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Paulus MC, Drent M, Kouw IWK, Balvers MGJ, Bast A, van Zanten ARH. Vitamin K: a potential missing link in critical illness-a scoping review. Crit Care 2024; 28:212. [PMID: 38956732 PMCID: PMC11218309 DOI: 10.1186/s13054-024-05001-2] [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: 05/17/2024] [Accepted: 06/24/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Vitamin K is essential for numerous physiological processes, including coagulation, bone metabolism, tissue calcification, and antioxidant activity. Deficiency, prevalent in critically ill ICU patients, impacts coagulation and increases the risk of bleeding and other complications. This review aims to elucidate the metabolism of vitamin K in the context of critical illness and identify a potential therapeutic approach. METHODS In December 2023, a scoping review was conducted using the PRISMA Extension for Scoping Reviews. Literature was searched in PubMed, Embase, and Cochrane databases without restrictions. Inclusion criteria were studies on adult ICU patients discussing vitamin K deficiency and/or supplementation. RESULTS A total of 1712 articles were screened, and 13 met the inclusion criteria. Vitamin K deficiency in ICU patients is linked to malnutrition, impaired absorption, antibiotic use, increased turnover, and genetic factors. Observational studies show higher PIVKA-II levels in ICU patients, indicating reduced vitamin K status. Risk factors include inadequate intake, disrupted absorption, and increased physiological demands. Supplementation studies suggest vitamin K can improve status but not normalize it completely. Vitamin K deficiency may correlate with prolonged ICU stays, mechanical ventilation, and increased mortality. Factors such as genetic polymorphisms and disrupted microbiomes also contribute to deficiency, underscoring the need for individualized nutritional strategies and further research on optimal supplementation dosages and administration routes. CONCLUSIONS Addressing vitamin K deficiency in ICU patients is crucial for mitigating risks associated with critical illness, yet optimal management strategies require further investigation. IMPACT RESEARCH To the best of our knowledge, this review is the first to address the prevalence and progression of vitamin K deficiency in critically ill patients. It guides clinicians in diagnosing and managing vitamin K deficiency in intensive care and suggests practical strategies for supplementing vitamin K in critically ill patients. This review provides a comprehensive overview of the existing literature, and serves as a valuable resource for clinicians, researchers, and policymakers in critical care medicine.
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Affiliation(s)
- Michelle Carmen Paulus
- Department of Intensive Care Medicine & Research, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP, Ede, The Netherlands
- Division of Human Nutrition and Health, Nutritional Biology, Wageningen University & Research, HELIX (Building 124), Stippeneng 4, 6708 WE, Wageningen, The Netherlands
| | - Marjolein Drent
- Department of Pharmacology and Toxicology, Faculty of Health, Medicine, and Life Science, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
- Interstitial Lung Diseases (ILD) Center of Excellence, St. Antonius Hospital, Nieuwegein, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
- ILD Care Foundation Research Team, Heideoordlaan 8, 6711NR, Ede, The Netherlands
| | - Imre Willemijn Kehinde Kouw
- Department of Intensive Care Medicine & Research, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP, Ede, The Netherlands
- Division of Human Nutrition and Health, Nutritional Biology, Wageningen University & Research, HELIX (Building 124), Stippeneng 4, 6708 WE, Wageningen, The Netherlands
| | - Michiel Gerard Juliaan Balvers
- Division of Human Nutrition and Health, Nutritional Biology, Wageningen University & Research, HELIX (Building 124), Stippeneng 4, 6708 WE, Wageningen, The Netherlands
| | - Aalt Bast
- Department of Pharmacology and Toxicology, Faculty of Health, Medicine, and Life Science, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
- ILD Care Foundation Research Team, Heideoordlaan 8, 6711NR, Ede, The Netherlands
| | - Arthur Raymond Hubert van Zanten
- Department of Intensive Care Medicine & Research, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP, Ede, The Netherlands.
- Division of Human Nutrition and Health, Nutritional Biology, Wageningen University & Research, HELIX (Building 124), Stippeneng 4, 6708 WE, Wageningen, The Netherlands.
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2
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Ji B, Liu XB. Coronary artery calcification: concepts and clinical applications. Ann Med Surg (Lond) 2024; 86:2848-2855. [PMID: 38694287 PMCID: PMC11060298 DOI: 10.1097/ms9.0000000000002016] [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: 12/19/2023] [Accepted: 03/18/2024] [Indexed: 05/04/2024] Open
Abstract
Vascular calcification is an important hallmark of atherosclerosis. Coronary artery calcification (CAC) implies the presence of coronary artery disease (CAD), irrespective of risk factors or symptoms, is concomitant with the development of advanced atherosclerosis. Coronary thrombosis is the most common clinical end event leading to acute coronary syndrome (ACS). The least common type of pathology associated with thrombosis is the calcified nodule (CN). It usually occurs in elderly patients with severely calcified and tortuous arteries. The prevalence of calcified nodules in patients with ACS may be underestimated due to the lack of easily recognisable diagnostic methods. In this review, the authors will focus on the classification, clinical significance, pathogenesis, and diagnostic evaluation and treatment of CAC to further explore the clinical significance of CN.
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Affiliation(s)
| | - Xue-Bo Liu
- Department of Cardiology, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
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3
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Wang YT, Chen JH, Liao SF, Chen YJ, Lip GYH, Yeh JS. Cardiac and renal outcomes of direct oral anticoagulants in patients with atrial fibrillation. Eur J Clin Invest 2024; 54:e14086. [PMID: 37635402 DOI: 10.1111/eci.14086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/03/2023] [Accepted: 08/14/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Oral anticoagulation therapy with warfarin or direct oral anticoagulants (DOACs) is the mainstay for stroke prevention in patients with non-valvular atrial fibrillation (AF). The DOACs might have a lower risk of declining renal function than warfarin. This study aimed to compare renal outcomes among rivaroxaban, edoxaban, dabigatran, and warfarin. METHOD This cohort study identified 2203 adults with AF who started anticoagulation therapy between 1 July 2013 and 31 December 2020, in a clinical database at a single centre. Inverse probability of treatment weighting was adopted to balance baseline characteristics among four anticoagulants treatment groups. The primary outcome was a composite of cardiac and renal outcomes, involving a ≥30% decline in estimated glomerular filtration rate (eGFR), renal failure and cardiovascular death. RESULTS After propensity score weighting, dabigatran was associated with significantly lower risks of a ≥30% decline in eGFR (hazard ratio [HR]: .69, 95% confidence interval [CI]: .497-.951, p = .0237), doubling of the serum creatinine level (HR: .49, 95% CI: .259-.927, p = .0282) and the cardiac and renal outcome composite (HR: .67, 95% CI: .485-.913, p = .0115) than warfarin. Rivaroxaban and edoxaban did not show significant protective effects on renal outcomes compared to warfarin. CONCLUSION In this study, patients treated with dabigatran had significantly reduced risks of declining renal function and composite cardiac and renal events than those treated with warfarin. However, rivaroxaban and edoxaban were not associated with lower risks of any renal outcomes than warfarin. More studies are warranted to investigate and compare the impact of renal function between different DOACs in patients with AF.
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Affiliation(s)
- Yu-Ting Wang
- Department of Pharmacy, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Jo-Hsin Chen
- Department of Pharmacy, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Shu-Fen Liao
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
- Department of Medical Research, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yu-Jen Chen
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jong-Shiuan Yeh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
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Law MM, Tan SJ, Wong MC, Toussaint ND. Atrial Fibrillation in Kidney Failure: Challenges in Risk Assessment and Anticoagulation Management. Kidney Med 2023; 5:100690. [PMID: 37547561 PMCID: PMC10403723 DOI: 10.1016/j.xkme.2023.100690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
Management of atrial fibrillation (AF) is a clinical conundrum in people with kidney failure. Stroke risk is disproportionately high, but clinicians have a limited armamentarium to improve outcomes in this population in whom there is a concurrently high bleeding risk. Direct oral anticoagulants may have a superior benefit-risk profile compared with vitamin K antagonists in people on hemodialysis. Although research has predominantly focused on identifying a safe and effective oral anticoagulation option to reduce stroke risk in people with kidney failure (and predominantly those on hemodialysis), it remains uncertain how clinicians discriminate between people who would derive net clinical benefit as opposed to net harm. The recommended CHA2DS2-VASc score cutoffs provide poor discriminatory value, and there is an urgent need to identify robust markers of thromboembolic risk in kidney failure. There is increasing data to challenge the prior dogma of risk equivalence across AF type, and the American Heart Association highlights moving beyond AF as a binary entity to consider the prognostic significance of AF burden. Implantable cardiac monitor studies reveal high rates and varied burden of subclinical and paroxysmal AF in people on hemodialysis. The association between AF burden and the proarrhythmic environment of hemodialysis with cyclical volume loading, offloading, and electrolyte changes is not well studied. We review the significance of AF burden as a contributor to thromboembolic risk, its potential as the missing link in risk assessment, and updated evidence for anticoagulation in people with kidney failure.
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Affiliation(s)
- Mandy M. Law
- Department of Nephrology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Sven-Jean Tan
- Department of Nephrology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Michael C.G. Wong
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Department of Cardiology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Nigel D. Toussaint
- Department of Nephrology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
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Armentaro G, D’Arrigo G, Bo M, Cassano V, Miceli S, Pitino A, Tripepi G, Romeo SMG, Sesti G, Lip GYH, Pastori D, Gori M, Sciacqua A. Medium-term and long-term renal function changes with direct oral anticoagulants in elderly patients with atrial fibrillation. Front Pharmacol 2023; 14:1210560. [PMID: 37469870 PMCID: PMC10352777 DOI: 10.3389/fphar.2023.1210560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 06/21/2023] [Indexed: 07/21/2023] Open
Abstract
Objective: Atrial Fibrillation (AF) and chronic kidney disease frequently coexist in the elderly. Warfarin-like drugs (WLDs) may be associated with a relatively greater decrease of estimated glomerular filtration rate (eGFR) as compared to direct oral anticoagulants (DOACs), but there is no evidence on the medium- and long-term changes. To further elucidate this issue in elderly patients with AF, we investigated the renal function deterioration in the two groups of the study (DOACs or WLDs). Patients and Methods: A total of 420 AF patients were enrolled (mean age: 77.0 ± 6.0 years; 136 on WLDs and 284 on DOACs). These patients underwent three eGFR measurements during the follow-up period. The between-arms difference of eGFR decline over time was investigated by Linear Mixed Models and group-based trajectory model analyses. Results: In the whole study cohort, after a median follow-up of 4.9 years (interquartile range: 2.7-7.0 years), eGFR decreased from 67.4 ± 18.2 to 47.1 ± 14.3 mL/min/1.73 m2 (p < 0.001). Remarkably, patients on DOACs experienced a significantly smaller eGFR decline than WLDs patients (-21.3% vs. -45.1%, p < 0.001) and this was true both in the medium-term (-6.6 vs. -19.9 mL/min/1.73 m2) and in the long-term (-13.5 versus -34.2 mL/min/1.73 m2) period. After stratification into five subgroups according to trajectories of renal function decline over time, logistic regression showed that DOACs patients had from 3.03 to 4.24-fold greater likelihood to belong to the trajectory with less marked eGFR decline over time than WLDs patients. Conclusion: Elderly patients with AF on treatment with DOACs had a relatively smaller decline of eGFR over time compared to those on treatment with WLDs. This is consistent with what was partly reported in the literature.
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Affiliation(s)
- Giuseppe Armentaro
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Graziella D’Arrigo
- Institute of Clinical Physiology (IFC-CNR), Section of Reggio Calabria, Reggio Calabria, Italy
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, Molinette Hospital, Turin, Italy
| | - Velia Cassano
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Sofia Miceli
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Annalisa Pitino
- Institute of Clinical Physiology (IFC-CNR), Section of Rome, Rome, Italy
| | - Giovanni Tripepi
- Institute of Clinical Physiology (IFC-CNR), Section of Reggio Calabria, Reggio Calabria, Italy
| | | | - Giorgio Sesti
- Department of Clinical and Molecular Medicine, University Rome-Sapienza, Rome, Italy
| | - Gregory Y. H. Lip
- Department of Clinical MedicineAalborg University, Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, Denmark
| | - Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Mercedes Gori
- Institute of Clinical Physiology (IFC-CNR), Section of Rome, Rome, Italy
| | - Angela Sciacqua
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
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Aldana-Bitar J, Moore J, Manubolu VS, Dahal S, Verghese D, Lakshmanan S, Hussein L, Crabtree T, Jonas R, Min JK, Earls JP, Budoff MJ. Plaque Progression Differences Between Apixaban and Rivaroxaban in Patients With Atrial Fibrillation Measured With Cardiac Computed Tomography and Plaque Quantification. Am J Ther 2023; 30:e313-e320. [PMID: 36731003 DOI: 10.1097/mjt.0000000000001569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have been associated with less calcification and coronary plaque progression than warfarin. Whether different DOACs have different effects on coronary plaque burden and progression is not known. We compared the 12-month effects of apixaban and rivaroxaban on plaque characteristics and vascular morphology in patients with atrial fibrillation through quantitative cardiac computed tomographic angiography. STUDY QUESTION In patients with nonvalvular atrial fibrillation using apixaban or rivaroxaban, are there differences in plaque quantification and progression measured with cardiac computed tomography? STUDY DESIGN This is a post hoc analysis of 2 paired prospective, single-centered, randomized, open-label trials with blinded adjudication of results. In total, 74 patients were prospectively randomized in parallel trials: 29 to apixaban (2.5-5 mg BID) and 45 to rivaroxaban (20 mg QD). Serial cardiac computed tomographic angiography was performed at baseline and 52 weeks. MEASURES AND OUTCOMES Comprehensive whole-heart analysis was performed for differences in the progression of percent atheroma volume (PAV), calcified plaque (CP) PAV, noncalcified plaque (NCP) PAV, positive arterial remodeling (PR) ≥1.10, and high-risk plaque (Cleerly Labs, New York, NY). RESULTS Both groups had progression of all 3 plaque types (apixaban: CP 8.7 mm 3 , NCP 69.7 mm 3 , and LD-NCP 27.2 mm 3 ; rivaroxaban: CP 22.9 mm 3 , NCP 66.3 mm 3 , and LD-NCP 11.0 mm 3 ) and a total annual plaque PAV change (apixaban: PAV 1.5%, PAV-CP 0.12%, and PAV-NCP 0.92%; rivaroxaban: PAV 2.1%, PAV-CP 0.46%, and PAV-NCP 1.40%). There was significantly lower PAV-CP progression in the apixaban group compared with the rivaroxaban group (0.12% vs. 0.46% P = 0.02). High-risk plaque characteristics showed a significant change in PR of apixaban versus rivaroxaban ( P = 0.01). When the propensity score weighting model is applied, only PR changes are statistically significant ( P = 0.04). CONCLUSIONS In both groups, there is progression of all types of plaque. There was a significant difference between apixaban and rivaroxaban on coronary calcification, with significantly lower calcific plaque progression in the apixaban group, and change in positive remodeling. With weighted modeling, only PR changes are statistically significant between the 2 DOACs.
