
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19
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Nguyen Q, Rivera-Lebron BN. Venous Thromboembolism in Special Populations: Preexisting Cardiopulmonary Disease, Cirrhosis, End-Stage Renal Disease, and Asplenia. Clin Chest Med 2019; 39:515-524. [PMID: 30122176 DOI: 10.1016/j.ccm.2018.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Venous thromboembolism (VTE) is a common cause of morbidity and mortality. Presence of preexisting conditions, such as cardiopulmonary diseases, cirrhosis, renal dysfunction, and asplenia, commonly occurs in VTE patients. Moreover, these conditions often are risk factors for developing VTE. These preexisting conditions make VTE diagnosis and treatment challenging and worsen outcomes. Current guidelines do not include detailed features in the diagnosis and management of patients with preexisting conditions. This review discusses presence of VTE in patients with preexisting cardiopulmonary diseases, cirrhosis, renal dysfunction, and asplenia.
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Affiliation(s)
- Quyen Nguyen
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, UPMC Montefiore, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Belinda N Rivera-Lebron
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, UPMC Montefiore, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA.
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20
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Bhatia HS, Hsu JC, Kim RJ. Atrial fibrillation and chronic kidney disease: A review of options for therapeutic anticoagulation to reduce thromboembolism risk. Clin Cardiol 2018; 41:1395-1402. [PMID: 30259531 DOI: 10.1002/clc.23085] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 09/20/2018] [Accepted: 09/22/2018] [Indexed: 01/09/2023] Open
Abstract
Atrial fibrillation and chronic kidney disease (CKD) commonly occur together, which poses a therapeutic dilemma due to increased risk of both systemic thromboembolism and bleeding. Chronic kidney disease also has implications for medication selection. The objective of this review is to evaluate the options for anticoagulation for thromboembolism prevention in patients with atrial fibrillation and chronic kidney disease. We searched PubMed for studies of patients with atrial fibrillation and CKD on warfarin or a direct oral anticoagulant (DOAC) for thromboembolism prevention through January 1 2018, in addition to evaluating major trials evaluating DOACs and warfarin use as well as society guidelines. For patients with mild to moderate chronic kidney disease, primarily observational data supports the use of warfarin, and high quality trial data and meta-analyses support the use and possible superiority of DOACs. For patients with severe chronic kidney disease, there are limited data on warfarin which supports its use, and data for DOACs is limited primarily to pharmacologic studies which support dose reductions but lack information on patient outcomes. For patients with end-stage renal disease, studies on warfarin are conflicting, but the majority suggest a lack of benefit and possible harm; studies in DOACs are very limited, but apixaban is the least renally cleared and may be both safe and effective. In conclusion, warfarin or DOACs may be used based on the degree of severity of chronic kidney disease, but further study in needed in patients with end-stage renal disease.
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Affiliation(s)
- Harpreet S Bhatia
- Department of Medicine, Weill Cornell Medicine, New York, New York.,Division of Cardiology, Department of Medicine, University of California, San Diego, California
| | - Jonathan C Hsu
- Division of Cardiology, Department of Medicine, University of California, San Diego, California
| | - Robert J Kim
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, New York
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Lu HY, Liao KM. Increased risk of deep vein thrombosis in end-stage renal disease patients. BMC Nephrol 2018; 19:204. [PMID: 30115029 PMCID: PMC6097196 DOI: 10.1186/s12882-018-0989-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 07/20/2018] [Indexed: 02/07/2023] Open
Abstract
Background Previous studies have shown that chronic kidney disease increases the risk of deep vein thrombosis (DVT). DVT is the risk of pulmonary embolism among persons with end-stage renal disease (ESRD). Information on the incidence of DVT in ESRD is limited, and no studies have been conducted in the Asian population. The aim of our study was to investigate the incidence of DVT in Asian ESRD patients by comparing with the non-ESRD patients and to identify the associated risk factors. Methods This study retrieved patients who were diagnosed with ESRD (ICD-9-CM codes 585 or 586) between January 1, 2004, and December 31, 2010, from the National Health Insurance Research Database in Taiwan. All ESRD patients had received a catastrophic illness card from the Ministry of Health and Welfare in Taiwan, with the major illness identified as ESRD. Patients who had DVT before the index date or who had incomplete records were excluded from the analysis. A total of 4865 ESRD patients were enrolled. There are 3564 ESRD patients included after exclusion of patients with previous DVT and patients with incomplete records. The control subjects were randomly selected as the patients without ESRD by matching study subjects according to age (±3 years), gender, and the year of admission at a 2:1 ratio from the same dataset. Results The incidence rate of DVT was substantially higher in the ESRD group than in the without-ESRD group (20.9 vs. 1.46 per 10^4 person-years). The adjusted hazard ratio (aHR 13.92; 95% CI 9.25–20.95) of DVT for the ESRD patients was 13.92 times that for the non-ESRD patients. ESRD patients older than 50 years had a higher risk of DVT (aHR 1.65; 95% CI 1.13–2.40; P = 0.01). Hyperlipidemia was significantly associated with an increased risk of DVT (aHR 1.73; 95% CI 1.08–2.78; P = 0.02). ESRD patients with three or more comorbidities were substantially more likely to have DVT (aHR 1.45; 95% CI 1.03–2.03; P = 0.03). Conclusions ESRD patients had a higher risk of DVT than non-ESRD patients. Among the ESRD patients, being older than 50 years and having dyslipidemia increased the risk of DVT.
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Affiliation(s)
- Hsueh-Yi Lu
- Department of Industrial Engineering and Management, National, Yunlin University of Science and Technology, Yun-Lin, Taiwan
| | - Kuang-Ming Liao
- Department of Internal Medicine, Chi Mei Medical Center, Chiali, Taiwan.
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22
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Venous thromboembolism, factor VIII and chronic kidney disease. Thromb Res 2018; 170:10-19. [PMID: 30081388 DOI: 10.1016/j.thromres.2018.07.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 07/30/2018] [Indexed: 12/12/2022]
Abstract
Chronic kidney disease (CKD) affects 30 million Americans and is associated with approximately a two-fold increased risk of venous thromboembolism (VTE). There is a graded increased risk of VTE across declining kidney function, as measured by estimated glomerular filtration rate (eGFR) and albuminuria. When patients with end-stage kidney disease (ESKD) experience VTE they are more likely than the general population to be hospitalized and they have a higher mortality. The incidence and consequences of VTE may also differ depending on the cause of kidney disease. In addition, kidney transplant patients with VTE are at a greater risk for death and graft loss than transplant patients without VTE. The reasons that patients with CKD are at increased risk of VTE are not well understood, but recent data suggest that factor VIII is a mediator. Factor VIII is an essential cofactor in the coagulation cascade and a strong risk factor for VTE in general. It is inversely correlated with eGFR and prospective studies demonstrate that factor VIII activity predicts incident CKD and rapid eGFR decline. The etiology of CKD may also influence factor VIII levels. This review summarizes the epidemiology VTE in CKD and reviews the biochemistry of factor VIII and determinants of its levels, including von Willebrand factor and ABO blood group. We explore mechanisms by which the complications of CKD might give rise to higher factor VIII and suggests future research directions to understand how factor VIII and CKD are linked.
