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Ji JH, Kim HW, Park J, Park SJ, Cheon JH, Kim TI, Park JJ. Risk factors for post-polypectomy bleeding in patients with end-stage renal disease undergoing colonoscopic polypectomy. Surg Endosc 2024; 38:846-856. [PMID: 38082006 DOI: 10.1007/s00464-023-10626-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 11/29/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND AND AIMS Little is known about the risk factors of bleeding after colonoscopic polypectomy in patients with end-stage renal disease (ESRD). This study investigated the incidence and risk factors of post-polypectomy bleeding (PPB), including immediate and delayed bleeding, in patients with ESRD. METHODS Ninety-two patients with ESRD who underwent colonoscopic polypectomy between September 2005 and June 2020 at a single tertiary referral center were included. The patients' medical records were retrospectively reviewed. Patient- and polyp-related factors associated with immediate PPB (IPPB) were analyzed using logistic regression analysis. Additionally, the optimal cutoff polyp size related to a significant increase in the risk of IPPB was determined by performing receiver operating characteristic (ROC) analysis and calculating the area under the ROC curve (AUC). RESULTS In total, 286 polyps were removed. IPPB occurred in 24 (26.1%) patients and 46 (16.1%) polyps and delayed PPB occurred in 2 (2.2%) patients. According to multivariate analysis, the polyp size (> 7 mm), old age (> 70), and endoscopic mucosal resection (EMR) as the polypectomy method (EMR versus non-EMR) were found to be independent risk factors for IPPB. According to the Youden index method, the optimal cutoff polyp size to identify high-risk polyps for IPPB was 7 mm (AUC = 0.755; sensitivity, 76.1%; specificity, 69.6%). CONCLUSIONS Colonoscopic polypectomy should be performed with caution in patients with ESRD, especially in those with the following risk factors: advanced age (> 70 years), polyp size > 7 mm, and EMR as the polypectomy method.
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Affiliation(s)
- Jung Hyun Ji
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Woo Kim
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jihye Park
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Jun Park
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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2
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Kukreja N, Rodriguez IE, Moore HB, LaRiviere W, Crouch C, Stewart E, Nydam TL, Kennealey P, Hendrickse AD, Pomfret EA, Fernandez-Bustamante A. The in-vitro influence of urea concentration on thromboelastrography in patients with and without end stage renal disease. Am J Surg 2023; 226:817-822. [PMID: 37407391 PMCID: PMC10733546 DOI: 10.1016/j.amjsurg.2023.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/25/2023] [Accepted: 06/20/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND End stage renal disease (ESRD) is associated with platelet dysfunction but also thromboembolic complications. The specific role of increased blood urea nitrogen (BUN) on coagulation is unclear. We aimed to characterize thromboelastography (TEG) parameters from males and females with ESRD and normal kidney function and evaluate if exogenous urea in vitro reproduced those TEG differences. METHODS We collected blood samples from 20 living kidney donors and 20 kidney recipients. TEG was performed without and with two increasing urea concentrations in vitro. TEG parameters were compared between recipients and donors. RESULTS Blood from kidney recipients showed baseline increased maximum amplitude (MA) and shortened time to maximum amplitude (TMA) compared to donors. These differences were not confirmed in females. In all patients, BUN was inversely correlated with TMA (r = -0.342; p = 0.031). In males, BUN and creatinine concentrations showed a direct correlation with MA (0.583; p = 0.007) and an inverse correlation with TMA (r = -0.520; p = 0.019). Urea in vitro decreased R-time (p = 0.005) and increased LY30 (p = 0.009) in donors but not recipients. CONCLUSIONS ESRD is associated with increased MA and decreased TMA on TEG. No change in MA was observed with increasing urea concentrations in vitro. Gender-specific variability in TEG parameters were observed.
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Affiliation(s)
- Naveen Kukreja
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Ivan E Rodriguez
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hunter B Moore
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Cara Crouch
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Erin Stewart
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Trevor L Nydam
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Peter Kennealey
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adrian D Hendrickse
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Elizabeth A Pomfret
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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Gomchok D, Ge RL, Wuren T. Platelets in Renal Disease. Int J Mol Sci 2023; 24:14724. [PMID: 37834171 PMCID: PMC10572297 DOI: 10.3390/ijms241914724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/18/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023] Open
Abstract
Kidney disease is a major global health concern, affecting millions of people. Nephrologists have shown interest in platelets because of coagulation disorders caused by renal diseases. With a better understanding of platelets, it has been found that these anucleate and abundant blood cells not only play a role in hemostasis, but also have important functions in inflammation and immunity. Platelets are not only affected by kidney disease, but may also contribute to kidney disease progression by mediating inflammation and immune effects. This review summarizes the current evidence regarding platelet abnormalities in renal disease, and the multiple effects of platelets on kidney disease progression. The relationship between platelets and kidney disease is still being explored, and further research can provide mechanistic insights into the relationship between thrombosis, bleeding, and inflammation related to kidney disease, and elucidate targeted therapies for patients with kidney disease.
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Affiliation(s)
- Drolma Gomchok
- Research Center for High Altitude Medicine, School of Medicine, Qinghai University, Xining 810001, China; (D.G.); (R.-L.G.)
| | - Ri-Li Ge
- Research Center for High Altitude Medicine, School of Medicine, Qinghai University, Xining 810001, China; (D.G.); (R.-L.G.)
- Key Laboratory for Application for High Altitude Medicine, Qinghai University, Xining 810001, China
| | - Tana Wuren
- Research Center for High Altitude Medicine, School of Medicine, Qinghai University, Xining 810001, China; (D.G.); (R.-L.G.)
- Key Laboratory for Application for High Altitude Medicine, Qinghai University, Xining 810001, China
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Karvellas CJ, Gustot T, Fernandez J. Management of the acute on chronic liver failure in the intensive care unit. Liver Int 2023. [PMID: 37365997 DOI: 10.1111/liv.15659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/01/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
Acute on chronic liver failure (ACLF) reflects the development of organ failure(s) in a patient with cirrhosis and is associated with high short-term mortality. Given that ACLF has many different 'phenotypes', medical management needs to take into account the relationship between precipitating insult, organ systems involved and underlying physiology of chronic liver disease/cirrhosis. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (e.g. infection, severe alcoholic hepatitis and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo liver transplantation or recovery. Management of these patients is complex since they are prone to develop new organ failures and infectious or bleeding complications. ICU therapy parallels that applied in the general ICU population in some complications but differs in others. Given that liver transplantation in ACLF is an emerging and evolving field, multidisciplinary teams with expertise in critical care and transplant medicine best accomplish management of the critically ill ACLF patient. The focus of this review is to identify the common complications of ACLF and to describe the proper management in critically ill patients awaiting liver transplantation in our centres, including organ support, prognostic assessment and how to assess when recovery is unlikely.
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Affiliation(s)
- Constantine J Karvellas
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
| | - Thierry Gustot
- Department of Gastroenterology, Hepato-Pancreatology and Digestive Oncology, H.U.B., CUB Hôpital Erasme, Brussels, Belgium
| | - Javier Fernandez
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Barcelona, Spain
- EF CLIF, EASL-CLIF Consortium, Barcelona, Spain
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Muacevic A, Adler JR, Hong J. Spontaneous Retroperitoneal Hematoma: A Deadly Complication for Patients Awaiting Liver Transplant. Cureus 2022; 14:e32522. [PMID: 36654646 PMCID: PMC9838682 DOI: 10.7759/cureus.32522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Patients with end-stage liver disease (ESLD) are at increased risk for hemorrhage and spontaneous retroperitoneal hematoma (sRPH) and also carry a high mortality rate. We sought to review the natural history of sRPH in patients with ESLD at a single center. METHODS All patients admitted to a single transplantation intensive care unit (TICU) at Froedtert and the Medical College of Wisconsin Transplant Center between June 2016 and August 2018 were retrospectively reviewed. Six ESLD patients with sRPH were studied. Clinical outcome measures were liver disease severity, sRPH treatment, and patient survival. RESULTS Six patients were included, four male and two female patients, with a median age of 56.5 years (range 30-67 years). All had alcohol-induced liver cirrhosis. The median Model for End-Stage Liver Disease (MELD) score at the time of sRPH diagnosis was 40 (range 30-43). The most commonly identified source of bleeding was from lumbar arteries. One patient had recurrent bleeding after embolization and underwent repeat embolization. Five patients died. The median time to death from the diagnosis of sRPH was 7.2 days (range 2-12 days). The patient who survived following embolization had the lowest MELD score. CONCLUSION Critically ill cirrhotic patients with sRPH have a significant mortality rate. Embolization is successful, albeit seldom. This is the largest retrospective series of sRPH in cirrhotic patients in the literature.
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Binder V, Chruścicka-Smaga B, Bergum B, Jaisson S, Gillery P, Sivertsen J, Hervig T, Kaminska M, Tilvawala R, Nemmara VV, Thompson PR, Potempa J, Marti HP, Mydel P. Carbamylation of Integrin α IIb β 3: The Mechanistic Link to Platelet Dysfunction in ESKD. J Am Soc Nephrol 2022; 33:1841-1856. [PMID: 36038265 PMCID: PMC9528322 DOI: 10.1681/asn.2022010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 06/05/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Bleeding diatheses, common among patients with ESKD, can lead to serious complications, particularly during invasive procedures. Chronic urea overload significantly increases cyanate concentrations in patients with ESKD, leading to carbamylation, an irreversible modification of proteins and peptides. METHODS To investigate carbamylation as a potential mechanistic link between uremia and platelet dysfunction in ESKD, we used liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) to quantify total homocitrulline, and biotin-conjugated phenylglyoxal labeling and Western blot to detect carbamylated integrin α IIb β 3 (a receptor required for platelet aggregation). Flow cytometry was used to study activation of isolated platelets and platelet-rich plasma. In a transient transfection system, we tested activity and fibrinogen binding of different mutated forms of the receptor. We assessed platelet adhesion and aggregation in microplate assays. RESULTS Carbamylation inhibited platelet activation, adhesion, and aggregation. Patients on hemodialysis exhibited significantly reduced activation of α IIb β 3 compared with healthy controls. We found significant carbamylation of both subunits of α IIb β 3 on platelets from patients receiving hemodialysis versus only minor modification in controls. In the transient transfection system, modification of lysine 185 in the β 3 subunit was associated with loss of receptor activity and fibrinogen binding. Supplementation of free amino acids, which was shown to protect plasma proteins from carbamylation-induced damage in patients on hemodialysis, prevented loss of α IIb β 3 activity in vitro. CONCLUSIONS Carbamylation of α IIb β 3-specifically modification of the K185 residue-might represent a mechanistic link between uremia and dysfunctional primary hemostasis in patients on hemodialysis. The observation that free amino acids prevented the carbamylation-induced loss of α IIb β 3 activity suggests amino acid administration during dialysis may help to normalize platelet function.
