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Kohara C, Yamada S, Tanaka S, Hiyamuta H, Kitamura H, Arase H, Shimamoto S, Taniguchi M, Tsuruya K, Kitazono T, Nakano T. Blood Hemoglobin Concentrations and the Incidence of Lower Extremity Peripheral Arterial Disease in Patients Undergoing Hemodialysis: 10-Year Outcomes of the Q-Cohort Study. J Am Heart Assoc 2024; 13:e033853. [PMID: 39101503 DOI: 10.1161/jaha.123.033853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 06/20/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Lower extremity peripheral arterial disease is a potentially lethal cardiovascular complication in patients undergoing hemodialysis. Anemia is a risk factor for cardiovascular disease among the hemodialysis population. However, whether blood hemoglobin concentration is associated with the risk of peripheral arterial disease progression in this population remains undetermined. METHODS AND RESULTS This is an extension of a 4-year multicenter, prospective, observational cohort study to 10 years. A total of 3504 Japanese patients undergoing maintenance hemodialysis were recruited between 2006 and 2007. The primary exposure was blood hemoglobin concentration at baseline. The main outcome was the first-ever incidence of major adverse limb events (MALE), composed of endovascular treatment, bypass surgery, and amputation. Multivariable-adjusted Cox proportional hazards model, Fine-Gray subdistribution hazards model, restricted cubic spline analysis, and restricted mean survival time analysis were used to determine the association of blood hemoglobin concentration with the incidence of MALE. During a median follow-up of 8.0 years, 257 patients experienced MALE. A Cox proportional hazards model showed that the risk of MALE in patients with blood hemoglobin concentrations <10.0 g/dL was significantly higher than in patients with concentrations of 11.0 to 11.9 g/dL, even after adjusting for confounding factors. In contrast, elevated hemoglobin concentration (≥12.0 g/dL) was not significantly associated with increased risk of MALE. Similar associations were observed when the Fine-Gray subdistribution regression model was used by setting all-cause mortality as the competing risk. CONCLUSIONS A low blood hemoglobin concentration is an independent risk factor for peripheral arterial disease progression in patients undergoing maintenance hemodialysis.
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Affiliation(s)
- Chiaki Kohara
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Shunsuke Yamada
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Shigeru Tanaka
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Hiroto Hiyamuta
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Hiromasa Kitamura
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Hokuto Arase
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Sho Shimamoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | | | | | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
- Kidney Care Unit Kyushu University Hospital Fukuoka Japan
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Shechter A, Shiyovich A, Skalsky K, Gilutz H, Plakht Y. Interaction between anemia and renal dysfunction in relation to long-term survival following acute myocardial infarction. Clin Res Cardiol 2024:10.1007/s00392-024-02375-9. [PMID: 38231283 DOI: 10.1007/s00392-024-02375-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/08/2024] [Indexed: 01/18/2024]
Abstract
BACKGROUND Anemia and chronic kidney disease (CKD) adversely affect prognosis following acute myocardial infarction (AMI). We aimed to assess their interaction regarding long-term survival post-AMI. METHODS This is a single-center, retrospective analysis of consecutive AMI survivors. Stratified by admission-time anemia status and CKD grade, as determined by hemoglobin and creatinine levels, the cohort was evaluated for all-cause mortality at 10 years after hospital discharge. RESULTS A total of 11,395 patients (69.1% males, mean age 65.8 ± 13.9 years, 49.6% with ST elevation MI) were included, of whom 29.9% had anemia and 15.9% - grade 3b or higher CKD. CKD was more advanced among anemic patients and the prevalence of anemia rose as CKD grade increased (p for trend < 0.001). At 10 years, 47.8% of patients died. Notwithstanding differences in baseline characteristics, presentation, and treatment between those with various anemia status and CKD grades, anemia presence (HR 1.40, 95% CI 1.32-1.49, p < 0.001) and increasing CKD grade (HR 1.10, 95% CI 1.02-1.20, p for trend < 0.001) were independently associated with a higher mortality risk. The incremental hazard imposed by either anemia or more advanced CKD was limited to patients with normal renal function and up to grade 3a (in the total cohort and the conservative treatment subgroup) or 4 (in the invasive revascularization subgroup) CKD. The added risk associated with increasing CKD grade also affected non-anemic individuals irrespective of the specific CKD grade. CONCLUSION Anemia and more advanced CKD are associated with reduced long-term survival post-AMI, inflicting higher risk when conjoined in lower-grade CKD.
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Affiliation(s)
- Alon Shechter
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, 127 S San Vicente Blvd A3100, Los Angeles, CA, 90048, USA.
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel.
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Arthur Shiyovich
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Cardiovascular Division, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Keren Skalsky
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Harel Gilutz
- Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Ygal Plakht
- Department of Nursing, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Department of Emergency Medicine, Soroka University Medical Center, Be'er Sheva, Israel
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Qian WL, Yang ZG, Shi R, Guo YK, Fang H, Shen MT, Li Y. Left atrioventricular interaction and impaired left atrial phasic function in type 2 diabetes mellitus patients with or without anemia: a cardiac magnetic resonance study. Cardiovasc Diabetol 2023; 22:178. [PMID: 37443014 PMCID: PMC10347718 DOI: 10.1186/s12933-023-01910-8] [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: 06/01/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023] Open
Abstract
OBJECTIVE Type 2 diabetes mellitus (T2DM) and anemia are related to some cardiovascular diseases and can predict poor outcomes. Both of them can damage the heart in their own ways, but their combined effects have not been well explored. This study aimed to explore the combined effects of T2DM and anemia and the interaction between left atrial (LA) and left ventricular (LV) function by cardiac magnetic resonance (CMR). MATERIALS AND METHODS A total of 177 T2DM patients without anemia, 68 T2DM patients with anemia and 73 sex-matched controls were retrospectively enrolled in this study from June 2015 to September 2022. Their LA phasic function and LV function parameters were compared to explore the combined effects of T2DM and anemia and the interaction between LA and LV function. Univariate and multivariate linear regression were done to explore the independent factors influencing LA phasic function and LV function. RESULTS Compared with controls and T2DM patients without anemia, T2DM patients with anemia were older and had higher heart rate, higher creatinine, lower estimated glomerular filtration rate (eGFR) and lower hemoglobin (Hb) (all p < 0.05). LV global longitudinal peak strain (GLPS) significantly declined from T2DM patients with anemia to T2DM patients without anemia to controls (p < 0.001). LA volumetric function and strain were significantly impaired in T2DM patients with anemia compared with the other groups (all p < 0.05). In addition to age, eGFR, Hb and HbA1c, the LV GLPS was independently associated with all LA phasic strains (LA reservoir strain, β =0.465; LA conduit strain, β = 0.450; LA pump strain, β = 0.360, all p < 0.05). LA global conduit strain, total LA ejection fraction (LAEF) and active LAEF were independently associated with LV GLPS and LVEF. CONCLUSION Both LA and LV function were severely impaired in T2DM patients with anemia, and T2DM and anemia were independently associated with LA phasic function. Deleterious interaction between LA function and LV function would happen in T2DM patients with or without anemia. Timely and effective monitoring and management of both LA and LV function will benefit T2DM patients.
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Affiliation(s)
- Wen-Lei Qian
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Zhi-Gang Yang
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Rui Shi
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Ying-Kun Guo
- Department of Radiology, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, West China Second University Hospital, Sichuan University, 20# South Renmin Road, Chengdu, Sichuan, 610041, China
| | - Han Fang
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Meng-Ting Shen
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Yuan Li
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, Sichuan, 610041, China.
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Ubbink R, Streng LWJM, Raat NJH, Harms FA, Te Boekhorst PAW, Stolker RJ, Mik EG. Measuring Mitochondrial Oxygen Tension during Red Blood Cell Transfusion in Chronic Anemia Patients: A Pilot Study. Biomedicines 2023; 11:1873. [PMID: 37509512 PMCID: PMC10376882 DOI: 10.3390/biomedicines11071873] [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: 09/09/2022] [Revised: 06/19/2023] [Accepted: 06/26/2023] [Indexed: 07/30/2023] Open
Abstract
In light of the associated risks, the question has been raised whether the decision to give a blood transfusion should solely be based on the hemoglobin level. As mitochondria are the final destination of oxygen transport, mitochondrial parameters are suggested to be of added value. The aims of this pilot study were to investigate the effect of a red blood cell transfusion on mitochondrial oxygenation as measured by the COMET device in chronic anemia patients and to explore the clinical usability of the COMET monitor in blood transfusion treatments, especially the feasibility of performing measurements in an outpatient setting. To correct the effect of volume load on mitochondrial oxygenation, a red blood cell transfusion and a saline infusion were given in random order. In total, 21 patients were included, and this resulted in 31 observations. If patients participated twice, the order of infusion was reversed. In both the measurements wherein a blood transfusion was given first and wherein 500 mL of 0.9% saline was given first, the median mitochondrial oxygen tension decreased after red blood cell transfusion. The results of this study have strengthened the need for further research into the effect of blood transfusion tissue oxygenation and the potential role of mitochondrial parameters herein.