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Reed D, Palkimas S, Hockman R, Abraham S, Le T, Maitland H. Safety and effectiveness of apixaban compared to warfarin in dialysis patients. Res Pract Thromb Haemost 2018; 2:291-298. [PMID: 30046731 PMCID: PMC6055495 DOI: 10.1002/rth2.12083] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 01/20/2018] [Indexed: 11/05/2022] Open
Abstract
Background: The use of apixaban for stroke prophylaxis or for the treatment of venous thromboembolism in end stage renal disease (ESRD) patients maintained on dialysis is based on one single-dose pharmacokinetic study. There is a deficiency of clinical evidence supporting safety in this population.Objective: The purpose of this study was to determine the safety and efficacy of apixaban compared with warfarin in dialysis patients.Patients/methods: This is a retrospective cohort study conducted at the University of Virginia Medical Center. A total of 124 ESRD patients maintained on dialysis who either received apixaban (n = 74) or warfarin (n = 50) between January 1, 2014 and October 31, 2016 were included in the study. We used multivariable logistic regression to compare the likelihood of patients experiencing a bleeding event based on anticoagulant therapy.Results: The apixaban group experienced fewer overall bleeding events than the warfarin group (18.9% vs 42.0%; P = .01); this significant difference persisted in adjusted analysis (OR = 0.15; 95% CI = 0.05-0.46; P = .001). Major bleeding events were less frequent in the apixaban group compared with patients on warfarin (5.4% vs 22.0%; P = .01). There were no recurrent ischemic strokes in either groups. A lower, non-significant, incidence of recurrent VTE was found in patients on apixaban compared with warfarin (4.4% vs 28.6%; P = .99).Conclusion: Compared to warfarin, our findings suggest that apixaban is a safe and effective alternative in patients with ESRD maintained on dialysis, with apixaban patients experiencing fewer bleeding events than warfarin patients.
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Affiliation(s)
- Daniel Reed
- Division of Hematology & OncologyUniversity of VirginiaCharlottesvilleVAUSA
| | - Surabhi Palkimas
- Department of PharmacyUniversity of VirginiaCharlottesvilleVAUSA
| | - Rebecca Hockman
- Department of PharmacyUniversity of VirginiaCharlottesvilleVAUSA
| | - Sumner Abraham
- Department of MedicineUniversity of VirginiaCharlottesvilleVAUSA
| | - Tri Le
- Division of Hematology & OncologyUniversity of VirginiaCharlottesvilleVAUSA
| | - Hillary Maitland
- Division of Hematology & OncologyUniversity of VirginiaCharlottesvilleVAUSA
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24
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[Anticoagulation in patients with chronic kidney disease : Recommendations from the working group "Heart-Kidney" of the German Cardiac Society and the German Society of Nephrology]. Internist (Berl) 2018; 58:512-521. [PMID: 28396914 DOI: 10.1007/s00108-017-0220-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Indications for anticoagulation are thromboembolic events, prosthetic heart valves, and atrial fibrillation with a corresponding risk score. Clinical trials have excluded patients with advanced chronic kidney disease and these data cannot be always generalized to patients with chronic kidney disease. Non-vitamin K antagonist oral anticoagulants (NOACs) are mostly not recommended or are contraindicated in advanced stages of chronic kidney disease. Observational studies have shown that dialysis patients with atrial fibrillation do not profit from coumarin anticoagulants; prospective studies are lacking.
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25
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Wang IK, Shen TC, Muo CH, Yen TH, Sung FC. Risk of pulmonary embolism in patients with end-stage renal disease receiving long-term dialysis. Nephrol Dial Transplant 2018; 32:1386-1393. [PMID: 27448674 DOI: 10.1093/ndt/gfw272] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 06/06/2016] [Indexed: 11/14/2022] Open
Abstract
Background This study compared the pulmonary embolism (PE) risks between Asian dialysis patients and a comparison cohort without clinical kidney disease. Methods From the National Health Insurance claims data of Taiwan, we identified 106 231 newly diagnosed end-stage renal disease patients undergoing dialysis in 1998-2010 and randomly selected 106 231 comparison subjects, frequency matched by age, sex and the index year. We further selected 7430 peritoneal dialysis (PD) patients and 7340 propensity score-matched hemodialysis (HD) patients. Incidence rates and hazard ratios (HRs) of PE and odds ratio (OR) of subsequent 30-day deaths from PE were evaluated among study cohorts by the end of 2011. Results The overall incident PE was nearly 3-fold greater in dialysis patients than in the comparison cohort (0.92 versus 0.33 per 1000 person-years), with an adjusted HR of 2.02 [95% confidence interval (CI) = 1.63-2.50]. The PE incidence was greater in the propensity score-matched HD patients, than in PD patients with an adjusted HR of 2.30 (95% CI = 1.23-4.29). There was a greater PE risk for central venous catheter users than non-users among HD patients (1.83 versus 0.75 per 1000 person-years). The 30-day mortality from PE was higher in dialysis patients than in the comparison cohort (16.5 versus 9.77%) with an adjusted OR of 2.56 (95% CI = 1.32-4.95). Conclusions Dialysis patients are at a nearly 2-fold increased hazard of developing PE and are at greater risk of fatality from PE compared with those without clinical kidney disease. This study also shows a higher PE risk in HD patients than in PD patients.