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Affiliation(s)
- Veronika Binder
- Broegelmann Research Laboratory, University of Bergen, Bergen, Norway
| | | | - Brith Bergum
- Broegelmann Research Laboratory, University of Bergen, Bergen, Norway
| | - Stéphane Jaisson
- Laboratory of Biochemistry and Molecular Biology, Unité Mixte de Recherche (UMR) Centre National de la Recherche Scientifique (CNRS) 7369, University of Reims Champagne-Ardenne, Reims, France
| | - Philippe Gillery
- Laboratory of Biochemistry and Molecular Biology, Unité Mixte de Recherche (UMR) Centre National de la Recherche Scientifique (CNRS) 7369, University of Reims Champagne-Ardenne, Reims, France
| | - Joar Sivertsen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Tor Hervig
- Broegelmann Research Laboratory, University of Bergen, Bergen, Norway
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Marta Kaminska
- Broegelmann Research Laboratory, University of Bergen, Bergen, Norway
| | - Ronak Tilvawala
- Department of Biochemistry and Pharmacology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Venkatesh V. Nemmara
- Department of Biochemistry and Pharmacology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Paul R. Thompson
- Department of Biochemistry and Pharmacology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jan Potempa
- Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
- Department of Oral Immunology and Infectious Diseases, University of Louisville School of Dentistry, Louisville, Kentucky
| | - Hans-Peter Marti
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Piotr Mydel
- Broegelmann Research Laboratory, University of Bergen, Bergen, Norway
- Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
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Fishbane S, Ganz T, Pratt RD. Ferric pyrophosphate citrate for parenteral administration of maintenance iron: structure, mechanism of action, clinical efficacy and safety. Curr Med Res Opin 2022; 38:1417-1429. [PMID: 35726771 DOI: 10.1080/03007995.2022.2092373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Anemia is a common complication in patients with hemodialysis-dependent chronic kidney disease (HDD-CKD). Anemia is principally the result of erythropoietin deficiency, inflammation, and iron deficiency. High molecular weight iron oxide nanoparticles (IONP) are routinely administered intravenously to replace iron losses and, although effective, there are lingering concerns about possible safety issues. Ferric pyrophosphate citrate (FPC, Triferic, Triferic AVNU [Triferic and Triferic AVNU are the proprietary name for ferric pyrophosphate citrate. Triferic and Triferic AVNU are registered trademarks of Rockwell medical Inc.]) is a complex iron salt that donates iron directly to plasma transferrin. FPC is devoid of any carbohydrate moiety and is administered via the dialysate or intravenously during each hemodialysis session to replace iron and maintain hemoglobin. Controlled clinical trials of up to 48 weeks in duration have demonstrated the efficacy of regular administration of dialysate FPC for maintaining hemoglobin levels and iron balance in HDD-CKD patients. Clinical data also suggest that dialysate FPC may reduce the dose requirements for and use of erythropoiesis-stimulating agents and IONPs in HDD-CKD patients. Safety data from clinical studies and post-marketing surveillance show that FPC is well tolerated and not associated with an increased risk of infection, inflammation, iron overload, or serious hypersensitivity reactions. FPC represents an effective and well-tolerated choice for iron replacement and maintenance of hemoglobin in the long-term management of HDD-CKD patients.
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Affiliation(s)
- Steven Fishbane
- Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Tomas Ganz
- University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA
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Smyth A, Judge C, Wang X, Pare G, Rangarajan S, Canavan M, Chin SL, Al-Hussain F, Yusufali AM, Elsayed A, Damasceno A, Avezum A, Czlonkowska A, Rosengren A, Dans AL, Oguz A, Mondo C, Weimar C, Ryglewicz D, Xavier D, Lanas F, Malaga G, Hankey GJ, Iversen HK, Zhang H, Yusoff K, Pogosova N, Lopez-Jamarillo P, Langhorne P, Diaz R, Oveisgharan S, Yusuf S, O'Donnell M. Renal Impairment and Risk of Acute Stroke: The INTERSTROKE Study. Neuroepidemiology 2021; 55:206-215. [PMID: 33951632 DOI: 10.1159/000515239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/11/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Previous studies reported an association of renal impairment with stroke, but there are uncertainties underpinning this association. AIMS We explored if the association is explained by shared risk factors or is independent and whether there are regional or stroke subtype variations. METHODS INTERSTROKE is a case-control study and the largest international study of risk factors for first acute stroke, completed in 27 countries. We included individuals with available serum creatinine values and calculated estimated glomerular filtration rate (eGFR). Renal impairment was defined as eGFR <60 mL/min/1.73 m2. Multivariable conditional logistic regression was used to determine the association of renal function with stroke. RESULTS Of 21,127 participants, 41.0% were female, the mean age was 62.3 ± 13.4 years, and the mean eGFR was 79.9 ± 23.5 mL/min/1.73 m2. The prevalence of renal impairment was higher in cases (22.9% vs. 17.7%, p < 0.001) and differed by region (p < 0.001). After adjustment, lower eGFR was associated with increased odds of stroke. Renal impairment was associated with increased odds of all stroke (OR 1.35; 95% CI: 1.24-1.47), with higher odds for intracerebral hemorrhage (OR 1.60; 95% CI: 1.35-1.89) than ischemic stroke (OR 1.29; 95% CI: 1.17-1.42) (pinteraction 0.12). The largest magnitudes of association were seen in younger participants and those living in Africa, South Asia, or South America (pinteraction < 0.001 for all stroke). Renal impairment was also associated with poorer clinical outcome (RRR 2.97; 95% CI: 2.50-3.54 for death within 1 month). CONCLUSION Renal impairment is an important risk factor for stroke, particularly in younger patients, and is associated with more severe stroke and worse outcomes.
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Affiliation(s)
- Andrew Smyth
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.,HRB Clinical Research Facility Galway, School of Medicine, NUI Galway, Galway, Ireland.,Department of Nephrology, Galway University Hospitals, Galway, Ireland
| | - Conor Judge
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.,HRB Clinical Research Facility Galway, School of Medicine, NUI Galway, Galway, Ireland.,Department of Nephrology, Galway University Hospitals, Galway, Ireland
| | - Xingu Wang
- Beijing Hypertension League Institute, Beijing, China
| | - Guillaume Pare
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Michelle Canavan
- HRB Clinical Research Facility Galway, School of Medicine, NUI Galway, Galway, Ireland
| | - Siu Lim Chin
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | | | | | | | | | | | - Annika Rosengren
- Sahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Antonio L Dans
- College of Medicine, University of Philippines, Manila, Philippines
| | - Aytekin Oguz
- Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Charles Mondo
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
| | | | | | - Denis Xavier
- St John's Medical College and Research Institute, Bangalore, India
| | - Fernando Lanas
- Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
| | | | - Graeme J Hankey
- School of Medicine and Pharmacology, The University of Western Australia, Perth, Washington, Australia
| | - Helle K Iversen
- Stroke Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hongye Zhang
- Beijing Hypertension League Institute, Beijing, China
| | - Khalid Yusoff
- Universiti Teknologi MARA, Selayang, Selangor, Malaysia, UCSI University, Cheras, Kuala Lumpur, Malaysia
| | - Nana Pogosova
- National Medical Research Center of Cardiology, Moscow, Russian Federation
| | - Patricio Lopez-Jamarillo
- Instituto de Investigaciones FOSCAL, Escuela de Medicina, Universidad de Santander, Bucaramanga, Colombia
| | - Peter Langhorne
- Academic Section of Geriatric Medicine, Glasgow Royal Infirmary, University of Glasgow, Glasgow, United Kingdom
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica, Rosario, Argentina
| | - Shahram Oveisgharan
- Rush Alzheimer Disease Research Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Martin O'Donnell
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.,HRB Clinical Research Facility Galway, School of Medicine, NUI Galway, Galway, Ireland
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Grant JK, Ebner B, Vincent L, Maning J, Olorunfemi O, Olarte NI, Colombo R, Munagala M, Chaparro S. Assessing in-hospital cardiovascular, thrombotic and bleeding outcomes in patients with chronic liver disease undergoing left ventricular assist device implantation. Thromb Res 2021; 202:184-190. [PMID: 33892219 DOI: 10.1016/j.thromres.2021.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Chronic liver disease (CLD) and advanced heart failure (HF) often co-exist with coagulopathy and hematologic abnormalities being major concerns in this cohort. Perioperative outcomes of patients undergoing LVAD implantation can be affected by coagulopathy, associated with a higher International Normalized Ratio (INR) and cytopenias, as well as pre-operative use of antiplatelet therapy and systemic anticoagulation. Our study is aimed at evaluating the in-hospital mortality and clinical outcomes of patients with CLD who underwent LVAD implantation compared to patients who underwent LVAD implantation without CLD. METHODS The National Inpatient Sample Database was queried from 2012 to 2017 for relevant International Classification of Diseases (ICD)-9 and ICD-10 procedural and diagnostic codes. Baseline characteristics and in-hospital outcomes were compared in patients with chronic liver disease and those without, who underwent LVAD implantation. RESULTS A total of 22,955 patients underwent LVAD implantation, 2200 of which had CLD. There was no difference in mean age between those with and without CLD (52.8 ± 14.2 vs. 55.7 ± 15.4 years old, p < 0.001), and 23.7% of patients were female. The proportion of patients with CLD undergoing LVAD implantation trended downward between 2012 and 2017 (average annual growth rate: "-14.8%"). In-hospital post-LVAD outcomes revealed: all-cause inpatient mortality (14.8% vs. 11.1%), major bleeding (34.3% vs. 30.2%), transfusion of platelets (18.0% vs. 14.0%), subarachnoid hemorrhage (1.6% vs. 0.7%) and hospital length of stay were greater in patients with CLD (p < 0.001 for all values). LVAD thrombosis (6.6% vs. 9.4%) and postoperative ischemic stroke (3.4% vs. 6.1%) occurred less in patients with CLD (p < 0.001 for both). There were no statistically significant differences in occurrence of post-LVAD gastrointestinal bleeding and transfusion of fresh frozen plasma or packed red blood cells (p > 0.05 for all). Using a multivariate logistic regression model to adjust for confounding factors, CLD was predictive of increased in-hospital all-cause mortality in patients undergoing LVAD implantation (adjusted odds ratio: 1.29, 95% confidence interval [CI]; 1.06 to 1.56, p = 0.010). CONCLUSION LVAD implantation in patients with chronic liver disease was associated with increased mortality and post-LVAD major bleeding with increased utilization of platelet products yet comparable thrombotic complications. Further studies are needed to evaluate the balance and pathophysiology of bleeding risks when compared to thrombosis, as well as predictors in patients with chronic liver disease.