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Affiliation(s)
- Rinse Ubbink
- Laboratory of Experimental Anesthesiology, Department of Anesthesiology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
| | - Lucia W J M Streng
- Laboratory of Experimental Anesthesiology, Department of Anesthesiology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
| | - Nicolaas J H Raat
- Laboratory of Experimental Anesthesiology, Department of Anesthesiology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
| | - Floor A Harms
- Laboratory of Experimental Anesthesiology, Department of Anesthesiology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
| | - Peter A W Te Boekhorst
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
| | - Robert J Stolker
- Laboratory of Experimental Anesthesiology, Department of Anesthesiology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
| | - Egbert G Mik
- Laboratory of Experimental Anesthesiology, Department of Anesthesiology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
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5
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Al-hakeim HK, Twaij BAA, Ahmed MH, Almulla AF, Moustafa SR, Maes M. In end-stage kidney disease, inflammation, erythron abnormalities and declined kidney function tests are accompanied by increased affective symptoms, chronic-fatigue, and fibromyalgia.. [DOI: 10.1101/2023.01.12.23284460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
AbstractBackgroundNumerous neuropsychiatric symptoms, including affective symptoms, chronic fatigue syndrome, and fibromyalgia symptoms, are present in patients with end-stage renal disease (ESRD). This study examines the relationship between neuropsychiatric symptoms and red blood cell (RBC) parameters, kidney function tests, zinc, C-reactive protein, and calcium levels in patients with ESRD.MethodsThe above biomarkers and the Beck-Depression Inventory, the Hamilton Anxiety Rating Scale, and the Fibro-Fatigue Rating Scale were measured in 70 patients with end-stage renal disease (ESRD) and 46 healthy controls.ResultsIncreased scores of depressive, anxious, cognitive, and physiosomatic symptoms (including chronic fatigue, fibromyalgia, and autonomous symptoms) characterise ESRD. One latent vector could be extracted from these diverse symptom domains, which are, therefore, manifestations of a common core referred to as the physio-affective phenome. The combined effects of aberrations in red blood cells (RBC) (number of RBC, hematocrit, and haemoglobin), kidney function tests (glomerular filtration rate, ureum, creatinine, albumin, and total serum protein), C-reactive protein, zinc, and copper explained 85.0% of the variance in the physio-affective phenome. In addition, the effects of kidney function decline on the phenome were partially mediated by RBC aberrations and elevated copper, whereas the effects of dialysis frequency were entirely mediated by decreased zinc and elevated CRP.ConclusionsAffective (depression and anxiety), cognitive, and physiosomatic symptoms due to ESRD are interrelated manifestations of the physio-affective phenome, which is driven by (in descending order of importance) kidney dysfunctions, erythron deficits, inflammation, elevated copper, and decreased zinc.
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Neurosurgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00037-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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7
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Bulle EB, Klanderman RB, Pendergrast J, Cserti-Gazdewich C, Callum J, Vlaar APJ. The recipe for TACO: A narrative review on the pathophysiology and potential mitigation strategies of transfusion-associated circulatory overload. Blood Rev 2021; 52:100891. [PMID: 34627651 DOI: 10.1016/j.blre.2021.100891] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/24/2021] [Accepted: 09/24/2021] [Indexed: 12/31/2022]
Abstract
Transfusion associated circulatory overload (TACO) is one of the leading causes of transfusion related morbidity and mortality. TACO is the result of hydrostatic pulmonary edema following transfusion. However, up to 50% of all TACO cases appear after transfusion of a single unit, suggesting other factors, aside from volume, play a role in its pathophysiology. TACO follows a two-hit model, in which the first hit is an existing disease or comorbidity that renders patients volume incompliant, and the second hit is the transfusion. First hit factors include, amongst others, cardiac and renal failure. Blood product factors, setting TACO apart from crystalloid overload, include colloid osmotic pressure effects, viscosity, pro-inflammatory mediators and storage lesion byproducts. Differing hemodynamic changes, glycocalyx injury, endothelial damage and inflammatory reactions can all contribute to developing TACO. This narrative review explores pathophysiological mechanisms for TACO, discusses related therapeutic and preventative measures, and identifies areas of interest for future research.
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Affiliation(s)
- Esther B Bulle
- Department of Intensive Care, University of Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands; Laboratory for Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), University of Amsterdam, Amsterdam UMC, the Netherlands.
| | - Robert B Klanderman
- Department of Intensive Care, University of Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands; Laboratory for Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), University of Amsterdam, Amsterdam UMC, the Netherlands.
| | - Jacob Pendergrast
- Laboratory Medicine Program, University Health Network, Toronto, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada.
| | - Christine Cserti-Gazdewich
- Laboratory Medicine Program, University Health Network, Toronto, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada.
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Queen's University and Kingston Health Sciences Centre, Canada.
| | - Alexander P J Vlaar
- Department of Intensive Care, University of Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands; Laboratory for Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), University of Amsterdam, Amsterdam UMC, the Netherlands.
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8
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Padda J, Khalid K, Hitawala G, Batra N, Pokhriyal S, Mohan A, Cooper AC, Jean-Charles G. Acute Anemia and Myocardial Infarction. Cureus 2021; 13:e17096. [PMID: 34527482 PMCID: PMC8432420 DOI: 10.7759/cureus.17096] [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] [Accepted: 08/11/2021] [Indexed: 11/05/2022] Open
Abstract
Various studies have established the prognosis of anemia in myocardial infarction (MI). Both chronic and acute anemia lead to poor outcomes in MI. Regardless, the association of anemia with MI and its management varies. In this study, the literature was analyzed to determine the association between acute anemia and MI based on the pathophysiology, outcomes, and management options. Acute anemia results in decreased blood supply and sudden hypoxia to the heart. Additionally, it exacerbates the preexisting compromised coronary blood supply in patients with MI. Thus, there is a disproportionate oxygen supply and demand ratio to the heart. It was found that anemia increases all-cause mortality in acute MI. However, it is unclear whether anemia is the direct contributor to mortality in these patients. For the management of MI, percutaneous coronary intervention (PCI) is commonly used. Increased incidence of hospital-acquired anemia (HAA) is reported in patients after PCI. However, the cause of HAA in these patients is not well established. Antiplatelet therapy in these patients is also considered to be the culprit for HAA. Nonetheless, no clear evidence is available. There is no consensus or criteria for the treatment of acute anemia in MI patients. Researchers have explored management options such as blood transfusion, erythropoietin-stimulating agent, and iron therapy. Further studies are warranted for a better understanding and management of MI in patients with anemia and vice versa.
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Affiliation(s)
- Jaskamal Padda
- Internal Medicine, JC Medical Center, Orlando, USA.,Internal Medicine, Avalon University School of Medicine, Willemstad, CUW
| | | | | | - Nitya Batra
- Internal Medicine, JC Medical Center, Orlando, USA
| | | | - Ayushi Mohan
- Internal Medicine, JC Medical Center, Orlando, USA
| | | | - Gutteridge Jean-Charles
- Internal Medicine, JC Medical Center, Orlando, USA.,Internal Medicine, Advent Health & Orlando Health Hospital, Orlando, USA
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9
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Schoenes B, Schrezenmeier H, Welte M. Rationale Therapie mit Erythrozytenkonzentraten – Update 2020. TRANSFUSIONSMEDIZIN 2021. [DOI: 10.1055/a-1256-4487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
ZusammenfassungDer Einsatz von Erythrozytenkonzentraten muss dem Gebot einer rationalen Indikation folgen. Um dies weiter zu gewährleisten, wurden die 2009 publizierten und zuletzt 2014 in Teilen revidierten „Querschnitts-Leitlinien zur Therapie mit Blutkomponenten und Plasmaderivaten“ 1 der Bundesärztekammer 2020 einer systematischen Novellierung unterzogen. Der Artikel stellt sie vor.
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Rysz J, Franczyk B, Ławiński J, Gluba-Brzózka A. Oxidative Stress in ESRD Patients on Dialysis and the Risk of Cardiovascular Diseases. Antioxidants (Basel) 2020; 9:antiox9111079. [PMID: 33153174 PMCID: PMC7693989 DOI: 10.3390/antiox9111079] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/22/2020] [Accepted: 10/27/2020] [Indexed: 02/07/2023] Open
Abstract
Chronic kidney disease is highly prevalent worldwide. The decline of renal function is associated with inadequate removal of a variety of uremic toxins that exert detrimental effects on cells functioning, thus affecting the cardiovascular system. The occurrence of cardiovascular aberrations in CKD is related to the impact of traditional risk factors and non-traditional CKD-associated risk factors, including anemia; inflammation; oxidative stress; the presence of some uremic toxins; and factors related to the type, frequency of dialysis and the composition of dialysis fluid. Cardiovascular diseases are the most frequent cause for the deaths of patients with all stages of renal failure. The kidney is one of the vital sources of antioxidant enzymes, therefore, the impairment of this organ is associated with decreased levels of these enzymes as well as increased levels of pro-oxidants. Uremic toxins have been shown to play a vital role in the onset of oxidative stress. Hemodialysis itself also enhances oxidative stress. Elevated oxidative stress has been demonstrated to be strictly related to kidney and cardiac damage as it aggravates kidney dysfunction and induces cardiac hypertrophy. Antioxidant therapies may prove to be beneficial since they can decrease oxidative stress, reduce uremic cardiovascular toxicity and improve survival.
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Affiliation(s)
- Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-419 Łódź, Poland; (J.R.); (B.F.)
| | - Beata Franczyk
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-419 Łódź, Poland; (J.R.); (B.F.)
| | - Janusz Ławiński
- Department of Urology, Institute of Medical Sciences, Medical College of Rzeszow University, 35-959 Rzeszow, Poland;
| | - Anna Gluba-Brzózka
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-419 Łódź, Poland; (J.R.); (B.F.)
