Evaluation of novel coagulation and platelet function assays in patients with chronic kidney disease

Hallmarks for Thrombotic and Hemorrhagic Risks in Chronic Kidney Disease Patients

Chronic kidney disease (CKD) is a global health issue causing a significant health burden. CKD patients develop thrombotic and hemorrhagic complications, and cardiovascular diseases are associated with increased hospitalization and mortality in this population. The hemostatic alterations are multifactorial in these patients; therefore, the results of different studies are varying and controversial. Endothelial and platelet dysfunction, coagulation abnormalities, comorbidities, and hemoincompatibility of the dialysis membranes are major contributors of hypo- and hypercoagulability in CKD patients. Due to the tendency of CKD patients to exhibit a prothrombotic state and bleeding risk, they require personalized clinical assessment to understand the impact of antithrombotic therapy. The evidence of efficacy and safety of antiplatelet and anticoagulant treatments is limited for end-stage renal disease patients due to their exclusion from major randomized clinical trials. Moreover, designing hemocompatible dialyzer membranes could be a suitable approach to reduce platelet activation, coagulopathy, and thrombus formation. This review discusses the molecular mechanisms underlying thrombotic and hemorrhagic risk in patients with CKD, leading to cardiovascular complications in these patients, as well as the evidence and guidance for promising approaches to optimal therapeutic management.

Concerns about the application of resistance exercise with blood-flow restriction and thrombosis risk in hemodialysis patients

BACKGROUND

Hemodialysis (HD) per se is a risk factor for thrombosis. Considering the growing body of evidence on blood-flow restriction (BFR) exercise in HD patients, identification of possible risk factors related to the prothrombotic agent D-dimer is required for the safety and feasibility of this training model. The aim of the present study was to identify risk factors associated with higher D-dimer levels and to determine the acute effect of resistance exercise (RE) with BFR on this molecule.

METHODS

Two hundred and six HD patients volunteered for this study (all with a glomerular filtration rate of <15 mL/min/1.73 m2). The RE + BFR session consisted of 50% arterial occlusion pressure during 50 min sessions of HD (intradialytic exercise). RE repetitions included concentric and eccentric lifting phases (each lasting 2 s) and were supervised by a strength and conditioning specialist.

RESULTS

Several variables were associated with elevated levels of D-dimer, including higher blood glucose, citrate use, recent cardiovascular events, recent intercurrents, higher inflammatory status, catheter as vascular access, older patients (>70 years old), and HD vintage. Furthermore, RE + BFR significantly increases D-dimer after 4 h. Patients with borderline baseline D-dimer levels (400-490 ng/mL) displayed increased risk of elevating D-dimer over the normal range (≥500 ng/mL).

CONCLUSION

These results identified factors associated with a heightened prothrombotic state and may assist in the screening process for HD patients who wish to undergo RE + BFR. D-dimer and/or other fibrinolysis factors should be assessed at baseline and throughout the protocol as a precautionary measure to maximize safety during RE + BFR.

COVID-19 increases extracorporeal coagulation during hemodialysis associated with upregulation of vWF/FBLN5 signaling in patients with severe/critical symptoms

BACKGROUND

COVID-19 has been shown to increase the risk of extracorporeal coagulation during hemodialysis in patients, but the underlying mechanism remains unclear. This study aimed to investigate the effect and mechanism of COVID-19 on the risk of extracorporeal coagulation in patients with chronic kidney disease undergoing hemodialysis.

METHODS

A retrospective analysis of the extracorporeal coagulation status of 339 hemodialysis patients at our center before and after COVID-19 infection was performed, including subgroup analyses. Post-infection blood composition was analyzed by protein spectrometry and ELISA.

RESULTS

Compared to the pre-COVID-19 infection period, COVID-19-induced extracorporeal coagulation predominantly occurred in patients with severe/critical symptoms. Further proteomic analysis demonstrated that in patients with severe/critical symptoms, the coagulation cascade reaction, platelet activation, inflammation, and oxidative stress-related pathways were significantly amplified compared to those in patients with no/mild symptoms. Notably, the vWF/FBLN5 pathway, which is associated with inflammation, vascular injury, and coagulation, was significantly upregulated.