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Affiliation(s)
- Jelani K Grant
- Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, United States of America.
| | - Bertrand Ebner
- Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, United States of America
| | - Louis Vincent
- Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, United States of America
| | - Jennifer Maning
- Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, United States of America
| | - Odunayo Olorunfemi
- Cardiovascular Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, United States of America
| | - Neal I Olarte
- Cardiovascular Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, United States of America
| | - Rosario Colombo
- Cardiovascular Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, United States of America
| | - Mrudula Munagala
- Cardiovascular Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, United States of America
| | - Sandra Chaparro
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, United States of America
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10
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Putz FJ, Jung EM, Putz C, Banas MC, Bergler T, Vienken J, Banas B. Contrast-Enhanced Ultrasonography as a Novel Method for the Dynamic Visualization of Blood Flow and Fiber Blockage in Dialyzers: A Feasibility Study. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:2265-2275. [PMID: 32553530 DOI: 10.1016/j.ultrasmedbio.2020.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/07/2020] [Accepted: 05/05/2020] [Indexed: 06/11/2023]
Abstract
The capillary dialyzer represents the central element of the extracorporeal blood circuit of a therapy system for hemodialysis. The aim of this study was to assess the blood-flow characteristics of dialyzers with the help of modern ultrasound techniques. Five brand-new dialyzers (FX80 classix, Fresenius Medical Care, Bad Homburg, Germany) and five dialyzers after a dialysis session were analyzed by different ultrasound techniques to detect functional and structural changes. B-mode and Doppler techniques were not suitable to describe differences in brand-new and clinically applied dialyzers. Contrast-enhanced ultrasonography, however, was able to visualize blood-flow profiles in the capillaries. Although dialyzers displayed no signs of clinical dysfunction, contrast-enhanced ultrasonography was able to detect blocked capillaries of varying degrees after a dialysis session in all five examined dialyzers. Consequently, the blood-flow velocity was higher in the remaining unblocked capillaries in comparison to the velocity in the brand-new dialyzers. This information may be helpful for improving the geometric design of dialyzers, including their capillary membranes, and optimizing anti-coagulation strategies in hemodialysis patients.
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Affiliation(s)
- Franz Josef Putz
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany.
| | - Ernst Michael Jung
- Interdisciplinary Ultrasound Department, University Hospital Regensburg, Regensburg, Germany
| | - Christina Putz
- Department of Cardio-thoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Miriam C Banas
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Tobias Bergler
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | | | - Bernhard Banas
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
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11
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Beuscher VD, Sprügel MI, Gerner ST, Sembill JA, Madzar D, Reindl C, Lücking H, Lang S, Hoelter P, Kuramatsu JB, Huttner HB. Chronic Kidney Disease and Clinical Outcomes in Patients with Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:104802. [PMID: 32689604 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104802] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/05/2020] [Accepted: 03/02/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND PURPOSE The influence of chronic kidney disease (CKD) on functional outcome in intracerebral hemorrhage (ICH) is scarcely investigated and reported findings are conflicting mostly because of nonaccounting for imbalances. Aim of the present study was to determine the impact of CKD on functional long-term outcome in ICH-patients. METHODS In this observational cohort study of spontaneous ICH-patients admitted to our Department of Neurology between 2006 and 2015 we investigated retrospectively as primary outcome the dichotomized functional status (modified-Rankin-Scale = 0-3-versus-4-6) at 12 months according to renal function (CKD versus non-CKD), including categorial estimates of the glomerular filtration rate subanalyses. Confounding was addressed by propensity-score(ps)-matching and adjusted multivariable regression analyses. RESULTS We identified 1076 eligible ICH-patients, of which 131 (12.2%) suffered from CKD on hospital admission. Confounders associated with CKD consisted of hypertension (P = .023), Diabetes mellitus (P = .001), prior ischemic stroke and/or transitory ischemic attack (TIA) (P = .021), congestive heart failure (P < .01), impaired liver function (P < .01), antiplatelet therapy (P = .01), poorer premorbid functional status (P < .01), and deep ICH-location (P = .006). After balancing for confounding, patients with CKD showed a significantly decreased rate of favorable functional outcome at 12 months (CKD:29 of 111(26.1%)-versus-non-CKD:78 of 206 (37.9%); P = .035). Subanalyses showed that stages of CKD were evenly associated with mortality at 12 months (GFR category G3a, OR:2.811; CI (1.130-6.994); P = .026; GFR category G3b, OR:1.874; CI (.694-5.058); P = .215; GFR category G4, OR:10.316; CI (1.976-53.856); P = .006; GFR category G5, OR:8.989; CI (1.900-42.518); P = .006). CONCLUSIONS As compared to ICH-patients without CKD, those with CKD show increased rates of mortality and worse functional outcomes even after statistical correction for imbalanced baseline characteritsics. This finding is presumably linked to comorbidity and warrants further investigation in prospective studies.
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Affiliation(s)
- Vanessa D Beuscher
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany.
| | | | - Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Jochen A Sembill
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Dominik Madzar
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Caroline Reindl
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Hannes Lücking
- Department of Neuroradiology, University Hospital Erlangen, Erlangen, Germany
| | - Stefan Lang
- Department of Neuroradiology, University Hospital Erlangen, Erlangen, Germany
| | - Philip Hoelter
- Department of Neuroradiology, University Hospital Erlangen, Erlangen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
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12
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Sarin SK, Choudhury A, Sharma MK, Maiwall R, Al Mahtab M, Rahman S, Saigal S, Saraf N, Soin AS, Devarbhavi H, Kim DJ, Dhiman RK, Duseja A, Taneja S, Eapen CE, Goel A, Ning Q, Chen T, Ma K, Duan Z, Yu C, Treeprasertsuk S, Hamid SS, Butt AS, Jafri W, Shukla A, Saraswat V, Tan SS, Sood A, Midha V, Goyal O, Ghazinyan H, Arora A, Hu J, Sahu M, Rao PN, Lee GH, Lim SG, Lesmana LA, Lesmana CR, Shah S, Prasad VGM, Payawal DA, Abbas Z, Dokmeci AK, Sollano JD, Carpio G, Shresta A, Lau GK, Fazal Karim M, Shiha G, Gani R, Kalista KF, Yuen MF, Alam S, Khanna R, Sood V, Lal BB, Pamecha V, Jindal A, Rajan V, Arora V, Yokosuka O, Niriella MA, Li H, Qi X, Tanaka A, Mochida S, Chaudhuri DR, Gane E, Win KM, Chen WT, Rela M, Kapoor D, Rastogi A, Kale P, Rastogi A, Sharma CB, Bajpai M, Singh V, Premkumar M, Maharashi S, Olithselvan A, Philips CA, Srivastava A, Yachha SK, Wani ZA, Thapa BR, Saraya A, Shalimar, Kumar A, Wadhawan M, Gupta S, Madan K, Sakhuja P, Vij V, Sharma BC, Garg H, Garg V, Kalal C, Anand L, Vyas T, Mathur RP, Kumar G, Jain P, Pasupuleti SSR, Chawla YK, Chowdhury A, Alam S, Song DS, Yang JM, Yoon EL. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update. Hepatol Int 2019; 13:353-390. [PMID: 31172417 PMCID: PMC6728300 DOI: 10.1007/s12072-019-09946-3] [Citation(s) in RCA: 434] [Impact Index Per Article: 86.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 04/03/2019] [Indexed: 02/07/2023]
Abstract
The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set up in 2004 on acute-on-chronic liver failure (ACLF) was published in 2009. With international groups volunteering to join, the "APASL ACLF Research Consortium (AARC)" was formed in 2012, which continued to collect prospective ACLF patient data. Based on the prospective data analysis of nearly 1400 patients, the AARC consensus was published in 2014. In the past nearly four-and-a-half years, the AARC database has been enriched to about 5200 cases by major hepatology centers across Asia. The data published during the interim period were carefully analyzed and areas of contention and new developments in the field of ACLF were prioritized in a systematic manner. The AARC database was also approached for answering some of the issues where published data were limited, such as liver failure grading, its impact on the 'Golden Therapeutic Window', extrahepatic organ dysfunction and failure, development of sepsis, distinctive features of acute decompensation from ACLF and pediatric ACLF and the issues were analyzed. These initiatives concluded in a two-day meeting in October 2018 at New Delhi with finalization of the new AARC consensus. Only those statements, which were based on evidence using the Grade System and were unanimously recommended, were accepted. Finalized statements were again circulated to all the experts and subsequently presented at the AARC investigators meeting at the AASLD in November 2018. The suggestions from the experts were used to revise and finalize the consensus. After detailed deliberations and data analysis, the original definition of ACLF was found to withstand the test of time and be able to identify a homogenous group of patients presenting with liver failure. New management options including the algorithms for the management of coagulation disorders, renal replacement therapy, sepsis, variceal bleed, antivirals and criteria for liver transplantation for ACLF patients were proposed. The final consensus statements along with the relevant background information and areas requiring future studies are presented here.