- Correspondence: ; Tel.: +48-42-639-3750
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Bird JG, Morant K, Al-Souri D, Scott CG, Padang R, McCully RB, Kane GC, Pellikka PA, Luis SA. Impact of Anemia on Exercise and Pharmacologic Stress Echocardiography. J Am Soc Echocardiogr 2020; 33:1067-1076. [PMID: 32709477 DOI: 10.1016/j.echo.2020.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/01/2020] [Accepted: 04/01/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The safety and diagnostic accuracy of stress testing in anemic patients have not been well studied. Despite a lack of data, significant anemia may be considered a relative contraindication to stress testing because of safety concerns related to insufficient myocardial oxygen supply. METHODS The authors reviewed 28,829 consecutive patients with blood hemoglobin drawn within 48 hours of stress echocardiography (15,624 exercise and 13,205 dobutamine). The associations of blood hemoglobin concentration with arrhythmia and other stress echocardiographic findings were examined. Additionally, the effect of anemia on the positive predictive value of stress echocardiography for the detection of significant coronary artery stenosis (≥50%) was assessed in patients who subsequently underwent coronary angiography. RESULTS Anemia was present in 6,401 patients (22.2%) and was severe (hemoglobin < 8.0 g/dL) in 52. Stress testing with either exercise or dobutamine was safe, with no significant increase in serious arrhythmia events or need for hospitalization. In the exercise cohort, worsening anemia was associated with reduced treadmill exercise time, lower peak heart rate, peak rate-pressure product, and achieved workload. In the dobutamine stress cohort, worsening anemia was associated with higher resting heart rate, more use of atropine, and fewer patients attaining target heart rate. The positive predictive value of stress echocardiography was higher in patients with moderate anemia compared with those without anemia (71.8% vs 60.2%, P = .01). CONCLUSIONS This study demonstrates that stress testing is safe in patients with mild and moderately anemia, albeit with a small increase in mild supraventricular arrhythmias with exercise. However, worsening anemia was associated with a significant reduction in exercise capacity. Additionally, worsening anemia was associated with an improvement in the positive predictive value of stress echocardiography. Extrapolation of these data to patients with severe anemia should be performed with caution given the limited number of patients with severe anemia in this study.
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Affiliation(s)
- Jared G Bird
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kareem Morant
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Deema Al-Souri
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert B McCully
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Sushil Allen Luis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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Okada M, Taniguchi H, Taniguchi S, Kitakoji H, Itoh K, Imai K. Effect of acupuncture on the haemodynamic system in men. Acupunct Med 2020; 38:169-174. [PMID: 32000504 DOI: 10.1136/acupmed-2017-011578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Acupuncture stimulation decreases heart rate (HR) through somato-autonomic reflexes. However, the mechanisms responsible for other cardiovascular changes induced by acupuncture, such as its effects on stroke volume (SV) and blood pressure (BP), remain obscure. OBJECTIVE To evaluate continuously the comprehensive cardiovascular changes occurring during acupuncture. METHOD 20 healthy men participated in the study. HR, SV and BP were measured in the supine position using electrocardiogram, transthoracic impedance cardiography and continuous non-invasive finger blood pressure, respectively. Manual acupuncture stimulation using a stainless steel needle was performed at LI10 for 60 s after resting periods of approximately 15 min. RESULTS HR was reduced and SV increased, in parallel, during the period of acupuncture stimulation (P<0.01, respectively). Diastolic blood pressure (DBP) decreased in the 10 s period of acupuncture stimulation compared with the 120 s pre-stimulation period (P<0.01) and recovered close to the pre-stimulation reading instantly after the transient reduction. No change was observed in cardiac output (CO) derived from HR and SV. CONCLUSIONS This study indicates that HR reduction during acupuncture does occur, as previous reports have indicated. SV increased during acupuncture stimulation in parallel with HR reduction and CO was maintained during these changes. Any reduction in DBP caused by acupuncture recovered to baseline, likely due to baroreflexes.
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Affiliation(s)
- Misaki Okada
- Department of Acupuncture and Moxibustion, Meiji University of Integrative Medicine, Kyoto, Japan
| | - Hiroshi Taniguchi
- Department of Acupuncture and Moxibustion, Tokyo Ariake University of Medical and Health Sciences, Tokyo, Japan
| | - Sazu Taniguchi
- Department of Acupuncture and Moxibustion, Meiji University of Integrative Medicine, Kyoto, Japan
| | - Hiroshi Kitakoji
- Department of Acupuncture and Moxibustion, Meiji University of Integrative Medicine, Kyoto, Japan
| | - Kazunori Itoh
- Department of Acupuncture and Moxibustion, Meiji University of Integrative Medicine, Kyoto, Japan
| | - Kenji Imai
- Departmentof Acupuncture and Moxibustion, Faculty of Health Science, Teikyo Heisei University, Tokyo, Japan
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A Modern View on the Diagnostic and Therapy Anemia Chronic Diseases Problems. Fam Med 2019. [DOI: 10.30841/2307-5112.3.2019.178588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Nuhu F, Bhandari S. Oxidative Stress and Cardiovascular Complications in Chronic Kidney Disease, the Impact of Anaemia. Pharmaceuticals (Basel) 2018; 11:E103. [PMID: 30314359 PMCID: PMC6316624 DOI: 10.3390/ph11040103] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 09/30/2018] [Accepted: 10/01/2018] [Indexed: 12/17/2022] Open
Abstract
Patients with chronic kidney disease (CKD) have significant cardiovascular morbidity and mortality as a result of risk factors such as left ventricular hypertrophy (LVH), oxidative stress, and inflammation. The presence of anaemia in CKD further increases the risk of LVH and oxidative stress, thereby magnifying the deleterious consequence in uraemic cardiomyopathy (UCM), and aggravating progression to failure and increasing the risk of sudden cardiac death. This short review highlights the specific cardio-renal oxidative stress in CKD and provides an understanding of the pathophysiology and impact of uraemic toxins, inflammation, and anaemia on oxidative stress.
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Affiliation(s)
- Faisal Nuhu
- School of Life Sciences (Biomedical), University of Hull, Cottingham Rd, Hull HU6 7RX, UK.
| | - Sunil Bhandari
- Hull York Medical School & Department of Renal Medicine, Hull and East Yorkshire NHS Hospital Trust, Hull HU3 2JZ, UK.
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Recommendations on RBC Transfusion in Infants and Children With Acquired and Congenital Heart Disease From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:S137-S148. [PMID: 30161069 PMCID: PMC6126364 DOI: 10.1097/pcc.0000000000001603] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To present the recommendations and supporting literature for RBC transfusions in critically ill children with acquired and congenital heart disease developed by the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN Consensus conference series of 38 international, multidisciplinary experts in RBC transfusion management of critically ill children. METHODS Experts developed evidence-based and, when evidence was lacking, expert-based clinical recommendations and research priorities for RBC transfusions in critically ill children. The cardiac disease subgroup included three experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA appropriateness method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS Twenty-one recommendations were developed and reached agreement. For children with myocardial dysfunction and/or pulmonary hypertension, there is no evidence that transfusion greater than hemoglobin of 10 g/dL is beneficial. For children with uncorrected heart disease, we recommended maintaining hemoglobin greater than 7-9.0 g/dL depending upon their cardiopulmonary reserve. For stable children undergoing biventricular repairs, we recommend not transfusing if the hemoglobin is greater than 7.0 g/dL. For infants undergoing staged palliative procedures with stable hemodynamics, we recommend avoiding transfusions solely based upon hemoglobin, if hemoglobin is greater than 9.0 g/dL. We recommend intraoperative and postoperative blood conservation measures. There are insufficient data supporting shorter storage duration RBCs. The risks and benefits of RBC transfusions in children with cardiac disease requires further study. CONCLUSIONS We present RBC transfusion management recommendations for the critically ill child with cardiac disease. Clinical recommendations emphasize relevant hemoglobin thresholds, and research recommendations emphasize need for further understanding of physiologic and hemoglobin thresholds and alternatives to RBC transfusion in subpopulations lacking pediatric literature.
