Oral antiplatelet drugs in patients with chronic kidney disease (CKD): a review

The correlation between protein energy wasting and the incidence of main adverse cardiovascular events in adult maintenance hemodialysis patients: a single-center retrospective cohort study

BACKGROUND

Protein energy wasting (PEW) is prevalent in adult maintenance hemodialysis (MHD) patients. Concurrently, cardiovascular diseases (CVD) remain a leading cause of mortality in MHD patients. However, the relationship between PEW and CVD in MHD patients remains unclear.

METHODS

We conducted a retrospective cohort study at Shanghai East Hospital. According to the inclusion and exclusion criteria, a total of 210 adult MHD patients were finally enrolled. Patients were categorized into two groups based on PEW diagnostic criteria, including 122 patients (58.1%) with PEW and 88 patients (41.9%) without PEW. We further analyzed the incidence of major adverse cardiovascular events (MACE) and all-cause mortality in one year, along with their risk factors.

RESULTS

MACE incidence was significantly higher in the PEW group compared with the non-PEW group (p = 0.015). Multivariate Cox regression showed PEW, CVD, high N-terminal pro-B-type natriuretic peptide (NT-proBNP) and low Kt/V urea were the risk factors of MACE. Age ≥ 65 years and high NT-proBNP were the risk factors of all-cause death. Among patients aged ≥ 65 years, PEW was associated with a higher risk of all-cause death (p = 0.043). Total cholesterol < 3.4 mmol/L, albumin < 38 g/L and prealbumin < 280 mg/L were the thresholds for MACE incidence in MHD patients with PEW.

CONCLUSION

Adult MHD patients with PEW had an increased risk of MACE and all-cause mortality. Strategies aimed at optimizing total cholesterol, albumin, and prealbumin levels may improve cardiovascular outcomes in adult MHD patients with PEW.

Pre-Stroke Loop Diuretics and Anemia in Elderly Patients Are Associated Factors of Severe Renal Dysfunction at the Time of Acute Stroke Onset

BACKGROUND

Severe renal dysfunction (SRD), an advanced stage of chronic kidney disease (CKD), can limit the treatment options for acute stroke (AS) patients. Therefore, it is important to investigate the associated factors of SRD in AS patients to inhibit CKD progression to SRD before AS. Sex differences exist in the renal function. Therefore, we investigated the frequency of SRD and its associated factors among AS patients by sex.

METHODS

Our cross-sectional study included patients admitted within 24 h of AS onset between 2013 and 2019 with available pre-stroke medication information. We used the Cockcroft-Gault equation for calculating the creatinine clearance (Ccr) and defined SRD as a Ccr < 30 mL/min. We performed multivariable logistic regression analysis to identify the independent factors associated with SRD.

RESULTS

Out of 4294 patients, 3472 matched our criteria. Of these, 1905 (54.9%) were male, with median ages of 75 and 81 years for males and females, respectively. The frequency of SRD was 9.7% in males and 18.7% in females. Loop diuretics and anemia were associated factors of SRD.

CONCLUSIONS

Pre-stroke loop diuretics and anemia in elderly patients were associated factors of SRD in both sexes. Individualized drug therapy and anemia management are essential to prevent SRD.

Subgroup analysis of the ASPirin in Reducing Events in the Elderly randomized clinical trial suggests aspirin did not improve outcomes in older adults with chronic kidney disease

The role of aspirin for primary prevention in older adults with chronic kidney disease (CKD) is unclear. Therefore, post hoc analysis of the randomized controlled trial ASPirin in Reducing Events in the Elderly (ASPREE) was undertaken comparing 100 mg of enteric-coated aspirin daily against matching placebo. Participants were community dwelling adults aged 70 years and older in Australia, 65 years and older in the United States, all free of a history of dementia or cardiovascular disease and of any disease expected to lead to death within five years. CKD was defined as present at baseline if either eGFR under 60mL/min/1.73m² or urine albumin to creatinine ratio 3 mg/mmol or more. In 4758 participants with and 13004 without CKD, the rates of a composite endpoint (dementia, persistent physical disability or death), major adverse cardiovascular events and clinically significant bleeding in the CKD participants were almost double those without CKD. Aspirin's effects as estimated by hazard ratios were generally similar between CKD and non-CKD groups for dementia, persistent physical disability or death, major adverse cardiovascular events and clinically significant bleeding. Thus, in our analysis aspirin did not improve outcomes in older people while increasing the risk of bleeding, with mostly consistent effects in participants with and without CKD.