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Affiliation(s)
- Jairo Aldana-Bitar
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Jeff Moore
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Venkat Sanjay Manubolu
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Suraj Dahal
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Dhiran Verghese
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Suvasini Lakshmanan
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Luay Hussein
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | | | | | | | - James P Earls
- Cleerly, New York, NY
- The George Washington University School of Medicine, Washington, DC
| | - Matthew J Budoff
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
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Trevisan M, Hjemdahl P, Clase CM, de Jong Y, Evans M, Bellocco R, Fu EL, Carrero JJ. Cardiorenal Outcomes Among Patients With Atrial Fibrillation Treated With Oral Anticoagulants. Am J Kidney Dis 2023; 81:307-317.e1. [PMID: 36208798 DOI: 10.1053/j.ajkd.2022.07.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 07/31/2022] [Indexed: 11/06/2022]
Abstract
RATIONALE & OBJECTIVE Direct oral anticoagulants (DOACs) have progressively replaced vitamin K antagonists (VKAs) for stroke prevention in patients with nonvalvular atrial fibrillation (AF). DOACs cause fewer bleeding complications, but their other advantages, particularly related to kidney outcomes, remain inconclusive. We studied the risks of chronic kidney disease (CKD) progression and acute kidney injury (AKI) after DOAC and VKA administration for nonvalvular AF. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Cohort study of Swedish patients enrolled in the Stockholm Creatinine Measurements (SCREAM) project with a diagnosis of nonvalvular AF during 2011-2018. EXPOSURE Initiation of DOAC or VKA treatment. OUTCOME Primary outcomes were CKD progression (composite of >30% estimated glomerular filtration rate [eGFR] decline and kidney failure) and AKI (by diagnosis or KDIGO-defined transient creatinine elevations). Secondary outcomes were death, major bleeding, and the composite of stroke and systemic embolism. ANALYTICAL APPROACH Propensity score weighted Cox regression was used to balance 50 baseline confounders. Sensitivity analyses included falsification end points, subgroups, and estimation of per-protocol effects. RESULTS We included 32,699 patients (56% initiated DOAC) who were observed for a median of 3.8 years. Their median age was 75 years, 45% were women, and 27% had an eGFR <60mL/min/1.73m2. The adjusted HRs for DOAC versus VKA were 0.87 (95% CI, 0.78-0.98) for the risk of CKD progression and 0.88 (95% CI, 0.80-0.97) for AKI. HRs were 0.77 (95% CI, 0.67-0.89) for major bleeding, 0.93 (95% CI, 0.78-1.11) for the composite of stroke and systemic embolism, and 1.04 (95% CI, 0.95-1.14) for death. The results were similar across subgroups of age, sex, and baseline eGFR when restricting to patients at high risk for thromboembolic events and when censoring follow up at treatment discontinuation or change in type of anticoagulation. LIMITATIONS Missing information on time in therapeutic range and treatment dosages. CONCLUSIONS Among patients with nonvalvular AF treated in routine clinical practice compared with VKA use, DOAC use was associated with a lower risk of CKD progression, AKI, and major bleeding but a similar risk of the composite of stroke, systemic embolism, or death.
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Affiliation(s)
- Marco Trevisan
- Department of Medical Epidemiology and Biostatistics, Campus Solna, Karolinska Institutet, Stockholm, Sweden
| | - Paul Hjemdahl
- Clinical Epidemiology Unit/Clinical Pharmacology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Catherine M Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Ontario, Canada
| | - Ype de Jong
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Marie Evans
- Department of Clinical Science Intervention and Technology, Hospital Huddinge, Karolinska University, Huddinge, Sweden
| | - Rino Bellocco
- Department of Medical Epidemiology and Biostatistics, Campus Solna, Karolinska Institutet, Stockholm, Sweden; Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Edouard L Fu
- Department of Medical Epidemiology and Biostatistics, Campus Solna, Karolinska Institutet, Stockholm, Sweden; Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Campus Solna, Karolinska Institutet, Stockholm, Sweden; Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.
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Yang Z, Wang J, Yuan Y, Cheng T, Ren F, Wang S, Zhang Z. Application of rivaroxaban in patients with non-valvular atrial fibrillation and end-stage kidney disease: A systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:1021959. [PMID: 36844734 PMCID: PMC9951003 DOI: 10.3389/fcvm.2023.1021959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 01/17/2023] [Indexed: 02/10/2023] Open
Abstract
Background Nowadays, the number of patients with non-valvular atrial fibrillation (NVAF) complicated by end-stage renal disease (ESKD) is increasing. There are significant challenges in anticoagulation with prescription drugs because of the high risk of bleeding and embolism among these patients. However, no randomized controlled trials (RCTs) of warfarin in combination with any non-vitamin K oral anticoagulant (NOACs) have been performed in patients with baseline creatinine clearance (CrCl) <25 ml/min, which makes it difficult to justify the use of anticoagulants in such patients. Then, we aimed to collect and summarize all evidence to enable the anticoagulation of rivaroxaban, which is less cleared by the kidneys, in patients with severe renal insufficiency and to complement and improve the evidence on the use of rivaroxaban for anticoagulation. Methods The present systematic review and meta-analysis searched the databases of PubMed, Embase, the Cochrane Library, CNKI, CBM, and Google Scholar for relevant studies from inception to 1 June 2022, with the restriction of English and Chinese. Eligible cohort studies and RCTs that reported efficacy outcomes [composite of stroke and systemic embolism (SSE), ischemic stroke (ICS), and systemic embolization] or safety outcomes [major bleeding, intracranial hemorrhage (ICH), and gastrointestinal bleeding (GIB)] of rivaroxaban in NVAF patients with ESKD were enrolled. Two authors completed the data extraction and quality assessment work, respectively. The Cochrane Collaboration tool for assessing the risk of bias was used for RCTs, and the NEW-Castle Ottawa scale was used for study quality assessment for cohort studies. Dichotomous variables were calculated as risk factors with 95% confidence intervals (CIs), and meta-analysis was performed to probe the effect of research design, rivaroxaban dose, and controlled drug factors on outcomes. Results In total, three studies were included for meta-analysis, involving 6,071 NVAF patients with ESKD, and two studies were included for qualitative analysis. All included studies were at low risk of bias. A meta-analysis demonstrated that mix-dose rivaroxaban caused no statistical discrepancy in the occurrence of thrombotic and bleeding events when compared to the control group (embolism, LogOR: -0.64, 95% CI: -1.05 to -0.23, P:0.25; bleeding, LogOR: -0.33, 95% CI: -0.63 to -0.03, P:0.15), and low-dose rivaroxaban produced similar results (embolism, LogOR: -1.04, 95% CI: -2.15 to 0.07, P:0.61; bleeding, LogOR: -0.81, 95% CI: -1.19 to -0.44, P:0.93). Conclusion In this study, low-dose rivaroxaban (10 mg, once a day) may benefit more than warfarin in patients with NVAF and ESKD. Systematic review registration https://www.crd.york.ac.uk/prospero/#recordDetails, identifier CRD42022330973.
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Affiliation(s)
- Zhenzhen Yang
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jieya Wang
- Department of Pharmacy, The Sixth Affiliated Hospital of Kunming Medical University, Yuxi, China
| | - Ye Yuan
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Tian Cheng
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Feifei Ren
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Songsong Wang
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China,Department of Pharmacology, Hebei Medical University, Shijiazhuang, China, Songsong Wang, ; orcid.org/0000-0003-0528-7920
| | - Zhiqing Zhang
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China,*Correspondence: Zhiqing Zhang,
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Muacevic A, Adler JR, Kulkarni N. Anticoagulation for Stroke Prevention of Concomitant Atrial Fibrillation and End-Stage Renal Disease: Insights of Cardiologists and Nephrologists From India. Cureus 2022; 14:e32788. [PMID: 36694536 PMCID: PMC9857051 DOI: 10.7759/cureus.32788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Patients with concomitant atrial fibrillation (AF) and end-stage renal disease (ESRD) are at increased risk of thrombosis and bleeding. Diligent anticoagulant therapy that prevents major bleeding is essential for stroke prevention. There is a dearth of evidence and guidance on anticoagulation in this patient subset. Methods A validated questionnaire was sent to 500 physicians across India. Anonymized responses from 353 consenting physicians (275 cardiologists and 78 nephrologists) were analyzed. Results Most physicians opined that the risk of progression of chronic kidney disease (CKD) stages 2-4 to ESRD was 1-5%, and that >10% of patients with ESRD had concomitant AF. Most physicians perceived that the risk of ischemic stroke, major bleeding, and mortality was 30-40%, <15%, and >40% respectively in patients with concomitant AF and ESRD. The first critical goal for the management of these patients was 'reduction of thrombotic risk', followed by 'prevention of bleeding' and finally 'prevention of ESRD progression' (72.0%, 68.0%, and 67.1% participants, respectively). Most participating physicians (93.8%) preferred non-vitamin K antagonist oral anticoagulants (NOACs) over warfarin for stroke prevention, and most of the participating physicians (94.9%) preferred an adjusted dose rather than the standard dose of the NOAC. Most of the responses were similar between cardiologists and nephrologists. Conclusion According to the survey response, patients with concomitant AF and ESRD have an increased risk of thrombosis, bleeding, and mortality. NOACs with dose adjustment are the preferred modality for stroke prevention among cardiologists and nephrologists in India, with the primary goal of preventing thrombotic events.
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Steiner D, Schmaldienst S, Lorenz M, Klauser-Braun R, Pabinger I, Ay C, Säemann M, Königsbrügge O. Atrial fibrillation and anticoagulation are associated with hospitalisations in patients with end-stage kidney disease on haemodialysis: a prospective population-based cohort study. Thromb J 2022; 20:71. [PMID: 36451221 PMCID: PMC9709737 DOI: 10.1186/s12959-022-00434-7] [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: 07/04/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Patients with end-stage kidney disease on haemodialysis suffer from frequent complications requiring hospitalisation. Atrial fibrillation is a burdensome comorbidity amongst patients on haemodialysis. We aimed to assess frequency, reasons, and duration of hospitalisations in haemodialysis patients and their association with atrial fibrillation and anticoagulation. METHODS Prevalent patients with end-stage kidney disease on haemodialysis were recruited into a prospective cohort study and observed for a median observation time of 3.4 years. Hospitalisations were recorded from discharge letters, medical records, and patient interviews. The association of atrial fibrillation, anticoagulation, and time-in-therapeutic range of vitamin K antagonist treatment with hospitalisations was analysed using negative binomial regression. RESULTS Out of 625 patients, 238 (38.1%) had atrial fibrillation. Median number of hospitalisations per patient was 3.0 (1.0-5.0). Incidence rate of hospitalisation was 1.7 per patient-year in all and 1.9 in atrial fibrillation patients, median duration per hospitalisation was 7.9 (4.8-12.9) and 8.8 (5.7-13.3) days, respectively. Most frequent reasons for hospitalisation were vascular access complication/intervention (11.7%) and infection/fever (11.4%), while bleeding events comprised 6.0% of all hospitalisations. Atrial fibrillation patients had 27% higher risk of hospitalisation than patients without atrial fibrillation (incidence rate ratio [IRR] 1.27, 95% confidence interval [CI] 1.10-1.47). In atrial fibrillation patients, anticoagulation (enoxaparin or phenprocoumon, 41.6% of AF patients) was associated with increased risk of all-cause (IRR 1.38, 95%CI 1.14-1.69) and bleeding-related hospitalisation (IRR 1.96, 95%CI 1.06-3.63). There was no association between anticoagulation and stroke-related hospitalisation. In atrial fibrillation patients on phenprocoumon, increasing time-in-therapeutic range was associated with decreased risk of all-cause (IRR 0.35, 95%CI 0.14-0.87), but not bleeding-related hospitalisation (IRR 0.13, 95%CI 0.01-1.38). CONCLUSION In haemodialysis patients, presence of atrial fibrillation and, among those with atrial fibrillation, anticoagulation were associated with higher risk of all-cause hospitalisation, including bleeding-related hospitalisation in the latter. Increasing time-in-therapeutic range in patients on vitamin K antagonist treatment was associated with decreased risk of all-cause, but not bleeding-related hospitalisation.
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Affiliation(s)
- Daniel Steiner
- grid.22937.3d0000 0000 9259 8492Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | | | | | | | - Ingrid Pabinger
- grid.22937.3d0000 0000 9259 8492Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Cihan Ay
- grid.22937.3d0000 0000 9259 8492Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Marcus Säemann
- Department of Medicine VI, Clinic Ottakring, Vienna, Austria
| | - Oliver Königsbrügge
- grid.22937.3d0000 0000 9259 8492Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
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Sánchez-González C, Herrero Calvo JA. Nonvalvular atrial fibrillation in patients undergoing chronic hemodialysis. Should dialysis patients with atrial fibrillation receive oral anticoagulation? Nefrologia 2022; 42:633-644. [PMID: 36907719 DOI: 10.1016/j.nefroe.2022.01.013] [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: 01/11/2022] [Accepted: 01/16/2022] [Indexed: 06/18/2023] Open
Abstract
Chronic kidney disease (CKD) is an independent risk factor for presenting atrial fibrillation (AF), which conditions an increased risk already present in CKD of suffering a thromboembolic event. And this risk is even higher in the hemodialysis (HD) population. On the other hand, in CKD patients and even more so in HD patients, the probability of suffering serious bleeding is also higher. Therefore, there is no consensus on whether or not to anticoagulate this population. Taking as a model what is advised for the general population, the most common attitude among nephrologists has been to opt for anticoagulation, even though there is no randomized studies to support it. Classically, anticoagulation has been done with vitamin K antagonists, at high cost for our patients: severe bleeding events, vascular calcification, and progression of nephropathy, among other complications. With the emergence of direct-acting anticoagulants, a hopeful outlook was opened in the field of anticoagulation, as they were postulated as more effective and safer drugs than antivitamin K. However, in clinical practice, this has not been the case. In this paper we review various aspects of AF and its anticoagulant treatment in the HD population.