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Abstract
Anemia is a common condition and is diagnosed on laboratory assessment. It is defined by abnormally low hemoglobin concentration or decreased red blood cells. Several classification systems exist. Laboratory markers provide important information. Acute anemia presents with symptoms owing to acute blood loss; chronic anemia may present with worsening fatigue, dyspnea, lightheadedness, or chest pain. Specific treatments depend on the underlying anemia and etiology. Iron is an alternative treatment for patients with microcytic anemia owing to iron deficiency. Hyperbaric oxygen is an option for alternative rescue therapy. Most patients with chronic anemia may be discharged with follow-up if hemodynamically stable.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, 3841 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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Hemoglobin Is a Vital Determinant of Arterial Oxygen Content in Hypoxemic Patients with Pulmonary Arteriovenous Malformations. Ann Am Thorac Soc 2018; 14:903-911. [PMID: 28267932 DOI: 10.1513/annalsats.201611-872oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
RATIONALE PaO2 and SaO2 are commonly measured in respiratory practice, but arterial oxygen content (CaO2) refers to the volume of oxygen delivered to the tissues per unit blood volume. CaO2 is calculated from SaO2 and the hemoglobin concentration in blood, recognizing that each gram of hemoglobin can transport approximately 1.34 ml of oxygen when fully saturated. OBJECTIVES To prospectively evaluate serial changes in CaO2 in humans, incorporating and excluding dynamic changes to oxygenation and hemoglobin parameters that may occur during life. METHODS A cohort of 497 consecutive patients at risk of both hypoxemia and anemia were recruited. The patients had radiologically proven pulmonary arteriovenous malformations (PAVMs), which result in hypoxemia due to right-to-left shunting, and concurrent hereditary hemorrhagic telangiectasia, which placed them at risk of iron deficiency anemia due to recurrent hemorrhagic iron losses. Presentation SaO2 (breathing room air, by pulse oximetry), hemoglobin, red cell and iron indices were measured, and CaO2 calculated as SaO2 × hemoglobin × 1.34 ml/g. Serial measurements were evaluated in 100 cases spanning up to 32.1 (median, 10.5) years. RESULTS Presentation CaO2 ranged from 7.6 to 27.5 (median, 17.6) ml/dl. CaO2 did not change appreciably across the SaO2 quartiles. In contrast, hemoglobin ranged from 5.9 to 21.8 g/dl (median, 14.1 g/dl), with a linear increase in CaO2 across hemoglobin quartiles. After PAVM embolization and an immediate increase in SaO2, hemoglobin fell and CaO2 was unchanged 1.6-12 (median, 4) months later. When hemoglobin fell because of iron deficiency, there was no change in SaO2. Similarly, when hemoglobin rose after iron treatment, there was no change in SaO2, and the expected CaO2 increment was observed. These relationships were not evident during pregnancy when hemoglobin fell, and PAVMs usually deteriorated: in pregnancy SaO2 commonly increased, and serial CaO2 values (incorporating hemodilution/anemia) more accurately reflected deteriorating PAVM status. An apparent fall in CaO2 with age in females was attributable to the development of iron deficiency. There was an unexplained increase in CaO2 with age in follow-up of males after embolization. CONCLUSIONS Hemoglobin/CaO2 should be further incorporated into oxygenation considerations. More attention should be given to modest changes in hemoglobin that substantially modify CaO2.
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Kisilevsky A, Gelb AW, Bustillo M, Flexman AM. Anaemia and red blood cell transfusion in intracranial neurosurgery: a comprehensive review. Br J Anaesth 2018; 120:988-998. [PMID: 29661416 DOI: 10.1016/j.bja.2017.11.108] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 11/08/2017] [Accepted: 11/30/2017] [Indexed: 01/04/2023] Open
Abstract
Both anaemia and blood transfusion are associated with poor outcomes in the neurosurgical population. Based on the available literature, the optimal haemoglobin concentration for neurologically injured patients appears to be in the range of 9.0-10.0 g dl-1, although the individual risks and benefits should be weighed. Several perioperative blood conservation strategies have been used successfully in neurosurgery, including correction of anaemia and coagulopathy, use of antifibrinolytics, and intraoperative cell salvage. Avoidance of non-steroidal anti-inflammatory drugs and starch-containing solutions is recommended given the potential for platelet dysfunction.
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Affiliation(s)
- A Kisilevsky
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
| | - A W Gelb
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - M Bustillo
- Department of Anesthesiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - A M Flexman
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada.
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Shovlin CL, Condliffe R, Donaldson JW, Kiely DG, Wort SJ. British Thoracic Society Clinical Statement on Pulmonary Arteriovenous Malformations. Thorax 2017; 72:1154-1163. [DOI: 10.1136/thoraxjnl-2017-210764] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 09/01/2017] [Accepted: 09/04/2017] [Indexed: 01/02/2023]
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Modest and Severe Maternal Iron Deficiency in Pregnancy are Associated with Fetal Anaemia and Organ-Specific Hypoxia in Rats. Sci Rep 2017; 7:46573. [PMID: 28440316 PMCID: PMC5404227 DOI: 10.1038/srep46573] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 03/17/2017] [Indexed: 02/06/2023] Open
Abstract
Prenatal iron-deficiency (ID) is known to alter fetal developmental trajectories, which predisposes the offspring to chronic disease in later life, although the underlying mechanisms remain unclear. Here, we sought to determine whether varying degrees of maternal anaemia could induce organ-specific patterns of hypoxia in the fetuses. Pregnant female Sprague Dawley rats were fed iron-restricted or iron-replete diets to induce a state of moderate (M-ID) or severe ID (S-ID) alongside respective controls. Ultrasound biomicroscopy was performed on gestational day (GD)20 to assess uterine and umbilical artery blood flow patterns. On GD21, tissues were collected and assessed for hypoxia using pimonidazole staining. Compared to controls, maternal haemoglobin (Hb) in M- and S-ID were reduced 17% (P < 0.01) and 48% (P < 0.001), corresponding to 39% (P < 0.001) and 65% (P < 0.001) decreases in fetal Hb. Prenatal ID caused asymmetric fetal growth restriction, which was most pronounced in S-ID. In both severities of ID, umbilical artery resistive index was increased (P < 0.01), while pulsatility index only increased in S-ID (P < 0.05). In both M-and S-ID, fetal kidneys and livers showed evidence of hypoxia (P < 0.01 vs. controls), whereas fetal brains and placentae remained normoxic. These findings indicate prenatal ID causes organ-specific fetal hypoxia, even in the absence of severe maternal anaemia.
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Nasser B, Tageldein M, AlMesned A, Kabbani M. Effects of blood transfusion on oxygen extraction ratio and central venous saturation in children after cardiac surgery. Ann Saudi Med 2017; 37:31-37. [PMID: 28151454 PMCID: PMC6148984 DOI: 10.5144/0256-4947.2017.31] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Red blood cell transfusion is common in critically ill children after cardiac surgery. Since the threshold for hemoglobin (Hb) transfusion need is not well defined, the threshold Hb level at which dependent critical oxygen uptake-to-delivery (VO2-DO2) status compensation is uncertain. OBJECTIVES To assess the effects of blood transfusion on the oxygen extraction ratio (O2ER) and central venous oxygen saturation (ScvO2) to identify a critical O2ER value that could help us determine the critical need for blood transfusion. DESIGN Prospective, observational cohort study. SETTING Cardiac Surgical Intensive Care Unit at Prince Sultan Cardiac Center in Qassim, Saudi Arabia. PATIENTS AND METHODS Between January 2013 and December 2015, we included all children with cardiac disease who underwent surgery and needed a blood transfusion. Demographic and laboratory data with physiological parameters before and 1 and 6 hours after transfusion were recorded and O2ER before and 6 hours after transfusion was computed. Cases were divided into two groups based on O2ER: Patients with increased O2ER (O2ER > 40%) and normal patients without increased O2ER (O2ER < =40%) before transfusion. MAIN OUTCOME MEASURE(S) Changes in O2ER and ScvO2 following blood transfusion. RESULTS Of 103 patients who had blood transfusion, 75 cases had normal O2ER before transfusion while 28 cases had increased O2ER before transfusion. Following blood transfusion, O2ER and ScvO2 improved in the group that had increased O2ER before transfusion, but not in the group that had normal O2ER before transfusion. CONCLUSIONS The clinical and hemodynamic indicators O2ER and ScvO2 may be considered as markers that can indicate a need for blood transfusion. LIMITATIONS The limitation of this study is the small number of patients that had increased O2ER before transfusion. There were few available variables to assess oxygen consumption.
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Affiliation(s)
- Bana Nasser
- Dr. Bana Nasser Buridha Qassim KSA,, Buridha, 2295, Saudi Arabia, T: 966-16-525200, , ORCID: http://orcid.org/0000-0002-4356-690
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Shovlin CL, Gilson C, Busbridge M, Patel D, Shi C, Dina R, Abdulla FN, Awan I. Can Iron Treatments Aggravate Epistaxis in Some Patients With Hereditary Hemorrhagic Telangiectasia? Laryngoscope 2016; 126:2468-2474. [PMID: 27107394 PMCID: PMC5095791 DOI: 10.1002/lary.25959] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 01/31/2016] [Accepted: 02/10/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVES/HYPOTHESIS To examine whether there is a rationale for iron treatments precipitating nosebleeds (epistaxis) in a subgroup of patients with hereditary hemorrhagic telangiectasia (HHT). STUDY DESIGN Survey evaluation of HHT patients, and a randomized control trial in healthy volunteers. METHODS Nosebleed severity in response to iron treatments and standard investigations were evaluated by unbiased surveys in patients with HHT. Serial blood samples from a randomized controlled trial of 18 healthy volunteers were used to examine responses to a single iron tablet (ferrous sulfate, 200 mg). RESULTS Iron tablet users were more likely to have daily nosebleeds than non-iron-users as adults, but there was no difference in the proportions reporting childhood or trauma-induced nosebleeds. Although iron and blood transfusions were commonly reported to improve nosebleeds, 35 of 732 (4.8%) iron tablet users, in addition to 17 of 261 (6.5%) iron infusion users, reported that their nosebleeds were exacerbated by the respective treatments. These rates were significantly higher than those reported for control investigations. Serum iron rose sharply in four of the volunteers ingesting ferrous sulfate (by 19.3-33.1 μmol/L in 2 hours), but not in 12 dietary controls (2-hour iron increment ranged from -2.2 to +5.0 μmol/L). High iron absorbers demonstrated greater increments in serum ferritin at 48 hours, but transient rises in circulating endothelial cells, an accepted marker of endothelial damage. CONCLUSIONS Iron supplementation is essential to treat or prevent iron deficiency, particularly in patients with pathological hemorrhagic iron losses. However, in a small subgroup of individuals, rapid changes in serum iron may provoke endothelial changes and hemorrhage. LEVEL OF EVIDENCE 4. Laryngoscope, 126:2468-2474, 2016.
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Affiliation(s)
- Claire L Shovlin
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom.