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Affiliation(s)
- I-Kuan Wang
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan.,Department of Internal Medicine, College of Medicine, China Medical University, Taichung, Taiwan.,Division of Nephrology, China Medical University Hospital, Taichung, Taiwan
| | - Te-Chun Shen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Hsin Muo
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Tzung-Hai Yen
- Division of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan.,Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Fung-Chang Sung
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan.,Department of Health Services Administration, College of Public Health, China Medical University, Taichung, Taiwan
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Cicora F, Petroni J, Roberti J. Prophylaxis of Pulmonary Embolism in Kidney Transplant Recipients. Curr Urol Rep 2018; 19:17. [DOI: 10.1007/s11934-018-0759-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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27
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Keller K, Beule J, Balzer JO, Dippold W. Renal function as a cofactor for risk stratification and short-term outcome in acute pulmonary embolism. Exp Gerontol 2017; 100:11-16. [DOI: 10.1016/j.exger.2017.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 10/03/2017] [Accepted: 10/07/2017] [Indexed: 12/15/2022]
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28
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Massicotte-Azarniouch D, Bader Eddeen A, LazoLanger A, Molnar AO, Lam NN, McCallum MK, Bota S, Zimmerman D, Garg AX, Harel Z, Perl J, Wald R, Sood MM. Risk of Venous Thromboembolism in Patients by Albuminuria and Estimated GFR. Am J Kidney Dis 2017; 70:826-833. [DOI: 10.1053/j.ajkd.2017.07.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 07/03/2017] [Indexed: 12/30/2022]
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29
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Lin MC, Streja E, Soohoo M, Hanna M, Savoj J, Kalantar-Zadeh K, Lau WL. Warfarin Use and Increased Mortality in End-Stage Renal Disease. Am J Nephrol 2017; 46:249-256. [PMID: 28910806 DOI: 10.1159/000481207] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 09/02/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Controversy exists regarding the benefits and risks of warfarin therapy in chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients. In this study, we assessed mortality and cardiovascular outcomes associated with warfarin treatment in patients with stages 3-5 CKD and ESRD admitted to the University of California-Irvine Medical Center. METHODS In a retrospective matched cohort study, we identified 59 adult patients with stages 3-6 CKD initiated on warfarin during the period 2011-2013, and 144 patients with stages 3-6 CKD who had indications for anticoagulation therapy but were not initiated on warfarin. All-cause mortality risk associated with warfarin treatment was estimated using Cox proportional hazard regression analysis, and the risk of significant bleeding and major adverse cardiovascular events were analyzed with Poisson regression analysis. Adjustment models were used to account for age, gender, diabetes mellitus, use of antiplatelet agents, and preexisting cardiovascular disease, and stratified by pre-dialysis CKD stages 3-5 vs. ESRD. FINDINGS During 5.8 years of follow-up, unadjusted mortality risk was higher in CKD patients on warfarin therapy (hazard ratio [HR] 2.34 with 95% CI 1.25-4.39; p < 0.01). After multivariate adjustment and stratification by CKD stage, the mortality risk remained significant in ESRD patients receiving warfarin (HR 6.62 with 95% CI 2.56-17.16; p < 0.001). Furthermore, adjusted rates of significant bleeding (incident rate ratio, IRR 3.57 with 95% CI 1.51-8.45; p < 0.01) and myocardial infarction (IRR 4.20 with 95% CI 1.78-9.91; p < 0.01) were higher among warfarin users. No differences in rates of ischemic or hemorrhagic strokes were found between the 2 groups. CONCLUSIONS Warfarin use was associated with several-fold higher risk of death, bleeding, and myocardial infarction in dialysis patients. If additional studies suggest similar associations, the use of warfarin in dialysis patients warrants immediate reconsideration.
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Affiliation(s)
- Mark C Lin
- School of Medicine, University of California, Irvine, CA, USA
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30
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Abstract
Venous thromboembolism (VTE) has a wide range of clinical presentations. Deep venous thrombosis may occur in upper or lower extremities or in visceral veins. Extremity deep venous thrombosis usually manifests with unilateral painful swelling in the limb, while visceral deep venous thrombosis manifestations vary on the basis of the involved organ. Pulmonary embolism classically manifests with sudden pleuritic chest pain and unexplained dyspnea. Superficial thrombophlebitis usually presents with acute inflammation around a palpable thrombosed superficial vein. Risk factors of VTE are either inherited or acquired. The inherited causes of VTE tend to be familial and more common in younger patients. The common acquired risk factors of VTE include previous history of venous thrombosis, immobilization, recent surgery or trauma, malignancy, and pregnancy. Identifying high-risk patients for VTE based on these risk factors is the cornerstone to provide the prophylactic treatment to prevent thrombotic events.
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31
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Yamasaki K, Haruyama N, Taniguchi M, Nishida T, Tominaga R, Kitazono T, Tsuruya K. Subacute pulmonary embolism in a hemodialysis patient, successfully treated with surgical thrombectomy. CEN Case Rep 2017; 5:74-77. [PMID: 28509182 DOI: 10.1007/s13730-015-0195-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 09/02/2015] [Indexed: 11/30/2022] Open
Abstract
A 53-year-old woman was admitted to our hospital with a 1-month history of gradually progressive resting dyspnea and lumbar backache. For the preceding 6 years, she had received regular hemodialysis for end-stage renal disease caused by autosomal dominant polycystic kidney disease and had taken tamoxifen for 3 years as post-operative chemotherapy for breast cancer. Before admission, the patient's symptoms had been attributed to volume overload, based on right thoracic fluid and leg edema. However, despite volume correction by dialysis therapy, her symptoms had not improved. The patient was transferred to our hospital, where she was diagnosed with subacute pulmonary embolism (PE). Emergent pulmonary thrombectomy was performed using cardio-pulmonary bypass. The patient was discharged from our hospital on post-operative day 23. Recent reports have shown that hemodialysis patients have a relatively higher risk of PE compared with the general population. Our case had additional risk factors for PE: female sex, decreased protein C level, tamoxifen use, and autosomal dominant polycystic kidney disease. These factors may have had a synergistic effect on the onset of PE.
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Affiliation(s)
- Keisuke Yamasaki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Nephrology, Yamaguchi Red Cross Hospital, Yamaguchi, Japan
| | - Naoki Haruyama
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masatomo Taniguchi
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takahiro Nishida
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryuji Tominaga
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazuhiko Tsuruya
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. .,Department of Integrated Therapy for Chronic Kidney Disease, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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32
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Gigante A, Di Mario F, Pierucci A, Amoroso A, Pignataro FS, Napoleone L, Basili S, Raparelli V. Kidney disease and venous thromboembolism: Does being woman make the difference? Eur J Intern Med 2017; 39:18-23. [PMID: 28258791 DOI: 10.1016/j.ejim.2017.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/20/2016] [Accepted: 02/16/2017] [Indexed: 01/05/2023]
Abstract
The risk of venous thromboembolism (VTE) is increased across the spectrum of chronic kidney disease (CKD), from mild to more advanced CKD, and typically characterizes nephrotic syndrome (NS). VTE risk in patients with kidney disease may be due to underlying hemostatic abnormalities, including activation of pro-thrombotic factors, inhibition of endogenous anticoagulation systems, enhanced platelet activation and aggregation, and decreased fibrinolytic activity. The mechanisms involved differ depending on the cause of the kidney impairment (i.e. presence of NS or CKD stage). Sex and gender differences, as well as, environmental factors or comorbidities may play a modulating role; however, specific sex and gender data on this topic are still rare. The aim of the present review is to discuss the VTE risk associated with impairment of kidney function, the potential mechanism accounting for it and the impact of sex differences in this clinical setting.