CONCLUSIONS

Patients with severe/critical COVID-19 symptoms are at a higher risk of extracorporeal coagulation during hemodialysis, which is associated with the upregulation of the vWF/FBLN5 signaling pathway. These findings highlight the importance of early anticoagulant therapy initiation in COVID-19 patients with severe/critical symptoms, particularly those undergoing hemodialysis. Additionally, vWF/FBLN5 upregulation may be a novel mechanism for virus-associated thrombosis/coagulation.

Association between systemic inflammatory indicators with the survival of chronic kidney disease: a prospective study based on NHANES

Background

systemic inflammation disorders were observed in chronic kidney disease (CKD). Whether the systemic inflammatory indicators could be optimal predictors for the survival of CKD remains less studied.

Methods

In this study, participants were selected from the datasets of the National Health and Nutrition Examination Survey (NHANES) between 1999 to 2018 years. Four systemic inflammatory indicators were evaluated by the peripheral blood tests including systemic immune-inflammation index (SII, platelet*neutrophil/lymphocyte), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR). Kaplan-Meier curves, restricted cubic spline (RCS), and Cox regression analysis were used to evaluate the association between the inflammatory index with the all-cause mortality of CKD. Receiver operating characteristic (ROC) and concordance index (C-index) were used to determine the predictive accuracy of varied systemic inflammatory indicators. Sensitive analyses were conducted to validate the robustness of the main findings.

Results

A total of 6,880 participants were included in this study. The mean age was 67.03 years old. Among the study population, the mean levels of systemic inflammatory indicators were 588.35 in SII, 2.45 in NLR, 133.85 in PLR, and 3.76 in LMR, respectively. The systemic inflammatory indicators of SII, NLR, and PLR were all significantly positively associated with the all-cause mortality of CKD patients, whereas the high value of LMR played a protectable role in CKD patients. NLR and LMR were the leading predictors in the survival of CKD patients [Hazard ratio (HR) =1.21, 95% confidence interval (CI): 1.07-1.36, p = 0.003 (3rd quartile), HR = 1.52, 95%CI: 1.35-1.72, p<0.001 (4th quartile) in NLR, and HR = 0.83, 95%CI: 0.75-0.92, p<0.001 (2nd quartile), HR = 0.73, 95%CI: 0.65-0.82, p<0.001 (3rd quartile), and = 0.74, 95%CI: 0.65-0.83, p<0.001 (4th quartile) in LMR], with a C-index of 0.612 and 0.624, respectively. The RCS curves showed non-linearity between systemic inflammatory indicators and all-cause mortality risk of the CKD population.

Conclusion

Our study highlights that systemic inflammatory indicators are important for predicting the survival of the U.S. population with CKD. The systemic inflammatory indicators would add additional clinical value to the health care of the CKD population.

Non-paroxysmal junctional tachycardia complicating disseminated intravascular coagulation during massive surgical hemorrhage: A case report

RATIONALE

Non-paroxysmal junctional tachycardia (NPJT) is a self-limiting supraventricular tachycardia associated with primary heart disease, cardiac surgery, digitalis toxicity, and metabolic or electrolyte imbalances. However, NPJT caused enhanced normal automaticity even in the absence of structural heart disease can be fatal if not managed properly.

PATIENT CONCERNS

A 74-year-old hypertensive female patient was scheduled for transureteroureterostomy and right ureteroneocystostomy under general anesthesia.

DIAGNOSIS

The patient developed NPJT without visible P wave and severe hypotension due to adrenergic stimulation in response to massive hemorrhage during surgery.

INTERVENTIONS

NPJT with hypotension was initially converted to sinus rhythm with normotension with administration of adenosine and esmolol. However uncontrolled surgical hemorrhage and administration of large dose of vasopressors eventually perpetuated NPJT refractory to antiarrhythmic drugs.

OUTCOMES

Despite intravenous fluid resuscitation and massive transfusion, the patient was deteriorated hemodynamically due to uncontrolled bleeding and persistent NPJT, which resulted in hypovolemic shock and fatal disseminated intravascular coagulation (DIC).