- Respiratory Medicine, Imperial College Healthcare National Health Service Trust, London, United Kingdom.
| | - Clare Gilson
- Respiratory Medicine, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Mark Busbridge
- Clinical Chemistry, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Dilip Patel
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Chenyang Shi
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Roberto Dina
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - F Naziya Abdulla
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College London School of Medicine, London, United Kingdom
| | - Iman Awan
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College London School of Medicine, London, United Kingdom
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Goel R, Cushing MM, Tobian AAR. Pediatric Patient Blood Management Programs: Not Just Transfusing Little Adults. Transfus Med Rev 2016; 30:235-41. [PMID: 27559005 DOI: 10.1016/j.tmrv.2016.07.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 07/19/2016] [Accepted: 07/21/2016] [Indexed: 01/29/2023]
Abstract
Red blood cell transfusions are a common life-saving intervention for neonates and children with anemia, but transfusion decisions, indications, and doses in neonates and children are different from those of adults. Patient blood management (PBM) programs are designed to assist clinicians with appropriately transfusing patients. Although PBM programs are well recognized and appreciated in the adult setting, they are quite far from standard of care in the pediatric patient population. Adult PBM standards cannot be uniformly applied to children, and there currently is significant variation in transfusion practices. Because transfusing unnecessarily can expose children to increased risk without benefit, it is important to design PBM programs to standardize transfusion decisions. This article assesses the key elements necessary for a successful pediatric PBM program, systematically explores various possible pediatric specific blood conservation strategies and the current available literature supporting them, and outlines the gaps in the evidence suggesting need for further/improved research. Pediatric PBM programs are critically important initiatives that not only involve a cooperative effort between pediatric surgery, anesthesia, perfusion, critical care, and transfusion medicine services but also need operational support from administration, clinical leadership, finance, and the hospital information technology personnel. These programs also expand the scope for high-quality collaborative research. A key component of pediatric PBM programs is monitoring pediatric blood utilization and assessing adherence to transfusion guidelines. Data suggest that restrictive transfusion strategies should be used for neonates and children similar to adults, but further research is needed to assess the best oxygenation requirements, hemoglobin threshold, and transfusion strategy for patients with active bleeding, hemodynamic instability, unstable cardiac disease, and cyanotic cardiac disease. Perioperative blood management strategies include minimizing blood draws, restricting transfusions, intraoperative cell salvage, acute normovolemic hemodilution, antifibrinolytic agents, and using point-of-care tests to guide transfusion decisions. However, further research is needed for the use of intravenous iron, erythropoiesis-stimulating agents, and possible use of whole blood and pathogen inactivation. There are numerous areas where newly formed collaborations could be used to investigate pediatric transfusion, and these studies would provide critical data to support vital pediatric PBM programs to optimize neonatal and pediatric care.
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Affiliation(s)
- Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY; Division of Pediatric Hematology/Oncology, Department of Pediatrics, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY
| | - Melissa M Cushing
- Division of Transfusion Medicine, Department of Pathology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY
| | - Aaron A R Tobian
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD.
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Shovlin C, Awan I, Cahilog Z, Abdulla F, Guttmacher A. Reported cardiac phenotypes in hereditary hemorrhagic telangiectasia emphasize burdens from arrhythmias, anemia and its treatments, but suggest reduced rates of myocardial infarction. Int J Cardiol 2016; 215:179-85. [DOI: 10.1016/j.ijcard.2016.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/02/2016] [Indexed: 01/17/2023]
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Long B, Koyfman A. Red Blood Cell Transfusion in the Emergency Department. J Emerg Med 2016; 51:120-30. [PMID: 27262735 DOI: 10.1016/j.jemermed.2016.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 04/09/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Transfusion of red blood cells (RBCs) is the primary management of anemia, which affects 90% of critically ill patients. Anemia has been associated with a poor prognosis in various settings, including critical illness. Recent literature has shown a hemoglobin transfusion threshold of 7 g/dL to be safe. This review examines several aspects of transfusion. OBJECTIVE We sought to provide emergency physicians with an updated review of indications for RBC transfusion in the emergency department. DISCUSSION The standard hemoglobin transfusion threshold was 10 g/dL. However, the body shows physiologic compensatory adaptations to chronic anemia. Transfusion reactions and infections are rare but can have significant morbidity and mortality. Products stored for <21 days have the lowest risk of reaction and infection. A restrictive threshold of 7 g/dL is recommended in the new American Association of Blood Banks guidelines and multiple meta-analyses and supported in gastrointestinal bleeding, sepsis, critical illness, and trauma. Patients with active ischemia in acute coronary syndrome and neurologic injury require additional study. The physician must consider the patient's hemodynamic status, comorbidities, risks and benefits of transfusion, and clinical setting in determining the need for transfusion. CONCLUSIONS RBC transfusion is not without risks, including transfusion reaction, infection, and potentially increased mortality. The age of transfusion products likely has no effect on products before 21 days of storage. A hemoglobin level of 7 g/dL is safe in the setting of critical illness, sepsis, gastrointestinal bleeding, and trauma. The clinician must evaluate and transfuse based on the clinical setting and patient hemodynamic status rather than using a specific threshold.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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Kim KJ, Baek IW, Yoon CH, Kim WU, Cho CS. Association of Anemic Hypoxia and Increased Pulmonary Artery Systolic Pressure in Patients With Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2016; 67:1702-11. [PMID: 26018410 DOI: 10.1002/acr.22630] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 04/20/2015] [Accepted: 05/19/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Pulmonary arterial hypertension (PAH) is a rare but serious complication of systemic lupus erythematosus (SLE). Chronic hypoxia is known to cause PAH resulting from pulmonary vascular remodeling. We investigated the association between anemic hypoxia and PAH in SLE patients. METHODS Systolic pulmonary artery pressure (PAP) was measured in 132 SLE patients by echocardiography. Increased PAP was defined as resting PAP > 40 mm Hg. Oxygen delivery (DO2) was estimated as the product of cardiac output and arterial oxygen content. RESULTS Of 132 patients, 17 (12.9%) had increased PAP, and these patients had significantly lower DO2 values than patients with normal PAP (P = 0.002). The DO2 values inversely correlated with PAP values (γ = -0.308, P < 0.001) and plasma N-terminal pro-brain natriuretic peptide levels (γ = -0.323, P = 0.001), but positively correlated with hemoglobin levels (γ = 0.402, P < 0.001). Compared to those with normal PAP, patients with increased PAP had significantly longer durations of anemia over the preceding 6-24 months. Patients with anemia of longer durations (≥3 months) in the preceding 6 months had a higher risk of increased PAP compared to those with shorter durations (P < 0.001). When SLE patients were divided into 3 groups according to hemoglobin and PAP, serum interleukin-6 (IL-6) levels increased across groups with higher PAP (P = 0.001 for trend), but decreased across tertiles of hemoglobin levels (P = 0.008 for trend). CONCLUSION Our data indicate an association between chronic anemic hypoxia and increased PAP in SLE patients and suggest that increased IL-6 might participate in this process.
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Affiliation(s)
- Ki-Jo Kim
- St. Vincent Hospital, The Catholic University of Korea, Suwon, Republic of Korea
| | - In-Woon Baek
- Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chong-Hyeon Yoon
- Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu, Republic of Korea
| | - Wan-Uk Kim
- Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul-Soo Cho
- Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
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Shovlin CL, Patel T, Jackson JE. Embolisation of PAVMs reported to improve nosebleeds by a subgroup of patients with hereditary haemorrhagic telangiectasia. ERJ Open Res 2016; 2:00035-2016. [PMID: 27730189 PMCID: PMC5005172 DOI: 10.1183/23120541.00035-2016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 04/02/2016] [Indexed: 11/07/2022] Open
Abstract
Pulmonary arteriovenous malformations (PAVMs) are structurally abnormal vessels that provide direct capillary-free communications between the pulmonary and systemic circulations, and hence, right-to-left shunts [1]. Due to impaired gas exchange, hypoxaemia is common but exercise tolerance is usually preserved through haematological (erythrocytotic) and cardiovascular compensations [2, 3], and patients are frequently asymptomatic [1–3]. Treatment of PAVMs is recommended to prevent paradoxical embolic sequelae such as ischaemic strokes [4] and brain abscess [5], commonly improves migraine headaches [6], and is a successful emergency treatment for haemorrhage. Pulmonary AVM embolisation appears to improve nosebleed severity for nearly one in six people with HHThttp://ow.ly/4mJqip
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Affiliation(s)
- Claire L Shovlin
- NHLI Cardiovascular Sciences, Imperial College London, London, UK
| | - Trishan Patel
- NHLI Cardiovascular Sciences, Imperial College London, London, UK; Dept of Medicine, St George's, University of London, London, UK
| | - James E Jackson
- Dept of Imaging, Imperial College Healthcare NHS Trust, London, UK
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Wang X, Qiu M, Qi J, Li J, Wang H, Li Y, Han Y. Impact of anemia on long-term ischemic events and bleeding events in patients undergoing percutaneous coronary intervention: a system review and meta-analysis. J Thorac Dis 2015; 7:2041-52. [PMID: 26716044 DOI: 10.3978/j.issn.2072-1439.2015.11.56] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Data focused on the ischemic events and bleeding events are still limited. We systematically reviewed the current available literature to investigate whether anemia increase incidence of long-term ischemic events and long-term bleeding events in patients undergoing PCI. METHODS PubMed and Embase were searched for case-control studies regarding the impact of anemia on long-term outcomes in patients undergoing percutaneous coronary intervention (PCI). The primary outcome was long-term ischemic events and long-term bleeding events. Mantel-Haenszel method with random effects model or fixed effects model was used to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Seventeen studies involving 68,528 patients (17,123 anemic patients and 51,405 non-anemic patients) were included. Pooled analysis suggested that anemic patients were at higher risk for long-term composite ischemic events (OR: 1.95, 95% CI, 1.21-3.14, P<0.01, I(2)=84%), long-term reinfarction (0R: 1.63, 95% CI, 1.16-2.28, P<0.01, I(2)=82%) and long-term bleeding events (OR: 2.89, 95% CI, 1.68-4.98, P<0.001, I(2)=89%). Anemia was also associated with long-term mortality (OR: 3.20, 95% CI, 2.72-3.75, P<0.01, I(2)=65%) and major adverse cardiac events (MACE) (OR: 2.06, 95% CI, 1.48-2.86, P<0.01, I(2)=91%). CONCLUSIONS Anemic patients undergoing PCI are at higher risk for both long-term ischemic events and bleeding events, and also at higher risk for long-term mortality and MACE. There's a need for further clarification and consistency regarding dosage, timing and duration of antithrombotic therapy for the prevention of ischemic events and bleeding events in anemic patients.