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Affiliation(s)
- Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Manoj K Sharma
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Salimur Rahman
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Sanjiv Saigal
- Department of Hepatology, Medanta The Medicity, Gurgaon, India
| | - Neeraj Saraf
- Department of Hepatology, Medanta The Medicity, Gurgaon, India
| | - A S Soin
- Department of Hepatology, Medanta The Medicity, Gurgaon, India
| | | | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, South Korea
| | - R K Dhiman
- Department of Hepatology, PGIMER, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, PGIMER, Chandigarh, India
| | - Sunil Taneja
- Department of Hepatology, PGIMER, Chandigarh, India
| | - C E Eapen
- Department of Hepatology, CMC, Vellore, India
| | - Ashish Goel
- Department of Hepatology, CMC, Vellore, India
| | - Q Ning
- Institute and Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Chen
- Translational Hepatology Institute Capital Medical University, Beijing You'an Hospital, Beijing, China
| | - Ke Ma
- Institute and Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Z Duan
- Translational Hepatology Institute Capital Medical University, Beijing You'an Hospital, Beijing, China
| | - Chen Yu
- Translational Hepatology Institute Capital Medical University, Beijing You'an Hospital, Beijing, China
| | | | - S S Hamid
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Amna S Butt
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Wasim Jafri
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Akash Shukla
- Department of Gastroenterology, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
| | | | - Soek Siam Tan
- Department of Medicine, Hospital Selayang, Bata Caves, Selangor, Malaysia
| | - Ajit Sood
- Department of Gastroenterology, DMC, Ludhiana, India
| | - Vandana Midha
- Department of Gastroenterology, DMC, Ludhiana, India
| | - Omesh Goyal
- Department of Gastroenterology, DMC, Ludhiana, India
| | - Hasmik Ghazinyan
- Department of Hepatology, Nork Clinical Hospital of Infectious Disease, Yerevan, Armenia
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital and GRIPMER, New Delhi, Delhi, India
| | - Jinhua Hu
- Department of Medicine, 302 Millitary Hospital, Beijing, China
| | - Manoj Sahu
- Department of Gastroenterology and Hepatology Sciences, IMS & SUM Hospital, Bhubaneswar, Odisha, India
| | - P N Rao
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Guan H Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Seng G Lim
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
| | | | | | - Samir Shah
- Department of Hepatology, Global Hospitals, Mumbai, India
| | | | - Diana A Payawal
- Fatima University Medical Center Manila, Manila, Philippines
| | - Zaigham Abbas
- Department of Medicine, Ziauddin University Hospital, Karachi, Pakistan
| | - A Kadir Dokmeci
- Department of Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Jose D Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Gian Carpio
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Ananta Shresta
- Department of Hepatology, Foundation Nepal Sitapaila Height, Kathmandu, Nepal
| | - G K Lau
- Department of Medicine, Humanity and Health Medical Group, New Kowloon, Hong Kong, China
| | - Md Fazal Karim
- Department of Hepatology, Sir Salimullah Medical College, Dhaka, Bangladesh
| | - Gamal Shiha
- Egyptian Liver Research Institute And Hospital, Cairo, Egypt
| | - Rino Gani
- Division of Hepatobiliary, Department of Internal Medicine, Faculty of Medicine, Cipto Mangunkusumo Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Kemal Fariz Kalista
- Division of Hepatobiliary, Department of Internal Medicine, Faculty of Medicine, Cipto Mangunkusumo Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Man-Fung Yuen
- Department of Medicine, Queen Mary Hospital Hong Kong, The University of Hong Kong, Hong Kong, China
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Vikrant Sood
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Bikrant Bihari Lal
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Viniyendra Pamecha
- Department of Hepatobilliary Pancreatic Surgery and Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - V Rajan
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Vinod Arora
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | | | | | - Hai Li
- Department of Gastroenterology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaolong Qi
- CHESS Frontier Center, The First Hospital of Lanzhou University, Lanzhou University, Lanzhou, China
| | - Atsushi Tanaka
- Department of Medicine, Tokyo University School of Medicine, Tokyo, Japan
| | - Satoshi Mochida
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | | | - Ed Gane
- New Zealand Liver Transplant Unit, Auckland Hospital, Auckland, New Zealand
| | | | - Wei Ting Chen
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang Gung Medical Foundation, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Mohd Rela
- Department of Liver Transplant Surgery, Dr. Rela Institute and Medical Centre, Chennai, India
| | | | - Amit Rastogi
- Department of Hepatology, Medanta The Medicity, Gurgaon, India
| | - Pratibha Kale
- Department of Microbiology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Archana Rastogi
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Chhagan Bihari Sharma
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Meenu Bajpai
- Department of Immunohematology and Transfusion Medicine, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | | | | | | | - A Olithselvan
- Division of Liver Transplantation and Hepatology, Manipal Hospitals, Bangalore, India
| | - Cyriac Abby Philips
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, SGPGIMS, Lucknow, India
| | | | | | - B R Thapa
- Department of Gastroenterology and Pediatric Gastroenterology, PGIMER, Chandigarh, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition, AIIMS, New Delhi, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, AIIMS, New Delhi, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital and GRIPMER, New Delhi, Delhi, India
| | - Manav Wadhawan
- Department of Gastroenterology, Hepatology and Liver Transplant, B L K Hospital, New Delhi, India
| | - Subash Gupta
- Centre for Liver and Biliary Science, Max Hospital, New Delhi, India
| | - Kaushal Madan
- Department of Gastroenterology, Hepatology and Liver Transplant, Max Hospital, New Delhi, India
| | - Puja Sakhuja
- Department of Pathology, GB Pant Hospital, New Delhi, India
| | - Vivek Vij
- Department of Liver Transplant and Hepatobilliary Surgery, Fortis Hospital, New Delhi, India
| | - Barjesh C Sharma
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Hitendra Garg
- Department of Gastroenterology, Hepatology and Liver Transplant, Apollo Hospital, New Delhi, India
| | - Vishal Garg
- Department of Gastroenterology, Hepatology and Liver Transplant, Apollo Hospital, New Delhi, India
| | - Chetan Kalal
- Department of Hepatology, Sir H N Reliance Hospital and Research Centre, Mumbai, India
| | - Lovkesh Anand
- Department of Gastroenterology and Hepatology, Narayana Hospital, Gurugram, India
| | - Tanmay Vyas
- Department of Hepatology, Parimal Multi-Speciality Hospital, Ahmedabad, India
| | - Rajan P Mathur
- Department of Nephrology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Statistics and Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Priyanka Jain
- Department of Statistics and Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Samba Siva Rao Pasupuleti
- Department of Statistics and Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Yogesh K Chawla
- Department of Hepatology and Gastroenterology, Kalinga Institute of Med Sciences, KIIT University, Bhubaneswar, India
| | - Abhijit Chowdhury
- Department of Hepatology, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Shahinul Alam
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Do Seon Song
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Eileen L Yoon
- Department Of Internal Medicine, Inje University College of Medicine, Busan, South Korea
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13
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Chokesuwattanaskul R, Thongprayoon C, Bathini T, Torres-Ortiz A, O'Corragain OA, Watthanasuntorn K, Lertjitbanjong P, Sharma K, Prechawat S, Ungprasert P, Kröner PT, Wijarnpreecha K, Cheungpasitporn W. Efficacy and safety of anticoagulation for atrial fibrillation in patients with cirrhosis: A systematic review and meta-analysis. Dig Liver Dis 2019; 51:489-495. [PMID: 30594462 DOI: 10.1016/j.dld.2018.12.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 11/16/2018] [Accepted: 12/01/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The atrial fibrillation-related stroke is clearly prevented by anticoagulation treatment, however, management of anticoagulation for AF in patients with cirrhosis represents a challenge due to bleeding concerns. To address this issue, a systematic review and meta-analysis of the literature was performed. METHODS A literature search for studies reporting the incidence of AF in patients with cirrhosis was conducted using MEDLINE, EMBASE and Cochrane Database, from inception through July 2018. RESULTS 7 cohort studies including 19,798 patients with AF and cirrhosis were identified. The use of anticoagulation (%) among included studies ranged from 8.3% to 53.9%. Anticoagulation use for AF in patients with cirrhosis was significantly associated with a reduced risk of stroke, with a pooled HR of 0.58 (95%CI: 0.35-0.96). When compared with no anticoagulation, the use of anticoagulation was not significantly associated with a higher risk of bleeding, with a pooled HR of 1.45 (95%CI: 0.96-2.17). Compared to warfarin, the use of direct oral anticoagulants (DOACs) was associated with a lower risk of bleeding among AF patients with cirrhosis. CONCLUSION Our study demonstrates that anticoagulation use for AF in patients with cirrhosis is associated with a reduced risk of stroke, without increasing significantly the risk of bleeding, when compared to those without anticoagulation.
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Affiliation(s)
- Ronpichai Chokesuwattanaskul
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
| | | | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ, USA
| | - Aldo Torres-Ortiz
- Department of Medicine, University of Mississippi Medical Center, MS, USA
| | - Oisin A O'Corragain
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA, USA
| | | | | | - Konika Sharma
- Department of Internal Medicine, Bassett Medical Center, NY, USA
| | - Somchai Prechawat
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Patompong Ungprasert
- Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Paul T Kröner
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Karn Wijarnpreecha
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, FL, USA
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14
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Chokesuwattanaskul R, Thongprayoon C, Bathini T, O'Corragain OA, Sharma K, Preechawat S, Wijarnpreecha K, Kröner PT, Ungprasert P, Cheungpasitporn W. Epidemiology of atrial fibrillation in patients with cirrhosis and clinical significance: a meta-analysis. Eur J Gastroenterol Hepatol 2019; 31:514-519. [PMID: 30451705 DOI: 10.1097/meg.0000000000001315] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The epidemiology of atrial fibrillation (AF) in patients with cirrhosis and its clinical significance remain unclear. This study aimed (i) to investigate the pooled prevalence and/or incidence of AF in patients with cirrhosis and (ii) to assess the mortality risk of AF in patients with cirrhosis. PATIENTS AND METHODS A literature search for studies that reported incidence of AF in patients with cirrhosis was carried out using Medline, Embase, and Cochrane Database from inception through July 2018. Pooled incidence with 95% confidence interval (CI) was calculated using a random-effect model. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42018102664). RESULTS Seven cohort studies including 385 866 patients with cirrhosis were identified. The pooled estimated prevalence of AF in patients with cirrhosis was 5.0% (95% CI: 2.8-8.6%). When studies that solely assessed patients undergoing transplant evaluation or on transplant waiting list were excluded, the pooled estimated prevalence of AF in patients with cirrhosis was 7.4% (95% CI: 3.5-15.2%). There was a significant association between AF and increased mortality risk in cirrhotic patients with a pooled odds ratio of 1.44 (95% CI: 1.36-1.53). CONCLUSION The overall estimated prevalence of AF among patients with cirrhosis is 5.0%. Our study demonstrates a statistically significant increased mortality risk in cirrhotic patients with AF.