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Kaźmierczak-Barańska J, Karwowski BT. Vitamin K Contribution to DNA Damage—Advantage or Disadvantage? A Human Health Response. Nutrients 2022; 14:nu14204219. [PMID: 36296903 PMCID: PMC9611527 DOI: 10.3390/nu14204219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/29/2022] [Accepted: 10/08/2022] [Indexed: 01/27/2023] Open
Abstract
Vitamin K is the common name for a group of compounds recognized as essential for blood clotting. The group comprises phylloquinone (K1)—a 2-methyl-3-phytyl-1,4-naphthoquinone; menaquinone (K2, MK)—a group of compounds with an unsaturated side chain in position 3 of a different number of isoprene units and a 1,4-naphthoquinone group and menadione (K3, MD)—a group of synthetic, water-soluble compounds 2-methyl-1,4-naphthoquinone. However, recent epidemiological studies suggest that vitamin K has various benefits that go beyond blood coagulation processes. A dietary intake of K1 is inversely associated with the risk of pancreatic cancer, K2 has the potential to induce a differentiation in leukemia cells or apoptosis of various types of cancer cells, and K3 has a documented anti-cancer effect. A healthy diet rich in fruit and vegetables ensures an optimal supply of K1 and K2, though consumers often prefer supplements. Interestingly, the synthetic form of vitamin K—menadione—appears in the cell during the metabolism of phylloquinone and is a precursor of MK-4, a form of vitamin K2 inaccessible in food. With this in mind, the purpose of this review is to emphasize the importance of vitamin K as a micronutrient, which not only has a beneficial effect on blood clotting and the skeleton, but also reduces the risk of cancer and other pro-inflammatory diseases. A proper diet should be a basic and common preventive procedure, resulting in a healthier society and reduced burden on healthcare systems.
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Mangge H, Prueller F, Dawczynski C, Curcic P, Sloup Z, Holter M, Herrmann M, Meinitzer A. Dramatic Decrease of Vitamin K2 Subtype Menaquinone-7 in COVID-19 Patients. Antioxidants (Basel) 2022; 11:antiox11071235. [PMID: 35883726 PMCID: PMC9312339 DOI: 10.3390/antiox11071235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 11/30/2022] Open
Abstract
(1) Background: Vitamin K (VK) is a fat-soluble compound with a common chemical structure, a 2-methyl-1,4-naphthoquinone ring, and a variable aliphatic side-chain. VK is involved in the synthesis of blood-clotting proteins, bone stability, anti-oxidative, and immune inflammatory-modulatory functions. Vitamin K also activates protein S, which acts as an antioxidant and anti-inflammatory. The fact that cytokine overproduction, oxidative stress, and disturbed microcirculation by thrombogenicity play a central role in severe COVID-19 prompted us to analyze this vitamin. (2) Methods: We analyzed by a validated liquid-chromatography tandem mass-spectrometry method serum vitamin K1, MK4, MK7, and VK epoxide levels in 104 healthy controls, 77 patients with non-COVID-19 pneumonia, and 135 hospitalized COVID-19 patients with potentially fatal outcomes admitted to our University Hospital between April and November 2020. We included the quotient between VK and triglyceride (TG, nmol/mmol/L) values in the analyses with respect to the TG transporter function for all VK subtypes. Additionally, we assessed anthropometric, routine laboratory, and clinical data from the laboratory and hospital information systems. (3) Results: The COVID-19 patients had significantly lower MK7 levels than non-COVID-19 pneumonia patients and healthy controls. COVID-19 and non-COVID-19 pneumonia patients had significantly lower vitamin K1 and significantly higher MK4 compared to healthy controls, but did not differ significantly from each other. Between COVID-19 non-survivors (n = 30) and survivors (n = 105) no significant differences were seen in all vitamin K subtypes, despite the fact that non-survivors had higher peak concentrations of IL-6, CRP, d-dimer, and higher oxygen needs, respectively. (4) Conclusions: The present data identified significantly decreased vitamin K1, K2 (MK7), and increased MK4 levels in patients with COVID-19 compared to healthy controls. Vitamin K2 (MK7) was lowest in COVID-19 patients irrespective of potentially fatal courses, indicating consumption of this VK subtype by COVID-19 immanent effects, most probably inflammatory and oxidative stress factors.
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Affiliation(s)
- Harald Mangge
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, 8036 Graz, Austria; (F.P.); (P.C.); (Z.S.); (M.H.); (A.M.)
- Correspondence: ; Tel.: +43-316-385-83340
| | - Florian Prueller
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, 8036 Graz, Austria; (F.P.); (P.C.); (Z.S.); (M.H.); (A.M.)
| | - Christine Dawczynski
- Institute of Nutritional Science, Friedrich Schiller University Jena, 07743 Jena, Germany;
| | - Pero Curcic
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, 8036 Graz, Austria; (F.P.); (P.C.); (Z.S.); (M.H.); (A.M.)
| | - Zdenka Sloup
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, 8036 Graz, Austria; (F.P.); (P.C.); (Z.S.); (M.H.); (A.M.)
| | - Magdalena Holter
- Institute of Medical Computer Sciences, Statistics and Documentation, Medical University of Graz, 8036 Graz, Austria;
| | - Markus Herrmann
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, 8036 Graz, Austria; (F.P.); (P.C.); (Z.S.); (M.H.); (A.M.)
| | - Andreas Meinitzer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, 8036 Graz, Austria; (F.P.); (P.C.); (Z.S.); (M.H.); (A.M.)
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14
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Berkner KL, Runge KW. Vitamin K-Dependent Protein Activation: Normal Gamma-Glutamyl Carboxylation and Disruption in Disease. Int J Mol Sci 2022; 23:5759. [PMID: 35628569 PMCID: PMC9146348 DOI: 10.3390/ijms23105759] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 05/11/2022] [Accepted: 05/14/2022] [Indexed: 12/12/2022] Open
Abstract
Vitamin K-dependent (VKD) proteins undergo an unusual post-translational modification, which is the conversion of specific Glu residues to carboxylated Glu (Gla). Gla generation is required for the activation of VKD proteins, and occurs in the endoplasmic reticulum during their secretion to either the cell surface or from the cell. The gamma-glutamyl carboxylase produces Gla using reduced vitamin K, which becomes oxygenated to vitamin K epoxide. Reduced vitamin K is then regenerated by a vitamin K oxidoreductase (VKORC1), and this interconversion of oxygenated and reduced vitamin K is referred to as the vitamin K cycle. Many of the VKD proteins support hemostasis, which is suppressed during therapy with warfarin that inhibits VKORC1 activity. VKD proteins also impact a broad range of physiologies beyond hemostasis, which includes regulation of calcification, apoptosis, complement, growth control, signal transduction and angiogenesis. The review covers the roles of VKD proteins, how they become activated, and how disruption of carboxylation can lead to disease. VKD proteins contain clusters of Gla residues that form a calcium-binding module important for activity, and carboxylase processivity allows the generation of multiple Glas. The review discusses how impaired carboxylase processivity results in the pseudoxanthoma elasticum-like disease.
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Affiliation(s)
- Kathleen L. Berkner
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic Lerner College of Medicine at CWRU, Cleveland, OH 44195, USA
| | - Kurt W. Runge
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Lerner College of Medicine at CWRU, Cleveland, OH 44195, USA;
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15
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Wei Y, Ma H, Xu B, Wang Z, He Q, Liu L, Zhou Z, Song Y, Chen P, Li J, Zhang Y, Mao G, Wang B, Tang G, Qin X, Zhang H, Xu X, Huo Y, Guo H. Joint Association of Low Vitamin K1 and D Status With First Stroke in General Hypertensive Adults: Results From the China Stroke Primary Prevention Trial (CSPPT). Front Neurol 2022; 13:881994. [PMID: 35645985 PMCID: PMC9135055 DOI: 10.3389/fneur.2022.881994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/11/2022] [Indexed: 11/28/2022] Open
Abstract
Background Vitamin K plays a role in preventing vascular calcification and may have a synergetic influence with vitamin D on cardiovascular health. However, whether this relationship applies to stroke, especially in a high-risk population of hypertensive individuals, remains unclear. The present study aims to study the joint association of low vitamin K1 and D status with first stroke in general hypertensive adults. Methods This study used a nested, case–control design with data from the China Stroke Primary Prevention Trial. The analysis included 604 first total stroke patients and 604 matched controls from a Chinese population with hypertension. Odds ratios (ORs) and 95% confidence intervals were calculated using conditional logistic regression. Results There was a non-linear negative association between plasma vitamin K1 and the risk of first total stroke or ischemic stroke in the enalapril-only group. Compared to participants in vitamin K1 quartile 1, a significantly lower risk of total stroke (OR = 0.58, 95% CI: 0.36, 0.91, P = 0.020) or ischemic stroke (OR = 0.34, 95% CI: 0.17, 0.63, P < 0.001) was found in participants in vitamin K1 quartile 2-4 in the enalapril-only group. When further divided into four subgroups by 25(OH)D and vitamin K1, a significantly higher risk of total stroke or ischemic stroke was observed in participants with both low vitamin K1 and 25(OH)D compared to those with both high vitamin K1 and 25(OH)D in the enalapril-only group. No increased risk was observed in the groups low in one vitamin only. Conclusion Low concentrations of both vitamin K1 and 25(OH)D were associated with increased risk of stroke.
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Affiliation(s)
- Yaping Wei
- Key Laboratory of Precision Nutrition and Food Quality, Department of Nutrition and Health, College of Food Sciences and Nutritional Engineering, China Agricultural University, Beijing, China
| | - Hai Ma
- Rongcheng Center for Disease Control and Prevention, Rongcheng, China
| | - Benjamin Xu
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Zhuo Wang
- Key Laboratory of Precision Nutrition and Food Quality, Department of Nutrition and Health, College of Food Sciences and Nutritional Engineering, China Agricultural University, Beijing, China
| | - Qiangqiang He
- Graduate School at Shenzhen, Tsinghua University, Shenzhen, China
- Shenzhen Evergreen Medical Institute, Shenzhen, China
| | - Lishun Liu
- Graduate School at Shenzhen, Tsinghua University, Shenzhen, China
- Shenzhen Evergreen Medical Institute, Shenzhen, China
| | - Ziyi Zhou
- Graduate School at Shenzhen, Tsinghua University, Shenzhen, China
- Shenzhen Evergreen Medical Institute, Shenzhen, China
| | - Yun Song
- Shenzhen Evergreen Medical Institute, Shenzhen, China
- Institute for Biomedicine, Anhui Medical University, Hefei, China
| | - Ping Chen
- College of Pharmacy, Jinan University, Guangzhou, China
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yan Zhang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Guangyun Mao
- Department of Preventive Medicine, School of Public Health & Management, Wenzhou Medical University, Wenzhou, China
| | - Binyan Wang
- Institute for Biomedicine, Anhui Medical University, Hefei, China
| | - Genfu Tang
- Institute for Biomedicine, Anhui Medical University, Hefei, China
| | - Xianhui Qin
- National Clinical Research Center for Kidney Disease, State Key Laboratory for Organ Failure Research, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hao Zhang
- Key Laboratory of Precision Nutrition and Food Quality, Department of Nutrition and Health, College of Food Sciences and Nutritional Engineering, China Agricultural University, Beijing, China
| | - Xiping Xu
- Key Laboratory of Precision Nutrition and Food Quality, Department of Nutrition and Health, College of Food Sciences and Nutritional Engineering, China Agricultural University, Beijing, China
- National Clinical Research Center for Kidney Disease, State Key Laboratory for Organ Failure Research, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Huiyuan Guo
- Key Laboratory of Precision Nutrition and Food Quality, Department of Nutrition and Health, College of Food Sciences and Nutritional Engineering, China Agricultural University, Beijing, China
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Pes K, Ortiz-Delgado JB, Sarasquete C, Laizé V, Fernández I. Short-term exposure to pharmaceuticals negatively impacts marine flatfish species: Histological, biochemical and molecular clues for an integrated ecosystem risk assessment. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2022; 90:103822. [PMID: 35101594 DOI: 10.1016/j.etap.2022.103822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 06/14/2023]
Abstract
The marine habitat and its biodiversity can be impacted by released pharmaceuticals. The short-term (7 days) effect of 3 commonly used drugs - warfarin, dexamethasone and imidazole - on Senegalese sole (Solea senegalensis) juveniles was investigated. Occurrence of hemorrhages, histopathological alterations, antioxidant status, activity of antioxidant enzymes and expression of genes involved in the xenobiotic response (pxr, abcb1 and cyp1a), were evaluated. The results showed a time and drug-dependent effect. Warfarin exposure induced hemorrhages, hepatocyte vacuolar degeneration, and altered the activity of glutathione peroxidase (GPx) and the expression of all the studied genes. Dexamethasone exposure increased liver glycogen content, altered antioxidant status, GPx and superoxide dismutase activities, as well as abcb1 and cyp1a expression. Imidazole induced hepatocyte vacuolar degeneration and ballooning, and altered the antioxidant status and expression of the tested genes. The present work anticipates a deeper impact of pharmaceuticals on the aquatic environment than previously reported, thus underlining the urgent need for an integrated risk assessment.
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Affiliation(s)
- Katia Pes
- Centro de Ciências do Mar (CCMAR), Universidade do Algarve, Campus de Gambelas, 8005-139 Faro, Portugal
| | - Juan B Ortiz-Delgado
- Instituto de Ciencias Marinas de Andalucía-ICMAN/CSIC, Campus Universitario Río San Pedro, Apdo. Oficial, 11510 Puerto Real, Cádiz, Spain
| | - Carmen Sarasquete
- Instituto de Ciencias Marinas de Andalucía-ICMAN/CSIC, Campus Universitario Río San Pedro, Apdo. Oficial, 11510 Puerto Real, Cádiz, Spain
| | - Vincent Laizé
- Centro de Ciências do Mar (CCMAR), Universidade do Algarve, Campus de Gambelas, 8005-139 Faro, Portugal; S2 AQUA - Sustainable and Smart Aquaculture Collaborative Laboratory, Olhão, Portugal
| | - Ignacio Fernández
- Aquaculture Research Center, Agro-Technological Institute of Castilla y León (ITACyL), Ctra. Arévalo, s/n, 40196 Zamarramala, Segovia, Spain; Centro Oceanográfico de Vigo, Instituto Español de Oceanografía (IEO-CSIC), 36390 Vigo, Spain.
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Anticoagulation Prior to COVID-19 Infection Has No Impact on 6 Months Mortality: A Propensity Score-Matched Cohort Study. J Clin Med 2022; 11:jcm11020352. [PMID: 35054046 PMCID: PMC8781160 DOI: 10.3390/jcm11020352] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/03/2022] [Accepted: 01/06/2022] [Indexed: 01/08/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) shows high incidence of thromboembolic events in humans. In the present study, we aimed to evaluate if anticoagulation prior to COVID-19 infection may impact clinical profile, as well as mortality rate among patients hospitalized with COVID-19. The study was based on retrospective analysis of medical records of patients with laboratory confirmed SARS-CoV-2 infection. After propensity score matching (PSM), a group of 236 patients receiving any anticoagulant treatment prior to COVID-19 infection (AT group) was compared to 236 patients without previous anticoagulation (no AT group). In 180 days, the observation we noted comparable mortality rate in AT and no AT groups (38.5% vs. 41.1%, p = 0.51). Similarly, we did not observe any statistically significant differences in admission in the intensive care unit (14.1% vs. 9.6%, p = 0.20), intubation and mechanical ventilation (15.0% vs. 11.6%, p = 0.38), catecholamines usage (14.3% vs. 13.8%, p = 0.86), and bleeding rate (6.3% vs. 8.9%, p = 0.37) in both groups. Our results suggest that antithrombotic treatment prior to COVID-19 infection is unlikely to be protective for morbidity and mortality in patients hospitalized with COVID-19.
