Warfarin Therapy in the HIV Medical Home Model: Low Rates of Therapeutic Anticoagulation Despite Adherence and Differences in Dosing Based on Specific Antiretrovirals

Abstract To determine the indications for, rates of therapeutic anticoagulation during, and complications of warfarin therapy in HIV-infected individuals, in whom long-term anticoagulation is frequently indicated. To identify risk factors for nonoptimal anticoagulation and to determine if warfarin dosing is differentially affected by specific antiretroviral agents. Retrospective study of a dedicated anticoagulation program at one of the largest clinics for HIV-infected individuals in the United States. Seventy-three HIV-infected individuals on warfarin were followed for a total of 911 visits. The rate of therapeutic internation normalized ratio (INR) levels was 34.5% when including only visits at which patients were assessed to be adherent with warfarin. In multivariable analysis, injection drug use at baseline was an independent risk factor for subtherapeutic INR (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.3-4.7, p=0.01). Additionally, warfarin adherence was protective of both subtherapeutic (OR 0.4, 95% CI 0.2-0.6, p<0.0001) and supratherapeutic (OR 0.5, 95% CI 0.3-0.9, p=0.02) INR status. Efavirenz-based antiretroviral regimens were associated with lower weekly warfarin doses (46?mg) to maintain therapeutic INR compared to lopinavir/ritonavir-based regimens (68?mg; p=0.01) and atazanavir/ritonavir-based regimens (71?mg; p=0.007). Consistently therapeutic warfarin therapy is difficult to achieve in HIV-infected individuals, even with a dedicated anticoagulation program. Adherence to warfarin therapy is important but rates of therapeutic INR levels are nonetheless low. Lower warfarin dosing was required for efavirenz compared to two commonly used protease inhibitor-based regimens. Because of these factors, the emergence of new oral anticoagulants is an important development for HIV-infected individuals who require long term anticoagulation therapy.     

Clinical predictors of prolonged delay in return of the international normalized ratio to within the therapeutic range after excessive anticoagulation with warfarin

BACKGROUND: An elevated international normalized ratio (INR) increases the risk for major hemorrhage during warfarin therapy. Optimal management of patients with asymptomatic elevations in INR is hampered by the lack of understanding of the time course of INR decay after cessation of warfarin therapy. OBJECTIVE: To identify predictors of the rate of INR normalization after excessive anticoagulation. DESIGN: Retrospective cohort study. SETTING: Outpatient anticoagulant therapy unit. PATIENTS: Outpatients with an INR greater than 6.0 were identified from August 1993 to September 1998. Patients in whom two doses of warfarin were withheld and a follow-up INR was obtained on the second calendar day were enrolled. No patient received vitamin K(1). MEASUREMENTS: The INR was measured 2 days after an INR greater than 6.0 was recorded. RESULTS: Of 633 study patients with an initial INR greater than 6.0, 232 (37%) still had an INR of 4.0 or greater after two doses of warfarin were withheld. Patients who required larger weekly maintenance doses of warfarin were less likely to have an INR of 4.0 or greater on day 2 (adjusted odds ratio per 10 mg of warfarin, 0.87 [95% CI, 0.79 to 0.97]). Other risk factors for having an INR of 4.0 or greater on day 2 included age (odds ratio per decade of life, 1.18 [CI, 1.01 to 1.38]), index INR (odds ratio per unit, 1.25 [CI, 1.14 to 1.37]), decompensated congestive heart failure (odds ratio, 2.79 [CI, 1.30 to 5.98]), and active cancer (odds ratio, 2.48 [CI, 1.11 to 5.57]). CONCLUSIONS: Steady-state warfarin dose, advanced age, and extreme elevation in INR are risk factors for prolonged delay in return of the INR to within the therapeutic range. Decompensated congestive heart failure and active cancer greatly increase this risk.     

