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Liu WS, Liang SS, Cheng MM, Wu MT, Li SY, Cheng TT, Liu TY, Tsai CY, Lai YT, Lin CH, Wang HT, Tsou HH. How renal toxins respond to renal function deterioration and oral toxic adsorbent in pH-controlled releasing capsule. ENVIRONMENTAL TOXICOLOGY 2024; 39:3930-3943. [PMID: 38572829 DOI: 10.1002/tox.24248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/08/2024] [Accepted: 03/14/2024] [Indexed: 04/05/2024]
Abstract
The number of patients with chronic kidney disease (CKD) is increasing. Oral toxin adsorbents may provide some value. Several uremic toxins, including indoxyl sulfate (IS), p-cresol (PCS), acrolein, per- and poly-fluoroalkyl substances (PFAS), and inflammation markers (interleukin 6 [IL-6] and tumor necrosis factor [TNF]-alpha) have been shown to be related to CKD progression. A total of 81 patients taking oral activated charcoal toxin adsorbents (AC-134), which were embedded in capsules that dissolved in the terminal ileum, three times a day for 1 month, were recruited. The renal function, hemoglobulin (Hb), inflammation markers, three PFAS (PFOA, PFOS, and PFNA), and acrolein were quantified. Compared with the baseline, an improved glomerular filtration rate (GFR) and significantly lower acrolein were noted. Furthermore, the CKD stage 4 and 5 group had significantly higher concentrations of IS, PCS, IL-6, and TNF but lower levels of Hb and PFAS compared with the CKD Stage 3 group at baseline and after the intervention. Hb was increased only in the CKD Stage 3 group after the trial (p = .032). Acrolein did not differ between the different CKD stage groups. Patients with improved GFR (responders) (about 77%) and nonresponders had similar baseline GFR. Responders had higher acrolein and PFOA levels throughout the study and a more significant reduction in acrolein, indicating a better digestion function. Both the higher PFOA and lower acrolein may be related to improved eGFR (and possibly to improvements in proteinuria, which we did not measure. Proteinuria is associated with PFAS loss in the urine), AC-134 showed the potential to improve the GFR and decrease acrolein, which might better indicate renal function change. Future studies are needed with longer follow-ups.
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Affiliation(s)
- Wen-Sheng Liu
- Division of Nephrology, Department of Medicine, Taipei City Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
- College of Science and Engineering, Fu Jen Catholic University, New Taipei City, Taiwan
- Institute of Food Safety and Health Risk Assessment, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
- Department of Special Education, University of Taipei, Taipei, Taiwan
| | - Shih-Shin Liang
- Institute of Biomedical Science, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
- Department of Biotechnology, College of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Mei-Mei Cheng
- Division of nephrology, Department of internal medicine, West Garden Hospital, Taipei, Taiwan
| | - Ming-Tsan Wu
- Department of internal medicine, Fu-Ling clinic, New Taipei City, Taiwan
| | - Szu-Yuan Li
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
- Division of Nephrology, and Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tien-Tien Cheng
- Institute of Food Safety and Health Risk Assessment, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Tsung-Yun Liu
- Institute of Food Safety and Health Risk Assessment, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Ching-Yao Tsai
- Institute of Public Health, Department of Public Health, College of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
- Department of Ophthalmology, Taipei City Hospital, Taipei, Taiwan
- Department of Business Administration, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Yen-Ting Lai
- Department of Physical Medicine and Rehabilitation, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
- Department of Nursing, College of Medical Technology and Nursing, Yuanpei University of Medical Technology, Hsinchu, Taiwan
| | - Chien-Hung Lin
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
- College of Science and Engineering, Fu Jen Catholic University, New Taipei City, Taiwan
- Division of Pediatric Immunology and Nephrology, Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiang-Tsui Wang
- Department of Pharmacology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Han-Hsing Tsou
- Institute of Food Safety and Health Risk Assessment, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
- Kim Forest Enterprise Co., Ltd., New Taipei City, Taiwan
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Ballegaard ELF, Lindhard K, Lindhardt M, Peters CD, Thomsen Nielsen F, Tietze IN, Borg R, Boesby L, Bertelsen MC, Brøsen JMB, Cibulskyte-Ninkovic D, Rantanen JM, Mose FH, Kampmann JD, Nielsen AS, Breinholt JK, Kofod DH, Bressendorff I, Clausen PV, Lange T, Køber L, Kamper AL, Bang CNF, Torp-Pedersen C, Hansen D, Grove EL, Gislason G, Dam Jensen J, Olesen JB, Hornum M, Rix M, Schou M, Carlson N. Protocol for a randomised controlled trial comparing warfarin with no oral anticoagulation in patients with atrial fibrillation on chronic dialysis: the Danish Warfarin-Dialysis (DANWARD) trial. BMJ Open 2024; 14:e081961. [PMID: 38413147 PMCID: PMC10900386 DOI: 10.1136/bmjopen-2023-081961] [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: 11/10/2023] [Accepted: 02/12/2024] [Indexed: 02/29/2024] Open
Abstract
INTRODUCTION Atrial fibrillation is highly prevalent in patients on chronic dialysis. It is unclear whether anticoagulant therapy for stroke prevention is beneficial in these patients. Vitamin K-antagonists (VKA) remain the predominant anticoagulant choice. Importantly, anticoagulation remains inconsistently used and a possible benefit remains untested in randomised clinical trials comparing oral anticoagulation with no treatment in patients on chronic dialysis. The Danish Warfarin-Dialysis (DANWARD) trial aims to investigate the safety and efficacy of VKAs in patients with atrial fibrillation on chronic dialysis. The hypothesis is that VKA treatment compared with no treatment is associated with stroke risk reduction and overall benefit. METHODS AND ANALYSIS The DANWARD trial is an investigator-initiated trial at 13 Danish dialysis centres. In an open-label randomised clinical trial study design, a total of 718 patients with atrial fibrillation on chronic dialysis will be randomised in a 1:1 ratio to receive either standard dose VKA targeting an international normalised ratio of 2.0-3.0 or no oral anticoagulation. Principal analyses will compare the risk of a primary efficacy endpoint, stroke or transient ischaemic attack and a primary safety endpoint, major bleeding, in patients allocated to VKA treatment and no treatment, respectively. The first patient was randomised in October 2019. Patients will be followed until 1 year after the inclusion of the last patient. ETHICS AND DISSEMINATION The study protocol was approved by the Regional Research Ethics Committee (journal number H-18050839) and the Danish Medicines Agency (case number 2018101877). The trial is conducted in accordance with the Helsinki declaration and standards of Good Clinical Practice. Study results will be disseminated to participating sites, at research conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBERS NCT03862859, EUDRA-CT 2018-000484-86 and CTIS ID 2022-502500-75-00.
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Affiliation(s)
- Ellen Linnea Freese Ballegaard
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kristine Lindhard
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Morten Lindhardt
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Internal Medicine 1, Holbæk Hospital, Holbæk, Denmark
| | - Christian Daugaard Peters
- Dept. of Clinical Medicine, Aarhus University, Aarhus N, Denmark
- Department of Renal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Finn Thomsen Nielsen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Medicine, Bornholms Hospital, Ronne, Denmark
| | | | - Rikke Borg
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Lene Boesby
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Marianne Camilla Bertelsen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Julie Maria Bøggild Brøsen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | | | | | - Frank Holden Mose
- Department of Nephrology, Gødstrup Regional Hospital, Herning, Denmark
| | - Jan Dominik Kampmann
- Internal medicine, Hospital of Southern Jutland Sonderborg Branch, Sonderborg, Denmark
| | - Alice Skovhede Nielsen
- Department of Medicine, Esbjerg Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Johanne Kodal Breinholt
- Department of Clinical Biochemistry, Esbjerg Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Dea Haagensen Kofod
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Iain Bressendorff
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Peter Vilhelm Clausen
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Kobenhavns, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anne-Lise Kamper
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Casper Niels Furbo Bang
- Department of Cardiology, Copenhagen University Hospital - Frederiksberg and Bispebjerg, Copenhagen, Denmark
| | | | - Ditte Hansen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Faculty of Health, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
| | - Jens Dam Jensen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Mads Hornum
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Rix
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten Schou
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Nicholas Carlson
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Lerner GB, Reynolds MA, Setty S, Deeb R, Rastogi P, Moeckel G, Sanchez H, Henriksen KJ, Chang A. The Detrimental Impact of End-Stage Kidney Disease Is Not Reflected in Autopsy Reports. Arch Pathol Lab Med 2024; 148:74-77. [PMID: 37014976 DOI: 10.5858/arpa.2022-0338-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 04/06/2023]
Abstract
CONTEXT.— End-stage kidney disease (ESKD) is defined as renal impairment requiring renal replacement therapy to sustain life. With a 1-year mortality of ∼20% to 30%, many die of complications related to this disease. OBJECTIVE.— To determine the percentage of autopsy cases of decedents with ESKD in which the contribution of ESKD to death is accurately reflected in the final report. DESIGN.— Autopsy case records were retrospectively reviewed at 4 institutions (Yale New Haven Hospital, University of Chicago Medical Center, University of Illinois at Chicago Hospital, University of Iowa Hospital). Clinical, macroscopic, and microscopic autopsy findings were reviewed, with attention to renal disease findings. RESULTS.— One hundred sixty decedents with documented ESKD and premortem dialysis who underwent autopsy assessment were identified. ESKD was implicated as a cause of death (CoD) or significant contributing factor in 44 cases (28%), but not in the remaining 116 cases (72%). Cardiovascular disease was the most common CoD in ESKD. There was significant interpathologist variation in the inclusion of ESKD as a CoD across institutions. These rates ranged from 85% correlation (23 of 27 cases), to 13% (4 of 31 and 8 of 62 cases at 2 institutions), and 22.5% (9 of 40 cases) across the 4 participating institutions. CONCLUSIONS.— The recognition at autopsy of ESKD as a CoD or contributing CoD at autopsy in patients undergoing dialysis remains low (28%). The detrimental impact of ESKD is not reflected in hospital autopsy reports, which carries implications for collection of vital statistics and allocation of research funding for kidney diseases.
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Affiliation(s)
- Gabriel B Lerner
- From the Department of Surgical Pathology, Yale University School of Medicine, New Haven, Connecticut (Lerner, Moeckel, Sanchez)
| | - Meredith A Reynolds
- the Department of Pathology, University of Chicago School of Medicine, Chicago, Illinois (Reynolds, Henriksen, Chang)
| | - Suman Setty
- the Departments of Pathology (Setty) and Medicine (Deeb), University of Illinois at Chicago, Chicago
| | - Reem Deeb
- the Departments of Pathology (Setty) and Medicine (Deeb), University of Illinois at Chicago, Chicago
| | - Prerna Rastogi
- the Department of Pathology, University of Iowa Carver College of Medicine, Iowa City (Rastogi)
| | - Gilbert Moeckel
- From the Department of Surgical Pathology, Yale University School of Medicine, New Haven, Connecticut (Lerner, Moeckel, Sanchez)
| | - Harold Sanchez
- From the Department of Surgical Pathology, Yale University School of Medicine, New Haven, Connecticut (Lerner, Moeckel, Sanchez)
| | - Kammi J Henriksen
- the Department of Pathology, University of Chicago School of Medicine, Chicago, Illinois (Reynolds, Henriksen, Chang)
| | - Anthony Chang
- the Department of Pathology, University of Chicago School of Medicine, Chicago, Illinois (Reynolds, Henriksen, Chang)
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4
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Aziz MA, Bojja S, Aziz AA, Javed N, Patel H. Gastrointestinal Bleeding in Patients With Acute Ischemic Stroke: A Literature Review. Cureus 2024; 16:e53210. [PMID: 38425599 PMCID: PMC10902729 DOI: 10.7759/cureus.53210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Stroke is an infarction of the central nervous system (brain, spinal cord, or retina) that results from a disruption in cerebral blood flow either due to ischemia or hemorrhage. Complications of acute stroke are common and include pneumonia, urinary tract infection, myocardial infarction, deep vein thrombosis, and pulmonary embolism, among several others, all of which increase the risk of poor clinical outcomes. Gastrointestinal bleeding is a well-known complication that can occur during the acute phase of stroke. In this review, we have summarized the existing data regarding the incidence, pathophysiology, risk factors, morbidity, mortality, and management strategies for gastrointestinal bleeding in patients with acute ischemic stroke.