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Fibrilación auricular no valvular en pacientes en hemodiálisis crónica. ¿Debemos anticoagular? Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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19
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Königsbrügge O, Meisel H, Beyer A, Schmaldienst S, Klauser-Braun R, Lorenz M, Auinger M, Kletzmayr J, Hecking M, Winkelmayer WC, Lang I, Pabinger I, Säemann M, Ay C. Anticoagulation use and the risk of stroke and major bleeding in patients on hemodialysis: From the VIVALDI, a population-based prospective cohort study. J Thromb Haemost 2021; 19:2984-2996. [PMID: 34418291 DOI: 10.1111/jth.15508] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/10/2021] [Accepted: 08/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Evidence supporting the use of anticoagulation for the prevention of stroke and thromboembolism in patients with kidney failure on hemodialysis (HD) and atrial fibrillation (AF) is limited. We prospectively assessed the incidences of stroke and major bleeding, as well as anticoagulation strategies in patients on HD with AF. METHODS We recruited 625 prevalent HD patients into a population-based observational cohort study. The primary prospective outcomes were thromboembolic events (stroke, transient ischemic attack, systemic embolism) and major bleeding. Secondary outcomes included a composite of thromboembolic events, major bleeding, and cardiovascular death to determine net clinical harm. RESULTS A total of 238 patients (38.1%) had AF, 165 (26.4%) already at baseline and 73 (15.9%) developed AF during a median follow up of 870 days. Forty (6.4%) thromboembolic events and 89 (14.2%) major bleedings occurred. Overall, 256 patients died (41.0%). In AF patients, use of vitamin K antagonists (VKAs) in 61 patients (25.6%) was not significantly associated with reduced risk of the primary thromboembolic outcome (subdistribution hazard ratio [SHR] 1.41 adjusted for age, sex, congestive heart failure, hypertension, stroke/transient ischemic attack/thromboembolism, vascular disease, and diabetes history score and antiplatelet co-medication (95% CI, 0.49-4.07), but with increased risk of major bleeding (SHR: 2.28; 95% CI, 1.09-4.79) compared with AF patients without anticoagulation (N = 139, 58.4%). Use of VKAs was associated with net clinical harm (adjusted SHR: 2.07; 95% CI, 1.25-3.42). CONCLUSIONS Although the nonrandomized nature of the study is prone to bias, anticoagulation with VKAs was not associated with decreased thromboembolic risk, but rather with increased risk of major bleeding and may be net harmful to patients with AF on HD.
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Affiliation(s)
- Oliver Königsbrügge
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Hannah Meisel
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Aljoscha Beyer
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | | | | | | | - Martin Auinger
- Department of Medicine III, Clinic Hietzing, Vienna, Austria
| | - Josef Kletzmayr
- Department of Medicine III, Clinic Donaustadt, Vienna, Austria
| | - Manfred Hecking
- Clinical Division of Nephrology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Wolfgang C Winkelmayer
- Section of Nephrology, Department of Medicine, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, USA
| | - Irene Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Marcus Säemann
- Department of Medicine VI, Clinic Ottakring, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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20
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Traber MG, Head B. Vitamin E: How much is enough, too much and why! Free Radic Biol Med 2021; 177:212-225. [PMID: 34699937 DOI: 10.1016/j.freeradbiomed.2021.10.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/08/2021] [Accepted: 10/11/2021] [Indexed: 12/12/2022]
Abstract
α-Tocopherol (α-T) is a required dietary nutrient for humans and thus is a vitamin. This narrative review focuses on vitamin E structures, functions, biological determinants and its deficiency symptoms in humans. The mechanisms for the preferential α-T tissue enrichment in the human body include the α-T transfer protein (TTPA) and the preferential metabolism of non-α-T forms. Potential new α-T biomarkers, pharmacokinetic data, and whether there are better approaches to evaluate and set the α-T dietary requirement are discussed. Finally, the possible role of α-T supplements in delay of chronic diseases and the evaluation of vitamin E safety are considered.
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Affiliation(s)
- Maret G Traber
- Linus Pauling Institute, USA; School of Biological and Population Health Sciences, College of Public Health and Human Sciences, USA.
| | - Brian Head
- Linus Pauling Institute, USA; Molecular and Cell Biology Program, Oregon State University, Corvallis, OR, USA
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21
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van Gorp RH, Baaten CCFMJ, Habibi A, Jaminon AMG, Peeters FECM, Leenders P, Crijns HJGMC, Heemskerk JWM, Reutelingsperger CP, Spronk HM, Schurgers LJ. Vitamin K antagonist use induces calcification and atherosclerotic plaque progression resulting in increased hypercoagulability. EUROPEAN HEART JOURNAL OPEN 2021; 1:oeab017. [PMID: 35919270 PMCID: PMC9241573 DOI: 10.1093/ehjopen/oeab017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/16/2021] [Accepted: 08/03/2021] [Indexed: 11/26/2022]
Abstract
Aims Vascular calcification is a hallmark of atherosclerotic burden and can predict the cardiovascular outcome. Vitamin K antagonists (VKA) are widely used anticoagulant drugs to treat patients at risk of arterial and venous thrombosis but are also associated with increase vascular calcification progression. We aim to unravel the paradox that VKA suppresses plasma coagulation but promotes vascular calcification and subsequent atherosclerosis-dependent coagulability of the vessel wall. Methods and results Apoe−/− mice were placed on western-type diet enriched with the VKA warfarin for 18 weeks to measure atherosclerotic plaque burden, calcification, and coagulation. Patients (n = 54) displaying paroxysmal atrial fibrillation with a low cardiovascular risk, who were treated with VKA were included to measure pre-thrombotic state. Finally, primary vascular smooth muscle cells (VSMC) derived from human tissue explants were used for in vitro experiments. In Apoe−/− mice, VKA increases both atherosclerotic plaque size and calcification. Higher plaque calcification was associated with increased plasma levels of thrombin-antithrombin and factor IXa-antithrombin complexes in mice and patients treated with VKA. Mechanistically, phenotypic switching of VSMC into synthetic VSMC promotes thrombin generation, which is enhanced in a tissue-factor (TF)-dependent manner by VSMC calcification. Moreover, calcified VSMC exposed to whole blood under flow significantly enhanced platelet deposition and TF-dependent fibrin formation. Conclusions Oral anticoagulation with VKA aggravates vascular calcification and atherosclerosis. VSMC phenotype differentiation impacts coagulation potential in a TF-dependent manner. VKA-induced vascular calcification increases hypercoagulability and could thereby potentially positively affect atherothrombosis.
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Affiliation(s)
- Rick H van Gorp
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre , Maastricht, The Netherlands
- Nattopharma ASA , Olso, Norway
| | - Constance C F M J Baaten
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre , Maastricht, The Netherlands
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen , Aachen, Germany
| | - Anxhela Habibi
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre , Maastricht, The Netherlands
| | - Armand M G Jaminon
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre , Maastricht, The Netherlands
| | - Frederique E C M Peeters
- Department of Cardiology, MUMC+ and Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre , Maastricht, The Netherlands
| | - Peter Leenders
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre , Maastricht, The Netherlands
| | - Harry J G M C Crijns
- Department of Cardiology, MUMC+ and Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre , Maastricht, The Netherlands
| | - Johan W M Heemskerk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre , Maastricht, The Netherlands
| | - Chris P Reutelingsperger
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre , Maastricht, The Netherlands
| | - Henri M Spronk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre , Maastricht, The Netherlands
| | - Leon J Schurgers
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre , Maastricht, The Netherlands
- Institute of Experimental Medicine and Systems Biology, RWTH Aachen University , Aachen, Germany
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22
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Iwai R, Ishii T, Fukushima Y, Okamoto T, Ichihashi M, Sasaki Y, Mizuatni KI. Matcha and Its Components Control Angiogenic Potential. J Nutr Sci Vitaminol (Tokyo) 2021; 67:118-125. [PMID: 33952732 DOI: 10.3177/jnsv.67.118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The brain needs the appropriate capillary networks to maintain normal brain function. Since previous studies showed age-related decrease in the cortical capillaries, it is suggested that protection against capillary aging is critical for maintaining brain function. Epidemiological studies have indicated that brain functions were protected from age-related decline by the long-term consumption of matcha. However, whether matcha has protective effects on capillary aging has not been studied yet. In this study, we utilized Flt1-DsR mice that expressed a red fluorescent protein in vascular endothelial cells to visualize cortical capillaries clearly. We found that cortical capillary density decreased in aging Flt1-DsR mice. Our results of the aortic ring assay and tube formation assay revealed that matcha and its components vitamin K1 and lutein, which are abundant in matcha powder, enhanced the angiogenic potential. Moreover, we evaluated the effect of long-term ingestion of matcha on mouse cortical capillary aging by using imaging experiments. The capillary density of the Flt1-DsR mice, which were fed matcha-containing food, indicated the protective effects of matcha ingestion on capillary aging in a limited cortical layer. These results suggest that biological regulation of matcha and its components affect the angiogenic potential, which is related to the prevention of capillary aging.
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Affiliation(s)
- Ryota Iwai
- Graduate School of Food and Medicinal Sciences, Kobe Gakuin University.,Graduate School of Pharmaceutical Sciences, Kobe Gakuin University
| | - Takeshi Ishii
- Graduate School of Food and Medicinal Sciences, Kobe Gakuin University
| | - Yoichi Fukushima
- Department of Health Food Sciences, University of Human Arts and Sciences
| | | | | | - Yasuto Sasaki
- Graduate School of Food and Medicinal Sciences, Kobe Gakuin University
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23
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The change of renal functions after nonvitamin K oral anticoagulants in patients with atrial fibrillation. IJC HEART & VASCULATURE 2021; 35:100844. [PMID: 34386573 PMCID: PMC8342949 DOI: 10.1016/j.ijcha.2021.100844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/30/2021] [Accepted: 07/14/2021] [Indexed: 11/29/2022]
Abstract
Oral anticoagulants decreased stroke and mortality in atrial fibrillation patients. There have been cumulative data suggesting that some oral anticoagulants may exert favorable renal outcomes.The aim of this study is to evaluate the renal outcomes in patients with atrial fibrillation who took oral anticoagulant. Methods: A Retrospective cohort study using hospital electronic database. Serum creatinine and GFR were collected at baseline and at 1 and 2 years. Results: Authors identified 734 patients with non-valvular AF who took oral anticoagulants. At the end of 2-year, the cumulative risk of significant GFR decline (eGFR drop > 30%) was 10.94% in warfarin group and 9.69% in NOACs group.The incidence rate of significant eGFR decline were comparable between NOACs and warfarin group which were 4.82 and 5.34 per 100-patient year respectively(HR 1.01 CI 0.62–1.66 , p- value 0.964).However, the adjusted mean eGFR change per year was significantly lower in NOAC group, especially rivaroxaban (coefficient 7.83 ,CI 4.44 11.22 , p-value < 0.001) and dabigatran (coefficient 6.22 ,CI 2.67–9.77 , p-value = 0.001) at 2 years. Conclusions: Significant GFR decline was not uncommon in non-valvular AF patients who received anticoagulant. Among these, the proportion of patients who had significant eGFR decline(>30%) were comparable between NOACs and warfarin at 2 years. However, there is a significantly less mean eGFR decline per year in patients who receive NOACs, notably with dabigatran and rivaroxaban, than those who receive warfarin.The findings of this study should be interpreted in the context of patients included in this study.
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24
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Botto GL, Ameri P, De Caterina R. Many Good Reasons to Switch from Vitamin K Antagonists to Non-Vitamin K Antagonists in Patients with Non-Valvular Atrial Fibrillation. J Clin Med 2021; 10:jcm10132866. [PMID: 34203416 PMCID: PMC8268480 DOI: 10.3390/jcm10132866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/17/2021] [Accepted: 06/19/2021] [Indexed: 12/14/2022] Open
Abstract
Non-vitamin K oral anticoagulants (NOACs) are the first choice for prophylaxis of cardioembolism in patients with non-valvular atrial fibrillation (AF) who are anticoagulant-naïve, as well as the preferable anticoagulation strategy in those who are on vitamin K antagonists (VKAs), but with a low time in therapeutic range (TTR). Nonetheless, there are many good reasons to consider switching from VKAs to NOACs also when TTR is >70%. From the pharmacological standpoint, anticoagulation with VKAs may remain erratic even in those patients who have high TTR values, owing to the mode of action of this drug class. Furthermore, experimental data suggest that, unlike VKAs, NOACs favorably modulate the effects of factor Xa and thrombin in the cardiovascular system through the protease-activated receptor family. Clinically, the most striking advantage provided by NOACs over VKAs, irrespective of the TTR, is the substantially lower risk of intracranial hemorrhage. NOACs have also been associated with less deterioration of renal function as compared with VKAs and may confer protection against cardiovascular events not strictly related to AF, especially the acute complications of peripheral artery disease. In this narrative review, we discuss the evidence according to which it is warranted to systematically substitute NOACs for VKAs for the prevention of AF-related stroke and systemic embolism.
