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Brand: hermes bag herbag, Warfarin Therapy That Results in an International Normalization Ratio above the Therapeutic Range Is Associated with Accelerated Progression of Chronic Kidney Disease Warfarin Therapy That Results in an International Normalization Ratio above the Therapeutic Range Is Associated with Accelerated Progression of Chronic Kidney DiseaseSergey V. Brodsky,a, Michael Collins,b Edward Park,b Brad H. Rovin,b Anjali A. Satoskar,a Gyongyi Nadasdy,a Haifeng Wu,a Udayan Bhatt,b Tibor Nadasdy,a and Lee A. Hebertb aDepartment of Pathology, The jrrenterprises.com Ohio State University, Columbus, Ohio, USA Sergey V. Brodsky, MD, PhD, Department of Pathology, The Ohio State University, 333 W. 10th Ave, B078 Graves Hall, Columbus, OH 43210 (USA), Tel. Karger AG, Basel This article has been cited by other articles in PMC. AbstractBackground/AimsWe had previously reported that acute kidney Celine Handbags Cheap injury (AKI) in warfarin treated chronic kidney disease celine glasses (CKD) patients may occur shortly after an acute increase in the International Normalization Ratio (INR) with formation of occlusive red blood casts. Recovery from this warfarin associated AKI is poor. Here we investigated whether excessive warfarin therapy could accelerate the progression of CKD. MethodsWe analyzed serum creatinine (SC) and INR in 103 consecutive CKD patients on warfarin therapy in our Nephrology program from 2005 to the present. ResultsForty nine patients experienced at least 1 episode of INR Of these, 18 patients (37%, Group 1) developed an unexplained increase in SC mg/dl coincident with INR (mean SC increase 0.61 0.44 mg/dl); 31 patients (63%, Group 2) showed stable SC (mean SC change 0.04 0.19 mg/dl). Subsequent CKD progression was accelerated in Group 1, but not in Group 2. The 2 groups were not different with respect to demographics, comorbidities, blood pressure, or therapies. However, African Americans were overrepresented in Group 1 (p = 0.035). ConclusionsOveranticoagulation is associated with faster progression of CKD in a high percentage of patients. Our results indicate the need for prospective trials. Nevertheless, we suggest that our findings are sufficiently compelling at this point to justi fy extra caution in warfarin treated CKD patients to avoid overanticoagulation. Key Words: Warfarin, Serum creatinine, Acute kidney injury, Chronic kidney disease IntroductionThere is now credible evidence from multiple sources that severe overanticoagulation with warfarin can cause acute kidney injury celine bags (AKI) and severe acute renal hermes las vegas failure [1,2,3]. Based on the kidney biopsy findings, the AKI was attributable to severe glomerular hematuria that resulted in extensive renal tubular obstruction by red blood cell casts [1,2,3]. Recovery of kidney function was poor. Of the 10 reported patients, only 4 experienced recovery of kidney function. Those at risk for this form of AKI appear to be those who are predisposed to glomerular hemorrhage, either because the have abnormalities of glomerular membrane basement membrane width [2,3,4,5] or chronic kidney disease (CKD) [1]. The present study assessed whether overanticoagulation with warfarin might also be a risk factor for accelerated progression of CKD. To the best of our knowledge, the present study is the first to address this question. Patients and MethodsThe present strategy was to first identify all of the CKD patients (stages 2 followed by our Nephrology division from 2005 to the present who received chronic warfarin therapy for any indication. This cohort consisted of 148 patients. From this cohort, we selected all of the patients who met all of the following selection criteria: (1) at least 1 episode of International Normalization Ratio (INR) (2) serial measures of serum creatinine (SC) for at least 1 year before and at least 1 year after the INR (3) a SC measure within 1 week of the increase in INR and (4) a medical record that provided a description of their clinical status and their therapies at the time of first INR This cohort consisted of 51 patients. A further exclusion criterion was a condition evident from the celine me alone review of the medical record that was present at the first INR that likely explained the AKI. On this basis, 2 patients were excluded because of acute onset of hypotension related to acute myocardial infarction (1 case) or acute overcontrol of blood pressure by antihypertensive medication (1 case). The remaining 49 patients were stratified according to whether they experienced an unexplained increase in SC. For study purposes, this increase in SC was taken as mg/dl. This increase is more than 3 standard deviations (SDs) above the mean value for the cohort. Thus, the increase in SC is not likely to be explained by laboratory variation. Also, an acute increase in SC hermes scarves mg/dl is commonly used to identify cases of AKI. The patients who experienced a SC increase of mg/dl were designated Group 1. The patients who did not experience a SC increase of mg/dl were designated Group 2. Statistical AnalysisResults are presented as mean SD if not otherwise specified. Differences between groups were analyzed by the two paired t test or analysis of variance test, where it was applicable. Categorical variables were analyzed by the contingency table analysis. ResultsOf the 148 patients initially considered for this study, 103 had serial measures of INR over a 2 year period. After the INR the SC levels of Group 1 tended to remain elevated, and were significantly greater than the corresponding values of SC in Group 2. Fig. 1 Changes in the SC levels associated with an INR increase IU in patients with and without accompanied AKI. Changes in the SC levels ( associated with INR increase in patients with accompanied AKI ( n = 18) and without. We also assessed the changes in the SC at the first INR when the SC results of Groups 1 and 2 were pooled. This analysis also showed a significant increase in the SC (from 1.42 0.53 to 1.67 0.69 mg/dl, p = 0.048). This is evidence that the significant difference in the SC at INR between Groups 1 and 2 is not the result of the definition of AKI used in the study. We found a higher prevalence of African Americans among the Group 1 patients, but all other variables showed no significant differences. Table 1 Demographic and clinical characteristics of patients with abnormal INR episodes and increase in SC We also assessed whether therapies at the time of the INR might have differed between Group 1 and Group 2. We found that none of the following therapies differed between Groups 1 and 2: angiotensin converting enzyme inhibitor, angiotensin receptor blocker, diuretic, statin, nonsteroidal anti inflammatory drugs, aspirin, or clopidogrel. In Group 1, the recent initiation of warfarin treatment (within the previous 3 months) tended to be more common than in Group 2 (33.3 vs. 12.9%, p = 0.087). There were no differences between Group 1 and Group 2 in the indications for warfarin therapy. The majority of patients received warfarin because of atrial fibrillation; deep vein thrombosis or thrombi in other vascular beds was the second cause of warfarin therapy. Some patients received warfarin because of antiphospholipid syndrome or a cardiac valve replacement. In addition, we did not find any difference between Group 1 and Group 2 patients with regard to the slope or intercept of the increase in SC levels versus time 1 year before warfarin therapy was begun (data not shown). Also, there was a trend towards a greater prevalence of diabetic nephropathy in Group 1 than in Group 2, although this difference did not achieve statistical significance. hermes bag herbag These people Totally new strong style Tips on how have to How to hermes bag herbag Are unquestionably all these Were you Is going to I |
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