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Affiliation(s)
| | - Srikaran Bojja
- Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, New York City, USA
| | - Ahmed Ali Aziz
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Nismat Javed
- Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, New York City, USA
| | - Harish Patel
- Gastroenterology and Hepatology, BronxCare Health System, New York City, USA
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5
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Diaz C, Quintero JA, Zarama V, Bustamante-Cristancho LA. Bleeding Complications in Uremic Patients After Ultrasound-Guided Central Venous Catheter Placement. Open Access Emerg Med 2023; 15:21-28. [PMID: 36660271 PMCID: PMC9843503 DOI: 10.2147/oaem.s384081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/09/2022] [Indexed: 01/13/2023] Open
Abstract
Introduction Bleeding associated with elevated blood urea nitrogen (BUN) is a known complication. Patients with uremia require a central venous catheter insertion by dialysis. The relation between BUN and bleeding complications during central venous catheter insertion is not yet clear. Objective We described the frequency of complications associated with central venous catheter implantation in uremic patients and evaluated the statistical relationship between bleeding complications and catheter type, number of punctures, and catheter insertion site. Also, we determined if any value of BUN is associated with bleeding complications. Methods We included patients with a serum value of BUN >70 mg/dl that required insertion of a central venous catheter. The quantitative variables were expressed through the measure of central tendency. A bivariate analysis and a ROC curve were performed. Results A total of 273 catheters were included in this study. Bleeding complications were detected in 69 cases (25.3%), and local bleeding was the most frequent complication in 51/69 cases. Statistically significant association was not established. We did not find a specific cut-off value directly related to BUN levels and the rate of complications. Conclusion Bleeding complications associated with the insertion of central venous catheter and the suspected disorder of hemostasis given by BUN levels >70 mg/dl are common. It was not possible to determine a BUN cut-off value to predict complications. The association analysis was not conclusive. High BUN levels should not be considered a high-risk condition for central venous cannulation under ultrasound guidance performed by trained personnel.
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Affiliation(s)
- Carime Diaz
- Critical Medicine, Emergency Department, Fundación Valle del Lili, Cali, 760032, Colombia
| | - Jaime A Quintero
- Critical Medicine, Emergency Department, Fundación Valle del Lili, Cali, 760032, Colombia,Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cali, 760032, Colombia,Correspondence: Jaime A Quintero, Critical Medicine, Emergency Department, Centro de Investigaciones Clínicas, Fundación Valle del Lili, Carrera 98 No. 18-49, Cali, 760032, Colombia, Tel +57 3184257759, Email
| | - Virginia Zarama
- Critical Medicine, Emergency Department, Fundación Valle del Lili, Cali, 760032, Colombia
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Kidney biopsy adequacy and complications in children - does technique matter? Eur J Pediatr 2022; 181:2677-2684. [PMID: 35414029 PMCID: PMC9192435 DOI: 10.1007/s00431-022-04464-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/04/2022]
Abstract
UNLABELLED Kidney biopsy is part of the diagnostic workup of many children with renal disease. Traditionally, a perpendicular approach to the biopsy has been used, but more recently, some proceduralists have favoured a tangential approach. It is not clear if one technique is superior with regards to tissue adequacy or complication rates. In our centre, interventional radiologists (IR) use general anaesthetic and a tangential approach, whereas paediatric nephrologists (PN) use sedation and a perpendicular approach. We examined consecutive native kidney biopsies performed between January 2008 and December 2017 for adequacy (sufficient tissue for light and electron microscopy and immunofluorescence) and examined the electronic medical records for data regarding technique and complications. IR performed 72 (29%) of the 245 native kidney biopsies, obtaining more total glomeruli (median 39 vs 16, p < 0.001) and more glomeruli per tissue core (median 13 vs 8, p < 0.001) than PN. No differences in specimen adequacy were observed between the two groups (79% IR vs 81% PN, p = 0.75) and a diagnosis could be made in 99% and 94% respectively (p = 0.1). A statistically lower rate of peri-nephric haematoma (28% vs 42%, p = 0.04) was detected in the IR group, but there were no significant differences in other complications. One patient required a blood transfusion (PN) and another required surgical intervention for a perinephric haematoma (IR). CONCLUSION IR obtained larger samples and number of glomeruli, but the overall adequacy for native kidney biopsies was good using both perpendicular and tangential techniques, with low rates of significant complications. WHAT IS KNOWN • Kidney biopsy is integral to the diagnostic work-up of many children with kidney disease. • Kidney biopsy is a safe procedure with well-established complications in a minority of children. WHAT IS NEW • Interventional radiologists had higher biopsy yield than paediatric nephrologists, possibly due to the tangential approach. • Biopsy adequacy rates are high using both techniques and provided a diagnosis in over 95% of cases.
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Ullah K, Bashir M, Ain NU, Sarfraz A, Sarfraz Z, Sarfraz M, Cherrez-Ojeda I. Medical Adjuvant Therapy in Reducing Thrombosis With Arteriovenous Grafts and Fistulae Use: A Meta-Analysis of Randomized Controlled Trials. Clin Appl Thromb Hemost 2021; 27:10760296211063882. [PMID: 34873965 PMCID: PMC8655473 DOI: 10.1177/10760296211063882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Hemodialysis is required for patients with end-stage renal disease (ESRD) that require arteriovenous (AV) grafts or fistulas for vascular access. These access points are prone to thrombosis. To determine the effect of medical adjuvant therapy on AV graft/fistula patency among patients with ESRD on hemodialysis. Adhering to the PRISMA 2020 statement, a systematic search was conducted until August 20, 2021, with keywords including arteriovenous graft, fistula, patency, thrombosis, hemodialysis, adjuvant treatment. The following databases were searched: PubMed, Scopus, Web of Science, CINAHL Plus, and Cochrane. A random-effects model was employed using Review Manager 5.4 for data analysis. The meta-analysis pooled in 1985 participants with 1000 (50.4%) in the medical adjuvant treatment group. At a snapshot, medical adjuvant therapy reduced the risk for graft thrombosis (RR = 0.64, P = .02). Notable medications included aspirin for graft thrombosis (RR = 0.36, P = .006) and ticlopidine for fistula thrombosis (RR = 0.53, P = .01). Certain antiplatelet therapies (aspirin and ticlopidine) reduced the number of patients with AV fistula/graft thrombosis among patients with high heterogeneity among the trials. Other therapies (fish oil, sulfinpyrazone, clopidogrel, and aspirin/dipyridamole) did not demonstrate significant improvement but may be promising once concrete evidence is available. Potential benefits of anti-platelet therapies may be explored to maintain the potency of AV grafts/fistulas through well-designed placebo-controlled trials and long-term follow-up.
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Affiliation(s)
- Kaleem Ullah
- 194774Independent Medical College Faisalabad, Faislabad, Pakistan
| | - Maham Bashir
- 429580Gujranwala Medical College, Gujranwala, Pakistan
| | - Noor Ul Ain
- 194774Independent Medical College Faisalabad, Faislabad, Pakistan
| | | | | | - Muzna Sarfraz
- 66886King Edward Medical University, Lahore, Pakistan
| | - Ivan Cherrez-Ojeda
- 27890Universidad Espíritu Santo, Samborondón, Ecuador.,Respiralab Research Center, Guayaquil, Ecuador
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8
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Barash M, Kurman JS. Patient selection and preoperative evaluation of percutaneous dilation tracheostomy in the intensive care unit. J Thorac Dis 2021; 13:5251-5260. [PMID: 34527364 PMCID: PMC8411154 DOI: 10.21037/jtd-2019-ipicu-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/10/2020] [Indexed: 11/06/2022]
Abstract
Percutaneous dilation tracheostomy (PDT) is increasingly performed at the bedside of critically ill patients in the intensive care unit (ICU). PDT is safe overall and has a number of benefits compared to surgical tracheostomy. A tracheostomy tube has numerous advantages compared to an endotracheal tube, including decreased work of breathing, ease of connecting to a mechanical ventilator, improved patient comfort and pulmonary hygiene. Common patient populations include those unable to wean from mechanical ventilation, those requiring enhanced pulmonary hygiene, and those with progressive neuromuscular weakness. Clinicians performing this procedure should be familiar with common indications for performing tracheostomy as well as absolute and relative contraindications. Special patient populations, including those with morbid obesity, aberrant anatomic and vascular anatomy, cervical spine injury, and high ventilatory requirements, should be approached with careful planning. Pre-procedure evaluation for coagulopathy, including basic laboratory analysis and medication review, should be undertaken. Pre-procedure ultrasound may be used to more accurately identify landmarks and vascular structures. The optimal timing for performing PDT is unknown and depends on the unique characteristics of each patient, perceived natural history of the disease process being addressed and open conversations with the patient or surrogate decision maker. In this review, we identify patient populations most likely to benefit from PDT and outline data behind optimal timing, pre-procedural laboratory evaluation and patient specific factors that may influence procedural success.
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Affiliation(s)
- Mark Barash
- Division of Pulmonary, Critical Care and Sleep Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jonathan S Kurman
- Division of Pulmonary, Critical Care and Sleep Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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9
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Matos-Ribeiro J, Castro-Chaves P, Oliveira-Ferreira M, Fonseca L, Pintalhao M. Early anticoagulation in atrial fibrillation-related acute ischaemic stroke: efficacy and safety profile. J Neurol 2021; 269:2099-2112. [PMID: 34499205 DOI: 10.1007/s00415-021-10788-z] [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: 05/12/2021] [Revised: 08/15/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To evaluate the effects of early anticoagulation on functional outcome, recurrent ischaemic events and haemorrhagic complications in Atrial Fibrillation (AF)-related acute ischaemic strokes (AIS). MATERIALS AND METHODS We retrospectively evaluated patients hospitalised in a Stroke Unit due to AF-related AIS. Patients were divided according to anticoagulation initiation timing (0-4 days, 5-14 days, no anticoagulation by the 14th day). We assessed the following outcomes at 3 months: favourable functional outcome [modified Rankin Scale (mRS) score 0-2 or equal to pre-stroke], recurrent ischaemic events and haemorrhagic complications after anticoagulation initiation. RESULTS We included 395 patients. Anticoagulation was initiated at days 0-4 in 33.9% of patients, days 5-14 in 25.3% and not initiated by the day 14 in 40.8%. Factors associated with earlier anticoagulation included lower previous mRS, valvular AF and lower stroke severity. Favourable functional outcome occurred in 40.2% of patients, with lower odds in those anticoagulated at 5-14 versus 0-4 days (OR: 0.47, 95% CI: 0.23-0.94), independently of age, previous mRS and stroke severity. Recurrent ischaemic events occurred in 8.3% of patients, with higher odds in non-anticoagulated patients by the 14th day, compared to the remainder groups (OR: 3.26, 95% CI: 1.29-8.22 vs. 0-4 days and OR: 8.16, 95% CI: 1.76-37.9 vs. 5-14 days). In patients who started anticoagulation (n = 288), haemorrhagic complications occurred in 10.8%, being more frequent in those who started at 0-4 days vs. > 14 days. However, it did not abolish the 0-4-day initiation's benefit on functional outcome. CONCLUSIONS Early anticoagulation was associated with lower ischaemic recurrence and better functional outcome at 3 months. Additional studies are needed to better clarify its haemorrhagic risk.