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Affiliation(s)
- A Gigante
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy.
| | - F Di Mario
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - A Pierucci
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - A Amoroso
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - F S Pignataro
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - L Napoleone
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - S Basili
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy; Research Center on Gender and Evaluation and Promotion of Quality in Medicine, (CEQUAM), Sapienza University of Rome, Rome, Italy
| | - V Raparelli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
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33
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Cheung KL, Zakai NA, Folsom AR, Kurella Tamura M, Peralta CA, Judd SE, Callas PW, Cushman M. Measures of Kidney Disease and the Risk of Venous Thromboembolism in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study. Am J Kidney Dis 2017; 70:182-190. [PMID: 28126238 DOI: 10.1053/j.ajkd.2016.10.039] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 10/30/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Kidney disease has been associated with venous thromboembolism (VTE) risk, but results conflict and there is little information regarding blacks. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 30,239 black and white adults 45 years or older enrolled in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study 2003 to 2007. PREDICTORS Estimated glomerular filtration rate (eGFR) using the combined creatinine-cystatin C (eGFRcr-cys) equation and urinary albumin-creatinine ratio (ACR). OUTCOMES The primary outcome was adjudicated VTE, and secondary outcomes were provoked and unprovoked VTE, separately. Mortality was a competing-risk event. RESULTS During 4.6 years of follow-up, 239 incident VTE events occurred over 124,624 person-years. Cause-specific HRs of VTE were calculated using proportional hazards regression adjusted for age, sex, race, region of residence, and body mass index. Adjusted VTE HRs for eGFRcr-cys of 60 to <90, 45 to <60, and <45 versus ≥90mL/min/1.73m2 were 1.28 (95% CI, 0.94-1.76), 1.30 (95% CI, 0.77-2.18), and 2.13 (95% CI, 1.21-3.76). Adjusted VTE HRs for ACR of 10 to <30, 30 to <300, and ≥300 versus <10mg/g were 1.14 (95% CI, 0.84-1.56), 1.15 (95% CI, 0.79-1.69), and 0.64 (95% CI, 0.25-1.62). Associations were similar for provoked and unprovoked VTE. LIMITATIONS Single measurement of eGFR and ACR may have led to misclassification. Smaller numbers of events may have limited power. CONCLUSIONS There was an independent association of low eGFR (<45 vs ≥90mL/min/1.73m2) with VTE risk, but no association of ACR and VTE.
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Affiliation(s)
| | - Neil A Zakai
- Larner College of Medicine, University of Vermont, Burlington, VT
| | | | - Manjula Kurella Tamura
- Geriatrics Research Education and Clinical Center, Stanford University and VA Palo Alto Health Care System, Palo Alto, CA
| | | | | | | | - Mary Cushman
- Larner College of Medicine, University of Vermont, Burlington, VT
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Ribic C, Crowther M. Thrombosis and anticoagulation in the setting of renal or liver disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:188-195. [PMID: 27913479 PMCID: PMC6142494 DOI: 10.1182/asheducation-2016.1.188] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Thrombosis and bleeding are among the most common causes of morbidity and mortality in patients with renal disease or liver disease. The pathophysiology underlying the increased risk for venous thromboembolism and bleeding in these 2 populations is distinct, as are considerations for anticoagulation. Anticoagulation in patients with kidney or liver disease increases the risk of bleeding; this risk is correlated with the degree of impairment of anticoagulant elimination by the kidneys and/or liver. Despite being in the same pharmacologic category, anticoagulant agents may have varied degrees of renal and liver metabolism. Therefore, specific anticoagulants may require dose reductions or be contraindicated in renal impairment and liver disease, whereas other drugs in the same class may not be subject to such restrictions. To minimize the risk of bleeding, while ensuring an adequate therapeutic effect, both appropriate anticoagulant drug choices and dose reductions are necessary. Renal and hepatic function may fluctuate, further complicating anticoagulation in these high-risk patient groups.
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Affiliation(s)
- Christine Ribic
- Department of Medicine and Department of Pathology and Molecular Medicine, McMaster University, and St Joseph's Healthcare, Hamilton, ON, Canada
| | - Mark Crowther
- Department of Medicine and Department of Pathology and Molecular Medicine, McMaster University, and St Joseph's Healthcare, Hamilton, ON, Canada
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35
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Kushiya F, Wada H, Sakakura M, Mori Y, Gabazza EC, Nishikawa M, Nobori T, Noguchi M, Izumi K, Nakasaki T, Takagi M, Shiku H. Prognostic Impact of Aortic Calcification Index and Ankle-Arm Blood Pressure Indexin Patients under Hemodialysis. Clin Appl Thromb Hemost 2016; 11:161-9. [PMID: 15821822 DOI: 10.1177/107602960501100205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The mortality rate is high in patients receiving hemodialysis (HD), atherosclerotic diseases being the major cause of death. As marker of clinical outcome, a prospective examination of atherosclerotic tests and atherosclerotic risk factors in patients receiving HD was performed. On April 2000, 84 patients receiving HD were followed up until April 2002. At entry to the study, several atherosclerotic tests, including ankle-arm blood pressure index (API), aortic calcification index (ACI), and atherosclerotic risk factors, were performed. In 36 patients with old thrombotic events, 26 had new thrombotic events. Of 48 patients without previous thrombotic events, 15 had new thrombotic events. During 2 years, 41 patients had new thrombotic events and 15 patients died due to thrombotic disorders. The HD durations were significantly longer in non-survivors than survivors and the body mass index was lower in non-survivors than survivors. There was a significant difference in the values of ACI and API between survivors and non-survivors, and between patients with and without thrombotic events. These findings suggest that the ACI and API have a prognostic value because they might predict the occurrence of thrombosis.
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Affiliation(s)
- Fumihiko Kushiya
- Second Department of Internal Medicine, Mie University School of Medicine, Tsu-city, Mie-Ken, Japan
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36
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Hsieh MY, Lin L, Chen TY, Wang RH, Huang SC, Liu H, Lai CL, Pu SY, Tsai KC, Wu CC. Pulmonary Hypertension in Hemodialysis Patients Following Repeated Endovascular Thrombectomy. ACTA CARDIOLOGICA SINICA 2016; 32:299-306. [PMID: 27274170 DOI: 10.6515/acs20150511c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The prevalence of pulmonary hypertension is unusually high in Taiwanese patients with end-stage renal disease. Thrombosis of hemodialysis grafts is common and pulmonary embolism has been reported after endovascular thrombectomy. The aim of this study was to evaluate the relationship between pulmonary hypertension and endovascular thrombectomy of hemodialysis grafts. METHODS One hundred and ten patients on hemodialysis via arteriovenous grafts were enrolled in our study. The mean pulmonary artery pressure (PAP) was measured by right heart catheterization. Clinical information was collected by review of medical records. Comorbid cardiopulmonary disease was evaluated by echocardiography and chest X-ray. The history of patient vascular access thrombosis was reviewed from database, hemodialysis records, and interviews with staff at hemodialysis centers. RESULTS Fifty-two participants (47%) had pulmonary hypertension diagnosed by right heart catheterization. There was no difference in the number of thrombectomy procedures between patients with and without pulmonary hypertension. Based on multivariate analysis, the number of prior endovascular thrombectomy procedures did not correlate with mean PAP (F-value = 1.10, p = 0.30) nor was it associated with pulmonary hypertension (odds ratio = 0.92, p = 0.17). CONCLUSIONS Prior endovascular arteriovenous graft thrombectomies were not associated with pulmonary hypertension or increased mean PAP in end-stage renal disease patients on maintenance hemodialysis.