The effect of warfarin and intensity of anticoagulation on outcome of intracerebral hemorrhage

BACKGROUND: Warfarin sodium is highly effective for prevention of embolic stroke, particularly in nonvalvular atrial fibrillation, but its expected benefit can be offset by risk of intracerebral hemorrhage (ICH). We studied the determinants of ICH outcome to quantify the independent effect of warfarin. METHODS: Consecutive patients with supratentorial ICH treated in a tertiary care hospital with a neurointensive care unit were prospectively identified during a 7-year period, and data on hemorrhage location, clinical characteristics, and warfarin use were collected. Independent predictors of 3-month mortality were determined using multiple logistic regression analysis. RESULTS: Of 435 consecutive patients aged 55 years or older, 102 (23.4%) were taking warfarin at the time of ICH. Three-month mortality was 25.8% for those not taking warfarin and 52.0% for those taking warfarin. Independent predictors of death were warfarin use (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.3-3.8), age 70 years or older (OR, 2.4; 95% CI, 1.4-4.0), and presence of diabetes mellitus (OR, 1.8; 95% CI, 1.0-3.3). Although 68.0% of all warfarin-related hemorrhages occurred at an international normalized ratio (INR) of 3.0 or less, increasing degrees of anticoagulation were strongly associated with increasing risk of death compared with no warfarin use. CONCLUSIONS: Patients taking warfarin had a doubling in the rate of intracerebral hemorrhage mortality in a dose-dependent manner. The data suggest that careful control of the INR, already known to limit the risk of warfarin-related ICH, may also limit its severity.     

Acute Kidney Injury in Elderly Patients With Chronic Kidney Disease: Do Angiotensin‐Converting Enzyme Inhibitors Carry a Risk?

In contrast to angiotensin receptor blockers (ARBs), mainly excreted by the liver, the dosage of angiotensin‐converting enzyme (ACE) inhibitors, cleared by the kidney, must be adapted to account for renal clearance in patients with chronic kidney disease (CKD) to avoid acute kidney injury (AKI). Community‐acquired AKI and the use of ACE inhibitors or ARBs in the emergency department were retrospectively assessed in 324 patients with baseline stage 3 or higher CKD. After stepwise regression analysis, the use of ACE inhibitors (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1–3.1; P=.02) and the presence of dehydration (OR, 30.8; 95% CI, 3.9–239.1) were associated with AKI. A total of 45% of patients using ACE inhibitors experienced overdosing, which causes most of the excess risk of AKI. These results suggest that dosage adjustment of ACE inhibitors to renal function or substitution of ACE inhibitors with ARBs could reduce the incidence of AKI. Moreover, ACE inhibitors and ARBs should be stopped in cases of dehydration.     

Treatment of excessive anticoagulation with phytonadione (vitamin K): a meta-analysis

BACKGROUND: Patients taking oral anticoagulants with an international normalized ratio (INR) greater than 4.0 are at increased risk for bleeding. We performed a meta-analysis to determine the effectiveness of phytonadione (vitamin K) in treating excessive anticoagulation. METHODS: The MEDLINE, EMBASE, and Cochrane Library databases were searched (without language restrictions) for articles published between January 1985 and September 2004. Randomized controlled trials or prospective, nonrandomized trials that used vitamin K to treat patients without major hemorrhage with an INR greater than 4.0 due to oral anticoagulant use were included. The primary outcome was achievement of the target INR (1.8-4.0) at 24 hours after vitamin K administration. Summary estimates were calculated using a random effects model. RESULTS: Twenty-one studies (10 randomized and 11 prospective trials) were included. Among oral vitamin K treatment arms (4, n = 75), the proportion with a target INR at 24 hours was 82% (95% confidence interval [CI], 70%-93%), which was similar to intravenous vitamin K treatment arms (6, n = 69; target INR, 77%; 95% CI, 60%-95%). Treatment arms of subcutaneous vitamin K (3, n = 58; 31%; 95% CI, 7%-55%) and placebo/observation (2, n = 27; 20%; 95% CI, 0%-47%) were less likely to achieve target INR at 24 hours. Only 1 of 21 trials appropriately assessed for adverse events, so a summary estimate for bleeding risk could not be generated. CONCLUSIONS: Limited evidence suggests that oral and intravenous vitamin K are equivalent and more effective for excessive anticoagulation than simply withholding warfarin sodium. Subcutaneous vitamin K, however, is inferior to oral and intravenous vitamin K for this indication and is similar to placebo. Whether treatment with vitamin K decreases hemorrhagic events cannot be determined from the published literature.     