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Affiliation(s)
- Joao Matos-Ribeiro
- Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - Paulo Castro-Chaves
- Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Cardiovascular Research Centre (UnIC), Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Stroke Unit, Department of Internal Medicine, São João Hospital Centre, Porto, Portugal
| | | | - Luísa Fonseca
- Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Department of Medicine, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mariana Pintalhao
- Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Cardiovascular Research Centre (UnIC), Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Stroke Unit, Department of Internal Medicine, São João Hospital Centre, Porto, Portugal
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10
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Tuñón J, Steg PG, Bhatt DL, Bittner VA, Díaz R, Goodman SG, Jukema JW, Kim YU, Li QH, Mueller C, Parkhomenko A, Pordy R, Sritara P, Szarek M, White HD, Zeiher AM, Schwartz GG. Effect of alirocumab on major adverse cardiovascular events according to renal function in patients with a recent acute coronary syndrome: prespecified analysis from the ODYSSEY OUTCOMES randomized clinical trial. Eur Heart J 2021; 41:4114-4123. [PMID: 32820320 PMCID: PMC7700757 DOI: 10.1093/eurheartj/ehaa498] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/18/2020] [Accepted: 05/29/2020] [Indexed: 12/15/2022] Open
Abstract
Aims Statins reduce cardiovascular risk in patients with acute coronary syndrome (ACS) and normal-to-moderately impaired renal function. It is not known whether proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors provide similar benefit across a range of renal function. We determined whether effects of the PCSK9 inhibitor alirocumab to reduce cardiovascular events and death after ACS are influenced by renal function. Methods and results ODYSSEY OUTCOMES compared alirocumab with placebo in patients with recent ACS and dyslipidaemia despite intensive statin treatment. Estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 was exclusionary. In 18 918 patients, baseline eGFR was 82.8 ± 17.6 mL/min/1.73 m2, and low-density lipoprotein cholesterol (LDL-C) was 92 ± 31 mg/dL. At 36 months, alirocumab decreased LDL-C by 48.5% vs. placebo but did not affect eGFR (P = 0.65). Overall, alirocumab reduced risk of the primary outcome (coronary heart disease death, non-fatal myocardial infarction, ischaemic stroke, or unstable angina requiring hospitalization) with fewer deaths. There was no interaction between continuous eGFR and treatment on the primary outcome or death (P = 0.14 and 0.59, respectively). Alirocumab reduced primary outcomes in patients with eGFR ≥90 mL/min/1.73 m2 (n = 7470; hazard ratio 0.784, 95% confidence interval 0.670–0.919; P = 0.003) and 60 to <90 (n = 9326; 0.833, 0.731–0.949; P = 0.006), but not in those with eGFR < 60 (n = 2122; 0.974, 0.805–1.178; P = 0.784). Adverse events other than local injection-site reactions were similar in both groups across all categories of eGFR. Conclusions In patients with recent ACS, alirocumab was associated with fewer cardiovascular events and deaths across the range of renal function studied, with larger relative risk reductions in those with eGFR > 60 mL/min/1.73 m2. ![]()
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Affiliation(s)
- José Tuñón
- Division of Cardiology, Fundación Jiménez Díaz, Autónoma University, and CIBER CV, Avenida Reyes Católicos 2, 28040 Madrid, Spain
| | - Philippe Gabriel Steg
- Department of Cardiology, Université de Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Université de Paris, FACT (French Alliance for Cardiovascular Trials), INSERM U1148, Paris, France.,National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London, UK
| | - Deepak L Bhatt
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Vera A Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rafael Díaz
- Cardiology Department, Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina; Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
| | - Shaun G Goodman
- Division of Cardiology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Yong-Un Kim
- R & D clinical Development, Sanofi, Paris, France
| | - Qian H Li
- Clinical Sciences-Cardiovascular & Metabolism Therapeutics, Regeneron Pharmaceuticals, Tarrytown, NY, USA
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | | | - Robert Pordy
- Clinical Sciences-Cardiovascular & Metabolism Therapeutics, Regeneron Pharmaceuticals, Tarrytown, NY, USA
| | | | - Michael Szarek
- State University of New York, Downstate School of Public Health, Brooklyn, NY, USA
| | - Harvey D White
- Green Lane Cardiovascular Services Auckland City Hospital, Auckland, New Zealand
| | - Andreas M Zeiher
- Department of Medicine III, Goethe University, Frankfurt am Main, Germany
| | - Gregory G Schwartz
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
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11
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Lew SQ, Khan AA, Rieders B, Agrawal ST. Haemoperitoneum after an endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of a pancreatic lesion in a peritoneal dialysis patient. BMJ Case Rep 2020; 13:13/11/e236573. [PMID: 33148597 DOI: 10.1136/bcr-2020-236573] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Haemoperitoneum was observed in a peritoneal dialysis (PD) patient after undergoing endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). EUS-FNA was performed to evaluate a pancreatic cyst seen on a prekidney transplant evaluation abdominal CT scan. Haemoperitoneum cleared with a PD exchange. In this case report, we discuss aetiologies for bleeding risks in patients with chronic kidney disease and focus on haemoperitoneum in patients receiving PD. We will also explore treatment options to minimise bleeding associated with an abdominal procedure such as EUS-FNA.
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Affiliation(s)
- Susie Q Lew
- Medicine, George Washington University, Washington, District of Columbia, USA
| | - Ali A Khan
- Medicine, George Washington University, Washington, District of Columbia, USA
| | - Brandon Rieders
- Medicine, George Washington University, Washington, District of Columbia, USA
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12
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Gal-Oz A, Papushado A, Kirgner I, Meirsdorf S, Schwartz D, Schwartz IF, Zubkov A, Grupper A. Thromboelastography versus bleeding time for risk of bleeding post native kidney biopsy. Ren Fail 2020; 42:10-18. [PMID: 31842662 PMCID: PMC6968702 DOI: 10.1080/0886022x.2019.1700805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Introduction The risk of bleeding has led to screening of the primary hemostasis before renal biopsy. A bleeding time test (BT) is considered standard practice, but reliance on this test is controversial and its benefits remain questionable. A possible alternative is thromboelastography (TEG). However, data regarding TEG in patients with renal dysfunction is limited. Objectives To determine TEG abnormalities and their consequences in patients who underwent a native kidney biopsy. Methods A retrospective study of 417 consecutive percutaneous native renal biopsies performed in our Center. If serum creatinine >1.5 mg/dL, the patient underwent either a BT test (period A, January 2015–31 December 2016) or TEG (period B, January 2017–August 2018). In patients with prolonged BT, or an abnormal low maximal amplitude (MA) parameter of TEG, or suspected clinical uremic thrombopathy, the use of desmopressin acetate (DDAVP) was considered. Results Most biopsies (90.6%) were done by the same dedicated radiologist. Fifty-one patients had a BT test, which was normal in all tested patients. Seventy-one patients underwent TEG, and it was abnormal in 34 of them, most patients had combined abnormalities. The only parameter related to abnormal TEG was older age (Odds Ratio 1.21 [95% CI 1.09–2.38] p = 0.04 for abnormal Kinetics; OR 1.37 (1.05–1.96) p = 0.037 for abnormal MA). Twenty-six patients (6.23%) had bleeding complications. Risk of bleeding was significantly related to age (1.4 [1.11–7.48] p = 0.04), systolic blood pressure (1.85 [1.258–9.65] p = 0.02), and serum creatinine (1.21 [1.06–3.134] p = 0.048). Conclusions TEG abnormalities in patients with renal dysfunction are variable and fail to predict bleeding during kidney biopsy. The decision to administer DDAVP as a preventive measure during these procedures should be based on clinical judgment only.
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Affiliation(s)
- Amir Gal-Oz
- ICU Department, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amitay Papushado
- Department of Internal Medicine "B", Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ilya Kirgner
- Hematology Department, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shmuel Meirsdorf
- Radiology Department, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Doron Schwartz
- Nephrology Department, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Idit Francesca Schwartz
- Nephrology Department, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Asia Zubkov
- Pathology Department, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ayelet Grupper
- Nephrology Department, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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13
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Hemodialysis Increases the Risk of Lower Gastrointestinal Bleeding and Angiodysplasia Bleeding: A Nationwide Population Study. Gastroenterol Res Pract 2020; 2020:7206171. [PMID: 32190042 PMCID: PMC7072111 DOI: 10.1155/2020/7206171] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/30/2020] [Accepted: 02/15/2020] [Indexed: 01/24/2023] Open
Abstract
Background Patients with chronic kidney disease (CKD) with or without hemodialysis were considered to have bleeding tendency and higher risk for gastrointestinal (GI) bleeding. Previous studies had documented that hemodialysis may increase the gastroduodenal ulcer bleeding. Few studies evaluated the relationship between CKD and lower GI bleeding. Materials and Methods. An observational cohort study design was conducted. The end-stage renal disease (ESRD) patients receiving regular hemodialysis (dialysis CKD), CKD patients without dialysis (dialysis-free CKD), and controls were selected from 1 million randomly sampled subjects in the National Health Insurance Research Database of Taiwan. These three group subjects were matched by age, sex, comorbidity, and enrollment time in a 1 : 2 : 2 ratio. The Cox proportional hazard regression models were used to identify the potential risk factors for lower gastrointestinal bleeding. Results Dialysis CKD patients (n = 574) had a higher incidence of lower GI bleeding than dialysis-free CKD patients (n = 574) had a higher incidence of lower GI bleeding than dialysis-free CKD patients (n = 574) had a higher incidence of lower GI bleeding than dialysis-free CKD patients (P < 0.001). Multivariate analysis showed that extreme old age (age ≥ 85), male gender, dialysis-free CKD, and dialysis CKD were independent factors of lower GI bleeding. Additionally, dialysis CKD patients also had a higher incidence of angiodysplasia bleeding compared to dialysis-free CKD patients and control subjects (1.1% vs. 0.1% and 0.1%, respectively; both P < 0.001). Multivariate analysis showed that extreme old age (age ≥ 85), male gender, dialysis-free CKD, and dialysis CKD were independent factors of lower GI bleeding. Additionally, dialysis CKD patients also had a higher incidence of angiodysplasia bleeding compared to dialysis-free CKD patients and control subjects (1.1% vs. 0.1% and 0.1%, respectively; both Conclusion Hemodialysis may have higher risk of lower GI bleeding and angiodysplasia bleeding.
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14
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Ye CN, Lin MC, Huang CL. Double penetration wound: A nail gun injury involving the head and heart. Radiol Case Rep 2020; 15:334-338. [PMID: 31993095 PMCID: PMC6976870 DOI: 10.1016/j.radcr.2019.11.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 11/25/2019] [Accepted: 11/28/2019] [Indexed: 12/27/2022] Open
Abstract
Nail gun injuries usually occur at the extremities due to working accidents. Intracranial or intrathoracic injuries are relatively rare, and cases combined with both injuries are even rarer. Such situations pose challenges for surgeons due to their uniqueness during operation. Radiologic imaging findings in our case were significant in indicating surgical findings. Herein, we report a patient who shot himself using a nail gun, damaging his brain and heart.
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Affiliation(s)
- Ciou-Nan Ye
- Department of General Medicine, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
| | - Ming-Chieh Lin
- Department of General Medicine, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
| | - Chien-Lin Huang
- Department of Cardiovascular Surgery, Kaohsiung Medical University Hospital, No.100, Tzyou 1st Rd., Sanmin Dist., Kaohsiung City 80756, Taiwan
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15
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Su X, Yan B, Wang L, Lv J, Cheng H, Chen Y. Effect of antiplatelet therapy on cardiovascular and kidney outcomes in patients with chronic kidney disease: a systematic review and meta-analysis. BMC Nephrol 2019; 20:309. [PMID: 31390997 PMCID: PMC6686545 DOI: 10.1186/s12882-019-1499-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 07/29/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The benefits and risks of antiplatelet therapy for patients with chronic kidney disease (CKD) remain controversial. We undertook a systematic review and meta-analysis to investigate the effects of antiplatelet therapy on major clinical outcomes. METHODS We systematically searched MEDLINE, Embase, and the Cochrane Library for trials published before April 2019 without language restriction. We included rrandomized controlled trials that involved adults with CKD and compared antiplatelet agents with controls. RESULTS Fifty eligible trials that included at least one event were identified, providing data for 27773patients with CKD, including 4518 major cardiovascular events and 1962 all-cause deaths. Antiplatelet therapy produced a 15% (OR, 0.85; 95% CI 0.74-0.94) reduction in the odds of major cardiovascular events (P = 0.002), a 48% reduction for access failure events (OR, 0.52; 95% CI, 0.31-0.73), but had no significantly effect on all-cause death (OR, 0.87; 95% CI, 0.71-1.01) or kidney failure events (OR, 0.87; 95% CI, 0.32-1.55). Adverse events were significantly increased by antiplatelet therapy, including major (OR, 1.33; 95% CI, 1.11-1.59) or minor bleeding (OR, 1.66; 95% CI, 1.27-2.05). Among every 1000 persons with CKD treated with antiplatelet therapy for 12 months, 23 major cardiovascular events will be prevented while nine major bleeding events will occur. CONCLUSIONS Major prevention with antiplatelet agents (cardiovascular events and access failure), might outweigh the risk of bleeding, and there seemed to be an overall net benefit. Individual evaluation and careful monitoring are required.