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Affiliation(s)
- Xiaoyan Wang
- 1 Graduate school, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
| | - Miaohan Qiu
- 1 Graduate school, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
| | - Jing Qi
- 1 Graduate school, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
| | - Jing Li
- 1 Graduate school, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
| | - Heyang Wang
- 1 Graduate school, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
| | - Yi Li
- 1 Graduate school, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
| | - Yaling Han
- 1 Graduate school, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
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Wang X, Qiu M, Li J, Wang H, Qi J, Wang G, Xu K, Liu H, Zhao X, Jing Q, Li Y, Han Y. Impacts of anemia on 3-year ischemic events in patients undergoing percutaneous coronary intervention: a propensity-matched study. J Thorac Dis 2015; 7:1951-9. [PMID: 26716033 DOI: 10.3978/j.issn.2072-1439.2015.10.66] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Anemia correlates with worse outcomes in patients undergoing percutaneous coronary intervention (PCI), improved anemia can improve the outcomes in patients who underwent PCI. But the influence of anemia on long-term ischemic events after PCI remains unknown. METHODS We analyzed 8,825 consecutive patients who underwent PCI at General Hospital of Shenyang Military Region and identified 581 patients with anemia. Patients (anemia vs. no anemia) were compared using a propensity score analysis to best match between groups. The main outcome of this study is 3-year ischemic events after PCI, the secondary outcome of this study is 3-year mortality and major adverse cardiac events (MACE) after PCI. RESULTS Compared with nonanemic patients, anemic patients were often female (38.90% vs. 14.51%) and elder patients (66.44% vs. 34.95%). Anemic patients have lower left ventricular ejection fraction (LVEF) and creatinine clearance (Ccr) and were more likely to have history of cardiovascular and cerebrovascular diseases, hypertension, peripheral vascular diseases (PVD) (P<0.05). However, the prevalences of diabetes and hyperlipidemia were lower in anemic patients (P<0.01). Anemia was an independent predictor for 3-year ischemic events [hazard ratio (HR): 2.20, 95% confidence intervals (CI): 1.61-3.00, P<0.01], 3-year mortality (HR: 3.58, 95% CI: 1.75-7.32, P<0.01) and 3-year MACE (HR: 2.14, 95% CI: 1.64-2.79, P<0.01) after PCI in post-match samples. The incidence of 3-year ischemic events was 41.0% and 19.3% in anemic and nonanemic patients, respectively. CONCLUSIONS Anemia is an independent predictor for 3-year ischemic events, 3-year mortality and 3-year MACE in patients who underwent PCI. Further studies need to explore the impact of the pathogenesis and progress, prevention and therapy of anemia on the outcome of patients undergoing PCI.
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Affiliation(s)
- Xiaoyan Wang
- 1 Graduate School, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
| | - Miaohan Qiu
- 1 Graduate School, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
| | - Jing Li
- 1 Graduate School, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
| | - Heyang Wang
- 1 Graduate School, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
| | - Jing Qi
- 1 Graduate School, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
| | - Geng Wang
- 1 Graduate School, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
| | - Kai Xu
- 1 Graduate School, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
| | - Haiwei Liu
- 1 Graduate School, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
| | - Xin Zhao
- 1 Graduate School, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
| | - Quanmin Jing
- 1 Graduate School, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
| | - Yi Li
- 1 Graduate School, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
| | - Yaling Han
- 1 Graduate School, Dalian Medical University, Dalian 116044, China ; 2 Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang 110016, China
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Renal functional and structural integrity in infants with iron deficiency anemia: relation to oxidative stress and response to iron therapy. Pediatr Nephrol 2015; 30:1835-42. [PMID: 25980471 DOI: 10.1007/s00467-015-3122-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 04/23/2015] [Accepted: 04/27/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND Iron deficiency anemia (IDA) is the most common nutritional deficiency in the world. The aim of our study was to evaluate and compare renal functional and structural integrity in 50 infants with IDA and 50 healthy controls and to assess the relation between IDA and oxidative stress and response to iron therapy. METHODS This was a prospective study in which peripheral blood samples were collected from all study subjects and the following laboratory investigations performed: serum iron profile, urinary microalbumin, urinary leucine aminopeptidase (LAP), fractional excretion of sodium (FeNa), serum total antioxidant capacity (TAC), serum malondialdehyde (MDA), serum and urinary trace elements (iron, copper, zinc, calcium and magnesium). All patients received oral iron therapy and were followed-up for 3 months. RESULTS The levels of baseline urinary markers were higher among the patients with IDA than among the controls (p < 0.05). Patients had a lower pre-therapy TAC and lower serum zinc and magnesium levels than controls as well as higher MDA and serum copper levels (p < 0.05). MDA level was positively correlated to microalbumin and LAP level (p < 0.05). Urinary LAP concentration was positively correlated to urinary trace element concentrations (p < 0.05). A significant decrease in microalbumin, LAP, FeNa, and urinary trace elements was observed post-iron therapy while hemoglobin and ferritin levels were increased (p < 0.05). CONCLUSION Among the study subjects, IDA had an adverse influence on renal functional and structural integrity which could be reversed with iron therapy. Oxidative stress played an important role in the pathogenesis of renal injury in IDA.
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Shovlin CL. Circulatory contributors to the phenotype in hereditary hemorrhagic telangiectasia. Front Genet 2015; 6:101. [PMID: 25914716 PMCID: PMC4391027 DOI: 10.3389/fgene.2015.00101] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 02/25/2015] [Indexed: 12/11/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is mechanistically and therapeutically challenging, not only because of the molecular and cellular perturbations that generate vascular abnormalities, but also the modifications to circulatory physiology that result, and are likely to exacerbate vascular injury. First, most HHT patients have visceral arteriovenous malformations (AVMs). Significant visceral AVMs reduce the systemic vascular resistance: supra-normal cardiac outputs are required to maintain arterial blood pressure, and may result in significant pulmonary venous hypertension. Secondly, bleeding from nasal and gastrointestinal telangiectasia leads to iron losses of such magnitude that in most cases, diet is insufficient to meet the ‘hemorrhage adjusted iron requirement.’ Resultant iron deficiency restricts erythropoiesis, leading to anemia and further increases in cardiac output. Low iron levels are also associated with venous and arterial thromboses, elevated Factor VIII, and increased platelet aggregation to circulating 5HT (serotonin). Third, recent data highlight that reduced oxygenation of blood due to pulmonary AVMs results in a graded erythrocytotic response to maintain arterial oxygen content, and higher stroke volumes and/or heart rates to maintain oxygen delivery. Finally, HHT-independent factors such as diet, pregnancy, sepsis, and other intercurrent illnesses also influence vascular structures, hemorrhage, and iron handling in HHT patients. These considerations emphasize the complexity of mechanisms that impact on vascular structures in HHT, and also offer opportunities for targeted therapeutic approaches.
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Affiliation(s)
- Claire L Shovlin
- NHLI Cardiovascular Sciences, Imperial Centre for Translational and Experimental Medicine, Imperial College London London, UK ; Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust London, UK
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Spinelli E, Bartlett RH. Anemia and Transfusion in Critical Care. J Intensive Care Med 2015; 31:295-306. [DOI: 10.1177/0885066615571901] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 12/03/2014] [Indexed: 01/28/2023]
Abstract
Objective: The objective of this report is to review the physiology and management of anemia in critical care. Selected publications on physiology and transfusion related to anemia and critical care, including the modern randomized trials of conservative versus liberal transfusion policy, were used. Anemia is compensated and tolerated in most critically ill patients as long as oxygen delivery is at least twice oxygen consumption. There are risks to blood transfusion which can be minimized by blood banking practice. The availability of cultured red cells may allow correction of anemia without significant risk. The benefit of transfusion in anemia must be weighted against the risk in any specific patient. Conclusion and Recommendation: In a criticially ill patient, anemia should be managed to avoid oxygen supply dependency (oxygen delivery less than twice comsumption) and to maintain moderate oxygen delivery reserve (DO2/VO2 > 3).