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Affiliation(s)
- Giovanni Luca Botto
- Department of Cardiology—Electrophysiology, ASST Rhodense, Garbagnate Milanese, 20024 Milan, Italy; or
| | - Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, 16132 Genova, Italy
- Department of Internal Medicine, University of Genova, 16132 Genova, Italy
- Correspondence: ; Tel.: +39-010-353-8928; Fax: +39-010-555-6513
| | - Raffaele De Caterina
- Division of Cardiology, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56124 Pisa, Italy;
- Fondazione Villa Serena per la Ricerca, Città Sant’Angelo, 65103 Pescara, Italy
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25
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Zolotovskaya IA, Sabanova VD, Davydkin IL. The Role of Rivaroxaban in a Comprehensive Protection Strategy for Patients with Atrial Fibrillation. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-04-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Anticoagulant therapy of patients with atrial fibrillation is an integral part of their treatment strategy. The high risk of developing a cardioembolic stroke and the high comorbidity of this group of patients necessitates a comprehensive approach to treatment, taking into account all available risk factors. Atrial fibrillation is often asymptomatic and timely detection of these patients can be one of the most important tasks in the complex of measures aimed at protecting patients from stroke. The European Society of Cardiology's 2020 guidelines suggest the use of a CC to ABC patient management strategy. This strategy involves a number of measures aimed at managing atrial fibrillation, including confirming the diagnosis, determining the characteristics of atrial fibrillation and treatment tactics. One of the points of this strategy is the control of comorbidities and risk factors for cardiovascular diseases. To date, rivaroxaban has a number of convincing and reliable data on a high profile of efficacy and safety in the treatment of comorbid patients who not only have a high risk of stroke, but also need protection from coronary events and decreased renal filtration function. These data are confirmed by both the results of randomized clinical trials and data from real clinical practice. The review discusses the literature data describing the condition of patients with atrial fibrillation while taking direct oral anticoagulants, according to the search query “Atrial fibrillation, effectiveness and safety of rivaroxaban, warfarin, comorbidity, atrial fibrillation, efficacy and safety of rivaroxaban, warfarin, comorbid status” for the period from 2010 to 2020 in open sources PubMed and e-library, and a strategy for the comprehensive protection of patients with atrial fibrillation when using rivaroxaban is proposed for consideration.
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26
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Calciphylaxis-Associated Cutaneous Vascular Calcification in Noncalciphylaxis Patients. Am J Dermatopathol 2021; 42:557-563. [PMID: 32701689 DOI: 10.1097/dad.0000000000001519] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Calciphylaxis is a highly morbid disease that is strongly associated with chronic kidney disease (CKD); however, the histologic criteria for diagnosis have not been well established nor have their specificity for calciphylaxis been determined. This retrospective study aimed to examine the prevalence of histologic features commonly associated with calciphylaxis in noncalciphylaxis patients. We also sought to evaluate whether these features may be more prevalent in patients with CKD. To assess this, healthy marginal skin tissue from above-the-knee amputation specimens was compared between patients with CKD (n = 23) and without CKD (n = 47). Intravascular calcification of capillaries or small-to-medium arterioles was detected on von Kossa stain in 40.0% of the entire cohort. Capillary calcification and intravascular thrombosis were more prevalent in patients with CKD. Finely stippled capillary calcification was present in 26.1% of patients with CKD versus 8.5% of patients without CKD (P = 0.0484), and intravascular thrombosis was present in 8.7% of patients with CKD and 0.0% of patients without CKD (P = 0.0403). None of the patients in this study had clinical evidence of calciphylaxis at presentation and in at least a 1-year follow-up period. This study confirms that the histologic features previously associated with calciphylaxis are nonspecific and are more prevalent in patients with CKD.
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27
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The Dual Role of Vitamin K2 in "Bone-Vascular Crosstalk": Opposite Effects on Bone Loss and Vascular Calcification. Nutrients 2021; 13:nu13041222. [PMID: 33917175 PMCID: PMC8067793 DOI: 10.3390/nu13041222] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 03/30/2021] [Accepted: 04/04/2021] [Indexed: 12/13/2022] Open
Abstract
Osteoporosis (OP) and vascular calcification (VC) represent relevant health problems that frequently coexist in the elderly population. Traditionally, they have been considered independent processes, and mainly age-related. However, an increasing number of studies have reported their possible direct correlation, commonly defined as “bone-vascular crosstalk”. Vitamin K2 (VitK2), a family of several natural isoforms also known as menaquinones (MK), has recently received particular attention for its role in maintaining calcium homeostasis. In particular, VitK2 deficiency seems to be responsible of the so-called “calcium paradox” phenomenon, characterized by low calcium deposition in the bone and its accumulation in the vessel wall. Since these events may have important clinical consequences, and the role of VitK2 in bone-vascular crosstalk has only partially been explained, this review focuses on its effects on the bone and vascular system by providing a more recent literature update. Overall, the findings reported here propose the VitK2 family as natural bioactive molecules that could be able to play an important role in the prevention of bone loss and vascular calcification, thus encouraging further in-depth studies to achieve its use as a dietary food supplement.
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28
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The Effects of Warfarin and Direct Oral Anticoagulants on Systemic Vascular Calcification: A Review. Cells 2021; 10:cells10040773. [PMID: 33807457 PMCID: PMC8066517 DOI: 10.3390/cells10040773] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 12/30/2022] Open
Abstract
Warfarin has been utilized for decades as an effective anticoagulant in patients with a history of strong risk factors for venous thromboembolism (VTE). Established adverse effects include bleeding, skin necrosis, teratogenicity during pregnancy, cholesterol embolization, and nephropathy. One of the lesser-known long-term side effects of warfarin is an increase in systemic arterial calcification. This is significant due to the association between vascular calcification and cardiovascular morbidity and mortality. Direct oral anticoagulants (DOACs) have gained prominence in recent years, as they require less frequent monitoring and have a superior side effect profile to warfarin, specifically in relation to major bleeding. The cost and lack of data for DOACs in some disease processes have precluded universal use. Within the last four years, retrospective cohort studies, observational studies, and randomized trials have shown, through different imaging modalities, that multiple DOACs are associated with slower progression of vascular calcification than warfarin. This review highlights the pathophysiology and mechanisms behind vascular calcification due to warfarin and compares the effect of warfarin and DOACs on systemic vasculature.
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29
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Sitticharoenchai P, Takkavatakarn K, Boonyaratavej S, Praditpornsilpa K, Eiam-Ong S, Susantitaphong P. Non-Vitamin K Antagonist Oral Anticoagulants Provide Less Adverse Renal Outcomes Than Warfarin In Non-Valvular Atrial Fibrillation: A Systematic Review and MetaAnalysis. J Am Heart Assoc 2021; 10:e019609. [PMID: 33728927 PMCID: PMC8174352 DOI: 10.1161/jaha.120.019609] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Non‐vitamin K antagonist oral anticoagulants (NOACs) have better pharmacologic properties than warfarin and are recommended in preference to warfarin in most patients with non‐valvular atrial fibrillation. Besides lower bleeding complications, other advantages of NOACs over warfarin particularly renal outcomes remain inconclusive. Methods and Results Electronic searches were conducted through Medline, Scopus, Cochrane Library databases, and ClinicalTrial.gov. Randomized controlled trials and observational cohort studies reporting incidence rates and hazard ratio (HR) of renal outcomes (including acute kidney injury, worsening renal function, doubling serum creatinine, and end‐stage renal disease) were selected. The random‐effects model was used to calculate pooled incidence and HR with 95% CI. Eighteen studies were included. A total of 285 201 patients were enrolled, 118 863 patients with warfarin and 166 338 patients with NOACs. The NOACs group yielded lower incidence rates of all renal outcomes when compared with the warfarin group. Patients treated with NOACs showed significantly lower HR of risk of acute kidney injury (HR, 0.70, 95% CI, 0.64–0.76; P<0.001), worsening renal function (HR, 0.83; 95% CI, 0.73–0.95; P=0.006), doubling serum creatinine (HR, 0.58; 95% CI, 0.41–0.82; P=0.002), and end‐stage renal disease (HR, 0.82; 95% CI, 0.78–0.86; P<0.001). Conclusions In non‐valvular atrial fibrillation, patients treated with NOACs have a lower risk of both acute kidney injury and end‐stage renal disease when compared with warfarin.
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Affiliation(s)
- Patita Sitticharoenchai
- Division of Cardiology Department of Medicine Faculty of Medicine King Chulalongkorn Memorial HospitalChulalongkorn University Bangkok Thailand
| | - Kullaya Takkavatakarn
- Division of Nephrology Department of Medicine Faculty of Medicine King Chulalongkorn Memorial HospitalChulalongkorn University Bangkok Thailand
| | - Smonporn Boonyaratavej
- Division of Cardiology Department of Medicine Faculty of Medicine King Chulalongkorn Memorial HospitalChulalongkorn University Bangkok Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology Department of Medicine Faculty of Medicine King Chulalongkorn Memorial HospitalChulalongkorn University Bangkok Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology Department of Medicine Faculty of Medicine King Chulalongkorn Memorial HospitalChulalongkorn University Bangkok Thailand
| | - Paweena Susantitaphong
- Division of Nephrology Department of Medicine Faculty of Medicine King Chulalongkorn Memorial HospitalChulalongkorn University Bangkok Thailand.,Research Unit for Metabolic Bone Disease in CKD patients Faculty of Medicine Chulalongkorn University Bangkok Thailand
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30
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Lavorato VN, Miranda DCD, Isoldi MC, Drummond FR, Soares LL, Reis ECC, Pelúzio MDCG, Pedrosa ML, Silva ME, Natali AJ. Effects of aerobic exercise training and açai supplementation on cardiac structure and function in rats submitted to a high-fat diet. Food Res Int 2021; 141:110168. [PMID: 33642024 DOI: 10.1016/j.foodres.2021.110168] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 12/21/2020] [Accepted: 01/15/2021] [Indexed: 01/25/2023]
Abstract
This study evaluated the effect of aerobic exercise training (AET) and supplementation with açai on cardiac structure and function in rats submitted to a high-fat diet. Two-month old Fischer male rats were divided into 5 groups: Control (C), High-fat Diet (H), High-fat Diet + Açai (HA), High-fat Diet + AET (HT), High-fat Diet + Açai + AET (HAT). The high-fat diet had 21.8% lard and 1% cholesterol (H and HT), or supplemented with 1% lyophilized açai pulp (HA and HAT). The HT and HAT groups performed AET on a treadmill (5 days/week, 1 h/day, 60% of the maximum running speed) for 8 weeks. Exercise tolerance test were performed, and adiposity index calculated. After euthanasia, the left ventricle (LV) was dissected and processed for histological, single myocyte intracellular calcium ([Ca2+]i) transient and contractility, oxidative stress and gene expression analysis. AET improved running capacity and reduced the adiposity index. Both AET and açai supplementation inhibited the increase in the LV collagen content, the deleterious effects on the [Ca2+]i transient and contractility in cardiomyocytes and the increment in oxidative stress, caused by the consumption of a high-fat diet. Aerobic exercise training and açai supplementation can mitigate damage caused by high-fat diet in cardiac structure and function, though the combination of treatments had no additional effects.
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Affiliation(s)
- Victor Neiva Lavorato
- Department of Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil.
| | | | - Mauro César Isoldi
- Department of Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Filipe Rios Drummond
- Department of Physical Education, Federal University of Viçosa, Viçosa, Minas Gerais, Brazil
| | - Leôncio Lopes Soares
- Department of Physical Education, Federal University of Viçosa, Viçosa, Minas Gerais, Brazil.
| | | | | | - Maria Lúcia Pedrosa
- Department of Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | | | - Antônio José Natali
- Department of Physical Education, Federal University of Viçosa, Viçosa, Minas Gerais, Brazil.
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31
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Hao Z, Jin DY, Chen X, Schurgers LJ, Stafford DW, Tie JK. γ-Glutamyl carboxylase mutations differentially affect the biological function of vitamin K-dependent proteins. Blood 2021; 137:533-543. [PMID: 33507293 PMCID: PMC7845004 DOI: 10.1182/blood.2020006329] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/28/2020] [Indexed: 12/14/2022] Open
Abstract
γ-Glutamyl carboxylase (GGCX) is an integral membrane protein that catalyzes posttranslational carboxylation of a number of vitamin K-dependent (VKD) proteins involved in a wide variety of physiologic processes, including blood coagulation, vascular calcification, and bone metabolism. Naturally occurring GGCX mutations are associated with multiple distinct clinical phenotypes. However, the genotype-phenotype correlation of GGCX remains elusive. Here, we systematically examined the effect of all naturally occurring GGCX mutations on the carboxylation of 3 structure-function distinct VKD proteins in a cellular environment. GGCX mutations were transiently introduced into GGCX-deficient human embryonic kidney 293 cells stably expressing chimeric coagulation factor, matrix Gla protein (MGP), or osteocalcin as VKD reporter proteins, and then the carboxylation efficiency of these reporter proteins was evaluated. Our results show that GGCX mutations differentially affect the carboxylation of these reporter proteins and the efficiency of using vitamin K as a cofactor. Carboxylation of these reporter proteins by a C-terminal truncation mutation (R704X) implies that GGCX's C terminus plays a critical role in the binding of osteocalcin but not in the binding of coagulation factors and MGP. This has been confirmed by probing the protein-protein interaction between GGCX and its protein substrates in live cells using bimolecular fluorescence complementation and chemical cross-linking assays. Additionally, using a minigene splicing assay, we demonstrated that several GGCX missense mutations affect GGCX's pre-messenger RNA splicing rather than altering the corresponding amino acid residues. Results from this study interpreted the correlation of GGCX's genotype and its clinical phenotypes and clarified why vitamin K administration rectified bleeding disorders but not nonbleeding disorders.
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Affiliation(s)
- Zhenyu Hao
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC; and
| | - Da-Yun Jin
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC; and
| | - Xuejie Chen
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC; and
| | - Leon J Schurgers
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, The Netherlands
| | - Darrel W Stafford
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC; and
| | - Jian-Ke Tie
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC; and
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32
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The Safety and Efficacy of Rivaroxaban Compared with Warfarin in Patients with Atrial Fibrillation and Diabetes: A Systematic Review and Meta-analysis. Am J Cardiovasc Drugs 2021; 21:51-61. [PMID: 32514866 DOI: 10.1007/s40256-020-00407-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
AIMS This meta-analysis was conducted to compare the efficacy and safety of rivaroxaban with warfarin in patients with atrial fibrillation (AF) and diabetes mellitus. METHODS PubMed, Embase, Cochrane Library, and Web of Science databases were systematically searched from the establishment of databases up to 15 October 2019. Studies on efficacy and safety outcomes of rivaroxaban and warfarin were included. Efficacy and safety outcomes, including stroke, ischemic stroke, stroke or systemic embolism, myocardial infarction, major adverse cardiac events, major bleeding, intracranial hemorrhage, and major gastrointestinal bleeding were collected for meta-analysis. RESULTS Compared with warfarin, rivaroxaban could significantly reduce stroke (risk ratio [RR] 0.77; 95% confidence interval [CI] 0.63-0.95; P = 0.01), ischemic stroke (RR 0.74; 95% CI 0.63-0.87; P = 0.0004), stroke or systemic embolism (RR 0.73; 95% CI 0.60-0.89; P = 0.002), myocardial infarction (RR 0.68; 95% CI 0.56-0.82; P < 0.0001), and major adverse cardiac events (RR 0.71; 95% CI 0.53-0.94; P = 0.02) in patients with AF and diabetes. Moreover, rivaroxaban was associated with a lower risk of major bleeding (RR 0.79; 95% CI 0.65-0.96; P = 0.02), intracranial hemorrhage (RR 0.52; 95% CI 0.39-0.69; P < 0.00001), and major gastrointestinal bleeding (RR 0.74; 95% CI 0.56-0.98; P = 0.04). Similar results were obtained in stratified meta-analysis of cohort studies. CONCLUSION Our study suggests a favorable risk-benefit profile of rivaroxaban, with superior efficacy and safety over warfarin in patients with AF and diabetes.