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Affiliation(s)
- Xiaole Su
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Street, Chaoyang District, Beijing, China.,Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, No.382, Wuyi Road, Xinghualing Distirct, Taiyuan, China
| | - Bingjuan Yan
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, No.382, Wuyi Road, Xinghualing Distirct, Taiyuan, China
| | - Lihua Wang
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, No.382, Wuyi Road, Xinghualing Distirct, Taiyuan, China
| | - Jicheng Lv
- Division of Nephrology, Peking University First Hospital, Peking University Institute of Nephrology, No.8, Xishiku Street, Xicheng District, Beijing, China
| | - Hong Cheng
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Street, Chaoyang District, Beijing, China
| | - Yipu Chen
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Street, Chaoyang District, Beijing, China.
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16
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García-Compeán D, Del Cueto-Aguilera ÁN, Jiménez-Rodríguez AR, González-González JA, Maldonado-Garza HJ. Diagnostic and therapeutic challenges of gastrointestinal angiodysplasias: A critical review and view points. World J Gastroenterol 2019; 25:2549-2564. [PMID: 31210709 PMCID: PMC6558444 DOI: 10.3748/wjg.v25.i21.2549] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/19/2019] [Accepted: 04/29/2019] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal angiodysplasias (GIADs), also called angioectasias, are the most frequent vascular lesions. Its precise prevalence is unknown since most of them are asymptomatic. However, the incidence may be increasing since GIADs affect individuals aged more than 60 years and population life expectancy is globally increasing worldwide. They are responsible of about 5% to 10% of all gastrointestinal bleeding (GIB) cases. Most GIADs are placed in small bowel, where are the cause of 50 to 60% of obscure GIB diagnosed with video capsule endoscopy. They may be the cause of fatal severe bleeding episodes; nevertheless, recurrent overt or occult bleeding episodes requiring repeated expensive treatments and disturbing patient’s quality-of-life are more frequently observed. Diagnosis and treatment of GIADs (particularly those placed in small bowel) are a great challenge due to insidious disease behavior, inaccessibility to affected sites and limitations of available diagnostic procedures. Hemorrhagic causality out of the actively bleeding lesions detected by diagnostic procedures may be difficult to establish. No treatment guidelines are currently available, so there is a high variability in the management of these patients. In this review, the epidemiology and pathophysiology of GIADs and the status in the diagnosis and treatment, with special emphasis on small bowel angiodysplasias based on multiple publications, are critically discussed. In addition, a classification of GIADs based on their endoscopic characteristics is proposed. Finally, some aspects that need to be clarified in future research studies are highlighted.
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Affiliation(s)
- Diego García-Compeán
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Ángel N Del Cueto-Aguilera
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Alan R Jiménez-Rodríguez
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - José A González-González
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Héctor J Maldonado-Garza
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
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17
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Muftah M, Mulki R, Dhere T, Keilin S, Chawla S. Diagnostic and therapeutic considerations for obscure gastrointestinal bleeding in patients with chronic kidney disease. Ann Gastroenterol 2018; 32:113-123. [PMID: 30837783 PMCID: PMC6394262 DOI: 10.20524/aog.2018.0341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 11/18/2018] [Indexed: 12/12/2022] Open
Abstract
Recurrent obscure gastrointestinal bleeding amongst patients with chronic kidney disease is a challenging problem gastroenterologists are facing and is associated with an extensive diagnostic workup, limited therapeutic options, and high healthcare costs. Small-bowel angiodysplasia is the most common etiology of obscure and recurrent gastrointestinal bleeding in the general population. Chronic kidney disease is associated with a higher risk of gastrointestinal bleeding and of developing angiodysplasia compared with the general population. As a result, recurrent bleeding in this subgroup of patients is more prevalent and is associated with an increased number of endoscopic and radiographic procedures with uncertain benefit. Alternative medical therapies can reduce re-bleeding; however, more studies are needed to confirm their efficacy in this subgroup of patients.
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Affiliation(s)
- Mayssan Muftah
- Department of Medicine (Mayssan Muftah), Atlanta, United States
| | - Ramzi Mulki
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States
| | - Tanvi Dhere
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States
| | - Steven Keilin
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States
| | - Saurabh Chawla
- Medicine, Division of Digestive Diseases, Emory University School of Medicine (Ramzi Mulki, Tanvi Dhere, Steven Keilin, Saurabh Chawla), Atlanta, United States.,Grady Memorial Hospital (Saurabh Chawla), Atlanta, United States
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18
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Kennedy C, Wong L, Sexton DJ, Cowman J, Oglesby I, Kenny M, Conlon PJ, Kenny D. Successful kidney transplantation normalizes platelet function. Clin Kidney J 2018; 11:574-580. [PMID: 30087773 PMCID: PMC6070122 DOI: 10.1093/ckj/sfx148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 11/27/2017] [Indexed: 12/23/2022] Open
Abstract
Background Uraemic platelet dysfunction is not completely understood, in part due to non-physiological platelet function assays. We have developed a physiological flow-based assay that quantifies platelet function in microlitre volumes of blood under arterial shear. The aim of this study was to characterize platelet function before and after kidney transplantation. Methods Ten patients scheduled for living donor kidney transplant surgery and nine healthy controls were analysed using the assay. The motional parameters of platelet behaviour on von Willebrand factor (VWF) were recorded using customized platelet tracking software. The assay was repeated 3–8 weeks post-transplant in the transplant group and at an interval of >3 weeks in normal healthy volunteers. Results Platelet–VWF interactions were markedly reduced in the 10 pre-transplant patients compared with the healthy controls. In seven patients with immediate graft function, dynamic platelet function returned to normal (despite a small decrease in haemoglobin and haematocrit), but remained markedly abnormal in the three patients with delayed graft function (DGF). Conclusions Dynamic platelet function returned to normal following transplantation in those with immediate graft function. This early improvement was not observed in those with DGF. There may be important clinical implications, as patients with DGF are more likely to undergo invasive procedures, including transplant biopsies and insertion of central venous catheters.
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Affiliation(s)
- Claire Kennedy
- Department of Nephrology, Beaumont Hospital, Dublin, Ireland.,Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Limy Wong
- Department of Nephrology, Beaumont Hospital, Dublin, Ireland
| | - Donal J Sexton
- Department of Nephrology, Beaumont Hospital, Dublin, Ireland
| | - Jonathan Cowman
- Department of Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland.,Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Irene Oglesby
- Department of Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Martin Kenny
- Department of Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Peter J Conlon
- Department of Nephrology, Beaumont Hospital, Dublin, Ireland.,Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Dermot Kenny
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland.,Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
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19
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Karunaratne K, Taube D, Khalil N, Perry R, Malhotra PA. Neurological complications of renal dialysis and transplantation. Pract Neurol 2017; 18:115-125. [PMID: 29288211 DOI: 10.1136/practneurol-2017-001657] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2017] [Indexed: 11/04/2022]
Abstract
Neurological complications from renal replacement therapy contribute significantly to morbidity and mortality in patients with renal failure. Such complications can affect either the central or peripheral nervous systems. Most neurological disturbances associated with the uraemic state do not respond fully to renal replacement therapy. There are also complications specifically associated with dialysis and transplantation. A multidisciplinary approach, involving both nephrologists and neurologists, is critical for the diagnosis and effective management of these disorders.
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Affiliation(s)
- Kushan Karunaratne
- Department of Neurology, Imperial College Healthcare NHS Trust, London, UK
| | - David Taube
- Department of Renal and Transplantation Medicine, West London Renal and Transplant Centre, Imperial College Kidney and Transplant Institute, London, UK
| | - Nofal Khalil
- Department of Neurophysiology, Imperial College Healthcare NHS Trust, London, UK
| | - Richard Perry
- Department of Neurology, Imperial College Healthcare NHS Trust, London, UK.,Division of Brain Sciences, Imperial College London, London, UK
| | - Paresh A Malhotra
- Department of Neurology, Imperial College Healthcare NHS Trust, London, UK.,Division of Brain Sciences, Imperial College London, London, UK
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20
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Abstract
For the over 400,000 patients in the United States dependent on hemodialysis, arteriovenous (AV) access thrombosis may lead to missed dialysis sessions, inpatient admissions and the need for placement of temporary dialysis catheters. It is also the leading cause of permanent access loss. Percutaneous declotting is generally preferred over surgical thrombectomy. Various percutaneous approaches can be employed including the lyse-and-wait technique, thromboaspiration, pulse spray aided pharmacomechanical thrombolysis, and use of mechanical thrombectomy device.
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Affiliation(s)
- Keith Bertram Quencer
- Division of Interventional Radiology, Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Rahmi Oklu
- Division of Interventional Radiology, Department of Radiology, Mayo Clinic, Phoenix, AZ, USA
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21
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Mohapatra A, Valson AT, Gopal B, Singh S, Nair SC, Viswabandya A, Varughese S, Tamilarasi V, John GT. Hemostatic Abnormalities in Severe Renal Failure: Do They Bark or Bite? Indian J Nephrol 2017; 28:135-142. [PMID: 29861564 PMCID: PMC5952452 DOI: 10.4103/ijn.ijn_104_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Abnormal primary hemostasis is believed to be the most significant contributor to uremic bleeding. This study aimed to describe the prevalence and profile of primary and secondary hemostatic disorders in patients with chronic kidney disease (CKD) Stages 4 and 5 and to determine their association if any, with degree of uremia. Stages 4 and 5 predialysis CKD patients attending nephrology outpatient clinic were prospectively recruited and the following bleeding parameters were measured in all patients: platelet count, bleeding time (BT), Factor VIII assay, von Willebrand factor antigen (vWF:Ag), vWF:ristocetin cofactor activity (vWF:RCo), ratio of vWF:ristocetin cofactor activity to vWF antigen (vWF:RCo/vWF:Ag), prothrombin time (PT), and activated partial thromboplastin time (aPTT). Forty-five patients (80%, males) with a mean age of 39.4 years, 82% (n = 37) in Stage 5 CKD, were recruited for the study. The prevalence of thrombocytopenia was significantly higher among patients from West Bengal (15/26, 57.7%) compared to other study patients (2/19, 10.5%; P = 0.001); however, all had macrothrombocytes with normal BT, suggestive of the Harris syndrome. Factor VIII, vWF:Ag, vWF:RCo, vWF:RCo/vWF:Ag ratio, BT, PT, and aPTT were abnormal in 0 (0%), 0 (0%), 0 (0%), 4 (8.8%), 1 (2.2%), 7 (15.6%), and 5 (11.1%) patients, respectively. Except for thrombocytopenia, the prevalence of hemostatic abnormalities did not differ between CKD Stages 4 and 5. Hemostatic abnormalities are uncommon in Stages 4–5 CKD and except for thrombocytopenia, are not associated with degree of uremia. Constitutional macrothrombocytopenia is associated with normal BT even in CKD.