Warfarin anticoagulation and outcomes in patients with atrial fibrillation: a systematic review and metaanalysis

OBJECTIVE: To examine the relationship between international normalized ratio (INR) and outcomes (major bleeding events and strokes) in patients with atrial fibrillation (AF) receiving anticoagulation with warfarin. METHODS: A systematic review and metaanalysis of studies published in the English language between January 1, 1985, and October 30, 2002, was performed. MEDLINE (PubMed), Current Contents, and relevant reference lists were searched. Studies enrolling patients with nonvalvular AF receiving warfarin anticoagulation were eligible for inclusion if they reported stroke and/or major bleeding events in relation to INR, or time spent in therapeutic range. The risk of bleeds in overanticoagulated patients (INR > 3) and the risk of strokes in underanticoagulated patients (INR < 2) were assessed. RESULTS: Twenty-one studies (6,248 patients) met all inclusion criteria. Of the 21 studies, a target conventional INR of 2 to 3 was used in 9 studies. An INR < 2, compared with an INR > or = 2, was associated with an odds ratio (OR) for ischemic events of 5.07 (95% confidence interval [CI], 2.92 to 8.80). An INR > 3, compared with an INR < or = 3, was associated with an OR for bleeding events of 3.21 (95% CI, 1.24 to 8.28). On average, in the four studies with a target INR range of 2 to 3, patients with AF receiving warfarin spent 61% of time within, 13% of time above, and 26% below the therapeutic range. CONCLUSION: Available evidence indicates that in patients with nonvalvular AF, the risk of ischemic stroke with insufficient warfarin anticoagulation (INR < 2), and the risk of bleeding events with overanticoagulation (INR > 3) are significantly higher relative to patients with AF maintained within the recommended INR of 2 to 3. However, the published data are sparse, heterogeneous, and primarily reported from clinical trials. More studies evaluating clinical outcomes in relation to INR are needed, especially in a real-world setting.     

How do anticoagulated atrial fibrillation patients who suffer ischemic stroke or spontaneous intracerebral hemorrhage differ?

Background

Atrial fibrillation (AF) increases risk of ischemic stroke, and oral anticoagulation (OAC) increases risk of intracerebral hemorrhage (ICH). This study aimed to compare OAC‐treated AF patients with an ischemic stroke/transient ischemic attack (TIA) or spontaneous ICH as their first lifetime cerebrovascular event, especially focusing on patients with therapeutic international normalized ratio (INR).

Hypothesis

We assumed that in AF patients suffering ischemic stroke/TIA or ICH, patient characteristics could be different in patients with therapeutic INR than in patients with warfarin.

Methods

FibStroke is a multicenter, retrospective registry collating details of AF patients with ischemic stroke/TIA or intracranial hemorrhage in 2003–2012. This substudy included AF patients on OAC with first lifetime ischemic stroke/TIA or spontaneous ICH.

Results

A total of 1457 patients with 1290 ischemic strokes/TIAs and 167 ICHs were identified. Of these, 553 (42.9%) strokes/TIAs and 96 (57.5%) ICHs occurred in patients with INR within therapeutic range. During OAC with therapeutic INR, congestive heart failure (odds ratio [OR]: 2.33, 95% confidence interval [CI]: 1.18–4.58) and hypercholesterolemia (OR: 2.52, 95% CI: 1.51–4.19) were more common in patients with ischemic stroke/TIA, whereas a history of bleeding (OR: 0.30, 95% CI: 0.11–0.82) was less common when compared with patients with ICH. In the whole cohort, renal impairment (OR: 1.86, 95% CI: 1.23–2.80) and mechanical valve prosthesis (OR: 4.41, 95% CI: 1.32–14.7) were overrepresented in patients with stroke/TIA, whereas aspirin use (OR: 0.52, 95% CI: 0.30–0.91) and high INR (OR: 0.40, 95% CI: 0.33–0.48) were overrepresented in patients with ICH.