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Affiliation(s)
- Ronpichai Chokesuwattanaskul
- Department of Medicine, Division of Cardiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society
| | | | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, Arizona
| | - Oisin A O'Corragain
- Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania
| | - Konika Sharma
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, New York
| | - Somchai Preechawat
- Department of Medicine, Division of Cardiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society
| | | | - Paul T Kröner
- Division of Gastroenterology, Mayo Clinic, Jacksonville, Florida
| | - Patompong Ungprasert
- Department of Research and Development, Clinical Epidemiology Unit, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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15
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Gonzalez J, Bryant S, Hermes-DeSantis ER. Transdermal estradiol for the management of refractory uremic bleeding. Am J Health Syst Pharm 2019; 75:e177-e183. [PMID: 29691259 DOI: 10.2146/ajhp170241] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE The efficacy and thrombogenicity of transdermal estradiol in the management of refractory uremic bleeding in adults are examined. SUMMARY Platelet dysfunction from chronic kidney disease may induce uremic bleeding. This type of bleeding may involve the skin, oral and nasal mucosa, gingivae, respiratory system, and gastrointestinal or urinary tract. While the mainstay of treatment for uremic bleeding primarily involves dialysis and use of prohemostatic agents such as desmopressin and erythropoiesis-stimulating agents, certain patients may experience bleeding refractory to these interventions. In this clinical scenario, a weak conditional recommendation (grade 2C) supporting transdermal estradiol as a therapy of last resort exists. Limited data suggest that transdermal estradiol may reduce bleeding time and transfusion requirements in dialysis patients with recurrent episodes of hematochezia, gastrointestinal telangiectasia, and hematomas. The management of uremic bleeding will require long-term therapy, and case reports have documented the safe use of transdermal estradiol for up to 25 months. Oral conjugated estrogens increase the risk of deep vein thrombosis in women; however, the transdermal route of administration has been associated with a lower incidence of venous thromboembolism and stroke relative to oral estrogen and, in some studies, its associated risk of thrombosis is not significantly different when compared with placebo. CONCLUSION Patients who are refractory to routine interventions for uremic bleeding may benefit from transdermal estrogen despite the limited data. Extended therapy with low-dose transdermal estrogen (≤50 μg daily) may provide a hemostatic benefit that outweighs thrombotic risk.
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Affiliation(s)
- Jimmy Gonzalez
- Western New England University, College of Pharmacy and Health Sciences, Springfield, MA .,Cooley Dickinson Hospital, Northampton, MA
| | - Samantha Bryant
- Division of Drug Information, Food and Drug Administration, Silver Spring, MD
| | - Evelyn R Hermes-DeSantis
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ.,Robert Wood Johnson University Hospital, New Brunswick, NJ
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16
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Coagulation Defects in the Cirrhotic Patient Undergoing Liver Transplantation. Transplantation 2018; 102:1453-1458. [DOI: 10.1097/tp.0000000000002273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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17
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Suzuki M, Yoshioka M, Ohno Y, Akune Y. Plasma metabolomic analysis in mature female common bottlenose dolphins: profiling the characteristics of metabolites after overnight fasting by comparison with data in beagle dogs. Sci Rep 2018; 8:12030. [PMID: 30104643 PMCID: PMC6089887 DOI: 10.1038/s41598-018-30563-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 08/02/2018] [Indexed: 12/14/2022] Open
Abstract
The present study was aimed at determining the characteristics of plasma metabolites in bottlenose dolphins to provide a greater understanding of their metabolism and to obtain information for the health management of cetaceans. Capillary electrophoresis-time-of-flight mass spectrometry (CE-TOFMS) and liquid chromatograph-time-of-flight mass spectrometry (LC-TOFMS) were conducted on plasma samples after overnight fasting from three common bottlenose dolphins as well as three beagle dogs (representative terrestrial carnivores) for comparison. In total, 257 and 227 plasma metabolites were identified in the dolphins and the dogs, respectively. Although a small number of animals were used for each species, the heatmap patterns, a principal component analysis and a cluster analysis confirmed that the composition of metabolites could be segregated from each other. Of 257 compounds detected in dolphin plasma, 24 compounds including branched amino acids, creatinine, urea, and methylhistidine were more abundant than in dogs; 26 compounds including long-chained acyl-carnitines and fatty acids, astaxanthin, and pantothenic acid were detected only in dolphins. In contrast, 25 compounds containing lactic acid and glycerol 3-phosphate were lower in dolphins compared to dogs. These data imply active protein metabolism, differences in usage of lipids, a unique urea cycle, and a low activity of the glycolytic pathway in dolphins.
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Affiliation(s)
- Miwa Suzuki
- Department of Marine Resources and Sciences, College of Bioresource Sciences, Nihon University, Kameino, Fujisawa, Kanagawa, 252-0880, Japan.
| | - Motoi Yoshioka
- Cetacean Research Center, Graduate School of Bioresources, Mie University, Kurimamachiya, Tsu, Mie, 514-8507, Japan.
| | - Yoshito Ohno
- Port of Nagoya Public Aquarium, Minato, Nagoya, Aichi, 455-0033, Japan
| | - Yuichiro Akune
- Port of Nagoya Public Aquarium, Minato, Nagoya, Aichi, 455-0033, Japan
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18
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Hung A, Garcia-Tsao G. Acute kidney injury, but not sepsis, is associated with higher procedure-related bleeding in patients with decompensated cirrhosis. Liver Int 2018; 38:1437-1441. [PMID: 29393567 PMCID: PMC6072624 DOI: 10.1111/liv.13712] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 01/12/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bleeding after low-risk invasive procedures can be life-threatening or can lead to further complications in decompensated cirrhosis patients. In unstratified cohorts of hospitalized patients with cirrhosis, the rate of procedure-related bleeding is low despite abnormal coagulation parameters. Our objective was to identify patients with decompensated cirrhosis at a high risk of developing procedure-related bleeding in whom the value of pre-procedure transfusions could be assessed. METHODS Hospitalized patients with cirrhosis who developed post-paracentesis hemoperitoneum confirmed by CT scan, from the period of January 2012 to August 2016, constituted the study group. They were compared to patients hospitalized in the same period in whom post-paracentesis hemoperitoneum was suspected but ruled out by CT scan. A retrospective chart review was conducted to determine specifics of the adverse event, patient characteristics and risk factors for bleeding. RESULTS On multivariate analysis, acute kidney injury prior to paracentesis was the only independent predictor of post-paracentesis hemoperitoneum (OR 4.3, 95% CI 1.3-13.5, P = .01), independent of MELD score, large volume paracentesis, sepsis, platelets, INR and haemoglobin levels. CONCLUSIONS Infection/sepsis is generally considered predictive of bleeding in cirrhosis. Our study suggests that acute kidney injury, and not sepsis, is the most important predictor of post-procedure bleeding in patients with decompensated cirrhosis. Although end-stage renal disease is a known cause of bleeding in non-cirrhotic patients, there are no studies establishing acute kidney injury as a risk factor for post-procedure bleeding in cirrhosis. Future studies investigating blood product transfusion needs in cirrhosis prior to procedures should carefully look at patients with acute kidney injury.
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Affiliation(s)
- Adelina Hung
- Digestive Diseases Section, Department of Medicine, Yale University, New Haven, CT, USA
| | - Guadalupe Garcia-Tsao
- Digestive Diseases Section, Department of Medicine, Yale University, New Haven, CT, USA,Digestive Diseases Section, Department of Internal medicine, VA-CT Healthcare System, West Haven, CT, USA
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19
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Becattini C, Giustozzi M, Ranalli MG, Bogliari G, Cianella F, Verso M, Agnelli G, Vedovati MC. Variation of renal function over time is associated with major bleeding in patients treated with direct oral anticoagulants for atrial fibrillation. J Thromb Haemost 2018; 16:833-841. [PMID: 29460334 DOI: 10.1111/jth.13985] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Indexed: 02/04/2023]
Abstract
Essential In patients on treatment with direct anticoagulants (DOACs) variation of renal function is common. The effect of variations of renal function over time on major bleeding is not well defined. Variation of renal function over time is an independent predictor of major bleeding. Identifying conditions associated with variation of renal function may increase safety of DOACs. SUMMARY Background Chronic kidney disease is a risk factor for major bleeding in patients with atrial fibrillation (AF) treated with warfarin. Objective To assess the effect of variations in renal function over time on the risk of major bleeding during treatment with direct oral anticoagulants (DOACs) in patients with non-valvular AF. Methods Consecutive AF patients were prospectively followed after they had received the first DOAC prescription. Estimated glomerular filtration rate (eGFR) was periodically assessed, and the incidence of major bleeding was recorded. A joint survival model was used to estimate the association between variation in eGFR and the risk of major bleeding. Results During a mean follow-up of 575 days, 44 major bleeds occurred in 449 patients (6.1% per patient-year). eGFR over time was inversely and independently associated with the risk of major bleeding; every 1 mL min-1 absolute decrease in eGFR was associated with a 2% increase in the risk of major bleeding (hazard ratio [HR] 1.02, 95% confidence interval [CI] 1.01-1.04). A similar effect of the variation in eGFR over time was observed on the risk of clinically relevant non-major bleeding (HR 1.02, 95% CI 1.01-1.03). Deterioration of renal function leading to a change in eGFR staging was associated with an increase in the risk of major bleeding (HR 2.43, 95% CI 1.33-4.45). Conclusions Variation in renal function over time is associated with the risk of major bleeding in AF patients treated with DOACs in real life. Identification of intervening clinical conditions associated with variation in renal function is essential to reduce the risk of major bleeding and to make DOAC treatment more safe.
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Affiliation(s)
- C Becattini
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - M Giustozzi
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - M G Ranalli
- Department of Political Science, Statistics Division, University of Perugia, Perugia, Italy
| | - G Bogliari
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - F Cianella
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - M Verso
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - G Agnelli
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - M C Vedovati
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy
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20
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Melgaard L, Overvad TF, Skjøth F, Christensen JH, Larsen TB, Lip GYH. Risk of stroke and bleeding in patients with heart failure and chronic kidney disease: a nationwide cohort study. ESC Heart Fail 2018; 5:319-326. [PMID: 29383860 PMCID: PMC5880668 DOI: 10.1002/ehf2.12256] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/23/2017] [Accepted: 12/06/2017] [Indexed: 11/30/2022] Open
Abstract
Aims The aim of this study was to assess the prognostic value of chronic kidney disease (CKD) in relation to ischaemic stroke, intracranial haemorrhage, major bleeding, and all‐cause death in heart failure patients without atrial fibrillation. Methods and results In this observational cohort study, heart failure patients without atrial fibrillation were identified using Danish nationwide registries. Risk of stroke, major haemorrhage, and death were calculated after 1 and 5 years to compare patients with and without CKD, ±dialysis [dialysis: CKD with renal replacement therapy (CKD‐RRT); no dialysis: CKD‐no RRT]. A total of 43 199 heart failure patients were included, among which 0.8% had CKD‐RRT and 5.9% had CKD‐no RRT. When compared with heart failure patients without CKD, both CKD‐RRT and CKD‐no RRT were associated with a higher 5 year rate of major bleeding (CKD‐RRT: adjusted hazard ratio (aHR): 2.91, 95% confidence interval (CI): 2.29 to 3.70; CKD‐no RRT: aHR: 1.28, 95% CI: 1.13 to 1.45) and all‐cause death (CKD‐RRT: aHR: 2.40, 95% CI: 2.07 to 2.77; CKD‐no RRT: aHR: 1.63, 95% CI: 1.55 to 1.73). For the endpoints of ischaemic stroke and intracranial bleeding, only CKD‐no RRT was associated with significantly higher 5 year rates (ischaemic stroke: aHR: 1.31, 95% CI: 1.13 to 1.52; intracranial haemorrhage: aHR: 1.66, 95% CI: 1.04 to 2.65). Conclusions Compared with patients without CKD, among incident heart failure patients without atrial fibrillation, CKD both with and without dialysis was associated with a higher rate of major bleeding and all‐cause death. Only CKD‐no RRT was associated with a higher rate of ischaemic stroke and intracranial bleeding.