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Affiliation(s)
- A Mohapatra
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - A T Valson
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - B Gopal
- Department of Nephrology, Central Northern Adelaide Renal and Transplant Service, Adelaide, Australia
| | - S Singh
- Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - S C Nair
- Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - A Viswabandya
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - S Varughese
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - V Tamilarasi
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - G T John
- Department of Renal Medicine, Royal Brisbane and Women's Hospital, Queensland, Australia
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22
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Baffour FI, Hickson LJ, Stegall MD, Dean PG, Gunderson TM, Atwell TD, Kurup AN, Schmitz JJ, Park WD, Schmit GD. Effects of Aspirin Therapy on Ultrasound-Guided Renal Allograft Biopsy Bleeding Complications. J Vasc Interv Radiol 2016; 28:188-194. [PMID: 27993506 DOI: 10.1016/j.jvir.2016.10.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 10/20/2016] [Accepted: 10/21/2016] [Indexed: 02/01/2023] Open
Abstract
PURPOSE To determine if patient aspirin exposure and timing affect bleeding risk after renal allograft biopsy. MATERIALS AND METHODS Review of 6,700 renal allograft biopsies (in 2,362 unique patients) was performed. Median patient age was 53.0 years [interquartile range 43.0, 62.0]; 56.2% of patients were male. Of biopsies, 4,706 (70.2%) were performed in patients with no aspirin exposure within 10 days of biopsy; 664 (9.9%), were performed within 8-10 days of aspirin exposure; 855 (12.8%), within 4-7 days; and 475 (7.1%), within 0-3 days. Follow-up to 3 months after the procedure was completed in all patients. Biopsies were categorized as protocol or indication; 19.7% were indication biopsies. Bleeding complications were graded based on SIR criteria. Logistic regression models examined the association between aspirin use and bleeding events. RESULTS Rate [95% confidence interval] of major bleeding complications was 0.24% [0.14, 0.39], and rate of any bleeding complication was 0.66% [0.46, 0.90]. Bleeding events were significantly associated with patients undergoing indication biopsies compared with protocol biopsies (odds ratio [OR] 2.27, P = .012). Patient factors associated with major bleeding complications in multivariate models included estimated glomerular filtration rate (OR 0.61, P = .016) and platelet count (OR 0.64, P = .033). Aspirin use was not significantly associated with increased risk of bleeding complication except for use of 325 mg of aspirin within 3 days of biopsy (any complication OR 3.87 [1.12, 13.4], P = .032; major complication OR 6.30 [1.27, 31.3], P = .024). CONCLUSIONS Renal allograft biopsy bleeding complications are very rare, particularly for protocol biopsies. Use of 325 mg of aspirin within 3 days of renal allograft biopsy was associated with increased bleeding complications.
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Affiliation(s)
| | - LaTonya J Hickson
- Division of Nephrology and Hypertension, 200 First Street SW, Rochester, MN 55905
| | - Mark D Stegall
- Department of Medicine, Division of Transplant Surgery, 200 First Street SW, Rochester, MN 55905
| | - Patrick G Dean
- Department of Medicine, Division of Transplant Surgery, 200 First Street SW, Rochester, MN 55905
| | - Tina M Gunderson
- Department of Surgery, Division of Biomedical Statistics and Informatics, 200 First Street SW, Rochester, MN 55905
| | - Thomas D Atwell
- Division of Ultrasound, 200 First Street SW, Rochester, MN 55905
| | - A Nicholas Kurup
- Division of Ultrasound, 200 First Street SW, Rochester, MN 55905
| | - John J Schmitz
- Division of Abdominal Imaging, 200 First Street SW, Rochester, MN 55905
| | - Walter D Park
- Division of Surgery Research Services, 200 First Street SW, Rochester, MN 55905; Department of Health Sciences Research, and William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Grant D Schmit
- Division of Abdominal Imaging, 200 First Street SW, Rochester, MN 55905
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23
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Fülöp T, Alemu B, Dossabhoy NR, Bain JH, Pruett DE, Szombathelyi A, Dreisbach AW, Tapolyai M. Safety and efficacy of percutaneous renal biopsy by physicians-in-training in an academic teaching setting. South Med J 2014; 107:520-5. [PMID: 25084192 DOI: 10.14423/smj.0000000000000148] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The safety and efficacy of percutaneous renal biopsy (PKB) are relatively little studied in a training setting. We sought to review our recent experience with bedside PKB in our training program. METHODS We performed a retrospective cohort review of our consecutive 2.5-year renal biopsy experience (May 2007-November 2009) at the University of Mississippi Nephrology Fellowship. All of the biopsies were performed exclusively by renal fellows using real-time ultrasound (US) visualization within the framework of a structured US-PKB training course. RESULTS A total of 64 patients underwent PKB during the index period; 50 (78.1%) of these procedures were performed on native kidneys. Participant age was 39.8 ± 13.7 years, blood pressures measured 140.1/85.3 ± 21.5/14.9 mm Hg, serum creatinine was 3.05 ± 3.15 mg/dL, and median random urine protein:creatinine ratio was 2.38 (25%-75% interquartile range 0.49-7.32). The biopsied kidneys measured 11.8 (±1.6) cm. We recovered 18.8 ± 11.5 glomeruli per procedure; two biopsies were unsuccessful. Focal glomerular sclerosis and lupus nephritis (22% and 25%, respectively) predominated among the specimens. Only three specimens returned with no diagnostic changes. There was a close correlation between preceding history and recovered diagnoses of diabetic changes and lupus nephritis (r 0.605 and 0.842; P < 0.0001 for both). Initial hemoglobin of 10.8 ± 1.8 g/dL dropped to 10.2 (1.9) g/dL after the procedure (P < 0.0001). Five (7.8%) patients needed transfusion; one patient experienced persistent urine leakage; however, none of the patients needed surgical or radiological intervention or died. CONCLUSIONS In the setting of a well-structured training environment, US-guided PKB is a reasonably safe and valuable component of renal fellowship training.
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Affiliation(s)
- Tibor Fülöp
- From the Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, the Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, the Department of Mathematics, Louisiana State University-Shreveport, the Edward Via College of Osteopathic Medicine, Columbia, South Carolina, and the W.J.B. Dorn VA Medical Center, University of South Carolina, Columbia. B.A., J.H.B., and D.E.P. are former fellows of the Department of Medicine (Division of Nephrology), University of Mississippi Medical Center, Jackson. B.A. is currently affiliated with Midwest Nephrology Associates, Midwest City, Oklahoma; J.H.B. is currently affiliated with Ferguson Medical Group, Sikeston, Missouri; and D.E.P. is currently affiliated with Renal Associates of Northeast Louisiana, Monroe
| | - Bereket Alemu
- From the Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, the Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, the Department of Mathematics, Louisiana State University-Shreveport, the Edward Via College of Osteopathic Medicine, Columbia, South Carolina, and the W.J.B. Dorn VA Medical Center, University of South Carolina, Columbia. B.A., J.H.B., and D.E.P. are former fellows of the Department of Medicine (Division of Nephrology), University of Mississippi Medical Center, Jackson. B.A. is currently affiliated with Midwest Nephrology Associates, Midwest City, Oklahoma; J.H.B. is currently affiliated with Ferguson Medical Group, Sikeston, Missouri; and D.E.P. is currently affiliated with Renal Associates of Northeast Louisiana, Monroe
| | - Neville R Dossabhoy
- From the Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, the Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, the Department of Mathematics, Louisiana State University-Shreveport, the Edward Via College of Osteopathic Medicine, Columbia, South Carolina, and the W.J.B. Dorn VA Medical Center, University of South Carolina, Columbia. B.A., J.H.B., and D.E.P. are former fellows of the Department of Medicine (Division of Nephrology), University of Mississippi Medical Center, Jackson. B.A. is currently affiliated with Midwest Nephrology Associates, Midwest City, Oklahoma; J.H.B. is currently affiliated with Ferguson Medical Group, Sikeston, Missouri; and D.E.P. is currently affiliated with Renal Associates of Northeast Louisiana, Monroe
| | - Justin H Bain
- From the Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, the Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, the Department of Mathematics, Louisiana State University-Shreveport, the Edward Via College of Osteopathic Medicine, Columbia, South Carolina, and the W.J.B. Dorn VA Medical Center, University of South Carolina, Columbia. B.A., J.H.B., and D.E.P. are former fellows of the Department of Medicine (Division of Nephrology), University of Mississippi Medical Center, Jackson. B.A. is currently affiliated with Midwest Nephrology Associates, Midwest City, Oklahoma; J.H.B. is currently affiliated with Ferguson Medical Group, Sikeston, Missouri; and D.E.P. is currently affiliated with Renal Associates of Northeast Louisiana, Monroe
| | - David E Pruett
- From the Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, the Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, the Department of Mathematics, Louisiana State University-Shreveport, the Edward Via College of Osteopathic Medicine, Columbia, South Carolina, and the W.J.B. Dorn VA Medical Center, University of South Carolina, Columbia. B.A., J.H.B., and D.E.P. are former fellows of the Department of Medicine (Division of Nephrology), University of Mississippi Medical Center, Jackson. B.A. is currently affiliated with Midwest Nephrology Associates, Midwest City, Oklahoma; J.H.B. is currently affiliated with Ferguson Medical Group, Sikeston, Missouri; and D.E.P. is currently affiliated with Renal Associates of Northeast Louisiana, Monroe
| | - Anita Szombathelyi
- From the Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, the Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, the Department of Mathematics, Louisiana State University-Shreveport, the Edward Via College of Osteopathic Medicine, Columbia, South Carolina, and the W.J.B. Dorn VA Medical Center, University of South Carolina, Columbia. B.A., J.H.B., and D.E.P. are former fellows of the Department of Medicine (Division of Nephrology), University of Mississippi Medical Center, Jackson. B.A. is currently affiliated with Midwest Nephrology Associates, Midwest City, Oklahoma; J.H.B. is currently affiliated with Ferguson Medical Group, Sikeston, Missouri; and D.E.P. is currently affiliated with Renal Associates of Northeast Louisiana, Monroe
| | - Albert W Dreisbach
- From the Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, the Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, the Department of Mathematics, Louisiana State University-Shreveport, the Edward Via College of Osteopathic Medicine, Columbia, South Carolina, and the W.J.B. Dorn VA Medical Center, University of South Carolina, Columbia. B.A., J.H.B., and D.E.P. are former fellows of the Department of Medicine (Division of Nephrology), University of Mississippi Medical Center, Jackson. B.A. is currently affiliated with Midwest Nephrology Associates, Midwest City, Oklahoma; J.H.B. is currently affiliated with Ferguson Medical Group, Sikeston, Missouri; and D.E.P. is currently affiliated with Renal Associates of Northeast Louisiana, Monroe
| | - Mihály Tapolyai
- From the Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, the Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, the Department of Mathematics, Louisiana State University-Shreveport, the Edward Via College of Osteopathic Medicine, Columbia, South Carolina, and the W.J.B. Dorn VA Medical Center, University of South Carolina, Columbia. B.A., J.H.B., and D.E.P. are former fellows of the Department of Medicine (Division of Nephrology), University of Mississippi Medical Center, Jackson. B.A. is currently affiliated with Midwest Nephrology Associates, Midwest City, Oklahoma; J.H.B. is currently affiliated with Ferguson Medical Group, Sikeston, Missouri; and D.E.P. is currently affiliated with Renal Associates of Northeast Louisiana, Monroe
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Bhangoo MS, Hein P, Nicholson L, Carter C. Spontaneous subdural haemorrhage in a patient with scleroderma renal crisis. BMJ Case Rep 2014; 2014:bcr-2014-205471. [PMID: 25193814 DOI: 10.1136/bcr-2014-205471] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 52-year-old woman with a history of systemic sclerosis presented with new onset seizures and renal failure. The patient's history, laboratory data and pathology supported the diagnosis of scleroderma renal crisis. The patient was also noted to have a subdural haemorrhage (SDH) in the absence of trauma. This is the first report of scleroderma renal crisis associated with a spontaneous SDH.
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Affiliation(s)
| | - Paul Hein
- Scripps Green Hospital, La Jolla, California, USA
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25
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Kim AJ, Lim HJ, Ro H, Ko KP, Han SY, Chang JH, Lee HH, Chung W, Jung JY. Low-dose aspirin for prevention of cardiovascular disease in patients with chronic kidney disease. PLoS One 2014; 9:e104179. [PMID: 25093403 PMCID: PMC4122498 DOI: 10.1371/journal.pone.0104179] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 07/07/2014] [Indexed: 12/13/2022] Open
Abstract
Background Chronic kidney disease (CKD) is a major risk factor for the development of cardiovascular disease (CVD). Previous trials have investigated the effects of low-dose aspirin on CVD prevention in patients with diabetes; however, patients with CKD were not examined. The role of aspirin in diabetics is controversial, and the available literature is contradictory. Therefore, we studied whether low-dose aspirin would be beneficial for patients with CKD, a group that is at high risk for CVD. Method From a total of 25340 patients with CKD, 1884 recipients of low-dose aspirin (100 mg/day) were paired 1∶1 with non-recipients for analysis using propensity score matching. The primary endpoint was the development of atherosclerotic CVD, including coronary arterial disease, stroke, and peripheral arterial disease. Secondary endpoints included death from any cause, bleeding events, doubling of serum creatinine, and renal death. Results The incidence of a primary endpoint of any atherosclerotic CVD was significantly higher in the aspirin users than in the non-users (P<0.001). Secondary endpoints, including all-cause mortality and composite bleeding events, were not significantly different between the aspirin users and the non-users. However, the doubling of serum creatinine levels (P = 0.001) and renal death (P = 0.042) were significantly associated with the use of aspirin. Conclusion These results suggest that the use of low-dose aspirin in patients with CKD may have harmful consequences related to the development of CVD and renal progression.