Conclusions

In anticoagulated AF patients with therapeutic INR and first lifetime cerebrovascular event, congestive heart failure and hypercholesterolemia were associated with ischemic stroke/TIA and history of bleeding with ICH.     

华法林对中国人心房颤动患者抗栓的安全性和有效性研究

目的　通过回顾性分析心房颤动 (房颤 )患者的抗栓治疗 ,初步探讨中国人华法林国际标准化率 (INR)的合理范围。方法　调查 4 35例房颤患者应用华法林抗凝及INR监测情况 ,分析出血和血栓栓塞事件的危险因素及与INR的关系。结果　华法林疗程时间中位数 7个月 ,平均剂量为(2 77± 0 83)mg。共发生出血事件 31例 (7 11% ) ,其中严重出血 5例 ,轻微出血 2 6例。发生出血患者年龄略高于对照组 [(6 5 1± 10 0 )岁与 (6 2 0± 12 2岁 ) ],但差异无统计学意义 (P =0 2 5 9) ;出血患者血压高于对照组 ,合并心力衰竭较多 (P =0 0 5 )。多因素分析中INR≥ 3为预测出血的独立危险因素 (OR =3 74 )。血栓栓塞事件 37(17 4 7% )例 ,发生缺血性卒中或栓塞的危险随INR下降明显增加。结论　房颤患者华法林抗凝目标INR值应避免低于 1 5或高于 3 0。     

Risk factors for acute kidney injury after pancreatoduodenectomy,and association with postoperative complications and death

BackgroundAcute kidney injury (AKI) is associated with increased morbidity and mortality after general surgery, although little is known among patients undergoing pancreatoduodenectomy. The objective was to investigate the association between AKI and postoperative complications and death after pancreatoduodenectomy.MethodsAll patients ≥18 years who underwent a pancreatoduodenectomy 2008–2019 at the Karolinska University Hospital, Stockholm, Sweden, were included. Standardized criteria for AKI, including estimated glomerular filtration rate (eGFR) and urine volume measurements, were used to grade postoperative AKI.ResultsIn total, 970 patients were included with a median age of 68 years (IQR 61–74) of whom 517 (53.3%) were men. There were 137 (14.1%) patients who developed postoperative AKI. Risk factors for AKI included lower preoperative eGFR, cardiovascular disease and treatment with renin-angiotensin system inhibitors or diuretics. Those who developed AKI had a higher risk of severe postoperative complications, including Clavien-Dindo score ≥ IIIa (adjusted OR 3.35, 95% CI 2.24–5.01) and ICU admission (adjusted OR 7.83, 95% CI 4.39–13.99). In time-to-event analysis, AKI was associated with an increased risk for both 30-day mortality (adjusted HR 4.51, 95% CI 1.54–13.27) and 90-day mortality (adjusted HR 4.93, 95% CI 2.37–10.26). Patients with benign histology and AKI also had an increased 1-year mortality (HR 4.89, 95% CI 1.88–12.71).ConclusionsPostoperative AKI was associated with major postoperative complications and an increased risk of postoperative mortality. Monitoring changes in serum creatinine levels and urine volume output could be important in the immediate perioperative period to improve outcomes after pancreatoduodenectomy.     