LESSONS

NPJT can occur by enhanced automaticity due to increased catecholamine during severe surgical hemorrhage. Although NPJT is generally self-limiting, it can be refractory to antiarrhythmic agents and accelerate hypotension if the surgical bleeding is uncontrolled. Therefore, aggressive management of the primary pathologic condition is crucial for the management of NPJT and hemodynamic collapse even in the absence of structural heart disease.

Thrombectomy versus combined thrombolysis and thrombectomy in patients with large vessel occlusion and chronic kidney disease

Background

Whether intravenous thrombolysis (IVT) should be bridged before mechanical thrombectomy (MT) remains uncertain in patients with large vessel occlusion (LVO) and chronic kidney disease (CKD).

Methods

This research systematically enrolled every patient with both acute ischemic stroke (AIS) and CKD who received MT and fulfilled the criteria for IVT from January 2015 to December 2022. According to whether they underwent IVT, the patients were categorized into two cohorts: MT and combined IVT + MT. A binary logistic regression model was used to adjust for potential confounders, and propensity score matching analysis was used to assess the efficacy and safety of IVT in AIS patients with CKD who underwent MT.

Results

A total number of 406 patients were ultimately included in this study, with 236 patients in the MT group and 170 in the combined group. After PSM, there were 170 patients in the MT group and 170 in the combined group, and the clinical characteristics between the two groups were well balanced. The MT + IVT group had better long-term functional outcomes than the MT group (35.9% versus 21.2%, P = 0.003) and more modified thrombolysis in cerebral infarction (mTICI) (2b-3) (94.1% versus 87.6%, P = 0.038), while no significant difference was found regarding symptomatic intracranial hemorrhage (sICH). In line with the results observed in the in the postmatched population, the logistic regression revealed that patients in the IVT + MT group demonstrated superior clinical outcomes (adjusted OR 0.440 [95% CI (0.267-0.726)], P = 0.001) in the prematched population.

Conclusion

For LVO patients with CKD and indications for IVT, IVT bridging MT improves their prognosis compared with direct MT.

Coagulation Disorders and Thrombotic Complications in Heart Failure With Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is associated with multiple cardiovascular and noncardiovascular comorbidities and risk factors which increase the risk of thrombotic complications, such as atrial fibrillation, chronic kidney disease, arterial hypertension and type 2 diabetes mellitus. Subsequently, thromboembolic risk stratification in this population poses a great challenge. Since date from the large randomized clinical trials mostly include both patients with truly preserved EF, and those with heart failure with mildly reduced ejection fraction, there is an unmet need to characterize the patients with truly preserved EF. Considering the significant evidence gap in this area, we sought to describe the coagulation disorders and thrombotic complications in patients with HFpEF and discuss the specific thromboembolic risk factors in patients with HFpEF, with the goal to tailor risk stratification to an individual patient.

Development and Validation of a Risk-Prediction Nomogram for Preoperative Blood Type and Antibody Testing in Spinal Fusion Surgery

OBJECTIVE

With advancements in minimally invasive techniques, the use of spinal fusion surgery is rapidly increasing and transfusion rates are decreasing. Routine preoperative ABO/Rh blood type and antibody screening (T&S) laboratory tests may not be appropriate for all spinal fusion patients. Herein, we constructed a nomogram to assess patient transfusion risk based on various risk factors in patients undergoing spinal fusion surgery, so that preoperative T&S testing can be selectively scheduled in appropriate patients to reduce healthcare and patient costs.

METHODS

Patients who underwent spinal fusion surgery between 01/2020 and 03/2023 were retrospectively examined and classified into the training (n = 3533, 70%) and validation (n = 1515, 30%) datasets. LASSO and multivariable logistic regression were used to analyze risk factors for blood transfusion. Nomogram predictive model was built according to the independent predictors and mode predictive power was validated using consistency index (C-index), Hosmer-Lemeshow (HL) test, calibration curve analysis and area under the curve (AUC) for receiver operating characteristic (ROC) curve. Bootstrap resampling was used for internal validation. Decision curve analysis (DCA) was applied to evaluate the model's performance in the clinic.