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Affiliation(s)
- Ae Jin Kim
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hye Jin Lim
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Han Ro
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
- Gachon University School of Medicine, Incheon, Korea
| | - Kwang-Pil Ko
- Department of Preventive Medicine, Gachon University School of Medicine, Incheon, Korea
| | - Song Yi Han
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jae Hyun Chang
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
- Gachon University School of Medicine, Incheon, Korea
| | - Hyun Hee Lee
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
- Gachon University School of Medicine, Incheon, Korea
| | - Wookyung Chung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
- Gachon University School of Medicine, Incheon, Korea
| | - Ji Yong Jung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
- Gachon University School of Medicine, Incheon, Korea
- * E-mail:
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27
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Abstract
Physiologically, there is an intimate link between the kidney and the blood. Many of the kidney diseases are the result of alteration in the blood such as dysproteinemia, microangiopathic hemolytic anemia (MAHA), hemolysis, etc. On the other hand, the kidney is the organ responsible for the regulation of hematopoiesis. Renal dysfunction can lead to both anemia and polycythemia. In addition, recent understanding of the MAHA process reveals that the renal microvasculature plays a key role in the pathogenesis. Finally, the failure of the kidney to clear toxins from the body can result in alteration involving hemostasis, as well as leukocyte function and survival.
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Affiliation(s)
- Nelson Leung
- Mayo Clinic, Division of Nephrology and Hypertension, and Division of Hematology, Rochester, MN, USA.
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28
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Ingrasciotta Y, Sultana J, Giorgianni F, Caputi AP, Arcoraci V, Tari DU, Linguiti C, Perrotta M, Nucita A, Pellegrini F, Fontana A, Cavagna L, Santoro D, Trifirò G. The burden of nephrotoxic drug prescriptions in patients with chronic kidney disease: a retrospective population-based study in Southern Italy. PLoS One 2014; 9:e89072. [PMID: 24558471 PMCID: PMC3928406 DOI: 10.1371/journal.pone.0089072] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 01/14/2014] [Indexed: 12/20/2022] Open
Abstract
Background The use of nephrotoxic drugs can further worsening renal function in chronic kidney disease (CKD) patients. It is therefore imperative to explore prescribing practices that can negatively affect CKD patients. Aim To analyze the use of nephrotoxic drugs in CKD patients in a general population of Southern Italy during the years 2006–2011. Methods The general practice “Arianna” database contains data from 158,510 persons, registered with 123 general practitioners (GPs) of Caserta. CKD patients were identified searching: CKD-related ICD-9 CM codes among causes of hospitalization; CKD-relevant procedures undergone in hospital (e.g. dialysis); drug prescriptions issued for a CKD-related indication. A list of nephrotoxic drugs was compiled and validated by pharmacologists and nephrologists. The summary of product characteristics was used to classify drugs as ‘contraindicated’ or ‘to be used with caution’ in renal diseases. Frequency of nephrotoxic drug use, overall, by drug class and single compounds, by GPs within one year prior or after first CKD diagnosis and within one year after dialysis entry was calculated. Results Overall, 1,989 CKD patients and 112 dialysed patients were identified. Among CKD patients, 49.8% and 45.2% received at least one prescription for a contraindicated nephrotoxic drug within one year prior or after first CKD diagnosis, respectively. In detail, 1,119 CKD patients (56.3%) had at least one nonsteroidal anti-inflammatory drugs (NSAIDs) prescription between CKD diagnosis and end of follow-up. A large proportion of CKD patients (35.6%) were treated with NSAIDs for periods exceeding 90 days. Contraindicated nephrotoxic drugs were used commonly in CKD, with nimesulide (16.6%) and diclofenac (11.0%) being most frequently used. Conclusions Contraindicated nephrotoxic drugs were highly prescribed in CKD patients from a general population of Southern Italy. CKD diagnosis did not seem to reduce significantly the prescription of nephrotoxic drugs, which may increase the risk of preventable renal function deterioration.
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Affiliation(s)
- Ylenia Ingrasciotta
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Janet Sultana
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Francesco Giorgianni
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | - Vincenzo Arcoraci
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | | | | | - Andrea Nucita
- Department of Cognitive Science, Educational and Cultural Studies (CSECS), University of Messina, Messina, Italy
| | - Fabio Pellegrini
- Unit of Biostatistics, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| | - Andrea Fontana
- Unit of Biostatistics, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| | - Lorenzo Cavagna
- Division of Rheumatology, University and IRCCS Foundation Policlinico S. Matteo, Pavia, Italy
| | - Domenico Santoro
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Gianluca Trifirò
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- * E-mail:
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Sami SS, Al-Araji SA, Ragunath K. Review article: gastrointestinal angiodysplasia - pathogenesis, diagnosis and management. Aliment Pharmacol Ther 2014; 39:15-34. [PMID: 24138285 DOI: 10.1111/apt.12527] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 08/14/2013] [Accepted: 09/18/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Angiodysplasia (AD) of the gastrointestinal (GI) tract is an important condition that can cause significant morbidity and -rarely - mortality. AIM To provide an up-to-date comprehensive summary of the literature evaluating this disease entity with a particular focus on pathogenesis as well as current and emerging diagnostic and therapeutic modalities. Recommendations for treatment will be made on the basis of the current available evidence and consensus opinion of the authors. METHODS A systematic literature search was performed. The search strategy used the keywords 'angiodysplasia' or 'arteriovenous malformation' or 'angioectasia' or 'vascular ectasia' or 'vascular lesions' or 'vascular abnormalities' or 'vascular malformations' in the title or abstract. RESULTS Most AD lesions (54-81.9%) are detected in the caecum and ascending colon. They may develop secondary to chronic low-grade intermittent obstruction of submucosal veins coupled with increased vascular endothelial growth factor-dependent proliferation. Endotherapy with argon plasma coagulation resolves bleeding in 85% of patients with colonic AD. In patients who fail (or are not suitable for) other interventions, treatment with thalidomide or octreotide can lead to a clinically meaningful response in 71.4% and 77% of patients respectively. CONCLUSIONS Angiodysplasia is a rare, but important, cause of both overt and occult GI bleeding especially in the older patients. Advances in endoscopic imaging and therapeutic techniques have led to improved outcomes in these patients. The choice of treatment should be decided on a patient-by-patient basis. Further research is required to better understand the pathogenesis and identify potential therapeutic targets.
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Affiliation(s)
- S S Sami
- Nottingham Digestive Diseases Centre & NIHR Biomedical research Unit, Queens Medical Centre, Nottingham, UK
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Gansevoort RT, Correa-Rotter R, Hemmelgarn BR, Jafar TH, Heerspink HJL, Mann JF, Matsushita K, Wen CP. Chronic kidney disease and cardiovascular risk: epidemiology, mechanisms, and prevention. Lancet 2013; 382:339-52. [PMID: 23727170 DOI: 10.1016/s0140-6736(13)60595-4] [Citation(s) in RCA: 1386] [Impact Index Per Article: 126.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Since the first description of the association between chronic kidney disease and heart disease, many epidemiological studies have confirmed and extended this finding. As chronic kidney disease progresses, kidney-specific risk factors for cardiovascular events and disease come into play. As a result, the risk for cardiovascular disease is notably increased in individuals with chronic kidney disease. When adjusted for traditional cardiovascular risk factors, impaired kidney function and raised concentrations of albumin in urine increase the risk of cardiovascular disease by two to four times. Yet, cardiovascular disease is frequently underdiagnosed and undertreated in patients with chronic kidney disease. This group of patients should, therefore, be acknowledged as having high cardiovascular risk that needs particular medical attention at an individual level. This view should be incorporated in the development of guidelines and when defining research priorities. Here, we discuss the epidemiology and pathophysiological mechanisms of cardiovascular risk in patients with chronic kidney disease, and discuss methods of prevention.
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Affiliation(s)
- Ron T Gansevoort
- Department of Nephrology, University Medical Centre Groningen, University Hospital Groningen, Groningen, Netherlands.
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Affiliation(s)
- Shir-Jing Ho
- SEALSDepartment of Haematology, St George Hospital, Gray St, Kogarah, NSW 2217, Australia
| | - Rosalie Gemmell
- SEALSDepartment of Haematology, St George Hospital, Gray St, Kogarah, NSW 2217, Australia
| | - Timothy A. Brighton
- SEALSDepartment of Haematology, Prince of Wales Hospital, High St, Randwick, NSW 2031, Australia
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Chiramel GK, Keshava SN, Tamilarasi N, John GT. Is liver biopsy safe in patients with chronic renal disease? Indian J Gastroenterol 2013; 32:277-8. [PMID: 23054949 DOI: 10.1007/s12664-012-0256-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Whole blood platelet aggregation and release reaction testing in uremic patients. BIOMED RESEARCH INTERNATIONAL 2013; 2013:486290. [PMID: 23878808 PMCID: PMC3708384 DOI: 10.1155/2013/486290] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 06/12/2013] [Accepted: 06/17/2013] [Indexed: 11/29/2022]
Abstract
Background. Platelet function analysis utilizing platelet-rich plasma and optical density based aggregometry fails to identify patients at risk for uremia associated complications. Methods. We employed whole blood platelet aggregation analysis based on impedance as well as determination of ATP release from platelet granules detected by a chemiluminescence method. Ten chronic kidney disease (CKD) stage 4 or 5 predialysis patients underwent platelet evaluation. Our study aims to evaluate this platform in this patient population to determine if abnormalities could be detected. Results. Analysis revealed normal aggregation and ATP release to collagen, ADP, and high-dose ristocetin. ATP release had a low response to arachidonic acid (0.37 ± 0.26 nmoles, reference range: 0.6–1.4 nmoles). Platelet aggregation to low-dose ristocetin revealed an exaggerated response (20.9 ± 18.7 ohms, reference range: 0–5 ohms). Conclusions. Whole blood platelet analysis detected platelet dysfunction which may be associated with bleeding and thrombotic risks in uremia. Diminished ATP release to arachidonic acid (an aspirin-like defect) in uremic patients may result in platelet associated bleeding. An increased aggregation response to low-dose ristocetin (a type IIb von Willebrand disease-like defect) is associated with thrombus formation. This platelet hyperreactivity may be associated with a thrombotic diathesis as seen in some uremic patients.