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Affiliation(s)
- Mu-Yang Hsieh
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu
| | - Lin Lin
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu
| | - Tsung-Yan Chen
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu
| | - Ren-Huei Wang
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu
| | - Su-Chin Huang
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu
| | - HsiuChiao Liu
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu
| | - Chao-Lun Lai
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu; ; College of Medicine, National Taiwan University, Taipei; ; Department of Internal Medicine and Center for Critical Care Medicine, National Taiwan University Hospital Hsinchu Branch, Hsinchu; ; Department of Internal Medicine, College of Medicine; ; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei
| | - Shih-Yen Pu
- Cardiology Department, Ton-Yen General Hospital, Hsinchu
| | | | - Chih-Cheng Wu
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu; ; College of Medicine, National Taiwan University, Taipei; ; School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Hatch Q, Nelson D, Martin M, Maykel JA, Johnson EK, Champagne BJ, Hyman NH, Steele SR. Can sepsis predict deep venous thrombosis in colorectal surgery? Am J Surg 2016; 211:53-8. [DOI: 10.1016/j.amjsurg.2015.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 06/17/2015] [Accepted: 06/29/2015] [Indexed: 01/27/2023]
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Tsai J, Grant AM, Beckman MG, Grosse SD, Yusuf HR, Richardson LC. Determinants of venous thromboembolism among hospitalizations of US adults: a multilevel analysis. PLoS One 2015; 10:e0123842. [PMID: 25879844 PMCID: PMC4399914 DOI: 10.1371/journal.pone.0123842] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 02/25/2015] [Indexed: 12/01/2022] Open
Abstract
Background Venous thromboembolism (VTE) is a significant clinical and public health concern. We evaluated a variety of multilevel factors—demographics, clinical and insurance status, preexisting comorbid conditions, and hospital characteristics—for VTE diagnosis among hospitalizations of US adults. Methods We generated adjusted odds ratios with 95% confidence intervals (CIs) and determined sources of outcome variation by conducting multilevel logistic regression analysis of data from the 2011 Nationwide Inpatient Sample that included 6,710,066 hospitalizations of US adults nested within 1,039 hospitals. Results Among hospitalizations of adults, age, sex, race or ethnicity, total days of hospital stay, status of health insurance, and operating room procedure were important determinants of VTE diagnosis; each of the following preexisting comorbid conditions—acquired immune deficiency syndrome, anemia, arthritis, congestive heart failure, coagulopathy, hypertension, lymphoma, metastatic cancer, other neurological disorders, obesity, paralysis, pulmonary circulation disorders, renal failure, solid tumor without metastasis, and weight loss—was associated independently with 1.04 (95% CI: 1.02−1.06) to 2.91 (95% CI: 2.81−3.00) times increased likelihood of VTE diagnosis than among hospitalizations of adults without any of these corresponding conditions. The presence of 2 or more of such conditions was associated a 180%−450% increased likelihood of a VTE diagnosis. Hospitalizations of adults who were treated in urban hospitals were associated with a 14%−15% increased likelihood of having a VTE diagnosis than those treated in rural hospitals. Approximately 7.4% of the total variation in VTE diagnosis occurred between hospitals. Conclusion The presence of certain comorbidities and hospital contextual factors is associated with significantly elevated likelihood of VTE diagnosis among hospitalizations of adults. The findings of this study underscore the importance of clinical risk assessment and adherence to evidence-based clinical practice guidelines in preventing VTE, as well as the need to evaluate potential contextual factors that might modify the risk of VTE among hospitalized patients.
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Affiliation(s)
- James Tsai
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- * E-mail:
| | - Althea M. Grant
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Michele G. Beckman
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Scott D. Grosse
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Hussain R. Yusuf
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Lisa C. Richardson
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Abstract
Chronic kidney disease (CKD) is characterized by retention of a number of toxins, which unleash cellular damage. CKD environment with these toxins and a host of metabolic abnormalities (collectively termed as uremic milieu) is highly thrombogenic. CKD represents a strong and independent risk factor for both spontaneous venous and arterial (postvascular injury) thrombosis. Emerging evidence points to a previously unrecognized role of some of the prothrombotic uremic toxins. Here, we provide an overview of thrombosis in CKD and an update on indolic uremic toxins, which robustly increase tissue factor, a potent procoagulant, in several vascular cell types enhancing thrombosis. This panel of uremic toxins, which we term "thrombolome" (thrombosis and metabolome), represents a novel risk factor for thrombosis and can be further explored as biomarker for postvascular interventional thrombosis in patients with CKD.
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Affiliation(s)
- Shashar Moshe
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jean Francis
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Vipul Chitalia
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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Sakhuja A, Stephany B, Deitzer D, Kumar G, Schold JD. Trends of pulmonary embolism before and after kidney transplantation in black versus white patients. Transplant Proc 2015; 46:1353-61. [PMID: 24935299 DOI: 10.1016/j.transproceed.2014.01.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 01/16/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) is an important cause of in-hospital mortality and is common in renal transplantation and maintenance dialysis patients. PE incidence is higher among patients who are black; however, differences in trends of incidence and outcomes of PE by race among patients on dialysis and after renal transplantation is not well known. METHODS In this observational study, the incidences of PE hospitalizations and mortality were studied in those with renal transplant, on maintenance dialysis, and in general population. Incidences were compared across racial groups. Renal transplantation status as a predictor of mortality was also examined. RESULTS The incidences of PE in general population, dialysis, and renal transplant groups were 70.5, 518.8, and 158.8 per 100,000 population, respectively. Incidence was higher in blacks across all groups. The age-adjusted incidence of PE admissions increased over time in all groups with greater increase in blacks in non-transplant groups (the slope in dialysis for blacks was 112.1 versus that for whites at 49.4; P = .001; the slope in general population for blacks was 9.3 versus 3.4 for whites; P = .003). The mortality rate in general population was not significantly different than renal transplant group (3.4% versus 1.9%, P = .2); however, was lower than 6.8% seen in dialysis group (P < .001). The mortality rate was not different between whites and blacks. Maintenance dialysis was an independent predictor of mortality (odds ratio [OR] 1.94; 95% confidence interval [CI] 1.62-2.32). CONCLUSIONS PE in those with renal transplant is more common than in general population but less common than those on maintenance dialysis. The mortality rate for PE hospitalizations is equivocal between renal transplant and general population but higher for patients on dialysis. The incidence of PE hospitalizations is not only higher among blacks, but is increasing disproportionately in this group among those who are on maintenance dialysis and within general population.