Analysis of risk factors for over-anticoagulation in patients receiving long-term warfarin

A cohort of patients with an INR >7.0 were identified prospectively and compared with a group of patients with stable anticoagulant control. During the study 15 100 INR measurements were recorded and 31 (0.2%) were >7.0. Odds ratios of patient characteristics were calculated as an estimate of relative risk for the development of a high INR. The highest risk factor was a target INR of 3.5 (OR 7.3, 95% CI 2.6–20.2). The second highest risk factor was antibiotic therapy in the 4 weeks preceding the high INR (OR 6.2, 95% CI 1.4–27.7). Bleeding was reported more frequently in the high INR group (OR 5.4, 95% CI 2.1–13.9). Five major bleeds occurred in this group compared to none in the stable group. This analysis identifies risk factors for over-anticoagulation and hence when to intensify monitoring and when to consider pre-emptive warfarin dose reductions.     

Oral anticoagulation – how intense and for how long?

Patients with mechanical heart valve prostheses require life-long anticoagulation and the intensity is optimal at an International Normalized Ratio (INR) of 3.0–4.0. Individual deviations from this range should be based on the type of prosthesis, the position of the prosthesis and the risk of haemorrhage. Efforts should be made to quickly correct excessive anticoagulation and to keep the treatment within the targeted range during the largest possible fraction of the time. In nonvalvular atrial fibrillation there is a greater reduction of the risk of thromboembolic complications with the use of warfarin compared to aspirin. The intensity should be equal to INR 2.0–3.0, since lower intensities are not sufficiently effective, even in combination with aspirin. Aspirin is still preferred for patients younger than 65 years without additional risk factor. Oral anticoagulation gives a significant long-term reduction of recurrent myocardial infarction and of total stroke after myocardial infarction. The optimal intensity is between INR 2.0 and 4.0. Running trials will determine if aspirin and warfarin yield comparable results. Patients with peripheral arterial disease, who undergo reconstructive surgery, seem to benefit from long-term postoperative oral anticoagulation, which improves limb salvage, prolongs the patency of the vein bypass and survival of the patient. There is a need of trials addressing the intensity of anticoagulation and comparing oral anticoagulation with aspirin in this field. For venous thromboembolism 6 weeks of oral anticoagulation is sufficient for patients with calf vein thrombosis and a temporary risk factor. Proximal deep vein thrombosis, pulmonary embolism and/or unknown or permanent risk factor for thrombosis require longer treatment durations, ideally around 6 months. The prophylaxis should be targeted at an INR of 2.0–2.85, which is effective and minimizes the risk of haemorrhage. Certain biochemical thrombogenic factors will necessitate prolonged full anticoagulation. Efforts are being made to improve the safety of anticoagulant therapy through better organization of the monitoring, education of the patients, investigations of the various risks for complications as well as the development of new agents with less interactions and more selective and reproducible effects.     

Early therapeutic persistence on dabigatran versus warfarin therapy in patients with atrial fibrillation: results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry

Anticoagulation is highly effective for the prevention of stroke in patients with atrial fibrillation (AF) but it is dependent on patients continuing therapy. While studies have demonstrated suboptimal therapeutic persistence on warfarin, few have studied persistence rates with non vitamin K antagonist oral anticoagulants (NOACs) such as dabigatran. We examined rates of continued use of dabigatran versus warfarin over 1 year among AF patients in the ORBIT-AF registry between June 29, 2010 and August 09, 2011. Multivariable logistic regression analysis was used to identify characteristics associated with 1-year persistent use of dabigatran therapy or warfarin. At baseline, 6.4 and 93.6% of 7150 AF patients were on dabigatran and warfarin, respectively. At 12 months, dabigatran-treated patients were less likely to have continued their therapy than warfarin-treated patients [Adjusted persistence rates: 66% (95% CI 60–72) vs. 82% (95% CI 80–84), p?<?.0001]. Predictors of dabigatran persistence included: CHA₂DS₂-VASc risk scores?≥?2 OR 5.69, (95% CI 1.50–21.6) and BMI greater than 25 mg/m² but less than 38 kg/m² 1.05 (1.01–1.09). Predictors of persistence on warfarin included: African American race (vs. White) 1.53 (1.07–2.19), Hispanic ethnicity (vs. White) 1.66 (1.06–2.60), paroxysmal and persistent AF (vs. new-onset) 1.68 (1.21–2.33) and 1.91 (1.35–2.69) respectively, LVH 1.40 (1.08–1.81), and CHA₂DS₂-VASc risk scores?≥?2 1.94 (1.18–3.19). While 1-year persistence rates for dabigatran were lower than warfarin, persistence rates for both agents were not ideal. Future studies evaluating contemporary persistence are needed in order to assist in better targeting interventions aimed to improve anticoagulation persistence.     