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Parasa S, Navaneethan U, Sridhar ARM, Venkatesh PGK, Olden K. End-stage renal disease is associated with worse outcomes in hospitalized patients with peptic ulcer bleeding. Gastrointest Endosc 2013; 77:609-16. [PMID: 23357495 DOI: 10.1016/j.gie.2012.11.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Accepted: 11/09/2012] [Indexed: 01/10/2023]
Abstract
BACKGROUND Patients with end-stage renal disease (ESRD) are at increased risk of peptic ulcer bleeding (PUB). To our knowledge, there are no population-based studies of the impact of ESRD on PUB. OBJECTIVE To determine nationwide impact of ESRD on outcomes of hospitalized patients with PUB. DESIGN Cross-sectional study. SETTING Hospitals from a 2008 Nationwide Inpatient Sample. PATIENTS We used the International Classification of Diseases, the 9th Revision, Clinical Modification codes to identify patients who had a primary discharge diagnosis of PUB. MAIN OUTCOME MEASUREMENT In-hospital mortality, length of stay, and hospitalization charges. INTERVENTIONS Comparison of PUB outcomes in patients with and without ESRD. RESULTS Of a total of 102,525 discharged patients with PUB, 3272 had a diagnosis of both PUB and ESRD, whereas 99,253 had a diagnosis of PUB alone without ESRD. The mortality of ESRD patients with PUB was significantly higher than that of the control group without ESRD (4.8% vs 1.9%, P < .0001). On multivariate analysis, patients with PUB and ESRD had greater mortality than patients admitted to the hospital with PUB alone (adjusted odds ratio [aOR] 2.1; 95% confidence interval [CI], 1.3-3.4), were more likely to undergo surgery (aOR 1.4; 95% CI, 1.2-1.7), and had a longer hospital stay (aOR 2.1; 95% CI, 1.2-2.9). These patients also incurred higher hospitalization charges ($54,668 vs $32,869, P < .01) compared with patients with PUB alone. LIMITATIONS Administrative data set. CONCLUSIONS ESRD is associated with a significant health care burden in hospitalized patients with PUB. The presence of ESRD contributes to a higher mortality rate, longer hospital stay, and increased need for surgery.
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Affiliation(s)
- Sravanthi Parasa
- Department of Medicine, Washington Hospital Center, Washington, DC, USA
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Lee JG, Lee KB, Jang IM, Roh H, Ahn MY, Woo HY, Hwang HW. Low glomerular filtration rate increases hemorrhagic transformation in acute ischemic stroke. Cerebrovasc Dis 2013; 35:53-9. [PMID: 23428997 DOI: 10.1159/000345087] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 10/11/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Decreased glomerular filtration rate (GFR) can increase the risk of bleeding tendency and hemorrhagic stroke. However, the relationship between the levels of GFR and hemorrhagic transformation (HT) after acute ischemic stroke is largely unknown. The aim of this study was to assess whether GFR level is associated with HT in acute ischemic stroke. METHODS We reviewed 770 consecutive patients with acute ischemic stroke within 7 days from September 2007 to February 2012 in a prospective stroke registry database. We calculated the patient's GFR using the Cockcroft-Gault equation, and divided them into 3 groups: ≥60, 30-59 and <30 ml/min/1.73 m(2). HTs were identified by follow-up computed tomography (CT) or magnetic resonance imaging, and were defined as (1) any degree of high density within the area of low attenuation of vascular territory on noncontrast brain CT, or (2) low-signal intensity area in gradient echo within high-signal intensity meaning acute infarct on diffusion-weighted imaging. Multivariable logistic regression analyses were used to estimate the risk of GFR for HT. Stratification analyses were done according to the presence of HT high risk factors: atrial fibrillation (AF), thrombolysis and large size infarction. Additional logistic regression model for symptomatic HTs was established with the same variables. RESULTS HTs were noted in 131 patients (17.0%) and symptomatic HTs in 63 patients (8.2%). In univariate analysis, HTs were more frequent in patients with AF (51.9 vs. 16.7%, p < 0.001) and large-size infarction (42.0 vs. 5.3%, p < 0.001). The risk of HT was associated with decreased GFR among 3 subgroups classified according to the value of estimated GFR: 49/394 (12.4%) in the GFR ≥60 group, 66/312 (21.2%) in the 30≤ GFR <59 group and 16/64 (25.0%) in the GFR <30 group (p = 0.002). We found a significant association between the GFR <30 group and HTs in acute ischemic stroke (OR 2.90; 95% CI 1.26-6.68, p = 0.012) after adjusting for other risk factors. Moreover, the incidence of HTs was higher in the subgroups without thrombolysis (OR 3.49; 95% CI 1.44-8.46) and without AF (OR 3.44; 95% CI 1.10-10.76). Decreased GFR also had a tendency of increasing symptomatic HTs (OR 2.39; 95% CI 0.72-7.94, p = 0.154). CONCLUSIONS Low levels of GFR are associated with a high risk of HT after acute ischemic stroke. Further studies are needed to elucidate whether HT in the patients with renal insufficiency are related to a worse outcome after acute ischemic stroke.
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Affiliation(s)
- Jung-Gon Lee
- Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
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Prada-Delgado O, Estévez-Loureiro R, Calviño-Santos R, Barge-Caballero E, Salgado-Fernández J, Piñón-Esteban P, Vázquez-Rodríguez JM, Aldama-López G, Flores-Ríos X, Soler-Martín MR, Vázquez-González N, Castro-Beiras A. Renal insufficiency and vascular complications after primary angioplasty via femoral route. Impact of vascular closure devices use. Rev Esp Cardiol 2012; 65:258-64. [PMID: 22305819 DOI: 10.1016/j.recesp.2011.10.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Accepted: 10/28/2011] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND OBJECTIVES We sought to determine the incidence of vascular complications in patients with chronic kidney disease undergoing primary angioplasty via the femoral route; we also evaluated the safety and efficacy of the use of vascular closure devices in this setting. METHODS Registry of 527 patients undergoing primary angioplasty via the femoral route from January 2003 to December 2008. Chronic kidney disease was defined as creatinine clearance less than 60 mL/min. The primary endpoint was the presence of major vascular complications. RESULTS Baseline chronic kidney disease was observed in 166 (31.5%) patients. Patients with chronic kidney disease experienced higher rates of major vascular complications compared to those without worsening of renal function (8.4% vs 4.2%; P=.045), especially those requiring transfusion (6.6% vs 1.9%; P=.006). Among patients with chronic kidney disease, 129 (77.7%) received a vascular closure device and manual compression was used in 37 patients (22.3%). The risk of major vascular complications was significantly lower with vascular closure device use compared to manual compression (4.7% vs 21.6%; P=.003). Multivariable logistic regression analysis showed that the use of a vascular closure device was independently associated with a decreased risk of major vascular complications in patients with chronic kidney disease undergoing primary angioplasty (odds ratio=0.11; 95% confidence interval, 0.03-0.41; P=.001). CONCLUSIONS Patients with chronic kidney disease undergoing primary angioplasty via the femoral route experience higher rates of major vascular complications. The use of vascular closure devices in this group of patients is safe and is associated with lower rates of major vascular complications compared to manual compression.
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Affiliation(s)
- Oscar Prada-Delgado
- Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
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Hanna EB, Chen AY, Roe MT, Wiviott SD, Fox CS, Saucedo JF. Characteristics and in-hospital outcomes of patients with non-ST-segment elevation myocardial infarction and chronic kidney disease undergoing percutaneous coronary intervention. JACC Cardiovasc Interv 2012; 4:1002-8. [PMID: 21939940 DOI: 10.1016/j.jcin.2011.05.022] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 04/21/2011] [Accepted: 05/24/2011] [Indexed: 01/26/2023]
Abstract
OBJECTIVES This study sought to evaluate the characteristics, therapies, and outcomes of patients with chronic kidney disease (CKD) presenting with non-ST-segment elevation myocardial infarction (NSTEMI) and managed with percutaneous coronary intervention (PCI). This specific population has not been evaluated previously. BACKGROUND Among patients with acute coronary syndrome, the presence of renal dysfunction is associated with an increased risk of death and major bleeding. METHODS We examined data on 40,074 NSTEMI patients managed with PCI who were captured by the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) registry. Patients were divided according to baseline renal function in 4 groups: no CKD and CKD stages 3, 4, and 5. RESULTS Overall, 31.1% (n = 12,045) of patients with NSTEMI undergoing PCI had CKD. Compared with patients with normal renal function, CKD patients managed with PCI had significantly more history of myocardial infarction, heart failure, and more 3-vessel coronary artery disease. They received fewer antithrombotic therapies but were treated more frequently with bivalirudin. In addition, they had significantly higher rates of in-hospital mortality and major bleeding. CKD stage 4 was associated with the highest risk of adverse events relative to no CKD. The multivariable adjusted odds ratios of in-hospital mortality for CKD stages 3, 4, and 5 relative to no CKD were 2.0, 2.8, and 2.6, respectively (global p value <0.0001), and the analogous adjusted odds ratios of major bleeding were 1.5, 2.8, and 1.8, respectively (global p value <0.0001). CONCLUSIONS CKD patients presenting with NSTEMI and managed with PCI have more comorbidities and receive guideline-recommended therapies less frequently than do patients without CKD. CKD is strongly associated with in-hospital mortality and bleeding in NSTEMI patients undergoing PCI.
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Affiliation(s)
- Elias B Hanna
- Department of Medicine, Cardiovascular Section, Louisiana State University, New Orleans, Louisiana 70112, USA.
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Incidence and risk factors of vascular complications following endovascular treatment of peripheral arterial disease via the popliteal artery. Cardiovasc Interv Ther 2011; 26:209-14. [PMID: 24122587 DOI: 10.1007/s12928-011-0060-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2010] [Accepted: 03/06/2011] [Indexed: 10/18/2022]
Abstract
To evaluate vascular complications associated with endovascular treatment (EVT) of peripheral arterial disease (PAD) through the popliteal artery and to identify the risk factors for these complications. Between November 2005 and January 2009, 63 patients with PAD received EVT via the popliteal artery. Retrograde (n = 58) and antegrade (n = 5) transpopliteal procedures were performed to target 77 lesions, including 12 distal to the trifurcation. Thirty-five punctures were performed under ultrasound guidance and 7 under angiographic guidance; 21 punctures were performed without any guidance. Vascular complications were evaluated by physical examination and duplex ultrasonography. Vascular complications at the popliteal puncture site occurred in 8 patients (12.7%): 6 hematomas and 2 arteriovenous fistulas (AVF). Seven of 24 patients receiving hemodialysis (HD) (29%) had significantly higher complications (P = 0.004) compared with 1 of 39 patients not receiving hemodialysis (non-HD) (2.6%). HD alone was also a significant risk factor for hematoma (P = 0.010). Both AVF occurred in HD patients (P = 0.141), and one occurred despite ultrasound-guided puncture. Ultrasound-guided puncture showed no significant improvement in reducing both complications. The combination of antiplatelet and anticoagulant therapy showed no statistical significance in overall complications. In non-HD patients, the transpopliteal approach in the EVT of PAD seems to be safe. More attention should be paid to HD patients when using the transpopliteal approach due to a higher complication rate.
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Nascimento B, Rizoli S, Rubenfeld G, Fukushima R, Ahmed N, Nathens A, Lin Y, Callum J. Cryoprecipitate transfusion: assessing appropriateness and dosing in trauma. Transfus Med 2011; 21:394-401. [PMID: 21851429 DOI: 10.1111/j.1365-3148.2011.01098.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Originally developed for patients with congenital factor VIII deficiency, cryoprecipitate is currently largely used for acquired hypofibrinogenemia in the context of bleeding. However, scant evidence supports this indication and cryoprecipitate is commonly used outside guidelines. In trauma, the appropriate cryoprecipitate dose and its impact on plasma fibrinogen levels are unclear. OBJECTIVES The aims were to evaluate (i) the appropriateness of cryoprecipitate transfusion in trauma and (ii) the plasma fibrinogen response to cryoprecipitate transfusion during massive transfusion in trauma. METHODS Retrospective review (January 1998-June 2008) of indications, dose and plasma fibrinogen response to cryoprecipitate transfusion at a large teaching hospital. A fibrinogen of <1.0 g L(-1) within 2 and 6 h of transfusion was used for evaluating appropriateness. RESULTS Ten thousand five hundred and forty cryoprecipitate units were transfused in 1004 patients. Thirty-seven percent and 31% were used in cardiac surgery and trauma, respectively. In 394 events in trauma, 238 (60%) and 259 (66%) were considered appropriate using the 2- and 6-h cut-off criteria, respectively. In patients who did not receive plasma components 2 h prior to cryoprecipitate, a dose of 8.7 (± 1.7) units caused a mean increase in fibrinogen levels of 0.55 (± 0.24) g L(-1), or 0.06 g L(-1) per unit. CONCLUSIONS In our hospital, where transfusion guidelines are overseen by transfusion medicine specialists and technologists, and policies for rapid blood component and laboratory turnaround times exist, it is possible to achieve high rates of appropriateness for cryoprecipitate transfusion in trauma. The current recommended dose causes a modest increase in fibrinogen levels (0.55 g L(-1) ).