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Affiliation(s)
- Elena Spinelli
- University of Michigan ECLS Laboratory, Ann Arbor, MI, USA
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Ghosh K, SenDasgupta C, Mahapatra S. Our experience of intraoperative autologous blood donation in patients undergoing elective valve surgery. Indian J Thorac Cardiovasc Surg 2015. [DOI: 10.1007/s12055-015-0359-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Shovlin CL. Pulmonary arteriovenous malformations. Am J Respir Crit Care Med 2014; 190:1217-28. [PMID: 25420112 PMCID: PMC4315816 DOI: 10.1164/rccm.201407-1254ci] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 10/20/2014] [Indexed: 11/16/2022] Open
Abstract
Within the past decade, pulmonary arteriovenous malformations (PAVMs) have evolved from rare curiosities to not uncommon clinical states, with the latest estimates suggesting a prevalence of ~1 in 2,600. PAVMs provide anatomic right-to-left shunts, allowing systemic venous blood to bypass gas exchange and pulmonary capillary bed processing. Hypoxemia and enhanced ventilatory demands result, although both are usually asymptomatic. Paradoxical emboli lead to strokes and cerebral abscesses, and these commonly occur in individuals with previously undiagnosed PAVMs. PAVM hemorrhage is rare but is the main cause of maternal death in pregnancy. PAVM occlusion by embolization is the standard of care to reduce these risks. However, recent data demonstrate that currently recommended management protocols can result in levels of radiation exposure that would be classified as harmful. Recent publications also provide a better appreciation of the hematologic and cardiovascular demands required to maintain arterial oxygen content and oxygen consumption in hypoxemic patients, identify patient subgroups at higher risk of complications, and emphasize the proportion of radiologically visible PAVMs too small to treat by embolization. This review, therefore, outlines medical states that exacerbate the consequences of PAVMs. Chief among these is iron deficiency, which is commonly present due to concurrent hereditary hemorrhagic telangiectasia: iron deficiency impairs hypoxemia compensations by restricting erythropoiesis and increases the risk of ischemic strokes. Management of periodontal disease, dental interventions, pulmonary hypertension, and pregnancy also requires specific consideration in the setting of PAVMs. The review concludes by discussing to what extent previously recommended protocols may benefit from modification or revision.
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Affiliation(s)
- Claire L. Shovlin
- NHLI Cardiovascular Sciences, Imperial College, London; and
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
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Shovlin CL. Iron deficiency, ischaemic strokes, and right-to-left shunts: From pulmonary arteriovenous malformations to patent foramen ovale? Intractable Rare Dis Res 2014; 3:60-4. [PMID: 25343129 PMCID: PMC4204536 DOI: 10.5582/irdr.2014.01008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 04/24/2014] [Indexed: 01/07/2023] Open
Abstract
Has the recent identification of iron deficiency as a risk factor for ischaemic stroke in patients with pulmonary arteriovenous malformations (AVMs) unmasked a new paradigm for stroke/infarct pathogenesis? This commentary reviews evidence that spans associations between iron deficiency and ischaemic strokes, iron deficiency enhancement of platelet aggregation in response to serotonin/5HT, settings in which plasma 5HT is elevated, and clinical trial confirmation that 5HT receptor antagonists prevent ischaemic stroke. The critical leap which directs attention away from atherothrombotic events at the neurovascular wall is that ischaemic strokes due to pulmonary AVMs are attributable to compromised pulmonary capillary bed filtration of venous blood. Right-to-left shunting is continuous through pulmonary AVMs, but also occurs intermittently in approximately 30% of the general population with intracardiac shunts such as patent foramen ovale (PFO). The testable hypothesis presented is that paradoxical embolism of venous platelet-based aggregates may constitute part of the causal chain between iron deficiency and ischaemic stroke, not only in the rare disease state of pulmonary AVMs, but also in major subgroups of the general population.
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Affiliation(s)
- Claire L. Shovlin
- NHLI Cardiovascular Sciences, Imperial College London, London, UK
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
- Address correspondence to: Dr. Claire L. Shovlin, NHLI Cardiovascular Sciences, Imperial Centre for Translational and Experimental Medicine, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0NN, UK. E-mail:
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Santhirapala V, Williams LC, Tighe HC, Jackson JE, Shovlin CL. Arterial oxygen content is precisely maintained by graded erythrocytotic responses in settings of high/normal serum iron levels, and predicts exercise capacity: an observational study of hypoxaemic patients with pulmonary arteriovenous malformations. PLoS One 2014; 9:e90777. [PMID: 24637882 PMCID: PMC3956463 DOI: 10.1371/journal.pone.0090777] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 02/04/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Oxygen, haemoglobin and cardiac output are integrated components of oxygen transport: each gram of haemoglobin transports 1.34 mls of oxygen in the blood. Low arterial partial pressure of oxygen (PaO2), and haemoglobin saturation (SaO2), are the indices used in clinical assessments, and usually result from low inspired oxygen concentrations, or alveolar/airways disease. Our objective was to examine low blood oxygen/haemoglobin relationships in chronically compensated states without concurrent hypoxic pulmonary vasoreactivity. METHODOLOGY 165 consecutive unselected patients with pulmonary arteriovenous malformations were studied, in 98 cases, pre/post embolisation treatment. 159 (96%) had hereditary haemorrhagic telangiectasia. Arterial oxygen content was calculated by SaO2 x haemoglobin x 1.34/100. PRINCIPAL FINDINGS There was wide variation in SaO2 on air (78.5-99, median 95)% but due to secondary erythrocytosis and resultant polycythaemia, SaO2 explained only 0.1% of the variance in arterial oxygen content per unit blood volume. Secondary erythrocytosis was achievable with low iron stores, but only if serum iron was high-normal: Low serum iron levels were associated with reduced haemoglobin per erythrocyte, and overall arterial oxygen content was lower in iron deficient patients (median 16.0 [IQR 14.9, 17.4]mls/dL compared to 18.8 [IQR 17.4, 20.1]mls/dL, p<0.0001). Exercise tolerance appeared unrelated to SaO2 but was significantly worse in patients with lower oxygen content (p<0.0001). A pre-defined athletic group had higher Hb:SaO2 and serum iron:ferritin ratios than non-athletes with normal exercise capacity. PAVM embolisation increased SaO2, but arterial oxygen content was precisely restored by a subsequent fall in haemoglobin: 86 (87.8%) patients reported no change in exercise tolerance at post-embolisation follow-up. SIGNIFICANCE Haemoglobin and oxygen measurements in isolation do not indicate the more physiologically relevant oxygen content per unit blood volume. This can be maintained for SaO2 ≥78.5%, and resets to the same arterial oxygen content after correction of hypoxaemia. Serum iron concentrations, not ferritin, seem to predict more successful polycythaemic responses.
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Affiliation(s)
- Vatshalan Santhirapala
- Imperial College School of Medicine, Imperial College, London, United Kingdom
- National Heart and Lung Institute (NHLI) Cardiovascular Science, Imperial College, London, United Kingdom
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Louisa C. Williams
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Hannah C. Tighe
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - James E. Jackson
- Department of Imaging, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Claire L. Shovlin
- National Heart and Lung Institute (NHLI) Cardiovascular Science, Imperial College, London, United Kingdom
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- * E-mail:
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Ischaemic strokes in patients with pulmonary arteriovenous malformations and hereditary hemorrhagic telangiectasia: associations with iron deficiency and platelets. PLoS One 2014; 9:e88812. [PMID: 24586400 PMCID: PMC3929507 DOI: 10.1371/journal.pone.0088812] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 01/13/2014] [Indexed: 01/24/2023] Open
Abstract
Background Pulmonary first pass filtration of particles marginally exceeding ∼7 µm (the size of a red blood cell) is used routinely in diagnostics, and allows cellular aggregates forming or entering the circulation in the preceding cardiac cycle to lodge safely in pulmonary capillaries/arterioles. Pulmonary arteriovenous malformations compromise capillary bed filtration, and are commonly associated with ischaemic stroke. Cohorts with CT-scan evident malformations associated with the highest contrast echocardiographic shunt grades are known to be at higher stroke risk. Our goal was to identify within this broad grouping, which patients were at higher risk of stroke. Methodology 497 consecutive patients with CT-proven pulmonary arteriovenous malformations due to hereditary haemorrhagic telangiectasia were studied. Relationships with radiologically-confirmed clinical ischaemic stroke were examined using logistic regression, receiver operating characteristic analyses, and platelet studies. Principal Findings Sixty-one individuals (12.3%) had acute, non-iatrogenic ischaemic clinical strokes at a median age of 52 (IQR 41–63) years. In crude and age-adjusted logistic regression, stroke risk was associated not with venous thromboemboli or conventional neurovascular risk factors, but with low serum iron (adjusted odds ratio 0.96 [95% confidence intervals 0.92, 1.00]), and more weakly with low oxygen saturations reflecting a larger right-to-left shunt (adjusted OR 0.96 [0.92, 1.01]). For the same pulmonary arteriovenous malformations, the stroke risk would approximately double with serum iron 6 µmol/L compared to mid-normal range (7–27 µmol/L). Platelet studies confirmed overlooked data that iron deficiency is associated with exuberant platelet aggregation to serotonin (5HT), correcting following iron treatment. By MANOVA, adjusting for participant and 5HT, iron or ferritin explained 14% of the variance in log-transformed aggregation-rate (p = 0.039/p = 0.021). Significance These data suggest that patients with compromised pulmonary capillary filtration due to pulmonary arteriovenous malformations are at increased risk of ischaemic stroke if they are iron deficient, and that mechanisms are likely to include enhanced aggregation of circulating platelets.