Risk factors for acute kidney injury and 30-day mortality after liver transplantation

Introduction. The aim of this study is to evaluate the risk factors for acute kidney injury (AKI) and 30-day mortality after liver transplantation.Material and methods. This is a retrospective cohort of consecutive adults undergoing orthotopic liver transplantation (OLT) at a referral hospital in Brazil, from January 2013 to January 2014. Risk factors for AKI and death were investigated.Results. A total 134 patients were included, with median age of 56 years. AKI was found in 46.7% of patients in the first 72 h after OLT. Risk factors for AKI were: viral hepatitis (OR 2.9, 95% CI = 1.2-7), warm ischemia time (OR 1.1, 95% CI = 1.01-1.2) and serum lactate (OR 1.3, 95%CI = 1.02-1.89). The length of intensive care unit (ICU) stay was longer in AKI group: 4 (3-7) days vs. 3 (2-4) days (p = 0.001), as well as overall hospitalization stay: 16 (9-26) days vs. 10 (8-14) days (p = 0.001). The 30-day mortality was 15%. AKI was an independent risk factor for mortality (OR 4.3, 95% CI = 1.3-14.6). MELD-Na ≥ 22 was a predictor for hemodialysis need (OR 8.4, 95%CI = 1.5-46.5). Chronic kidney disease (CKD) was found in 36 patients (56.2% of AKI patients).Conclusions. Viral hepatitis, longer warm ischemia time and high levels of serum lactate are risk factors for AKI after OLT. AKI is a risk factor for death and can lead to CKD in a high percentage of patients after OLT. A high MELD-Na score is a predictor for hemodialysis need.     

Sickle cell trait and renal disease among African American U.S. Army soldiers

Sickle cell trait and certain renal disorders are disproportionately prevalent among African American individuals, so a clear understanding of their association is important. We conducted a longitudinal study using the Stanford Military Data Repository to examine sickle cell trait in relation to the incidence of acute kidney injury (AKI) and chronic kidney disease (CKD). Our study population consisted of African American U.S. Army soldiers on active duty between January 2011 and December 2014. The cumulative incidence was 0·51% for AKI (236 cases out of 45 901 soldiers) and 0·56% for CKD (255 cases out of 45 882 soldiers). Discrete time logistic regression models adjusting for demographic-, military- and healthcare-related covariates showed that sickle cell trait was associated with significantly higher adjusted odds of both AKI [odds ratio (OR): 1·74; 95% confidence interval (CI): 1·17–2·59] and CKD (OR: 2·00; 95% CI: 1·39–2·88). Elevated odds of AKI and CKD were also observed in association with prior CKD and AKI, respectively, and with obesity and prior hypertension. Individuals with sickle cell trait and their providers should be aware of the possibility of increased risk of AKI and CKD to allow for timely intervention and possible prevention.     

Validity of current recommendation for peri-operative interruption of warfarin in Asians