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Affiliation(s)
- B Nascimento
- Department of Critical Care & Clinical Pathology & Surgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
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Kawahara T, Kawahara K, Ito H, Yamaguchi S, Mitsuhashi H, Makiyama K, Uemura H, Sakai M, Kubota Y. Spontaneous renal hemorrhage in hemodialysis patients. CASE REPORTS IN NEPHROLOGY AND UROLOGY 2011. [PMID: 23197944 PMCID: PMC3482069 DOI: 10.1159/000330192] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Dialysis patients have a tendency to bleed, and clinicians sometimes encounter cases with a significant amount of spontaneous hemorrhage. We herein report two cases of spontaneous renal hemorrhage in hemodialysis patients.
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Affiliation(s)
- Takashi Kawahara
- Department of Urology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Tang IYS, Walzer N, Aggarwal N, Tzvetanov I, Cotler S, Benedetti E. Management of the kidney transplant patient with chronic hepatitis C infection. Int J Nephrol 2011; 2011:245823. [PMID: 21603155 PMCID: PMC3096939 DOI: 10.4061/2011/245823] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Accepted: 01/25/2011] [Indexed: 12/11/2022] Open
Abstract
Chronic Hepatitis C (HCV) infection is an important cause of morbidity and mortality in patients with end-stage renal disease. Renal transplantation confers a survival advantage in HCV-infected patients. Renal transplant candidates with serologic evidence of HCV infection should undergo a liver biopsy to assess for fibrosis and cirrhosis. Patients with Metavir fibrosis score ≤3 and compensated cirrhosis should be evaluated for interferon-based therapy. Achievement of sustained virological response (SVR) may reduce the risks for both posttransplantation hepatic and extrahepatic complications such as de novo or recurrent glomerulonephritis associated with HCV. Patients who cannot achieve SVR and have no live kidney donor may be considered for HCV-positive kidneys. Interferon should be avoided after kidney transplant except for treatment of life-threatening liver injury, such as fibrosing cholestatic hepatitis. Early detection, prevention, and treatment of complications due to chronic HCV infection may improve the outcomes of kidney transplant recipients with chronic HCV infection.
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Affiliation(s)
- Ignatius Y S Tang
- Section of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
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Abstract
BACKGROUND Patients with chronic kidney disease (CKD) represent a challenge for the dentist seeking to prescribe medications. Understanding the medical management of renal insufficiency and the pharmacokinetics of common dental drugs will aid clinicians in safely treating these patients. TYPES OF STUDIES REVIEWED The authors reviewed the literature concerning the medical and pharmacological management of CKD. They reviewed the pharmacokinetic effects of drugs described in case reports and research articles and obtained from them recommendations regarding the use of drugs and adjustment of dosages. CLINICAL IMPLICATIONS Because CKD is progressive, patients have varying levels of renal function but do not yet have end-stage renal disease. Some drugs that dentists prescribe commonly may worsen a patient's renal function, lead to drug toxicity or both. Managing the care of patients and prescribing medications tailored to their needs begin with a recognition of the patient with renal disease at risk of developing adverse effects. Clinicians can identify these patients from information obtained in their medical histories and from the drugs they may be taking. CONCLUSIONS To treat patients with kidney disease, clinicians must recognize those at risk, have knowledge of the pharmacokinetic changes that occur and recognize that adjustment of drug dosages often is needed.
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Kazama I, Endo Y, Toyama H, Ejima Y, Kurosawa S, Murata Y, Matsubara M, Maruyama Y. Compensatory thrombopoietin production from the liver and bone marrow stimulates thrombopoiesis of living rat megakaryocytes in chronic renal failure. NEPHRON EXTRA 2011; 1:147-56. [PMID: 22470388 PMCID: PMC3290854 DOI: 10.1159/000333018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND/AIMS Decreased thrombopoiesis has been ascribed a role in the pathogenesis of uremic bleeding in chronic renal failure (CRF). However, serum thrombopoietin (TPO) levels are usually elevated in CRF patients, suggesting increased thrombopoiesis. The aim of this study was to determine the thrombopoietic activity in CRF. METHODS Male Sprague-Dawley rats that underwent 5/6 nephrectomy were used as the model of CRF. Age-matched sham-operated rats were used as controls. Single megakaryocytes were isolated from the rat bone marrow, and their size distribution was examined. Megakaryocyte membrane invaginations were monitored by confocal imaging of di-8-ANEPPS staining, and patch clamp whole-cell recordings of membrane capacitance. TPO gene expression was assessed in various tissues. RESULTS Circulating platelet counts and the number of large megakaryocytes were increased in the bone marrow of CRF rats. Massive di-8-ANEPPS staining and increased membrane capacitance in large megakaryocytes demonstrated increased membrane invaginations. Unaffected Kv1.3-channel currents per cell surface area demonstrated unaltered channel densities. TPO transcription was decreased in the renal cortex but increased in the liver and bone marrow of CRF rats. CONCLUSION Increased thrombopoiesis in CRF was thought to be a reactive mechanism to platelet dysfunction. Increased TPO production from the liver and bone marrow compensated for decreased production from damaged kidneys.
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Affiliation(s)
| | - Yasuhiro Endo
- Department of Anesthesiology, Tohoku University Hospital, Sendai, Japan
| | - Hiroaki Toyama
- Department of Anesthesiology, Tohoku University Hospital, Sendai, Japan
| | - Yutaka Ejima
- Department of Anesthesiology, Tohoku University Hospital, Sendai, Japan
| | - Shin Kurosawa
- Department of Anesthesiology, Tohoku University Hospital, Sendai, Japan
| | | | - Mitsunobu Matsubara
- Division of Molecular Medicine, Center for Translational and Advanced Animal Research, Tohoku University Graduate School of Medicine, Sendai, Japan
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DeLoughery TG. Management of acquired bleeding problems in cancer patients. Hematol Oncol Clin North Am 2010; 24:603-24. [PMID: 20488357 DOI: 10.1016/j.hoc.2010.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cancer patients can have acquired bleeding problems for many reasons. In this review, an approach to the evaluation and management of the bleeding patient is discussed. Specific issues including coagulation defects, thrombocytopenia, platelet dysfunction, and bleeding complications of specific hematological malignancies due to anticoagulation, are discussed.
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Affiliation(s)
- Thomas G DeLoughery
- Divisions of Hematology and Medical Oncology, Department of Medicine, L586, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098, USA.
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Cheung J, Yu A, LaBossiere J, Zhu Q, Fedorak RN. Peptic ulcer bleeding outcomes adversely affected by end-stage renal disease. Gastrointest Endosc 2010; 71:44-9. [PMID: 19595311 DOI: 10.1016/j.gie.2009.04.014] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2008] [Accepted: 04/10/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with end-stage renal disease (ESRD) and peptic ulcer disease (PUD) bleeding may be at high risk of bleeding complications. OBJECTIVE To investigate the outcomes of patients with ESRD and PUD bleeding. DESIGN ESRD patients with PUD bleeding were evaluated retrospectively. SETTING Two tertiary, university-affiliated hospitals. PATIENTS A total of 150 PUD bleeding patients were evaluated in 3 groups; end-stage renal disease (ESRD) patients on dialysis (ESRD group) (n = 50) were age matched with patients with chronic kidney disease (CKD) not requiring dialysis (CKD group) (n = 50) and those with normal kidney function (normal group) (n = 50). MAIN OUTCOME MEASUREMENTS Rebleeding, transfusions, length of hospitalization, mortality. RESULTS Multivariate analysis showed significant predictors of rebleeding to be ESRD and high-risk stigmata. The ESRD group had an odds ratio (OR) of 3.8 (95% CI, 1.4-10.5; P = .008) for rebleeding compared with the normal group, and an OR of 3.8 (95% CI, 1.4-10.3; P = .01) compared with the CKD group. The mean number of (+/- SD) transfusions was higher in the ESRD group (6.3 +/- 5.7 units) than in the normal group (3.6 +/- 3.9 units; P = .01). The mean length of hospitalization was higher in the ESRD group than in the normal group (34.0 vs 16.6 days; P = .01). A greater level of comorbidity was the only significant predictor of mortality (OR 6.0; 95% CI, 2.9-12.3; P = .001). LIMITATION Retrospective study. CONCLUSION ESRD dialysis patients with PUD bleeding have greater rebleeding than patients not on dialysis. ESRD patients should be managed as a high-risk group.
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Affiliation(s)
- Justin Cheung
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Abstract
Cancer patients can have acquired bleeding problems for many reasons. In this review, an approach to the bleeding patient in the Emergency Department is discussed. Specific issue including coagulation defects, thrombocytopenia, platelet dysfunction, bleeding complications of specific hematological malignancies and due to anticoagulation, are discussed.
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Affiliation(s)
- Thomas G DeLoughery
- Division of Hematology, Department of Medicine, L586, Oregon Health & Science University, Portland, OR 97201-3098, USA.
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Affiliation(s)
- Marc G Ghany
- Department of Health and Human Services, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
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Nakayama Y, Ohtani Y, Kobayakawa N, Kobayashi J, Kaneko Y, Aoyagi T. A Case of Early Phase Dialysis Associated Effusive Constrictive Pericarditis With Distinct Surgical Findings. Int Heart J 2009; 50:685-91. [DOI: 10.1536/ihj.50.685] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yukiteru Nakayama
- Department of Cardiovascular Medicine, Japanese Red Cross Medical Center
| | - Yoshitaka Ohtani
- Department of Cardiovascular Medicine, Japanese Red Cross Medical Center
| | - Naoshi Kobayakawa
- Department of Cardiovascular Medicine, Japanese Red Cross Medical Center
| | - Jotaro Kobayashi
- Department of Cardiovascular Surgery, Japanese Red Cross Medical Center
| | - Yukihiro Kaneko
- Department of Cardiovascular Surgery, Japanese Red Cross Medical Center
| | - Teruhiko Aoyagi
- Department of Cardiovascular Medicine, Japanese Red Cross Medical Center
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Ethier J, Bragg-Gresham JL, Piera L, Akizawa T, Asano Y, Mason N, Gillespie BW, Young EW. Aspirin prescription and outcomes in hemodialysis patients: the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2007; 50:602-11. [PMID: 17900460 DOI: 10.1053/j.ajkd.2007.07.007] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 07/05/2007] [Indexed: 01/26/2023]
Abstract
BACKGROUND We investigated aspirin-prescribing patterns and potential benefits on cardiovascular morbidity and mortality in hemodialysis patients. STUDY DESIGN Cohort study. SETTING & PARTICIPANTS Data included 28,320 randomly selected hemodialysis patients from the Dialysis Outcomes and Practice Patterns Study I and II. PREDICTOR Aspirin prescription at study baseline. OUTCOMES & MEASUREMENTS Prescription was investigated by means of logistic regression. All-cause mortality, all-cause hospitalization, cardiac event, myocardial infarction, cerebrovascular (CVA), gastrointestinal bleed, transient ischemic attack, and subdural hematoma were examined. Cox regression examined the risk of mortality and hospitalization. All models accounted for facility clustering and demographics and comorbid conditions. RESULTS Wide variation was found in aspirin prescription, from 8% in Japan to 41% in Australia and New Zealand. Characteristics significantly associated with increased odds of prescription included coronary artery disease, cerebrovascular disease, diabetes, male sex, nonblack race, peripheral vascular disease, age, hypertension, and absence of gastrointestinal bleeding. Aspirin was associated with decreased risk of stroke in all patients (relative risk [RR], 0.82; P < 0.01) and increased risk of myocardial infarction (RR, 1.21; P = 0.01) and cardiac event (RR, 1.08; P < 0.01) in all patients, with similar results for patients with coronary artery disease. There was no increase in gastrointestinal bleeding. LIMITATIONS Observational studies are not protected from biases, despite adjustments. There is potential for aspirin use to be underreported because of its availability without prescription. CONCLUSIONS The hypothesis that prescribing aspirin to hemodialysis patients decreases cardiovascular disease risk is not supported. Aspirin might decrease CVA and appears not to increase hemorrhagic risk. This should be an incentive for randomized controlled trials.
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Affiliation(s)
- Jean Ethier
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
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