RESULTS

Being female, age, BMI, admission route, critical patient, operative time, heart failure, end-stage renal disease or chronic kidney disease (ESRD or CKD), anemia, and coagulation defect were predictors of blood transfusion for spinal fusion. A prediction nomogram was developed according to a multivariate model with good discriminatory power (C-index = 0.887); Bootstrap resampling internal validation C-index was 0.883. Calibration curves showed strong matching between the predicted and actual probabilities of the training and validation sets. HL tests for the training and validation sets had p-values of 0.327 and 0.179, respectively, indicating good calibration. When applied to the training set, the following parameters were found: AUC: 0.895, 95% CI: 0.871-0.919, sensitivity 78.2%, specificity 86.7%, positive predictive value 29.4% and negative predictive value 98.2%. If the model were applied in the training set, 2911 T&S tests (82.4%) would be eliminated, equaling a RMB349,320 cost reduction. The AUC in the internal validation was: 0.879, 95% CI: 0.839-0.927, sensitivity 75.2%, specificity 88.8%, positive predictive value 34.3%, negative predictive value 97.9%, would eliminate 1276 T&S tests (84.2%), saving RMB 153,120. The DCA curve indicated good clinical application value.

CONCLUSION

The nomogram based on 10 independent factors can help healthcare professionals predict the risk of transfusion for patients undergoing spinal fusion surgery to target preoperative T&S testing to appropriate patients and reduce healthcare costs.

Molecular mechanism of Shengyang Yiwei Decoction in treating chronic kidney disease based on network pharmacology

There is a serious worldwide health problem caused by chronic kidney disease (CKD), yet there are few viable therapies. Therapeutic promise in the treatment of chronic kidney disease (CKD) has been shown by the use of the traditional Chinese herbal compound Shengyang Yiwei Decoction (SYD). However, the chemical processes through which SYD exerts its effects are still unknown. The purpose of this network pharmacology research is to better understand the molecular mechanism of action of Shengyang Yiwei Decoction (SYD) in the treatment of chronic kidney disease (CKD). Traditional Chinese Medicine Systems Pharmacology (TCMSP) was first searched for information on the chemical components of Shengyang Yiwei Decoction. The molecular targets of SYD were then predicted using the Pharm Mapper service. After that, we used databases like DIG-SEE, TTD, and OMIM to zero down on the targets most closely linked to CKD. Cytoscape 3.2.1 was used to generate the component-target network representing SYD's therapy of CKD. In addition, KEGG signal pathways and GO biological processes were analyzed using the DAVID database, and the findings were displayed via OmicShare Tools. Twenty-two active components were isolated from Shengyang Yiwei Decoction, and they were linked to 36 therapeutic targets for CKD in the current investigation. According to the results of the network pharmacology study, 41 signaling pathways are involved in mediating the therapeutic effects of SYD. In addition, SYD's broad therapeutic impact in CKD therapy was shown to include 29 molecular activities, 14 cell components, and 91 biological processes. This research utilizes a multivariate analysis to provide light on the strategies and outcomes of treating CKD using Shengyang Yiwei Decoction. Clinical therapeutic methods for CKD management may benefit greatly from a thorough knowledge of the underlying processes and material foundation of this disease.

Consumptive coagulopathy in the ICU

A consumptive coagulopathy describes a situation where there is a loss of hemostatic factors, which leads to an increased risk of bleeding. Some recent studies have used the term interchangeably with disseminated intravascular coagulation (DIC), but we have reverted to the older definition, which covers a broader range of issues where there is loss of hemostatic factors due to multiple causes, which includes systemic activation of coagulation as seen in DIC. Therefore, the term consumptive coagulopathy covers conditions from the hemostatic effects of major hemorrhage to the use of extracorporeal circuits to true DIC. We review the current understanding of the pathophysiology, diagnosis, and management of common consumptive coagulopathy in critical care patients, focusing on recent advances and controversies. Particular emphasis is given to DIC because it is a common and often life-threatening condition in critical care patients and is characterized by the simultaneous occurrence of widespread microvascular thrombosis and bleeding. Second, we focus on the effect of modern medical technology, such as extracorporeal membrane oxygenation, on hemostasis.

Risk and factors associated with venous thromboembolism following abdominal transplantation

Background

Venous thromboembolism (VTE) remains under-studied among patients undergoing kidney, liver and pancreas (abdominal) transplantation. We characterized the risk and predictors of VTE using a nationally-representative cohort.