Temporary interruption of anticoagulation therapy is usually recommended for anticoagulated patients undergoing invasive procedures to minimize their bleeding risks. We validated the current consensus recommendation on warfarin interruption which were based on Western population studies to determine if they could safely be applied to Asians. The international normalized ratios (INR) in twenty warfarinised patients with a stable INR of 2–3 were prospectively measured at days 0, 3 and 5 after stopping warfarin for procedures or at completion of treatment. The median INR at days 0, 3 and 5 were 2.30 (95% CI 2.16–2.43), 1.32 (95% CI 1.22–1.57) and 1.06 (95% CI 1.05–1.13) respectively (P < 0.001 for trend). All patients were below therapeutic INRs by day 3 with 14 patients (70%, 95% CI 49.92–90.08) achieving INR readings below 1.5. By day 5, all INRs were below 1.5 and only 2 patients (10%, 95% CI −3.15 to 23.15) had INRs above 1.2. There were no significant peri-procedure bleeding or thrombotic events in the 1 month following interruption of warfarin. Our results suggest that the current international recommendation of stopping warfarin for 5 days prior to procedure can safely be applied to Asians without compromising risk of bleeding or thrombosis.     

Epidemiology of acute kidney injury in patients with stroke: a retrospective analysis from the neurology ICU

Acute kidney injury (AKI) is proven to be an independent risk factor for adverse clinical outcomes in patients with stroke, but data about the epidemiology of AKI in these patients are not well characterized. Therefore, we investigated the incidence, risk factors, and the impact of AKI on the clinical outcomes in a group of Chinese patients with stroke. We retrospectively recruited 647 stroke patients from the neurology ICU between 2012 and 2013. AKI was identified according to the 2012 KDIGO criteria. Baseline estimated glomerular filtration rate (eGFR) was calculated using modified Chronic Kidney Disease Epidemiology Collaboration equation for Chinese patients. National Institutes of Health Stroke Scale (NIHSS) score was assessed for the stroke severity. A total of 135 (20.9%) patients developed AKI. Patients with AKI stages from 1 to 3 were 84 (62.2%), 26 (19.3%), and 25 (18.5%), respectively. Logistic regression analysis showed that independent risk factors for AKI were higher NIHSS score (OR, 1.027; 95% CI 1.003–1.051), lower baseline eGFR (OR, 0.985; 95% CI 0.977–0.993), the presence of hypertension (OR, 1.592; 95% CI 1.003–2.529), and infectious complications (OR, 3.387; 95% CI 1.997–5.803) (P < 0.05 for all). AKI patients were also significantly associated with all-cause mortality in the neurology ICU [OR and 95% CI of AKI-stage 1, AKI-stage 2, and AKI-stage 3 were 4.961 (2.191–11.232), 19.722 (6.354–61.217), and 48.625 (17.616–134.222), respectively (P < 0.001 for all)]. AKI is common among patients with stroke and is associated with worse clinical outcomes after stroke. Prevention of AKI seems to be very important among these patients, because they are exposed to many risk factors for developing AKI.     

Associations between hepatitis B infection and chronic kidney disease: 10-Year results from the U.S. National Inpatient Sample

IntroductionViral hepatitis infection is associated with negative impacts on renal function that may lead to nephropathy. We investigated associations between chronic hepatitis B virus (HBV) infection and chronic kidney disease (CKD) and/or end-stage renal disease (ESRD) in a large, representative sample from a nationwide U.S. database.MethodsThis population-based, retrospective observational study extracted data from the U.S. Nationwide Inpatient Sample (NIS) database, including adults ≥18 years old admitted to U.S. hospitals between 2005 and 2014 with records of chronic HBV infection in medical history. The final analytic sample included 70,674 HBV-infected patients and 282,696 matched non-HBV controls. Study endpoints were prevalent CKD and ESRD. Associations between CKD/ESRD and HBV and patients’ clinical characteristics were determined by logistic regression analysis.ResultsHBV infection was associated with slightly increased risk of prevalent CKD (OR: 1.06, 95% CI: 1.004–1.119) and an approximate 2-times risk of prevalent ESRD (OR: 1.98, 95% CI: 1.880–2.086). HBV infection in both genders was associated with slightly increased risk of CKD (males, OR: 1.09, 95% CI: 1.02–1.16; females, OR: 1.07, 95% CI: 0.98,1.17), and significantly associated with increased risk for CKD among non-diabetic patients (OR: 1.23, 95% CI: 1.15–1.32), white patients (OR: 1.14, 95% CI: 1.06–1.23) and Asian/Pacific Islanders (OR: 1.13, 95% CI: 0.98–1.30).ConclusionsChronic HBV infection is associated with slightly increased risk for CKD and greater risk for ESRD in males and females, Whites and Asian/Pacific Islanders and non-diabetic patients.     