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Affiliation(s)
- A Sakhuja
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio.
| | - B Stephany
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio
| | - D Deitzer
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio
| | - G Kumar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - J D Schold
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
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Ouatu A, Tãnase DM, Floria M, Ionescu SD, Ambãruş V, Arsenescu-Georgescu C. Chronic kidney disease: Prognostic marker of nonfatal pulmonary thromboembolism. Anatol J Cardiol 2014; 15:938-43. [PMID: 25868039 PMCID: PMC5336947 DOI: 10.5152/akd.2014.5739] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective: Renal dysfunction is associated with increased cardiovascular morbidity and mortality. The alteration in renal function as a marker of mortality in pulmonary thromboembolism (PTE) has not been studied extensively. Methods: Four hundred four consecutive patients diagnosed with non-high-risk PTE (without cardiogenic shock or blood pressure <90 mm Hg) were prospectively enrolled in the study between 2005-2010. Kidney function, based on glomerular filtration rate (GFR), calculated by the simplified modification in diet in renal disease (MDRD) equation (sMDRD); troponin I; B-type natriuretic peptide (BNP); and echocardiographic markers of right ventricular (RV) function were determined in survivors versus non-survivors after a 2-year follow-up. Results: GFR was significantly lower in non-survivors than in survivors: 51.85±19.08 mL/min/1.73 m2 and 71.65±23.21 mL/min/1.73 m2, respectively (p=0.000). The highest 2-year mortality rate (20%) was recorded in patients with moderate renal dysfunction associated with RV dysfunction. Using multivariate analysis, we found that GFR is an independent predictor of 2-year mortality (OR 0.973, 95% CI: 0.959-0.987, p=0.000), besides troponin I, dyslipidemia, acceleration time of pulmonary ejection, pericardial effusion, and BNP Conclusion: The association of renal dysfunction with right ventricular dysfunction in patients with non-fatal pulmonary thromboembolism resulted in high mortality. Renal dysfunction, assessed by glomerular filtration rate, may be used in the risk stratification of patients with non-high-risk pulmonary thromboembolism, besides troponin I, BNP and right ventricle echocardiographic dysfunction markers.
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Affiliation(s)
- Anca Ouatu
- Grigore T.Popa University of Medicine and Pharmacy; Iaşi-România; IIIrd Medical Clinic from Sf. Spiridon University Hospital; Iaşi-România.
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Christiansen CF, Schmidt M, Lamberg AL, Horváth-Puhó E, Baron JA, Jespersen B, Sørensen HT. Kidney disease and risk of venous thromboembolism: a nationwide population-based case-control study. J Thromb Haemost 2014; 12:1449-54. [PMID: 25040558 DOI: 10.1111/jth.12652] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 06/26/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic kidney disease is associated with hemostatic derangements, including both procoagulant activity and platelet dysfunction, which may influence the risk of venous thromboembolism. However, data associating kidney disease with risk of venous thromboembolism are sparse. OBJECTIVES We examined whether kidney disease is associated with increased risk of venous thromboembolism. METHODS We conducted this nationwide case-control study using data from medical databases. We included 128,096 patients with a hospital diagnosis of VTE in Denmark between 1980 and 2010 (54,473 had pulmonary embolism and 73,623 had deep venous thrombosis only) and 642,426 age- and gender-matched population controls based on risk-set sampling. We identified all previous hospital diagnoses of kidney disease, including nephrotic syndrome, glomerulonephritis without nephrotic syndrome, hypertensive nephropathy, chronic pyelonephritis/interstitial nephritis, polycystic kidney disease, diabetic nephropathy, or other kidney diseases. We used conditional logistic regression models to compute odds ratios (ORs) for venous thromboembolism with adjustment for potential confounders. RESULTS Kidney disease was associated with an adjusted OR for venous thromboembolism ranging from 1.41 (95% CI, 1.22-1.63) for hypertensive nephropathy to 2.89 (95% CI, 2.26-3.69) for patients with nephrotic syndrome. The association was strongest within the first 3 months after a diagnosis of chronic kidney disease (adjusted OR for nephrotic syndrome = 23.23; 95% CI, 8.58-62.89), gradually declining thereafter. The risk, however, remained elevated for more than 5 years, especially in patients with nephrotic syndrome and glomerulonephritis. CONCLUSIONS Kidney diseases, in particular nephrotic syndrome and glomerulonephritis, were associated with an increased risk of venous thromboembolism.
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Affiliation(s)
- C F Christiansen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Ocak G, Drechsler C, Vossen CY, Vos HL, Rosendaal FR, Reitsma PH, Hoffmann MM, März W, Ouwehand WH, Krediet RT, Boeschoten EW, Dekker FW, Wanner C, Verduijn M. Single nucleotide variants in the protein C pathway and mortality in dialysis patients. PLoS One 2014; 9:e97251. [PMID: 24816905 PMCID: PMC4016291 DOI: 10.1371/journal.pone.0097251] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 04/16/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The protein C pathway plays an important role in the maintenance of endothelial barrier function and in the inflammatory and coagulant processes that are characteristic of patients on dialysis. We investigated whether common single nucleotide variants (SNV) in genes encoding protein C pathway components were associated with all-cause 5 years mortality risk in dialysis patients. METHODS Single nucleotides variants in the factor V gene (F5 rs6025; factor V Leiden), the thrombomodulin gene (THBD rs1042580), the protein C gene (PROC rs1799808 and 1799809) and the endothelial protein C receptor gene (PROCR rs867186, rs2069951, and rs2069952) were genotyped in 1070 dialysis patients from the NEtherlands COoperative Study on the Adequacy of Dialysis (NECOSAD) cohort) and in 1243 dialysis patients from the German 4D cohort. RESULTS Factor V Leiden was associated with a 1.5-fold (95% CI 1.1-1.9) increased 5-year all-cause mortality risk and carriers of the AG/GG genotypes of the PROC rs1799809 had a 1.2-fold (95% CI 1.0-1.4) increased 5-year all-cause mortality risk. The other SNVs in THBD, PROC, and PROCR were not associated with 5-years mortality. CONCLUSION Our study suggests that factor V Leiden and PROC rs1799809 contributes to an increased mortality risk in dialysis patients.