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Affiliation(s)
- Line Melgaard
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Thure Filskov Overvad
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Flemming Skjøth
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | | | - Torben Bjerregaard Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Department of Cardiology, Thrombosis and Drug Research Unit, Aalborg University Hospital, Søndre Skovvej 15, DK-9000, Aalborg, Denmark
| | - Gregory Y H Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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21
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Zerbi S, Crippa S, Di Bella C, Nobili P, Bonforte G, Scanziani R. Splenic Rupture following Colonoscopy in a Hemodialysis Patient. Int J Artif Organs 2018; 29:335-6. [PMID: 16685678 DOI: 10.1177/039139880602900312] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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22
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23
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Olson JC, Karvellas CJ. Critical care management of the patient with cirrhosis awaiting liver transplant in the intensive care unit. Liver Transpl 2017; 23:1465-1476. [PMID: 28688155 DOI: 10.1002/lt.24815] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/28/2017] [Accepted: 06/29/2017] [Indexed: 02/07/2023]
Abstract
Patients with cirrhosis who are awaiting liver transplantation (LT) are at high risk for developing critical illnesses. Current liver allocation policies that dictate a "sickest first" approach coupled with a mismatch between need and availability of organs result in longer wait times, and thus, patients are becoming increasingly ill while awaiting organ transplantation. Even patients with well-compensated cirrhosis may suffer acute deterioration; the syndrome of acute-on-chronic liver failure (ACLF) results in multisystem organ dysfunction and a marked increase in associated short-term morbidity and mortality. For patients on transplant waiting lists, the development of multisystem organ failure may eliminate candidacy for transplant by virtue of being "too sick" to safely undergo transplantation surgery. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (eg, infection and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo LT. Management of the critically ill ACLF patient awaiting transplantation is best accomplished by multidisciplinary teams with expertise in critical care and transplant medicine. Such teams are well suited to address the needs of this unique patient population and to identify patients who may be too ill to proceed to transplantation surgery. The focus of this review is to identify the common complications of ACLF and to describe our approach management in critically ill patients awaiting LT in our centers. Liver Transplantation 23 1465-1476 2017 AASLD.
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Affiliation(s)
- Jody C Olson
- Divisions of Critical Care Medicine and Hepatology, University of Kansas Medical Center, Kansas City, KS
| | - Constantine J Karvellas
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada.,Division of Division of Gastroenterology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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24
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Lisman T, Porte RJ. Pathogenesis, prevention, and management of bleeding and thrombosis in patients with liver diseases. Res Pract Thromb Haemost 2017; 1:150-161. [PMID: 30046685 PMCID: PMC6058283 DOI: 10.1002/rth2.12028] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 06/21/2017] [Indexed: 12/14/2022] Open
Abstract
Patients with liver diseases may develop alterations in all components of the hemostatic system. Thrombocytopenia, low levels of coagulation factors and inhibitors, low levels of fibrinolytic proteins, and increased levels of endothelial-derived proteins such as von Willebrand factor are all part of the coagulopathy of liver disease. Due to concomitant changes in pro- and antihemostatic drivers, the net effects of these complex hemostatic changes have long been unclear. According to current concepts, the hemostatic system of patients with liver disease is in an unstable balance, which explains the occurrence of both bleeding and thrombotic complications. This review will discuss etiology and management of bleeding and thrombosis in liver disease and will outline unsolved clinical questions. In addition, we will discuss the role of intrahepatic activation of coagulation for progression of liver disease, a novel paradigm with potential consequences for the general management of patients with liver disease.
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Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Robert J. Porte
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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25
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Pei J, Harakalova M, den Ruijter H, Pasterkamp G, Duncker DJ, Verhaar MC, Asselbergs FW, Cheng C. Cardiorenal disease connection during post-menopause: The protective role of estrogen in uremic toxins induced microvascular dysfunction. Int J Cardiol 2017; 238:22-30. [PMID: 28341374 DOI: 10.1016/j.ijcard.2017.03.050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 02/14/2017] [Accepted: 03/12/2017] [Indexed: 01/03/2023]
Abstract
Female gender, post-menopause, chronic kidney disease (CKD) and (CKD linked) microvascular disease are important risk factors for developing heart failure with preserved ejection fraction (HFpEF). Enhancing our understanding of the interrelation between these risk factors could greatly benefit the identification of new drug targets for future therapy. This review discusses the evidence for the protective role of estradiol (E2) in CKD-associated microvascular disease and related HFpEF. Elevated circulating levels of uremic toxins (UTs) during CKD may act in synergy with hormonal changes during post-menopause and could lead to coronary microvascular endothelial dysfunction in HFpEF. To elucidate the molecular mechanism involved, published transcriptome datasets of indoxyl sulfate (IS), high inorganic phosphate (HP) or E2 treated human derived endothelial cells from the NCBI Gene Expression Omnibus database were analyzed. In total, 36 genes overlapped in both IS- and HP-activated gene sets, 188 genes were increased by UTs (HP and/or IS) and decreased by E2, and 572 genes were decreased by UTs and increased by E2. Based on a comprehensive in silico analysis and literature studies of collected gene sets, we conclude that CKD-accumulated UTs could negatively impact renal and cardiac endothelial homeostasis by triggering extensive inflammatory responses and initiating dysregulation of angiogenesis. E2 may protect (myo)endothelium by inhibiting UTs-induced inflammation and ameliorating UTs-related uremic bleeding and thrombotic diathesis via restored coagulation capacity and hemostasis in injured vessels.
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Affiliation(s)
- Jiayi Pei
- Department of Nephrology and Hypertension, Division of Internal Medicine and Dermatology, University Medical Center Utrecht, The Netherlands
| | - Magdalena Harakalova
- Department of Cardiology, University Medical Center Utrecht, The Netherlands; Netherlands Heart Institute, Utrecht, The Netherlands
| | - Hester den Ruijter
- Experimental Cardiology Laboratory, Department of Experimental Cardiology, University Medical Center Utrecht, The Netherlands
| | - Gerard Pasterkamp
- Experimental Cardiology Laboratory, Department of Experimental Cardiology, University Medical Center Utrecht, The Netherlands
| | - Dirk J Duncker
- Experimental Cardiology, Department of Cardiology, Thoraxcenter Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, Division of Internal Medicine and Dermatology, University Medical Center Utrecht, The Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, University Medical Center Utrecht, The Netherlands; Netherlands Heart Institute, Utrecht, The Netherlands; Institute of Cardiovascular Science, University College London, United Kingdom
| | - Caroline Cheng
- Department of Nephrology and Hypertension, Division of Internal Medicine and Dermatology, University Medical Center Utrecht, The Netherlands; Experimental Cardiology, Department of Cardiology, Thoraxcenter Erasmus University Medical Center, Rotterdam, The Netherlands.
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26
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Lambert MP. Platelets in liver and renal disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:251-255. [PMID: 27913488 PMCID: PMC6142504 DOI: 10.1182/asheducation-2016.1.251] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
This review will discuss how 2 common and morbid conditions, renal disease and liver disease, alter platelet number and function. It will review the impact of thrombocytopenia on bleeding complications in patients with these disorders and whether the low platelet count actually correlates with bleeding risk. Emerging data also suggest that platelets are much more than bystanders in both renal and liver disease, but instead play an active role in the pathobiology of these disorders. This review will briefly cover the emerging information on novel roles of platelets in the biology of renal and liver disease.
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Affiliation(s)
- Michele P Lambert
- Divisions of Hematology, Departments of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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27
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Iino C, Mikami T, Igarashi T, Aihara T, Ishii K, Sakamoto J, Tono H, Fukuda S. Evaluation of scoring models for identifying the need for therapeutic intervention of upper gastrointestinal bleeding: A new prediction score model for Japanese patients. Dig Endosc 2016; 28:714-721. [PMID: 27061908 DOI: 10.1111/den.12666] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 04/02/2016] [Accepted: 04/06/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Multiple scoring systems have been developed to predict outcomes in patients with upper gastrointestinal bleeding. We determined how well these and a newly established scoring model predict the need for therapeutic intervention, excluding transfusion, in Japanese patients with upper gastrointestinal bleeding. METHODS We reviewed data from 212 consecutive patients with upper gastrointestinal bleeding. Patients requiring endoscopic intervention, operation, or interventional radiology were allocated to the therapeutic intervention group. Firstly, we compared areas under the curve for the Glasgow-Blatchford, Clinical Rockall, and AIMS65 scores. Secondly, the scores and factors likely associated with upper gastrointestinal bleeding were analyzed with a logistic regression analysis to form a new scoring model. Thirdly, the new model and the existing model were investigated to evaluate their usefulness. RESULTS Therapeutic intervention was required in 109 patients (51.4%). The Glasgow-Blatchford score was superior to both the Clinical Rockall and AIMS65 scores for predicting therapeutic intervention need (area under the curve, 0.75 [95% confidence interval, 0.69-0.81] vs 0.53 [0.46-0.61] and 0.52 [0.44-0.60], respectively). Multivariate logistic regression analysis retained seven significant predictors in the model: systolic blood pressure <100 mmHg, syncope, hematemesis, hemoglobin <10 g/dL, blood urea nitrogen ≥22.4 mg/dL, estimated glomerular filtration rate ≤ 60 mL/min per 1.73 m2 , and antiplatelet medication. Based on these variables, we established a new scoring model with superior discrimination to those of existing scoring systems (area under the curve, 0.85 [0.80-0.90]). CONCLUSION We developed a superior scoring model for identifying therapeutic intervention need in Japanese patients with upper gastrointestinal bleeding.