Effect of anticoagulation on cardioembolic stroke severity,outcomes and response to intravenous thrombolysis

Our objective was to evaluate the effect of anticoagulation on cardioembolic stroke (CS) severity, outcomes, and response to intravenous thrombolysis (IVT). Observational study of CS patients admitted to a Stroke Center (2010–2013). The sample was classified into three groups based on pre-stroke oral anticoagulants (OAC) treatment (all acenocumarol) and the international normalized ratio (INR) on admission: (1) non-anticoagulated or anticoagulated patients with INR <1.5, (2) anticoagulated with INR 1.5–1.9 and (3) anticoagulated with INR ≥2. We compared demographic data, vascular risk factors, symptomatic intracranial hemorrhage, severity on admission (NIHSS) and 3 month outcomes (mRS). Overall 475 patients were included, 47.2 % male, mean age 75.5 (SD 10.7) years old, 31.8 % were on OAC. 76 % belonged to the INR <1.5 group, 13.3 % to the INR 1.5–1.9 and 10.5 % to the INR >2. 35 %of patients received IVT. Multivariate analyses showed that an INR ≥2 on admission was a factor associated with a higher probability of mild stroke (NIHSS <10) (OR 2.026, 95 % CI 1.006–4.082). Previous OAC in general (OR 2.109, 95 % CI 1.173–3.789) as well as INR 1.5–1.9 (OR 3.676, 95 % CI 1.510–8.946) were associated with favorable outcomes (mRS ≤2). OAC was not related to stroke outcomes in the subgroup of IVT patients. Therapeutic OAC levels are associated with lesser CS severity, and prior OAC treatment with favorable outcomes. In this study, OAC are not related with response to IVT.     

Real-time ultrasound guidance reduces total and major vascular complications in patients undergoing pulmonary vein antral isolation on therapeutic warfarin

Background

Vascular complications are a known risk of catheter-based pulmonary vein antral isolation (PVAI). Procedure-related thromboembolic events necessitate full-dose anticoagulation, which worsens outcomes in the event of vascular access injury.

Objective

Real-time ultrasound allows direct visualization of vascular structures. We hypothesized that ultrasound use with venipuncture reduces vascular complications associated with PVAI.

Methods

Retrospective analysis of all adverse events occurring with PVAI was performed during two periods: 2005–2006 when ultrasound was not used and 2008–2010 when ultrasound was routinely employed. All patients received full-dose IV heparin during PVAI. In the no ultrasound cohort, only 14 % underwent PVAI without stopping warfarin, while 91 % of patients in the ultrasound cohort were on continued warfarin. Only patients deemed at high risk for thromboembolism with a periprocedural international normalized ratio (INR) less than 2 were bridged with subcutaneous low-molecular-weight heparin.

Results

Ultrasound reduced total vascular complications (1.7 vs. 0.5 %, p?<?0.01) and decreased the incidence of major vascular complications by sevenfold. Warfarin with INR?≥?1.2 on the day of PVAI was associated with more vascular complications (4.3 vs. 1.2 %, p?<?0.01). Ultrasound guidance overcame the risk associated with warfarin therapy. Vascular complications in anticoagulated patients with INR?≥?1.2 using ultrasound guidance were two- and ninefold lower than those in patients not using ultrasound with an INR?<?1.2 (0.5 vs. 1.2 %, p?<?0.05) and INR?≥?1.2 (0.5 vs. 4.3 %, p?<?0.01), respectively.

Conclusion

Ultrasound-guided venipuncture improves the safety profile of PVAI, reducing vascular complications in patients on warfarin to levels below those with no ultrasound and off warfarin.