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Affiliation(s)
- Gürbey Ocak
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
| | - Christiane Drechsler
- Department of Medicine, Division of Nephrology, University Hospital, Würzburg, Germany
- Comprehensive Heart Failure Center, University of Wuerzburg, Wuerzburg, Germany
- Institute of Clinical Epidemiology and Biometry, University of Wuerzburg, Wuerzburg, Germany
| | - Carla Y. Vossen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hans L. Vos
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Frits R. Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Pieter H. Reitsma
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Michael M. Hoffmann
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center, Freiburg, Germany
| | - Winfried März
- Department of Public Health, Social and Preventive Medicine, University of Heidelberg, Mannheim, Germany
| | - Willem H. Ouwehand
- Department of Hematology, University of Cambridge and National Health Service Blood and Transplant, Cambridge, United Kingdom
- Department of Human Genetics, Wellcome Trust Sanger Institute, Cambridge, United Kingdom
| | - Raymond T. Krediet
- Department of Nephrology, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Friedo W. Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Christoph Wanner
- Department of Medicine, Division of Nephrology, University Hospital, Würzburg, Germany
- Comprehensive Heart Failure Center, University of Wuerzburg, Wuerzburg, Germany
| | - Marion Verduijn
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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Fabbian F, Gallerani M, Pala M, De Giorgi A, Salmi R, Manfredini F, Portaluppi F, Dentali F, Ageno W, Mikhailidis DP, Manfredini R. In-hospital mortality for pulmonary embolism: relationship with chronic kidney disease and end-stage renal disease. The hospital admission and discharge database of the Emilia Romagna region of Italy. Intern Emerg Med 2013; 8:735-40. [PMID: 23247683 DOI: 10.1007/s11739-012-0892-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 12/03/2012] [Indexed: 11/30/2022]
Abstract
The impact of chronic kidney disease (CKD) on the outcome of acute pulmonary embolism (PE) is uncertain. We aimed to evaluate the effect of renal dysfunction (defined by ICD-9-CM codification) on in-hospital mortality for PE. We considered all cases of PE (first event) recorded in the database of hospital admissions for the Emilia-Romagna region, Italy, from 1999 to 2009. The inclusion criterion was the presence, as a main discharge diagnosis, of acute PE codes according to ICD-9-CM. Diagnoses of immobilization, dementia, sepsis, skeletal fractures, hypertension, heart failure, myocardial infarction, diabetes mellitus, peripheral vascular disease, cerebrovascular disease, chronic pulmonary disease, pneumonia, malignancy, CKD and end-stage renal disease (ESRD) were also considered to evaluate comorbidity. The outcome was in-hospital mortality for PE, and multivariate logistic regression analyses was performed. We considered 24,690 cases of first episode of PE. In-hospital mortality for PE was not different in patients without renal dysfunction, with CKD, or ESRD (23.6 vs. 24 vs. 18 % p = ns). In-hospital mortality for PE was independently associated with age (OR 1.045, 95 % CI 1.042-1.048, p < 0.001), female sex (OR 1.322, 95 % CI 1.242-1.406, p < 0.001), hypertension (OR 1.096, 95 % CI 1.019-1.178, p = 0.013), diabetes mellitus (OR 1.120, 95 % CI 1.001-1.253, p = 0.049), dementia (OR 1.171, 95 % CI 1.020-1.346, p = 0.025), peripheral vascular disease (OR 1.349, 95 % CI 1.057-1.720, p = 0.016) and malignancy (OR 1.065, 95 % CI 1.016-1.116, p = 0.008). Age and comorbidity are associated with in-hospital mortality for PE, whereas CKD does not appear to be an independent predictor of adverse outcomes in patients hospitalized for PE.
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Affiliation(s)
- Fabio Fabbian
- Clinica Medica, Azienda Ospedaliera-Universitaria, University of Ferrara, via Aldo Moro 8, 44124, Cona, Ferrara, Italy,
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Oral anticoagulant therapy in patients receiving haemodialysis: is it time to abandon it? ScientificWorldJournal 2013; 2013:170576. [PMID: 24379737 PMCID: PMC3863463 DOI: 10.1155/2013/170576] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 10/28/2013] [Indexed: 12/03/2022] Open
Abstract
Oral anticoagulant (OAC) therapy in haemodialysis patients causes a great deal of controversy. This is because a number of pro- and anticoagulant factors play an important role in end-stage renal failure due to the nature of the disease itself. In these conditions, the pharmacokinetic and pharmacodynamic properties of the OACs used change as well. In the case of the treatment of venous thromboembolism, the only remaining option is OAC treatment according to regimens used for the general population. Prevention of HD vascular access thrombosis with the use of OACs is not very effective and can be dangerous. However, OAC treatment in patients with atrial fibrillation in dialysis population may be associated with an increase in the incidence of stroke and mortality. Doubts should be dispelled by prospective, randomised studies; at the moment, there is no justification for routine use of OACs in the above-mentioned indications. In selected cases of OAC therapy in this group of patients, it is absolutely necessary to control and monitor the applied treatment thoroughly. Indications for the use of OACs in patients with end-stage renal disease, including haemodialysis patients, should be currently limited.
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Al-Dorzi HM, Al-Heijan A, Tamim HM, Al-Ghamdi G, Arabi YM. Renal failure as a risk factor for venous thromboembolism in critically Ill patients: a cohort study. Thromb Res 2013; 132:671-5. [PMID: 24144445 DOI: 10.1016/j.thromres.2013.09.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 09/16/2013] [Accepted: 09/24/2013] [Indexed: 11/19/2022]
Abstract
RATIONALE The relationship between kidney function and venous thromboembolism (VTE) in critically ill patients is not well studied. The main objective of this study was to evaluate this relationship in patients admitted to a medical-surgical intensive care unit (ICU). METHODS This was a retrospective study of 798 patients admitted to a tertiary-care ICU and prospectively followed for the development of clinically suspected and radiologically diagnosed deep venous thrombosis or pulmonary embolism. Patients were divided based on admission creatinine and dialysis history into five groups: normal kidney function, RIFLE classes R, I and F (combined=acute kidney injury [AKI]) and endstage renal disease (ESRD). We compared VTE prophylaxis practices and VTE incidence in these groups and evaluated renal failure as a VTE risk factor using multivariate Cox regression analysis. RESULTS Of the 798 patients, 27.2% had AKI and 10.1% had ESRD. Unfractionated heparin use was similar in the five groups but enoxaparin use was less frequent in AKI (13.4%) and ESRD (3.8%) patients compared with patients with normal kidney function (39.0%). VTE occurred in 7.6% of patients with normal renal function, 7.8% AKI patients and 2.5% ESRD patients (p=0.22). The adjusted hazard ratios for VTE compared to patients with normal kidney function were 0.35 (95% confidence interval [CI], 0.08-1.47) for RIFLE class R, 1.19 (95% CI, 0.83-1.70) for RIFLE class I, 0.82 (95% CI, 0.59-1.14) for RIFLE class F and 0.71 (95% CI, 0.49-1.02, p=0.06) for ESRD. CONCLUSIONS Neither AKI nor ESRD was an independent risk factors for critically ill patients.
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Affiliation(s)
- Hasan M Al-Dorzi
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia; College of Medicine, King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, Mail code 1425, Riyadh, 11426, Saudi Arabia.