Methods

The 2014-2019 Nationwide Readmissions Database was queried to identify all adults undergoing abdominal transplantation. Patients who developed pulmonary embolism or deep venous thrombosis were considered the VTE cohort (others: nonVTE). Multivariable models were developed to identify factors linked with VTE and assess the independent associations between VTE and key outcomes.

Results

Of ~141,977 transplant recipients, 1.9 % (2722) developed VTE. The VTE cohort was similarly female (39.2 vs 38.0, p = 0.51), but more often demonstrated a higher Elixhauser comorbidity index (4.19 ± 1.40 vs 3.93 ± 1.39, p < 0.001).After adjustment, congestive heart failure (AOR 1.54, 95%CI 1.25-1.91), cardiac arrhythmias (AOR 1.54, 95%CI 1.34-1.78), peripheral vascular disease (AOR 1.29, 95%CI 1.02-1.63), coagulopathies (AOR 1.63, 95%CI 1.38-1.92), previous history of VTE (AOR 1.14, 95%CI 1.06-1.22), and heparin-induced thrombocytopenia (AOR 2.61, 95%CI 2.07-3.28) were associated with VTE. The development of VTE was linked with significantly greater in-hospital mortality (AOR 4.56, 95%CI 2.07-10.10), as well as infectious (AOR 2.59, 95%CI 1.55-4.21), cardiac (AOR 2.59, 95%CI 1.39-4.82), and respiratory (AOR 1.78, 95%CI 1.21-2.63) complications. VTE was further associated with increased length of stay (+8.18 days, 95%CI +1.32-15.41), expenditures (+$42,000, 95%CI $24,800-59,210), and odds of VTE upon readmission (AOR 4.51, 95%CI 1.32-15.41).

Conclusions

VTE after abdominal transplantation is linked with significantly greater in-hospital mortality, complications, resource utilization, and risk of VTE at readmission. Novel risk assessments and prophylaxis protocols are needed to reduce VTE incidence and sequelae.

Haemostasis in cirrhosis: Understanding destabilising factors during acute decompensation

Hospitalised patients with decompensated cirrhosis are in a rebalanced haemostatic state due to a parallel decline in both pro- and anti-haemostatic pathways. However, this rebalanced haemostatic state is highly susceptible to perturbations and may easily tilt towards hypocoagulability and bleeding. Acute kidney injury, bacterial infections and sepsis, and progression from acute decompensation to acute-on-chronic liver failure are associated with additional alterations of specific haemostatic pathways and a higher risk of bleeding. Unfortunately, there is no single laboratory method that can accurately stratify an individual patient's bleeding risk and guide pre-procedural prophylaxis. A better understanding of haemostatic alterations during acute illness would lead to more rational and individualised management of hospitalised patients with decompensated cirrhosis. This review will outline the latest findings on haemostatic alterations driven by acute kidney injury, bacterial infections/sepsis, and acute-on-chronic liver failure in these difficult-to-treat patients and provide evidence supporting more tailored management of bleeding risk.

Immune System Dysfunction and Inflammation in Hemodialysis Patients: Two Sides of the Same Coin

Biocompatibility in hemodialysis (HD) has considerably improved in recent decades, but remains an open issue to be solved, appearing essential to reduce systemic inflammation and enhance patients’ clinical outcomes. Clotting prevention, reduction in complement and leukocyte activation, and improvement of antioxidant effect represent the main goals. This review aims to analyze the different pathways involved in HD patients, leading to immune system dysfunction and inflammation. In particular, we mostly review the evidence about thrombogenicity, which probably represents the most important characteristic of bio-incompatibility. Platelet activation is one of the first steps occurring in HD patients, determining several events causing chronic sub-clinical inflammation and immune dysfunction involvement. Moreover, oxidative stress processes, resulting from a loss of balance between pro-oxidant factors and antioxidant mechanisms, have been described, highlighting the link with inflammation. We updated both innate and acquired immune system dysfunctions and their close link with uremic toxins occurring in HD patients, with several consequences leading to increased mortality. The elucidation of the role of immune dysfunction and inflammation in HD patients would enhance not only the understanding of disease physiopathology, but also has the potential to provide new insights into the development of therapeutic strategies.