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Affiliation(s)
- Chikara Iino
- Department of Internal Medicine, Hirosaki Municipal Hospital, Hirosaki, Japan. .,Department of Gastroenterology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
| | - Tatsuya Mikami
- Department of Internal Medicine, Hirosaki Municipal Hospital, Hirosaki, Japan.,Division of Endoscopy, Hirosaki University Hospital, Hirosaki, Japan
| | - Takasato Igarashi
- Department of Internal Medicine, Hirosaki Municipal Hospital, Hirosaki, Japan.,Department of Gastroenterology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Tomoyuki Aihara
- Department of Internal Medicine, Hirosaki Municipal Hospital, Hirosaki, Japan
| | - Kentaro Ishii
- Department of Internal Medicine, Hirosaki Municipal Hospital, Hirosaki, Japan
| | - Jyuichi Sakamoto
- Department of Internal Medicine, Hirosaki Municipal Hospital, Hirosaki, Japan
| | - Hiroshi Tono
- Department of Internal Medicine, Hirosaki Municipal Hospital, Hirosaki, Japan
| | - Shinsaku Fukuda
- Department of Gastroenterology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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28
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Complications and Mortality After Lumbar Spinal Fusion in Elderly Patients With Late Stage Renal Disease. Spine (Phila Pa 1976) 2016; 41:E1298-E1302. [PMID: 27054452 DOI: 10.1097/brs.0000000000001618] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective database review. OBJECTIVE To assess complication and mortality rates after lumbar spinal fusion surgery in patients with late stage renal disease. SUMMARY OF BACKGROUND DATA Lumbar spinal fusion surgeries are common in elderly patients who are well-known to have increased comorbidity burden. Elderly patients with severe chronic kidney disease (CKD) represent a population with poorly understood mortality and complication rates after spine surgery. METHODS Medicare data from the PearlDiver Database (2005-2012) was queried for patients who underwent primary 1-2 level posterolateral lumbar spine fusion surgeries. This cohort was divided into two study groups: a cohort with a preexisting diagnosis of late stage renal disease (N = 1654) and a control cohort of all other patients (N = 242,085). The control group was matched to the renal disease cohort by age, sex, and comorbidities. Moreover, 90-day complication rates and 90-day and 1-year mortality were assessed. RESULTS The renal disease cohort had increased rates of all medical complications (21.3 vs. 14.2%; odds ratio, OR, 1.64; 95% confidence intervals, CI, 1.44 -1.85; P < 0.0001). Increased rates of infection (4.4 vs. 1.8%; OR 2.43; 95% CI 1.87 - 3.16; P < 0.0001) and procedure-day blood transfusions (20.7 vs. 14.7%; OR 1.51; 95% CI 1.33 - 1.72; P < 0.0001) were also observed in the renal disease cohort. Both 90-day (1.1 vs. 0.2%; OR 5.05; 95% CI 2.90-8.77; P < 0.0001) and 1-year mortality (1.9 vs. 0.7%; OR 2.77; 95% CI 1.87-4.11; P < 0.0001) were significantly higher in the renal disease group compared with the control group. CONCLUSION Elderly patients with late-stage renal disease treated with 1-2 level posterolateral lumbar fusion have 1.6 times increased odds of experiencing a major medical complication within 3 months of surgery and 2.8 times increased odds of 1-year mortality when compared with matched controls. LEVEL OF EVIDENCE 3.
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29
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Martin A, Thilly N, Ayav C, Clerc-Urmes I, Held P, Frimat L, Peters NO. Étude T2HD. Anticoagulants oraux et antiagrégants plaquettaires : pratiques, bénéfices et risques chez l’hémodialysé chronique. Données observationnelles. Nephrol Ther 2016; 12:156-65. [DOI: 10.1016/j.nephro.2015.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 08/05/2015] [Accepted: 08/31/2015] [Indexed: 11/30/2022]
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30
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Liu Y, Lv P, Jin H, Cui W, Niu C, Zhao M, Fan C, Teng Y, Pan B, Peng Q, Luo J, Zheng L, Huang Y. Association between Low Estimated Glomerular Filtration Rate and Risk of Cerebral Small-Vessel Diseases: A Meta-Analysis. J Stroke Cerebrovasc Dis 2016; 25:710-6. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.11.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 11/03/2015] [Accepted: 11/07/2015] [Indexed: 11/27/2022] Open
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31
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Wang TKM, Sathananthan J, Marshall M, Kerr A, Hood C. Relationships between Anticoagulation, Risk Scores and Adverse Outcomes in Dialysis Patients with Atrial Fibrillation. Heart Lung Circ 2016; 25:243-9. [DOI: 10.1016/j.hlc.2015.08.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 08/17/2015] [Accepted: 08/20/2015] [Indexed: 11/29/2022]
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Nadim MK, Durand F, Kellum JA, Levitsky J, O'Leary JG, Karvellas CJ, Bajaj JS, Davenport A, Jalan R, Angeli P, Caldwell SH, Fernández J, Francoz C, Garcia-Tsao G, Ginès P, Ison MG, Kramer DJ, Mehta RL, Moreau R, Mulligan D, Olson JC, Pomfret EA, Senzolo M, Steadman RH, Subramanian RM, Vincent JL, Genyk YS. Management of the critically ill patient with cirrhosis: A multidisciplinary perspective. J Hepatol 2016; 64:717-35. [PMID: 26519602 DOI: 10.1016/j.jhep.2015.10.019] [Citation(s) in RCA: 178] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/30/2015] [Accepted: 10/19/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Mitra K Nadim
- Division of Nephrology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Francois Durand
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, University Paris VII Diderot, Paris, INSERM U1149, Paris and Département Hospitalo-Universitaire UNITY, Clichy, France
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Constantine J Karvellas
- Division of Critical Care Medicine and Gastroenterology/Hepatology, University of Alberta, Edmonton, AB, Canada
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, McGuire VA Medical Center, Richmond, VA, USA
| | - Andrew Davenport
- University College London Center for Nephrology, Royal Free Hospital, University College London Medical School, London, UK
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Paolo Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Javier Fernández
- Liver Unit, Hospital Clinic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Centro d'investigación biomedical en red de enfermedades hepáticas y digestivas, Barcelona, Spain
| | - Claire Francoz
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, University Paris VII Diderot, Paris, INSERM U1149, Paris and Département Hospitalo-Universitaire UNITY, Clichy, France
| | - Guadalupe Garcia-Tsao
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Pere Ginès
- Liver Unit, Hospital Clinic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Centro d'investigación biomedical en red de enfermedades hepáticas y digestivas, Barcelona, Spain
| | - Michael G Ison
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David J Kramer
- Aurora Critical Care Service, Aurora Health Care, Milwaukee, WI, USA
| | - Ravindra L Mehta
- Division of Nephrology, University of California San Diego, San Diego, CA, USA
| | - Richard Moreau
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, University Paris VII Diderot, Paris, INSERM U1149, Paris and Département Hospitalo-Universitaire UNITY, Clichy, France
| | - David Mulligan
- Section of Transplantation and Immunology, Department of Surgery, Yale-New Haven Hospital Transplantation Center, Yale School of Medicine, New Haven, CT, USA
| | - Jody C Olson
- Division of Hepatology, University of Kansas Hospital, Kansas City, KS, USA
| | - Elizabeth A Pomfret
- Department of Transplantation and Hepatobiliary Diseases, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgical and Gastroenterological Sciences, University Hospital of Padua, Padua, Italy
| | - Randolph H Steadman
- Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, USA
| | - Ram M Subramanian
- Divisions of Gastroenterology and Pulmonary & Critical Care Medicine, Emory University Hospital, Atlanta, GA, USA
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Yuri S Genyk
- Division of Hepatobiliary Surgery and Abdominal Organ Transplantation, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Shah A, Amarapurkar D, Dharod M, Chandnani M, Baijal R, Kumar P, Jain M, Patel N, Kamani P, Gautam S, Shah N, Kulkarni S, Doshi S. Coagulopathy in cirrhosis: A prospective study to correlate conventional tests of coagulation and bleeding following invasive procedures in cirrhotics. Indian J Gastroenterol 2015; 34:359-64. [PMID: 26487399 DOI: 10.1007/s12664-015-0584-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 08/04/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Conventional tests of coagulation which only measure procoagulant factors do not correctly estimate the actual in vivo hemostatic balance in cirrhosis. This prospective multicenter study was conducted to evaluate safety of various invasive procedures in the presence of abnormal coagulation tests and to correlate conventional coagulation parameters with clinically significant bleeding in cirrhotics. METHODS Three hundred and eighty patients (median age 54 years, 287 males) enrolled in the study were divided into two groups (A and B), according to the presence or absence of abnormal coagulation parameters (defined as INR ≥1.5 and/or platelet count ≤50,000/cum). RESULTS One hundred and twenty-eight patients (33.68%) were qualified in group A. Alcohol was the predominant etiology of cirrhosis (40% and 32% in groups A and B, respectively). The two groups were similar in baseline characteristics other than tests of coagulation and severity of liver disease. Low risk procedures (abdominal paracentesis most common) were carried out in 47% and 53% patients in two groups, respectively. None of the patients in either group had clinically significant bleeding. Similarly, high risk procedures (central vein cannulation, liver biopsy, etc.) were carried out in 14% and 10%, respectively, in two groups. Three patients in group A developed clinically significant bleeding, however, the difference was statistically nonsignificant (p=0.061). None of our patients received periprocedural correction of abnormal coagulation parameters with plasma/platelet concentrate. CONCLUSIONS Deranged conventional coagulation parameters did not predict clinically significant bleeding in cirrhosis. Whenever indicated, any invasive procedure could be safely carried out in patients with cirrhosis without prior correction of coagulation abnormalities.