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47
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Burton JO, Hamali HA, Singh R, Abbasian N, Parsons R, Patel AK, Goodall AH, Brunskill NJ. Elevated levels of procoagulant plasma microvesicles in dialysis patients. PLoS One 2013; 8:e72663. [PMID: 23936542 PMCID: PMC3732282 DOI: 10.1371/journal.pone.0072663] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 07/12/2013] [Indexed: 01/25/2023] Open
Abstract
Cardiovascular (CV) death remains the largest cause of mortality in dialysis patients, unexplained by traditional risk factors. Endothelial microvesicles (EMVs) are elevated in patients with traditional CV risk factors and acute coronary syndromes while platelet MVs (PMVs) are associated with atherosclerotic disease states. This study compared relative concentrations of circulating MVs from endothelial cells and platelets in two groups of dialysis patients and matched controls and investigated their relative thromboembolic risk. MVs were isolated from the blood of 20 haemodialysis (HD), 17 peritoneal dialysis (PD) patients and 20 matched controls. Relative concentrations of EMVs (CD144(+ ve)) and PMVs (CD42b(+ ve)) were measured by Western blotting and total MV concentrations were measured using nanoparticle-tracking analysis. The ability to support thrombin generation was measured by reconstituting the MVs in normal plasma, using the Continuous Automated Thrombogram assay triggered with 1µM tissue factor. The total concentration of MVs as well as the measured sub-types was higher in both patient groups compared to controls (p<0.05). MVs from HD and PD patients were able to generate more thrombin than the controls, with higher peak thrombin, and endogenous thrombin potential levels (p<0.02). However there were no differences in either the relative quantity or activity of MVs between the two patient groups (p>0.3). Dialysis patients have higher levels of circulating procoagulant MVs than healthy controls. This may represent a novel and potentially modifiable mediator or predictor of occlusive cardiovascular events in these patients.
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Affiliation(s)
- James O Burton
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, United Kingdom.
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Jun M, Lv J, Perkovic V, Jardine MJ. Managing cardiovascular risk in people with chronic kidney disease: a review of the evidence from randomized controlled trials. Ther Adv Chronic Dis 2012; 2:265-78. [PMID: 23251754 DOI: 10.1177/2040622311401775] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Cardiovascular disease is the leading cause of death and morbidity in people with chronic kidney disease (CKD) making measures to modify cardiovascular risk a clinical priority. The relationship between risk factors and cardiovascular outcomes is often substantially different in people with CKD compared with the general population, leading to uncertainty around pathophysiological mechanisms and the validity of generalizations from the general population. Furthermore, published reports of subgroup analyses from clinical trials have suggested that a range of interventions may have different effects in people with kidney disease compared with those with normal kidney function. There is a relative scarcity of randomized controlled trials (RCTs) conducted in CKD populations, and most such trials are small and underpowered. As a result, evidence to support cardiovascular risk modification measures for people with CKD is largely derived from small trials and post hoc analyses of RCTs conducted in the general population. In this review, we examine the available RCT evidence on interventions aimed at preventing cardiovascular events in people with kidney disease to identify beneficial treatments as well as current gaps in knowledge that should be a priority for future research.
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Affiliation(s)
- Min Jun
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
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49
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Boulware LE, Tangri N, Ephraim PL, Scialla JJ, Sozio SM, Crews DC, Shafi T, Miskulin DC, Liu J, St Peter W, Jaar BG, Wu AW, Powe NR, Navaneethan SD, Bandeen-Roche K. Comparative effectiveness studies to improve clinical outcomes in end stage renal disease: the DEcIDE patient outcomes in end stage renal disease study. BMC Nephrol 2012; 13:167. [PMID: 23217181 PMCID: PMC3554422 DOI: 10.1186/1471-2369-13-167] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 11/28/2012] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Evidence is lacking to inform providers' and patients' decisions about many common treatment strategies for patients with end stage renal disease (ESRD). METHODS/DESIGN The DEcIDE Patient Outcomes in ESRD Study is funded by the United States (US) Agency for Health Care Research and Quality to study the comparative effectiveness of: 1) antihypertensive therapies, 2) early versus later initiation of dialysis, and 3) intravenous iron therapies on clinical outcomes in patients with ESRD. Ongoing studies utilize four existing, nationally representative cohorts of patients with ESRD, including (1) the Choices for Healthy Outcomes in Caring for ESRD study (1041 incident dialysis patients recruited from October 1995 to June 1999 with complete outcome ascertainment through 2009), (2) the Dialysis Clinic Inc (45,124 incident dialysis patients initiating and receiving their care from 2003-2010 with complete outcome ascertainment through 2010), (3) the United States Renal Data System (333,308 incident dialysis patients from 2006-2009 with complete outcome ascertainment through 2010), and (4) the Cleveland Clinic Foundation Chronic Kidney Disease Registry (53,399 patients with chronic kidney disease with outcome ascertainment from 2005 through 2009). We ascertain patient reported outcomes (i.e., health-related quality of life), morbidity, and mortality using clinical and administrative data, and data obtained from national death indices. We use advanced statistical methods (e.g., propensity scoring and marginal structural modeling) to account for potential biases of our study designs. All data are de-identified for analyses. The conduct of studies and dissemination of findings are guided by input from Stakeholders in the ESRD community. DISCUSSION The DEcIDE Patient Outcomes in ESRD Study will provide needed evidence regarding the effectiveness of common treatments employed for dialysis patients. Carefully planned dissemination strategies to the ESRD community will enhance studies' impact on clinical care and patients' outcomes.
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Affiliation(s)
- L Ebony Boulware
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, 2024 E, Monument Street, Baltimore, MD 21205, USA.
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Ocak G, van Stralen KJ, Rosendaal FR, Verduijn M, Ravani P, Palsson R, Leivestad T, Hoitsma AJ, Ferrer-Alamar M, Finne P, De Meester J, Wanner C, Dekker FW, Jager KJ. Mortality due to pulmonary embolism, myocardial infarction, and stroke among incident dialysis patients. J Thromb Haemost 2012; 10:2484-93. [PMID: 22970891 DOI: 10.1111/j.1538-7836.2012.04921.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND It is has been suggested that dialysis patients have lower mortality rates for pulmonary embolism than the general population, because of platelet dysfunction and bleeding tendency. However, there is limited information whether dialysis is indeed associated with a decreased mortality risk from pulmonary embolism. OBJECTIVE The aim of our study was to evaluate whether mortality rate ratios for pulmonary embolism were lower than for myocardial infarction and stroke in dialysis patients compared with the general population. METHODS Cardiovascular causes of death for 130,439 incident dialysis patients registered in the ERA-EDTA Registry were compared with the cardiovascular causes of death for the European general population. RESULTS The age- and sex-standardized mortality rate (SMR) from pulmonary embolism was 12.2 (95% CI 10.2-14.6) times higher in dialysis patients than in the general population. The SMRs in dialysis patients compared with the general population were 11.0 (95% CI 10.6-11.4) for myocardial infarction, 8.4 (95% CI 8.0-8.8) for stroke, and 8.3 (95% CI 8.0-8.5) for other cardiovascular diseases. In dialysis patients, primary kidney disease due to diabetes was associated with an increased mortality risk due to pulmonary embolism (HR 1.9; 95% CI 1.0-3.8), myocardial infarction (HR 4.1; 95% CI 3.4-4.9), stroke (HR 3.5; 95% CI 2.8-4.4), and other cardiovascular causes of death (HR 3.4; 95% CI 2.9-3.9) compared with patients with polycystic kidney disease. CONCLUSIONS Dialysis patients were found to have an unexpected highly increased mortality rate for pulmonary embolism and increased mortality rates for myocardial infarction and stroke.
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Affiliation(s)
- G Ocak
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
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