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Pavlova TV. An Elderly Comorbid Patient with Atrial Fibrillation: What is Important to Know and What Should be Considered When Prescribing Anticoagulants? RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2020. [DOI: 10.20996/1819-6446-2020-12-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Anticoagulant therapy in elderly patients with atrial fibrillation and concomitant diseases is often the challenge for clinicians. The high risk of stroke is inherent in atrial fibrillation, and it increases when combined with coronary heart disease and chronic kidney disease. On the other hand, the comorbidity increases the risk of bleeding. Older age is also the risk factor of thrombotic and hemorrhagic complications. As a consequence, the choice of specific anticoagulant should be based on a solid evidences, obtained both from randomized clinical trials and from daily clinical practice. In the ROCKET AF trail the direct oral anticoagulant rivaroxaban showed a tendency to reduce the risk of thromboembolism by 20% compared with warfarin in the patients aged 75 years and older. The safety of rivaroxaban has been evaluated in the XANTUS POOLED program. According to the follow-up results for 12 months, more than 96% of patients didn't have any adverse event, and the number of patients with major bleeding was 1.5%. Several meta-analyzes reported a reduction of cardiovascular complications in patients treated by rivaroxaban. In the ROCKET AF trail, a “renal” dose of rivaroxaban (15 mg OD) was studied in patients with chronic kidney disease. The efficacy and safety of rivaroxaban were validated in this patients, and a simple algorithm for selecting the dose of this drug in patients with chronic kidney disease was provided.
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Magnocavallo M, Bellasi A, Mariani MV, Fusaro M, Ravera M, Paoletti E, Di Iorio B, Barbera V, Della Rocca DG, Palumbo R, Severino P, Lavalle C, Di Lullo L. Thromboembolic and Bleeding Risk in Atrial Fibrillation Patients with Chronic Kidney Disease: Role of Anticoagulation Therapy. J Clin Med 2020; 10:jcm10010083. [PMID: 33379379 PMCID: PMC7796391 DOI: 10.3390/jcm10010083] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/17/2022] Open
Abstract
Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related; several independent risk factors of AF are often frequent in CKD patients. AF prevalence is very common among these patients, ranging between 15% and 20% in advanced stages of CKD. Moreover, the results of several studies showed that AF patients with end stage renal disease (ESRD) have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD and vitamin K antagonists (VKAs), remaining the only drugs allowed, although they show numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients.
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Affiliation(s)
- Michele Magnocavallo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Antonio Bellasi
- Department of Research, Innovation and Brand Reputation, ASST-Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Maria Fusaro
- National Council of Research, Institute of Clinical Physiology, 56124 Pisa, Italy;
| | - Maura Ravera
- Nefrologia, Dialisi e Trapianto, Policlinico San Martino, 16132 Genova, Italy; (M.R.); (E.P.)
| | - Ernesto Paoletti
- Nefrologia, Dialisi e Trapianto, Policlinico San Martino, 16132 Genova, Italy; (M.R.); (E.P.)
| | - Biagio Di Iorio
- Department of Nephrology and Dialysis, Moscati Hospital, 83100 Avellino, Italy;
| | - Vincenzo Barbera
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Italy;
| | | | - Roberto Palumbo
- Department of Nephrology and Dialysis, Sant’Eugenio Hospital, 00144 Rome, Italy;
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Italy;
- Correspondence: ; Fax: +39-06-972233213
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Ménager P, Brière O, Gautier J, Riou J, Sacco G, Brangier A, Annweiler C. Regular Use of VKA Prior to COVID-19 Associated with Lower 7-Day Survival in Hospitalized Frail Elderly COVID-19 Patients: The GERIA-COVID Cohort Study. Nutrients 2020; 13:nu13010039. [PMID: 33374341 PMCID: PMC7824717 DOI: 10.3390/nu13010039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/20/2020] [Accepted: 12/22/2020] [Indexed: 12/14/2022] Open
Abstract
Background. Vitamin K concentrations are inversely associated with the clinical severity of COVID-19. The objective of this cohort study was to determine whether the regular use of vitamin K antagonist (VKA) prior to COVID-19 was associated with short-term mortality in frail older adults hospitalized for COVID-19. Methods. Eighty-two patients consecutively hospitalized for COVID-19 in a geriatric acute care unit were included. The association of the regular use of VKA prior to COVID-19 with survival after 7 days of COVID-19 was examined using a propensity-score-weighted Cox proportional-hazards model accounting for age, sex, severe undernutrition, diabetes mellitus, hypertension, prior myocardial infarction, congestive heart failure, prior stroke and/or transient ischemic attack, CHA2DS2-VASc score, HAS-BLED score, and eGFR. Results. Among 82 patients (mean ± SD age 88.8 ± 4.5 years; 48% women), 73 survived COVID-19 at day 7 while 9 died. There was no between-group difference at baseline, despite a trend for more frequent use of VKA in those who did not survive on day 7 (33.3% versus 8.2%, p = 0.056). While considering “using no VKA” as the reference (hazard ratio (HR) = 1), the HR for 7-day mortality in those regularly using VKA was 5.68 [95% CI: 1.17; 27.53]. Consistently, COVID-19 patients using VKA on a regular basis had shorter survival times than the others (p = 0.031). Conclusions. Regular use of VKA was associated with increased mortality at day 7 in hospitalized frail elderly patients with COVID-19.
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Affiliation(s)
- Pierre Ménager
- Department of Geriatric Medicine, Le Mans Hospital, F-72037 Le Mans, France;
- Department of Geriatric Medicine and Memory Clinic, Research Center on Autonomy and Longevity, University Hospital, F-49933 Angers, France; (O.B.); (J.G.); (G.S.); (A.B.)
| | - Olivier Brière
- Department of Geriatric Medicine and Memory Clinic, Research Center on Autonomy and Longevity, University Hospital, F-49933 Angers, France; (O.B.); (J.G.); (G.S.); (A.B.)
| | - Jennifer Gautier
- Department of Geriatric Medicine and Memory Clinic, Research Center on Autonomy and Longevity, University Hospital, F-49933 Angers, France; (O.B.); (J.G.); (G.S.); (A.B.)
| | - Jérémie Riou
- INSERM, MINT, 1066, University of Angers, F-49000 Angers, France;
- Delegation to Clinical Research and Innovation, Angers University Hospital, F-49933 Angers, France
| | - Guillaume Sacco
- Department of Geriatric Medicine and Memory Clinic, Research Center on Autonomy and Longevity, University Hospital, F-49933 Angers, France; (O.B.); (J.G.); (G.S.); (A.B.)
| | - Antoine Brangier
- Department of Geriatric Medicine and Memory Clinic, Research Center on Autonomy and Longevity, University Hospital, F-49933 Angers, France; (O.B.); (J.G.); (G.S.); (A.B.)
| | - Cédric Annweiler
- Department of Geriatric Medicine, Le Mans Hospital, F-72037 Le Mans, France;
- Department of Geriatric Medicine and Memory Clinic, Research Center on Autonomy and Longevity, University Hospital, F-49933 Angers, France; (O.B.); (J.G.); (G.S.); (A.B.)
- UPRES EA 4638, University of Angers, F-49000 Angers, France
- Gérontopôle Autonomie Longévité des Pays de la Loire, F-44000 Nantes, France
- Robarts Research Institute, Department of Medical Biophysics, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON N6A 5K8, Canada
- Correspondence: ; Tel.: +33-2-4135-4725; Fax: +33-2-4135-4894
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See LC, Lee HF, Chao TF, Li PR, Liu JR, Wu LS, Chang SH, Yeh YH, Kuo CT, Chan YH, Lip GYH. Effectiveness and Safety of Direct Oral Anticoagulants in an Asian Population with Atrial Fibrillation Undergoing Dialysis: A Population-Based Cohort Study and Meta-Analysis. Cardiovasc Drugs Ther 2020; 35:975-986. [DOI: 10.1007/s10557-020-07108-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 12/11/2022]
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Marietta M, Coluccio V, Boriani G, Luppi M. Effects of Anti-vitamin k oral anticoagulants on bone and cardiovascular health. Eur J Intern Med 2020; 79:1-11. [PMID: 32553585 DOI: 10.1016/j.ejim.2020.05.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/01/2020] [Accepted: 05/21/2020] [Indexed: 12/16/2022]
Abstract
Vitamin K antagonist oral anticoagulants (VKAs) have been proven over 50 years to be highly effective and acceptably safe in many settings and are still used by millions of people worldwide. The main concern about the safety of VKAs regards the risk of bleeding, but there is accumulation evidence of their potentially negative effects beyond hemostasis. Indeed, VKAs impair the action of several Vitamin-K Dependent Proteins (VKDP), such as Bone Gla protein, Matrix Gla protein, Gas6 Protein, Periostin and Gla-Ric Protein, involved in bone and vascular metabolism, thus exerting a detrimental effect on bone and vascular health. Indeed, although the evidence regarding this issue is not compelling, it has been shown that VKAs use decreases bone mass density, increases the risk of bone fractures and accelerates the process of vascular and valvular calcification. Vascular calcification is a major concern in Chronic Kidney Disease (CKD) patients, also in absence of VKAs, because of mineral metabolism derangement, chronic inflammation and oxidative stress. Direct Oral AntiCoagulants (DOACs) do not affect VKDP involved in vascular and valvular calcification, and do not induce calcific valve degeneration in animal models, being a possible alternative to AVK for CKD patients. However, the efficacy and safety of DOACs in this population, suggested by some recent observations, requires confirmation by dedicated, randomized study. We reviewed here the effects of VKAs in bone and vascular health as compared to DOACs, in order to provide the physicians with some data useful to wisely choose the most suitable anticoagulant for every patient.
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Affiliation(s)
- Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy.
| | - Valeria Coluccio
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Mario Luppi
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy; Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Modena, Italy
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Dofferhoff ASM, Piscaer I, Schurgers LJ, Visser MPJ, van den Ouweland JMW, de Jong PA, Gosens R, Hackeng TM, van Daal H, Lux P, Maassen C, Karssemeijer EGA, Vermeer C, Wouters EFM, Kistemaker LEM, Walk J, Janssen R. Reduced vitamin K status as a potentially modifiable risk factor of severe COVID-19. Clin Infect Dis 2020; 73:e4039-e4046. [PMID: 32852539 PMCID: PMC7499546 DOI: 10.1093/cid/ciaa1258] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/25/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Respiratory failure and thromboembolism are frequent in SARS-CoV-2-infected patients. Vitamin K activates both hepatic coagulation factors and extrahepatic endothelial anticoagulant protein S, required for thrombosis prevention. In times of vitamin K insufficiency, hepatic procoagulant factors are preferentially activated over extrahepatic proteins. Vitamin K also activates matrix Gla protein (MGP), which protects against pulmonary and vascular elastic fiber damage. We hypothesized that vitamin K may be implicated in coronavirus disease 2019 (COVID-19), linking pulmonary and thromboembolic disease. METHODS 135 hospitalized COVID-19 patients were compared with 184 historical controls. Poor outcome was defined as invasive ventilation and/or death. Inactive vitamin K-dependent MGP (dp-ucMGP) and prothrombin (PIVKA-II) were measured, inversely related to extrahepatic and hepatic vitamin K status, respectively. Desmosine was measured to quantify the rate of elastic fiber degradation. Arterial calcification severity was assessed by computed tomography. RESULTS Dp-ucMGP was elevated in COVID-19 patients compared to controls (p<0.001), with even higher dp-ucMGP in patients with poor outcomes (p<0.001). PIVKA-II was normal in 82.1% of patients. Dp-ucMGP was correlated with desmosine (p<0.001), and coronary artery (p=0.002) and thoracic aortic (p<0.001) calcification scores. CONCLUSIONS Dp-ucMGP was severely increased in COVID-19 patients, indicating extrahepatic vitamin K insufficiency, which was related to poor outcome while hepatic procoagulant factor II remained unaffected. These data suggest a mechanism of pneumonia-induced extrahepatic vitamin K depletion leading to accelerated elastic fiber damage and thrombosis in severe COVID-19 due to impaired activation of MGP and endothelial protein S, respectively. A clinical trial could assess whether vitamin K administration improves COVID-19 outcomes.
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Affiliation(s)
- Anton S M Dofferhoff
- Department of Internal Medicine, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Ianthe Piscaer
- Department of Respiratory Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Leon J Schurgers
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Margot P J Visser
- Department of Pulmonary Medicine, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | - Pim A de Jong
- Department of Radiology, University Medical Center Utrecht and Utrecht University, The Netherlands
| | - Reinoud Gosens
- Department of Molecular Pharmacology, University of Groningen, Groningen, The Netherlands
| | - Tilman M Hackeng
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Henny van Daal
- Department of Clinical Chemistry, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Petra Lux
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Cecile Maassen
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | | | - Cees Vermeer
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Emiel F M Wouters
- Department of Respiratory Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands.,Ludwig Boltzmann Institute for Lung Health, Vienna, Austria
| | | | - Jona Walk
- Department of Internal Medicine, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Rob Janssen
- Department of Pulmonary Medicine, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
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Cozzolino M, Cianciolo G, Podestà MA, Ciceri P, Galassi A, Gasperoni L, La Manna G. Current Therapy in CKD Patients Can Affect Vitamin K Status. Nutrients 2020; 12:nu12061609. [PMID: 32486167 PMCID: PMC7352600 DOI: 10.3390/nu12061609] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 12/15/2022] Open
Abstract
Chronic kidney disease (CKD) patients have a higher risk of cardiovascular (CVD) morbidity and mortality compared to the general population. The links between CKD and CVD are not fully elucidated but encompass both traditional and uremic-related risk factors. The term CKD-mineral and bone disorder (CKD-MBD) indicates a systemic disorder characterized by abnormal levels of calcium, phosphate, PTH and FGF-23, along with vitamin D deficiency, decreased bone mineral density or altered bone turnover and vascular calcification. A growing body of evidence shows that CKD patients can be affected by subclinical vitamin K deficiency; this has led to identifying such a condition as a potential therapeutic target given the specific role of Vitamin K in metabolism of several proteins involved in bone and vascular health. In other words, we can hypothesize that vitamin K deficiency is the common pathogenetic link between impaired bone mineralization and vascular calcification. However, some of the most common approaches to CKD, such as (1) low vitamin K intake due to nutritional restrictions, (2) warfarin treatment, (3) VDRA and calcimimetics, and (4) phosphate binders, may instead have the opposite effects on vitamin K metabolism and storage in CKD patients.