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Eyler RF, Unruh ML, Quinn DK, Mary Vilay A. Psychotherapeutic Agents in End-Stage Renal Disease. Semin Dial 2015; 28:417-26. [DOI: 10.1111/sdi.12370] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Rachel F. Eyler
- School of Pharmacy; University of Connecticut; Storrs Connecticut
| | - Mark L. Unruh
- School of Medicine; University of New Mexico; Albuquerque New Mexico
| | - Davin K. Quinn
- School of Medicine; University of New Mexico; Albuquerque New Mexico
| | - Aloun Mary Vilay
- College of Pharmacy; University of New Mexico; Albuquerque New Mexico
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Abstract
Liver disease is characterized by changes in all phases of hemostasis. These hemostatic alterations were long considered to predispose patients with liver disease towards a bleeding tendency, as they are associated with prolonged conventional coagulation tests. However, these patients may also suffer from thrombotic complications, and we now know that the hemostatic system in patient with liver disease is, in fact, in a rebalanced state. In this review we discuss the concept of rebalanced hemostasis and its implications for clinical management of patients with liver disease. For instance, there is no evidence that the use of prophylactic blood product transfusion prior to invasive procedures reduces bleeding risk. Clinicians should also be aware of the possibility of thrombosis occurring in patients with a liver disease, and regular thrombosis prophylaxis should not be withheld in these patients.
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Affiliation(s)
- Wilma Potze
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Centre Groningen, BA44, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
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El Bokl MA, Shawky A, Riad GS, Abdel Fattah HS, Shalaby H, Nady A, Khattab D. Procoagulant versus anticoagulant factors in cirrhotic patients. Arab J Gastroenterol 2014; 15:123-9. [DOI: 10.1016/j.ajg.2014.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 06/15/2014] [Accepted: 08/03/2014] [Indexed: 01/14/2023]
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Graves A, Yates P, Hofmann AO, Farmer S, Ferrari P. Predictors of perioperative blood transfusions in patients with chronic kidney disease undergoing elective knee and hip arthroplasty. Nephrology (Carlton) 2014; 19:404-9. [DOI: 10.1111/nep.12239] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2014] [Indexed: 12/30/2022]
Affiliation(s)
- Angela Graves
- Department of Nephrology; Fremantle Hospital; University of Western Australia; Perth Western Australia Australia
| | - Piers Yates
- Department of Orthopaedics; Fremantle Hospital; University of Western Australia; Perth Western Australia Australia
- School of Surgery; University of Western Australia; Perth Western Australia Australia
| | - Axel O Hofmann
- Western Australian Patient Blood Management Program; Health Department of Western Australia; Perth Western Australia Australia
- Institute of Anaesthesiology; University Hospital Zurich; Zurich Switzerland
| | - Shannon Farmer
- School of Surgery; University of Western Australia; Perth Western Australia Australia
- Western Australian Patient Blood Management Program; Health Department of Western Australia; Perth Western Australia Australia
- Centre for Population Health Research; Curtin University; Perth Western Australia Australia
| | - Paolo Ferrari
- Department of Nephrology; Fremantle Hospital; University of Western Australia; Perth Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth Western Australia Australia
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Makroo R, Walia R, Bhatia A, Chowdhry M. Transfusion requirements in living donor liver transplantation – Role of laboratory assessment and Model For End Stage Liver Disease (MELD) score. APOLLO MEDICINE 2014. [DOI: 10.1016/j.apme.2014.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Weeder PD, Porte RJ, Lisman T. Hemostasis in liver disease: implications of new concepts for perioperative management. Transfus Med Rev 2014; 28:107-13. [PMID: 24721432 DOI: 10.1016/j.tmrv.2014.03.002] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 03/09/2014] [Accepted: 03/10/2014] [Indexed: 02/08/2023]
Abstract
The hemostatic profile of patients with liver diseases is frequently profoundly different from that of healthy individuals. These complex alterations lead to abnormal results from routine laboratory tests, but because of the nature of these assays, they fail to accurately represent the patient's hemostatic state. Nevertheless, based on abnormal laboratory coagulation values, it has long been assumed that patients with liver disease have a natural bleeding tendency and are protected from thrombosis. This assumption is false; the average patient with liver disease is actually in a state of "rebalanced hemostasis" that can relatively easily be tipped toward both bleeding and thrombosis. The new paradigm of rebalanced hemostasis has strong implications for the clinic, which are presented in this review. There is no evidence that prophylactic transfusion of plasma helps to prevent procedure-related bleeding. In addition, the presence of independent risk factors such as poor kidney status or infections should be carefully assessed before invasive procedures. Furthermore, central venous pressure plays an important role in the risk of bleeding in patients with liver diseases, so during procedures, a restrictive infusion policy should be applied. Finally, thrombosis prophylaxis should not be withheld from patients with cirrhosis or acute liver failure, and clinicians should be alert to the possibility of thrombosis occurring in these patients.
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Affiliation(s)
- Pepijn D Weeder
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands.
| | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands.
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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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Krummel T, Scheidt E, Borni-Duval C, Bazin D, Lefebvre F, Nguyen P, Hannedouche T. Haemodialysis in patients treated with oral anticoagulant: should we heparinize? Nephrol Dial Transplant 2014; 29:906-13. [DOI: 10.1093/ndt/gft522] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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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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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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Augustin ID, Yeoh TY, Sprung J, Berry DJ, Schroeder DR, Weingarten TN. Association between chronic kidney disease and blood transfusions for knee and hip arthroplasty surgery. J Arthroplasty 2013; 28:928-31. [PMID: 23518427 DOI: 10.1016/j.arth.2013.02.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 01/17/2013] [Accepted: 02/06/2013] [Indexed: 02/01/2023] Open
Abstract
The study aim is to assess associations between chronic kidney disease (CKD) and blood transfusions during hospitalization for joint arthroplasty. Patients with Stage IV-V CKD who underwent elective total knee or hip arthroplasty from 2007 to 2010 were matched 2:1 with age, gender, and surgery type controls without kidney disease. Multivariable analyses for transfusion risk with preoperative hemoglobin, body mass index, cardiovascular disease, and surgical complexity as explanatory variables were performed. Ninety CKD patients were identified and had lower preoperative hemoglobin, higher incidence of cardiovascular disease and blood transfusions. CKD was independently associated with increased odds of transfusions (2.88, 95% confidence interval 1.33-6.23, P=0.007). Preoperative optimization of CKD patients should be considered to reduce transfusion rates.
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Affiliation(s)
- Ian D Augustin
- Department of Anesthesiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Aliasgharzadeh A, Gharehbaghian A, Taherian AA, Ghasemzadeh M, Salimian M. Modulation of hyperthermia-induced platelet aggregation inhibition in the presence of urea. Int J Hyperthermia 2013; 29:256-8. [PMID: 23517402 DOI: 10.3109/02656736.2013.772252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE This study has been conducted to evaluate the effect of urea on aggregation responses of heat-treated platelets. MATERIALS AND METHODS The urea was added to platelet-rich plasma (PRP) samples in final concentrations of 50 and 100 mM. PRP samples, with or without exogenous urea, were incubated at 37 °C, 39 °C and 41 °C for 90 min and then were stimulated with adenosine diphosphate (ADP) or epinephrine for measuring of platelet aggregation responses. The average reduction in aggregability of heat-treated samples with reference to mean value obtained for control samples treated at 37 °C was expressed as inhibition percentage. RESULTS Aggregation responses of the samples treated in the presence of 50 mM and 100 mM urea were significantly less inhibited by hyperthermia treatments compared with those treated without exogenous urea. CONCLUSION The results indicate that the inhibitory effect of hyperthermia on platelet aggregation responses could be significantly modulated by urea.
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Affiliation(s)
- Akbar Aliasgharzadeh
- Platelet Research Laboratory, Kashan University of Medical Sciences, Kashan, Iran
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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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Abstract
Introduction Bleeding is one of the most feared risks from a renal biopsy. To determine this risk, a clotting screen is performed prior to the biopsy to identify any coagulation abnormalities. In addition, concerns exist with respect to bleeding from platelet dysfunction and the special cases of paraprotenemia. Method Literature search of all the relevant articles in relation to bleeding risk from clotting abnormalities and platelet dysfunction in the setting of kidney biopsy was conducted. Results Bleeding risk from abnormal clotting screen is minimal in the absence of prior bleeding history in patients with renal disease. Administration of fresh frozen plasma in these cases is probably unnecessary and often causes delay in the procedure. In a similar way, platelet transfusions may not be appropriate in those with platelet dysfunction. Conclusions Global coagulation function tests are now available which need to be considered to determine bleeding risk before kidney biopsy, in conjunction with a good patient history.
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Affiliation(s)
- Jecko Thachil
- Department of Haematology , Central Manchester University Hospitals NHS Foundation Trust , Manchester M13 9WL , UK
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van Bladel ER, de Jager RL, Walter D, Cornelissen L, Gaillard CA, Boven LA, Roest M, Fijnheer R. Platelets of patients with chronic kidney disease demonstrate deficient platelet reactivity in vitro. BMC Nephrol 2012; 13:127. [PMID: 23020133 PMCID: PMC3473261 DOI: 10.1186/1471-2369-13-127] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 08/22/2012] [Indexed: 12/11/2022] Open
Abstract
Background In patients with chronic kidney disease studies focusing on platelet function and properties often are non-conclusive whereas only few studies use functional platelet tests. In this study we evaluated a recently developed functional flow cytometry based assay for the analysis of platelet function in chronic kidney disease. Methods Platelet reactivity was measured using flow cytometric analysis. Platelets in whole blood were triggered with different concentrations of agonists (TRAP, ADP, CRP). Platelet activation was quantified with staining for P-selectin, measuring the mean fluorescence intensity. Area under the curve and the concentration of half-maximal response were determined. Results We studied 23 patients with chronic kidney disease (9 patients with cardiorenal failure and 14 patients with end stage renal disease) and 19 healthy controls. Expression of P-selectin on the platelet surface measured as mean fluorescence intensity was significantly less in chronic kidney disease patients compared to controls after maximal stimulation with TRAP (9.7 (7.9-10.8) vs. 11.4 (9.2-12.2), P = 0.032), ADP (1.6 (1.2-2.1) vs. 2.6 (1.9-3.5), P = 0.002) and CRP (9.2 (8.5-10.8) vs. 11.5 (9.5-12.9), P = 0.004). Also the area under the curve was significantly different. There was no significant difference in half-maximal response between both groups. Conclusion In this study we found that patients with chronic kidney disease show reduced platelet reactivity in response of ADP, TRAP and CRP compared to controls. These results contribute to our understanding of the aberrant platelet function observed in patients with chronic kidney disease and emphasize the significance of using functional whole blood platelet activation assays.
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Affiliation(s)
- Esther R van Bladel
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
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Clinical Features and Neurologic Severity in Stroke Patients with Mild to Moderate Renal Dysfunction. J Stroke Cerebrovasc Dis 2012; 21:343-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2010.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2010] [Revised: 08/20/2010] [Accepted: 08/25/2010] [Indexed: 11/24/2022] Open
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