Role of direct oral anticoagulants in patients with kidney disease

The anticoagulation field is experiencing a renaissance that began with regulatory approval of the direct thrombin inhibitor dabigatran, a direct oral anticoagulant (DOAC), in 2010. The DOAC medication class has rapidly evolved to include the additional approval of 4 direct factor Xa inhibitors. Commensurately, DOAC use has increased and collectively account for the majority of new anticoagulant prescriptions. Despite exclusion of patients with moderate-to-severe kidney disease from most pivotal DOAC trials, DOACs are increasingly used in this setting. An advantage of DOACs is similar or improved antithrombotic efficacy with less bleeding risk when compared with traditional agents. Several post hoc analyses, retrospective studies, claims data studies, and meta-analyses suggest that these benefits extend to patients with kidney disease. However, the lack of randomized controlled trial data in specific kidney disease settings, with their unique pathophysiology, should be a call to action for the kidney community to systematically study these agents, especially because early data suggest that DOACs may pose less risk of anticoagulant-related nephropathy than do vitamin K antagonists. Most DOACs are renally cleared and are significantly protein bound in circulation; thus, the pharmacokinetics of these drugs are influenced by reduced renal function and proteinuria. DOACs are susceptible to altered metabolism by P-glycoprotein inhibitors and inducers, including drugs commonly used for the management of kidney disease comorbidities. We summarize the currently available literature on DOAC use in kidney disease and illustrate knowledge gaps that represent important opportunities for prospective investigation.

Prevention and treatment of stroke in patients with chronic kidney disease: an overview of evidence and current guidelines

Chronic kidney disease is strongly associated with an increased risk of stroke, small vessel disease, and vascular dementia. Common vascular factors for stroke, such as hypertension, diabetes, and atrial fibrillation, are more prevalent in patients with chronic kidney disease, accounting for this association. However, factors unique to these patients, such as uremia, oxidative stress, and mineral and bone abnormalities, as well as dialysis-related factors are also believed to contribute to risk. Despite improvements in stroke treatment and survival in the general population, the rate of improvement in patients with chronic kidney disease, especially those who are dialysis dependent, has lagged behind. There is a lack of or conflicting evidence that those with renal disease, particularly when advanced or older, consistently derive benefit from currently available preventive and therapeutic interventions for stroke in the general population. In this review, we explore the complexities and challenges of these interventions in the population with renal disease.

Incidence and impact on prognosis of impaired kidney function in Middle Eastern patients undergoing percutaneous coronary intervention: results from the first Jordanian PCI Registry

AIMS

The aim of this study was to evaluate the impact on prognosis of renal impairment (RI) in Middle Eastern patients after percutaneous coronary intervention (PCI).

METHODS AND RESULTS

PCI patients (N=2,426) were divided into three groups according to the estimated glomerular filtration rate (eGFR, ml/min/1.73 m2): normal renal function (eGFR ≥90), mild RI (eGFR 60-89), or moderate to severe RI (eGFR <60). Mean age of participants was 56±11 years. Normal renal function was present in 41.6%, mild RI in 44.2%, and moderate to severe RI in 14.2%. Patients with moderate to severe RI were older and had higher prevalence of hypertension and diabetes mellitus compared with other patients (p≤0.002). At one year, patients with moderate to severe RI had a higher incidence of cardiac mortality (3.78%) compared with patients with mild (1.77%) or no RI (1.49%), p=0.03. In multivariate analysis, moderate to severe RI was associated with higher one-year cardiac mortality compared to mild or no RI (odds ratio=3.7; 95% CI: 2.8-5.0, p=0.001).

CONCLUSIONS

Impaired renal function was present in about six out of 10 Middle Eastern patients undergoing PCI. Moderate to severe RI carries a higher risk of cardiac mortality at one year compared with mild or no RI.