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Affiliation(s)
- Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, 20142 Milan, Italy; (M.C.); (M.A.P.); (A.G.)
| | - Giuseppe Cianciolo
- Nephrology, Dialysis and Renal Transplant Unit, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola Hospital, University of Bologna, 40126 Bologna, Italy; (G.C.); (L.G.)
| | - Manuel Alfredo Podestà
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, 20142 Milan, Italy; (M.C.); (M.A.P.); (A.G.)
| | - Paola Ciceri
- Renal Research Laboratory, Department of Nephrology, Dialysis and Renal Transplant, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Andrea Galassi
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, 20142 Milan, Italy; (M.C.); (M.A.P.); (A.G.)
| | - Lorenzo Gasperoni
- Nephrology, Dialysis and Renal Transplant Unit, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola Hospital, University of Bologna, 40126 Bologna, Italy; (G.C.); (L.G.)
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola Hospital, University of Bologna, 40126 Bologna, Italy; (G.C.); (L.G.)
- Correspondence: ; Tel.: +39-051214-3255
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Artyukov AA, Zelepuga EA, Bogdanovich LN, Lupach NM, Novikov VL, Rutckova TA, Kozlovskaya EP. Marine Polyhydroxynaphthoquinone, Echinochrome A: Prevention of Atherosclerotic Inflammation and Probable Molecular Targets. J Clin Med 2020; 9:E1494. [PMID: 32429179 PMCID: PMC7291202 DOI: 10.3390/jcm9051494] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/06/2020] [Accepted: 05/13/2020] [Indexed: 12/16/2022] Open
Abstract
The effect of low doses of echinochrome A (EchA), a natural polyhydroxy-1,4-naphthoquinone pigment from the sea urchin Scaphechinus mirabilis, has been studied in clinical trials, when it was used as an active substance of the drug Histochrome® and biologically active supplement Thymarin. Several parameters of lipid metabolism, antioxidant status, and the state of the immune system were analyzed in patients with cardiovascular diseases (CVD), including contaminating atherosclerosis. It has been shown that EchA effectively normalizes lipid metabolism, recovers antioxidant status and reduces atherosclerotic inflammation, regardless of the method of these preparations' administrations. Treatment of EchA has led to the stabilization of patients, improved function of the intracellular matrix and decreased epithelial dysfunction. The increased expression of surface human leukocyte antigen DR isotype (HLA-DR) receptors reflects the intensification of intercellular cooperation of immune cells, as well as an increase in the efficiency of processing and presentation of antigens, while the regulation of CD95 + expression levels suggests the stimulation of cell renewal processes. The immune system goes to a different level of functioning. Computer simulations suggest that EchA, with its aromatic structure of the naphthoquinone nucleus, may be a suitable ligand of the cytosolic aryl cell receptor, which affects the response of the immune system and causes the rapid expression of detoxification enzymes such as CYP and DT diaphorase, which play a protective role with CVD. Therefore, EchA possesses not only an antiradical effect and antioxidant activity, but is also a SOD3 mimetic, producing hydrogen peroxide and controlling the expression of cell enzymes through hypoxia-inducible factors (HIF), peroxisome proliferator-activated receptors (PPARs) and aryl hydrocarbon receptor (AhR).
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Affiliation(s)
- Aleksandr A. Artyukov
- G.B. Elyakov Pacific Institute of Bioorganic Chemistry, Far Eastern Branch of the Russian Academy of Science, 159 Prospect 100-letiya Vladivostoka, Vladivostok 690022, Russia; (A.A.A.); (E.A.Z.); (V.L.N.); (T.A.R.)
| | - Elena A. Zelepuga
- G.B. Elyakov Pacific Institute of Bioorganic Chemistry, Far Eastern Branch of the Russian Academy of Science, 159 Prospect 100-letiya Vladivostoka, Vladivostok 690022, Russia; (A.A.A.); (E.A.Z.); (V.L.N.); (T.A.R.)
| | - Larisa N. Bogdanovich
- Medical Association of the Far Eastern Branch of the Russian Academy of Sciences (FEB RAS MO), Kirov Str., 95, Vladivostok 690022, Russia;
| | - Natalia M. Lupach
- Primorye Regional Clinical Hospital No. One (SHI), Aleutskaya Str., 57, Vladivostok, Primorsky Krai 690091, Russia;
| | - Vyacheslav L. Novikov
- G.B. Elyakov Pacific Institute of Bioorganic Chemistry, Far Eastern Branch of the Russian Academy of Science, 159 Prospect 100-letiya Vladivostoka, Vladivostok 690022, Russia; (A.A.A.); (E.A.Z.); (V.L.N.); (T.A.R.)
| | - Tatyana A. Rutckova
- G.B. Elyakov Pacific Institute of Bioorganic Chemistry, Far Eastern Branch of the Russian Academy of Science, 159 Prospect 100-letiya Vladivostoka, Vladivostok 690022, Russia; (A.A.A.); (E.A.Z.); (V.L.N.); (T.A.R.)
| | - Emma P. Kozlovskaya
- G.B. Elyakov Pacific Institute of Bioorganic Chemistry, Far Eastern Branch of the Russian Academy of Science, 159 Prospect 100-letiya Vladivostoka, Vladivostok 690022, Russia; (A.A.A.); (E.A.Z.); (V.L.N.); (T.A.R.)
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Ghosh S, Luo D, He W, Chen J, Su X, Huang H. Diabetes and calcification: The potential role of anti-diabetic drugs on vascular calcification regression. Pharmacol Res 2020; 158:104861. [PMID: 32407954 DOI: 10.1016/j.phrs.2020.104861] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/22/2020] [Accepted: 04/22/2020] [Indexed: 12/15/2022]
Abstract
Vascular calcification (VC) has been well-established as an independent and strong predictor of cardiovascular diseases (CVD) as well as major cardiac adverse events (MACE). VC is associated with increased mortality in patients with CVD. Pathologically, VC is now believed to be a multi-directional active process ultimately resulting in ectopic calcium deposition in vascular beds. On the other hand, prevalence of diabetes mellitus (DM) is gradually increasing thus making the current population more prone to future CVD. Although the mechanisms involved in development and progression of VC in DM patients are not fully understood, a series of evidences demonstrated positive association between DM and VC. It has been highlighted that different cellular pathways are involved in this process. These intermediates such as tumor necrosis factor alpha (TNF-α), various interleukins (ILs) and different cell-signaling pathways are over-expressed in DM patients leading to development of VC. Thus, considering the burden and significance of VC it is of great importance to find a therapeutic approach to prevent or minimize the development of VC in DM patients. Over the past few years various anti diabetic drugs (ADDs) have been introduced and many of them showed desired glucose control. But no study demonstrated the effects of these medications on regression of VC. In this review, we will briefly discuss the current understanding on DM and VC and how commonly used ADDs modulate the development or progression of VC.
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Affiliation(s)
- Sounak Ghosh
- Cardiovascular Department, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China; Department of Cardiology, Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Dongling Luo
- Cardiovascular Department, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Wanbing He
- Cardiovascular Department, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China; Department of Cardiology, Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jie Chen
- Department of Radiation Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoyan Su
- Tungwah Hospital of Sun Yat-sen University, Dongguan, China
| | - Hui Huang
- Cardiovascular Department, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China; Department of Cardiology, Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China.
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Florea A, Morgenroth A, Bucerius J, Schurgers LJ, Mottaghy FM. Locking and loading the bullet against micro-calcification. Eur J Prev Cardiol 2020; 28:1370-1375. [PMID: 33611501 DOI: 10.1177/2047487320911138] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/14/2020] [Indexed: 12/24/2022]
Abstract
AIMS Despite recent medical advances, cardiovascular disease remains the leading cause of death worldwide. As (micro)-calcification is a hallmark of atherosclerosis, this review will elaborately discuss advantages of sodium fluoride positron emission tomography (PET) as a reliable cardiovascular imaging technique for identifying the early onset of vascular calcification (i.e. locking onto the target). We assess state-of-the-art meta-analysis and clinical studies of possible treatment options and evaluate the concept of vitamin K supplementation to preserve vascular health (i.e. loading the bullet). METHODS AND RESULTS After a structured PubMed search, we identified 18F-sodium fluoride (18F-NaF) PET as the most suitable technique for detecting micro-calcification. Presenting the pros and cons of available treatments, vitamin K supplementation should be considered as a possible safe and cost-effective option to inhibit vascular (micro)-calcification. CONCLUSION This review demonstrates need for more extensive research in the concept of vitamin K supplementation (i.e. loading the bullet) and recommends monitoring the effects on vascular calcification using 18F-NaF PET (i.e. locking onto the target).
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Affiliation(s)
- Alexandru Florea
- Department of Nuclear Medicine, University Hospital RWTH Aachen, Aachen, Germany
- Department of Radiology and Nuclear Medicine, Academic Hospital Maastricht, Maastricht, Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Netherlands
| | - Agnieszka Morgenroth
- Department of Nuclear Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Jan Bucerius
- Department of Radiology and Nuclear Medicine, Academic Hospital Maastricht, Maastricht, Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Netherlands
- Department of Nuclear Medicine, University of Göttingen, Göttingen, Germany
| | - Leon J Schurgers
- School for Cardiovascular Diseases (CARIM), Maastricht University, Netherlands
- Department of Biochemistry, Maastricht University, Maastricht, Netherlands
| | - Felix M Mottaghy
- Department of Nuclear Medicine, University Hospital RWTH Aachen, Aachen, Germany
- Department of Radiology and Nuclear Medicine, Academic Hospital Maastricht, Maastricht, Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Netherlands
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43
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Ravera M, Bussalino E, Fusaro M, Di Lullo L, Aucella F, Paoletti E. Systematic DOACs oral anticoagulation in patients with atrial fibrillation and chronic kidney disease: the nephrologist's perspective. J Nephrol 2020; 33:483-495. [PMID: 32200488 DOI: 10.1007/s40620-020-00720-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/12/2020] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) is highly prevalent among patients with chronic kidney disease (CKD), and also associated with unfavorable outcome. Anticoagulant therapy is the mainstep of management in such patients, aimed at reducing the high risk of systemic thromboembolism and especially of ischemic stroke, which is reportedly associated with increased mortality in CKD patients. Even though new direct oral anticoagulant agents (DOACs) proved to be effective in patients with non valvular chronic AF, and are therefore recommended by recent guidelines for their treatment, warfarin is currently used in more than one-half of subjects needing oral anticoagulation, and only 30% of them are converted from a vitamin K antagonist- to a DOAC-based regimen. The main reason for not prescribing DOACs is often a reduction in renal function, even if mild. Aim of this review was therefore to evaluate the impact of DOAC therapy in the setting of CKD, from a nephrological perspective, by comparing available evidence on the role of DOACs in patients with CKD and AF with that emerging from traditional warfarin-based therapy. Both the pathogenesis of AF in CKD, and available findings of renal, cardiovascular and bone effects of DOACs in CKD are discussed, leading to the conclusion that DOAC therapy should be considered as the first line therapy for non valvular AF in patients with mild and moderate reduction of renal function, and could also be adopted for patients with severe CKD not on hemodialysis treatment, whereas there is insufficient evidence for ESRD patients on dialysis.
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Affiliation(s)
- Maura Ravera
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, Genoa, Italy.
| | - Elisabetta Bussalino
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, Genoa, Italy
| | - Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa, Italy
- Department of Medicine, University of Padova, Padua, Italy
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, Colleferro, Rome, Italy
| | - Filippo Aucella
- Nephrology and Dialysis Unit, IRCCS "Casa Sollievo della Sofferenza" Scientific Institute for Research and Health Care, San Giovanni Rotondo, Italy
| | - Ernesto Paoletti
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, Genoa, Italy
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Vitamin K as a Diet Supplement with Impact in Human Health: Current Evidence in Age-Related Diseases. Nutrients 2020; 12:nu12010138. [PMID: 31947821 PMCID: PMC7019739 DOI: 10.3390/nu12010138] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 12/24/2019] [Accepted: 12/31/2019] [Indexed: 12/12/2022] Open
Abstract
Vitamin K health benefits have been recently widely shown to extend beyond blood homeostasis and implicated in chronic low-grade inflammatory diseases such as cardiovascular disease, osteoarthritis, dementia, cognitive impairment, mobility disability, and frailty. Novel and more efficient nutritional and therapeutic options are urgently needed to lower the burden and the associated health care costs of these age-related diseases. Naturally occurring vitamin K comprise the phylloquinone (vitamin K1), and a series of menaquinones broadly designated as vitamin K2 that differ in source, absorption rates, tissue distribution, bioavailability, and target activity. Although vitamin K1 and K2 sources are mainly dietary, consumer preference for diet supplements is growing, especially when derived from marine resources. The aim of this review is to update the reader regarding the specific contribution and effect of each K1 and K2 vitamers in human health, identify potential methods for its sustainable and cost-efficient production, and novel natural sources of vitamin K and formulations to improve absorption and bioavailability. This new information will contribute to foster the use of vitamin K as a health-promoting supplement, which meets the increasing consumer demand. Simultaneously, relevant information on the clinical context and direct health consequences of vitamin K deficiency focusing in aging and age-related diseases will be discussed.
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45
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Stroke Prophylaxis in Patients with Atrial Fibrillation and End-Stage Renal Disease. J Clin Med 2020; 9:jcm9010123. [PMID: 31906546 PMCID: PMC7019832 DOI: 10.3390/jcm9010123] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 12/24/2019] [Accepted: 12/30/2019] [Indexed: 02/07/2023] Open
Abstract
Atrial fibrillation (AF) is an important comorbidity in patients with end-stage renal disease (ESRD) undergoing dialysis that portends increased health care utilization, morbidity, and mortality in this already high-risk population. Patients with ESRD have a particularly high stroke risk, which is further compounded by AF. However, the role of anticoagulation for stroke prophylaxis in ESRD and AF is debated. The ESRD population presents a unique challenge because of the combination of elevated stroke and bleeding risks. Warfarin has been traditionally used in this population, but it is associated with significant risks of minor and major bleeding, particularly intracranial, thus leading many clinicians to forgo anticoagulation altogether. When anticoagulation is prescribed, rates of adherence and persistence are poor, leaving many patients untreated. The direct oral anticoagulants (DOACs) may offer an alternative to warfarin in ESRD patients, but these agents have not been extensively studied in this population and uncertainties regarding comparative effectiveness (versus warfarin, each other, and no treatment) remain. In this review, we discuss the current evidence on the risk and benefits of anticoagulants in this challenging population and comparisons between warfarin and DOACs, and review future directions including options for non-pharmacologic stroke prevention.