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Salpeter SR, Buckley JS, Chatterjee S. Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review. Am J Med 2014; 127:124-131.e3. [PMID: 24331453 DOI: 10.1016/j.amjmed.2013.09.017] [Citation(s) in RCA: 164] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 09/10/2013] [Accepted: 09/14/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND There is accumulating evidence that restricting blood transfusions improves outcomes, with newer trials showing greater benefit from more restrictive strategies. We systematically evaluated the impact of various transfusion triggers on clinical outcomes. METHODS The MEDLINE database was searched from 1966 to April 2013 to find randomized trials evaluating a restrictive hemoglobin transfusion trigger of <7 g/dL, compared with a more liberal trigger. Two investigators independently extracted data from the trials. Outcomes evaluated included mortality, acute coronary syndrome, pulmonary edema, infections, rebleeding, number of patients transfused, and units of blood transfused per patient. Extracted data also included information on study setting, design, participant characteristics, and risk for bias of the included trials. A secondary analysis evaluated trials using less restrictive transfusion triggers, and a systematic review of observational studies evaluated more restrictive triggers. RESULTS In the primary analysis, pooled results from 3 trials with 2364 participants showed that a restrictive hemoglobin transfusion trigger of <7 g/dL resulted in reduced in-hospital mortality (risk ratio [RR], 0.74; confidence interval [CI], 0.60-0.92), total mortality (RR, 0.80; CI, 0.65-0.98), rebleeding (RR, 0.64; CI, 0.45-0.90), acute coronary syndrome (RR, 0.44; CI, 0.22-0.89), pulmonary edema (RR, 0.48; CI, 0.33-0.72), and bacterial infections (RR, 0.86; CI, 0.73-1.00), compared with a more liberal strategy. The number needed to treat with a restrictive strategy to prevent 1 death was 33. Pooled data from randomized trials with less restrictive transfusion strategies showed no significant effect on outcomes. CONCLUSIONS In patients with critical illness or bleed, restricting blood transfusions by using a hemoglobin trigger of <7 g/dL significantly reduces cardiac events, rebleeding, bacterial infections, and total mortality. A less restrictive transfusion strategy was not effective.
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Zollo RA, Eaton MP, Karcz M, Pasternak R, Glance LG. Blood transfusion in the perioperative period. Best Pract Res Clin Anaesthesiol 2013; 26:475-84. [PMID: 23351234 DOI: 10.1016/j.bpa.2012.10.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 10/10/2012] [Indexed: 11/26/2022]
Abstract
Anemia is associated with perioperative mortality and morbidity. Since the presence of anemia and blood transfusion often go hand in hand, it can be difficult to separate the effects of anemia from the effects of perioperative transfusion. The role for blood transfusion in mitigating the mortality and morbidity associated with anemia is unclear. A restrictive transfusion strategy has been advocated for hemodynamically stable patients, as blood transfusion exposes the patient to both infectious and non-infectious complications. Further research is warranted in patients with the acute coronary syndrome, as there is insufficient evidence to make recommendations for this patient population. Additional multi-center randomized controlled trials need to be conducted in perioperative and critically ill patients with large enough sample sizes to examine differences in mortality and major complications between liberal and restrictive transfusion strategies. Further trials need to incorporate current practices in improved blood storage and leukoreduction techniques.
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Affiliation(s)
- Raymond A Zollo
- Department of Anaesthesiology, University of Rochester School of Medicine, Rochester, NY 14642, United States.
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Shander A, Gross I, Hill S, Javidroozi M, Sledge S. A new perspective on best transfusion practices. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2013; 11:193-202. [PMID: 23399354 PMCID: PMC3626470 DOI: 10.2450/2012.0195-12] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 10/25/2012] [Indexed: 01/08/2023]
Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology and Critical Care Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey
- Institute for Patient Blood Management and Bloodless Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey
| | - Irwin Gross
- Department of Transfusion Services, Eastern Maine Medical Center, Bangor, Maine
| | - Steven Hill
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Mazyar Javidroozi
- Department of Anesthesiology and Critical Care Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey
| | - Sharon Sledge
- Department of Patient Blood Management, Newark Beth Israel Medical Center, Newark, New Jersey, United States of America
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Nielsen K, Dahl B, Johansson PI, Henneberg SW, Rasmussen LS. Intraoperative transfusion threshold and tissue oxygenation: a randomised trial. Transfus Med 2012; 22:418-25. [PMID: 23121563 DOI: 10.1111/j.1365-3148.2012.01196.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 09/16/2012] [Accepted: 09/16/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Transfusion with allogeneic red blood cells (RBCs) may be needed to maintain oxygen delivery during major surgery, but the appropriate haemoglobin (Hb) concentration threshold has not been well established. We hypothesised that a higher level of Hb would be associated with improved subcutaneous oxygen tension during major spinal surgery. MATERIALS AND METHODS Fifty patients aged 18 years or older scheduled for spinal fusion with instrumentation were included and randomised to receive RBCs at either a Hb concentration of 7·3 g dL(-1) (restrictive group) or a Hb concentration of 8·9 g dL(-1) (liberal group) (Registration no.: H-C-2009-072). Oxygen tension was measured with a polarographic electrode placed subcutaneously over the left deltoid muscle. The primary endpoint was subcutaneous oxygen tension at the time most patients were still undergoing surgery. RESULTS Forty-eight patients were included in the intention-to-treat analysis; 25 patients in the restrictive group and 23 patients in the liberal group. The median change in subcutaneous oxygen tension 60 min after surgical incision was -0·79 and -0·75 kPa in the restrictive and the liberal groups, respectively (P = 0·78). No significant difference was found in the lowest subcutaneous oxygen tension; -2·07 vs. -1·95 kPa in the restrictive and the liberal groups, respectively (P = 0·85). CONCLUSION A Hb concentration transfusion threshold of 8·9 g dL(-1) was not associated with a higher subcutaneous oxygen tension during major spinal surgery than a threshold of 7·3 g dL(-1), but the trial was compromised by methodological difficulties.
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Affiliation(s)
- K Nielsen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
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Crescenzi G, Torracca L, Capestro F, Matteucci MLS, Rossi M. Allogenic Blood Transfusion in Cardiac Surgery. J Card Surg 2012; 27:594-9. [DOI: 10.1111/j.1540-8191.2012.01522.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Macdonald JH, Fearn L, Jibani M, Marcora SM. Exertional fatigue in patients with CKD. Am J Kidney Dis 2012; 60:930-9. [PMID: 22883133 DOI: 10.1053/j.ajkd.2012.06.021] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 06/19/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND Fatigue is one of the most prevalent symptoms in chronic kidney disease (CKD). However, fatigue mechanisms are poorly understood due in part to nonspecific definitions. This study investigates exertional fatigue during simulated activities of daily living, focusing on oxygen delivery and utilization. STUDY DESIGN "Explanatory" matched-cohort study. PARTICIPANTS & SETTING 13 patients with CKD (stages 3b-4; mean age, 62 ± 13 [SD] years) and 13 healthy controls, mean matched for age, height, body mass and composition, and physical activity level. Participants completed an incremental cycle ergometer test to simulate energy expenditure of typical activities of daily living. FACTOR 4 exercise intensities: 1, 1.8, 2.4, and 3.1 metabolic equivalent tasks (METs). OUTCOMES The primary outcome was exertional fatigue by rating of perceived exertion (RPE) on a 6-20 scale. MEASUREMENTS Other multidimensional measures of fatigue: UK Short Form Health Survey 36 (UK SF-36) Vitality and Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue) subscales. Physiologic measures of the oxygen transport and utilization chain (expired gas analysis, cardiac output, and arterial oxygen content) and blood lactate. RESULTS RPE was increased in patients compared with controls at 2.4 (10.5 [ie, light] ± 2.7 vs 8.7 [very light] ± 1.7 units) and 3.1 (12.5 [somewhat hard] ± 2.6 vs 10.2 [light] ± 1.7 units) METs (interaction P = 0.03), which was consistent with higher chronic fatigue in patients by both the UK SF-36 Vitality (P = 0.01) and FACIT-Fatigue (P = 0.004) subscales. Arterial oxygen content was decreased in patients (P = 0.001), but cardiac output and oxygen extraction ratio were unchanged, decreasing oxygen delivery (P = 0.04). Respiratory exchange ratio (P = 0.004) and blood lactate production (P = 0.002) were increased. LIMITATIONS Those inherent to a matched-cohort study. CONCLUSIONS Using a novel application of the outcome measure RPE, patients with non-dialysis-dependent CKD reported considerable exertional fatigue during simulated activities of daily living. Poor compensation for mild anemia contributed to this symptom. In addition to anemia, the entire oxygen transport chain needs to be targeted to treat fatigue in patients with CKD.
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Affiliation(s)
- Jamie H Macdonald
- College of Health and Behavioural Sciences, Bangor University, Bangor, United Kingdom.
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Vincent JL, De Backer D. ICU nephrology: the implications of cardiovascular alterations in the acutely ill. Kidney Int 2012; 81:1060-6. [DOI: 10.1038/ki.2011.389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Cerebral Effect of Acute Normovolemic Hemodilution During Brain Tumor Resection. J Neurosurg Anesthesiol 2012; 24:19-24. [DOI: 10.1097/ana.0b013e31822f0346] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pavesi M, Inghilleri G, Albano G, Ricci C, Gaeta M, Randelli F. A predictive model to reduce allogenic transfusions in primary total hip arthroplasty. Transfus Apher Sci 2011; 45:265-8. [DOI: 10.1016/j.transci.2011.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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