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46
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De Vriese AS, Caluwé R, Pyfferoen L, De Bacquer D, De Boeck K, Delanote J, De Surgeloose D, Van Hoenacker P, Van Vlem B, Verbeke F. Multicenter Randomized Controlled Trial of Vitamin K Antagonist Replacement by Rivaroxaban with or without Vitamin K2 in Hemodialysis Patients with Atrial Fibrillation: the Valkyrie Study. J Am Soc Nephrol 2019; 31:186-196. [PMID: 31704740 DOI: 10.1681/asn.2019060579] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 09/11/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Vitamin K antagonists (VKAs), although commonly used to reduce thromboembolic risk in atrial fibrillation, have been incriminated as probable cause of accelerated vascular calcification (VC) in patients on hemodialysis. Functional vitamin K deficiency may further contribute to their susceptibility for VC. We investigated the effect of vitamin K status on VC progression in 132 patients on hemodialysis with atrial fibrillation treated with VKAs or qualifying for anticoagulation. METHODS Patients were randomized to VKAs with target INR 2-3, rivaroxaban 10 mg daily, or rivaroxaban 10 mg daily plus vitamin K2 2000 µg thrice weekly during 18 months. Systemic dp-ucMGP levels were quantified to assess vascular vitamin K status. Cardiac and thoracic aorta calcium scores and pulse wave velocity were measured to evaluate VC progression. RESULTS Baseline dp-ucMGP was severely elevated in all groups. Initiation or continuation of VKAs further increased dp-ucMGP, whereas levels decreased in the rivaroxaban group and to a larger extent in the rivaroxaban+vitamin K2 group, but remained nevertheless elevated. Changes in coronary artery, thoracic aorta, and cardiac valve calcium scores and pulse wave velocity were not significantly different among the treatment arms. All cause death, stroke, and cardiovascular event rates were similar between the groups. Bleeding outcomes were not significantly different, except for a lower number of life-threatening and major bleeding episodes in the rivaroxaban arms versus the VKA arm. CONCLUSIONS Withdrawal of VKAs and high-dose vitamin K2 improve vitamin K status in patients on hemodialysis, but have no significant favorable effect on VC progression. Severe bleeding complications may be lower with rivaroxaban than with VKAs.
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Affiliation(s)
- An S De Vriese
- Division of Nephrology and Infectious Diseases and .,Departments of Internal Medicine and
| | | | - Lotte Pyfferoen
- Department of Medical Imaging, AZ Sint-Jan Brugge, Brugge, Belgium
| | | | | | - Joost Delanote
- Department of Medical Imaging, AZ Sint-Jan Brugge, Brugge, Belgium
| | | | - Piet Van Hoenacker
- Department of Medical Imaging, Onze Lieve Vrouw Hospital, Aalst, Belgium
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Granadeiro L, Dirks RP, Ortiz-Delgado JB, Gavaia PJ, Sarasquete C, Laizé V, Cancela ML, Fernández I. Warfarin-exposed zebrafish embryos resembles human warfarin embryopathy in a dose and developmental-time dependent manner - From molecular mechanisms to environmental concerns. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2019; 181:559-571. [PMID: 31238190 DOI: 10.1016/j.ecoenv.2019.06.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/13/2019] [Accepted: 06/14/2019] [Indexed: 06/09/2023]
Abstract
Warfarin is the most worldwide used anticoagulant drug and rodenticide. Since it crosses placental barrier it can induce warfarin embryopathy (WE), a fetal mortality in neonates characterized by skeletal deformities in addition to brain hemorrhages. Although the effects of warfarin exposure in aquatic off target species were already described, the particular molecular toxicological mechanisms during early development are still unclear. Here, we used zebrafish (Danio rerio) to describe and compare the developmental effects of warfarin exposure (0, 15.13, 75.68 and 378.43 mM) on two distinct early developmental phases (embryos and eleuthero-embryos). Although exposure to both developmental phases induced fish mortality, only embryos exposed to the highest warfarin level exhibited features mimicking mammalian WE, e.g. high mortality, higher incidence of hemorrhages and altered skeletal development, among other effects. To gain insights into the toxic mechanisms underlying warfarin exposure, the transcriptome of embryos exposed to warfarin was explored through RNA-Seq and compared to that of control embryos. 766 differentially expressed (564 up- and 202 down-regulated) genes were identified. Gene Ontology analysis revealed particular cellular components (cytoplasm, extracellular matrix, lysosome and vacuole), biological processes (mainly amino acid and lipid metabolism and response to stimulus) and pathways (oxidative stress response and apoptosis signaling pathways) being significantly overrepresented in zebrafish embryos upon warfarin exposure. Protein-protein interaction further evidenced an altered redox system, blood coagulation and vasculogenesis, visual phototransduction and collagen formation upon warfarin exposure. The present study not only describes for the first time the WE in zebrafish, it provides new insights for a better risk assessment, and highlights the need for programming the rat eradication actions outside the fish spawning season to avoid an impact on off target fish community. The urge for the development of more species-specific anticoagulants for rodent pest control is also highlighted.
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Affiliation(s)
- Luis Granadeiro
- Centro de Ciências do Mar (CCMAR), Universidade do Algarve, Campus de Gambelas, 8005-139 Faro, Portugal
| | - Ron P Dirks
- ZF-screens B.V. J.H. Oortweg 19, 2333, CH Leiden, the Netherlands
| | - Juan B Ortiz-Delgado
- Instituto de Ciencias Marinas de Andalucía-ICMAN/CSIC, Campus Universitario Río San Pedro, Apdo. Oficial, 11510, Puerto Real, Cádiz, Spain
| | - Paulo J Gavaia
- Centro de Ciências do Mar (CCMAR), Universidade do Algarve, Campus de Gambelas, 8005-139 Faro, Portugal; Departamento de Ciências Biomédicas e Medicina (DCBM), Universidade do Algarve, Campus de Gambelas, 8005-139 Faro, Portugal
| | - Carmen Sarasquete
- Instituto de Ciencias Marinas de Andalucía-ICMAN/CSIC, Campus Universitario Río San Pedro, Apdo. Oficial, 11510, Puerto Real, Cádiz, Spain
| | - Vincent Laizé
- Centro de Ciências do Mar (CCMAR), Universidade do Algarve, Campus de Gambelas, 8005-139 Faro, Portugal
| | - M Leonor Cancela
- Centro de Ciências do Mar (CCMAR), Universidade do Algarve, Campus de Gambelas, 8005-139 Faro, Portugal; Departamento de Ciências Biomédicas e Medicina (DCBM), Universidade do Algarve, Campus de Gambelas, 8005-139 Faro, Portugal; Algarve Biomedical Center (ABC) and Centre for Biomedical Research (CBMR), Universidade do Algarve, Campus de Gambelas, 8005-139 Faro, Portugal
| | - Ignacio Fernández
- Centro de Ciências do Mar (CCMAR), Universidade do Algarve, Campus de Gambelas, 8005-139 Faro, Portugal; Center for Aquaculture Research, Agrarian Technological Institute of Castile and Leon, Ctra. Arévalo, S/n. 40196 Zamarramala, Segovia, Spain.
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Königsbrügge O, Ay C. Atrial fibrillation in patients with end-stage renal disease on hemodialysis: Magnitude of the problem and new approach to oral anticoagulation. Res Pract Thromb Haemost 2019; 3:578-588. [PMID: 31624777 PMCID: PMC6781927 DOI: 10.1002/rth2.12250] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 01/04/2023] Open
Abstract
Atrial fibrillation (AF) is a frequent comorbid condition in patients with end-stage renal disease on hemodialysis (HD) with a prevalence of up to 27%. The incidence rate of stroke in AF patients on HD is approximately 5%. The AF-associated risk of stroke is a major clinical challenge because current evidence for anticoagulation in HD patients with AF is based on observational data. Results from these observational studies is largely contradictory because they do not show a clear benefit of vitamin K antagonists over no treatment in terms of stroke prevention, and they show an increased risk of hemorrhage associated with anticoagulation treatment in HD patients. HD patients were not included in randomized trials of the direct oral anticoagulants (DOACs), and therefore there is no evidence to support efficacy and safety of DOACs compared to vitamin K antagonists in HD patients. The pharmacological characteristics of DOACs are of particular interest in the HD setting. The factor Xa inhibitors rivaroxaban, apixaban, and edoxaban are not predominantly eliminated via the kidneys. The thrombin inhibitor dabigatran is 80% eliminated via the kidneys but is dialyzable due to its low protein binding. In this narrative review, we examine the current state of evidence regarding the prevalence of AF in patients on HD, the associated risk of stroke, and the efficacy and safety of anticoagulation for stroke prevention in the HD setting. Further, based on the pharmacokinetic properties of DOACs, we discuss their potential use in patients on HD and ongoing randomized trials.
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Affiliation(s)
- Oliver Königsbrügge
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Cihan Ay
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
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49
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Lee CJY, Gerds TA, Carlson N, Bonde AN, Gislason GH, Lamberts M, Olesen JB, Pallisgaard JL, Hansen ML, Torp-Pedersen C. Risk of Myocardial Infarction in Anticoagulated Patients With Atrial Fibrillation. J Am Coll Cardiol 2019; 72:17-26. [PMID: 29957227 DOI: 10.1016/j.jacc.2018.04.036] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/11/2018] [Accepted: 04/03/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Evidence is conflicting as to the efficacy of direct oral anticoagulation (DOAC) and vitamin K antagonist (VKA) for prevention of myocardial infarction (MI). OBJECTIVES This study aimed to investigate the risk of MI associated with the use of apixaban, dabigatran, rivaroxaban, and VKA in patients with atrial fibrillation. METHODS Patients with atrial fibrillation were identified using Danish health care registers and stratified by initial oral anticoagulant treatment. Standardized absolute 1-year risks were estimated based on Cox regression for hazard rates of MI hospitalizations and mortality. Reported were absolute risks separately for the oral anticoagulation treatments and standardized to the characteristics of the study population. RESULTS Of the 31,739 patients included (median age, 74 years; 47% females), the standardized 1-year risk of MI for VKA was 1.6% (95% confidence interval [CI]: 1.3 to 1.8), apixaban was 1.2% (95% CI: 0.9 to 1.4), dabigatran was 1.2% (95% CI: 1.0 to 1.5), and rivaroxaban was 1.1% (95% CI: 0.8 to 1.3). No significant risk differences were observed in the standardized 1-year risks of MI among the DOACs: dabigatran versus apixaban (0.04%; 95% CI: -0.3 to 0.4), rivaroxaban versus apixaban (0.1%; 95% CI: -0.4 to 0.3), and rivaroxaban versus dabigatran (-0.1%; 95% CI: -0.5 to 0.2). The risk differences for DOACs versus VKA were all significant: -0.4% (95% CI: -0.7 to -0.1) for apixaban, -0.4% (95% CI: -0.7 to -0.03) for dabigatran, and -0.5% (95% CI: -0.8 to -0.2) for rivaroxaban. CONCLUSIONS No significant risk differences of MI were found in the direct comparisons of DOACs, and DOACs were all associated with a significant risk reduction of MI compared with VKA.
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Affiliation(s)
- Christina Ji-Young Lee
- Department of Health Science and Technology, Aalborg University and Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark; Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark.
| | - Thomas Alexander Gerds
- Department of Biostatistics, Copenhagen University, Copenhagen, Denmark; The Danish Heart Foundation, Copenhagen, Denmark
| | - Nicholas Carlson
- Department of Internal Medicine, Holbaek Hospital, Copenhagen, Denmark; The Danish Heart Foundation, Copenhagen, Denmark
| | - Anders Nissen Bonde
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
| | - Gunnar Hilmar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark; The Danish Heart Foundation, Copenhagen, Denmark
| | - Morten Lamberts
- The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
| | | | - Morten Lock Hansen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Health Science and Technology, Aalborg University and Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
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Petsophonsakul P, Furmanik M, Forsythe R, Dweck M, Schurink GW, Natour E, Reutelingsperger C, Jacobs M, Mees B, Schurgers L. Role of Vascular Smooth Muscle Cell Phenotypic Switching and Calcification in Aortic Aneurysm Formation. Arterioscler Thromb Vasc Biol 2019; 39:1351-1368. [PMID: 31144989 DOI: 10.1161/atvbaha.119.312787] [Citation(s) in RCA: 197] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Aortic aneurysm is a vascular disease whereby the ECM (extracellular matrix) of a blood vessel degenerates, leading to dilation and eventually vessel wall rupture. Recently, it was shown that calcification of the vessel wall is involved in both the initiation and progression of aneurysms. Changes in aortic wall structure that lead to aneurysm formation and vascular calcification are actively mediated by vascular smooth muscle cells. Vascular smooth muscle cells in a healthy vessel wall are termed contractile as they maintain vascular tone and remain quiescent. However, in pathological conditions they can dedifferentiate into a synthetic phenotype, whereby they secrete extracellular vesicles, proliferate, and migrate to repair injury. This process is called phenotypic switching and is often the first step in vascular pathology. Additionally, healthy vascular smooth muscle cells synthesize VKDPs (vitamin K-dependent proteins), which are involved in inhibition of vascular calcification. The metabolism of these proteins is known to be disrupted in vascular pathologies. In this review, we summarize the current literature on vascular smooth muscle cell phenotypic switching and vascular calcification in relation to aneurysm. Moreover, we address the role of vitamin K and VKDPs that are involved in vascular calcification and aneurysm. Visual Overview- An online visual overview is available for this article.
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Affiliation(s)
- Ploingarm Petsophonsakul
- From the Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (P.P., M.F., C.R., L.S.)
| | - Malgorzata Furmanik
- From the Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (P.P., M.F., C.R., L.S.)
| | - Rachael Forsythe
- Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (R.F., M.D.)
| | - Marc Dweck
- Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (R.F., M.D.)
| | - Geert Willem Schurink
- Department of Vascular Surgery (G.W.S., M.J., B.M.), Maastricht University Medical Center (MUMC), Maastricht, the Netherlands
| | - Ehsan Natour
- Department of Cardiovascular Surgery (E.N.), Maastricht University Medical Center (MUMC), Maastricht, the Netherlands.,European Vascular Center Aachen-Maastricht, Maastricht, the Netherlands (E.N., M.J., B.M.)
| | - Chris Reutelingsperger
- From the Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (P.P., M.F., C.R., L.S.)
| | - Michael Jacobs
- Department of Vascular Surgery (G.W.S., M.J., B.M.), Maastricht University Medical Center (MUMC), Maastricht, the Netherlands.,European Vascular Center Aachen-Maastricht, Maastricht, the Netherlands (E.N., M.J., B.M.)
| | - Barend Mees
- Department of Vascular Surgery (G.W.S., M.J., B.M.), Maastricht University Medical Center (MUMC), Maastricht, the Netherlands.,European Vascular Center Aachen-Maastricht, Maastricht, the Netherlands (E.N., M.J., B.M.)
| | - Leon Schurgers
- From the Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (P.P., M.F., C.R., L.S.)
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