Risk of Nephrolithiasis in Patients with Inflammatory Bowel Disease Receiving Biologic Treatment

INTRODUCTION

Inflammatory bowel disease is a chronic inflammatory disorder of the gastrointestinal tract. Biologic drugs target specific molecules in the body's immune system to control inflammation. Recent studies have suggested a potential link between their use and an increased risk of nephrolithiasis. We conducted a study to further investigate this association.

METHODS

The study used multiple logistic regression analysis to assess the association between the use of biologic drugs and nephrolithiasis. A p-value of <0.05 was considered statistically significant. SAS 9.4 was used for statistical analysis.

RESULTS

The final sample consisted of 22,895 cases, among which 5603 (24.51%) were receiving at least one biologic drug. The biologic drugs received were as follows: Adalimumab 2437 (10.66%), Infliximab 1996 (8.73%), Vedolizumab 1397 (6.11%), Ustekinumab 1304 (5.70%); Tofacitinib, 308 (1.35%); Certolizumab, 248 (1.08%); and Golimumab, 121 (0.53%). There were 1780 (7.74%) patients with Nephrolithiasis: 438 (8.0%) patients were receiving biologic treatment. We found that the use of Vedolizumab (OR = 1.307, 95% CI 1.076-1.588, p = 0.0071) increased the odds of Nephrolithiasis by 31%.

CONCLUSION

Vedolizumab use was associated with an increased risk of nephrolithiasis. The use of two or more biologic drugs also increased the risk compared to no biologic treatment.

Inferior Wall ST-Elevation Myocardial Infarction Complicated by Left Ventricular Pseudoaneurysm, Cardiac Tamponade, and Partial Papillary Muscle Rupture

Papillary muscle rupture (PMR) is a rare complication of myocardial infarction. Its incidence has been decreasing nowadays because of improved early revascularization techniques. When it occurs, surgical treatment is the only therapeutic lifesaving approach. We report a case of an 85-year-old female patient who presented to the emergency room with chest pain. An electrocardiogram showed inferior wall ST-elevation myocardial infarction. The patient was revascularized emergently with a drug-eluting stent to the obtuse marginal artery. An intra-aortic balloon pump was inserted for hemodynamic support. Six hours later, the patient developed shortness of breath with persistent hypotension. A transthoracic echocardiogram (TTE) showed a large pericardial effusion with a pseudoaneurysm in the infero-septal apex. Immediate drainage of pericardial fluid was performed. Seventy-two hours later, the patient had flash pulmonary edema. A new severe eccentric mitral regurgitation was discovered on transesophageal echocardiography (TEE). Findings revealed a partial posteromedial papillary muscle tear and prolapse of the A2 scallop. The patient was not a candidate for surgical replacement or percutaneous repair due to the high surgical risk and poor functional status, and she passed away on day fifteen of her hospital stay. Limited case series have shown promising benefits of percutaneous edge-to-edge mitral valve repair in selected high surgical risk patients and as a bridge to definitive mitral valve replacement. A diagnosis of PMR should be in the differential diagnosis, especially when evaluating hemodynamically unstable patients who present with prolonged symptoms.

Giant Coronary Artery Aneurysm: A Successful Diagnosis

Coronary artery aneurysms (CAAs) are rare, with giant CAAs being even rarer. The precise pathophysiology of this phenomenon is still unknown. CAAs are seldom reported life-threatening abnormalities of the cardiovascular system. We herein present a case of a 74-year-old man who presented at the hospital complaining of chest pain. An adenosine thallium scan revealed a small, reversible defect in the inferior wall of the left ventricle extending into the apex, consistent with ischemia. Echocardiography uncovered a large right coronary artery (RCA) aneurysm, measuring 5.6 × 7.5 cm. Diagnostic coronary angiography confirmed the presence of a large RCA aneurysm and aneurysmal dilation of the left anterior descending and circumflex arteries with no flow-limiting lesions. A reversed saphenous vein interposition graft was placed from the ascending aorta to the right posterior descending artery. The RCA aneurysmal sac was resected and sent to pathology, which uncovered myxoid degeneration of the media as well as thrombus formation. No complications were encountered during the procedure. Early diagnosis is vital to avoid fatal complications of CAAs, and therapeutic approaches are currently individualized in view of absence of evidence-based management strategies. 

Current Practice of Percutaneous Coronary Intervention in Patients With Coagulation Disorders

Acute coronary artery disease represents the leading cause of death worldwide. Some studies have shown that coagulation disorders can play a protective role against ischemic heart disease, presumably due to hypocoagulable state and decrease thrombin formation. However, autopsy reports showed atherosclerotic lesions in some patients with hemophilia. Since the introduction of clotting factors and replacement therapies, the life expectancy of patients with coagulation disorders has increased significantly. As a result, the incidence of cardiovascular diseases became higher making their treatment more challenging. Door to balloon strategy applies in ST-elevation myocardial infarction (STEMI), and percutaneous coronary intervention should not be delayed. While in non-STEMI (NSTEMI) and unstable angina, a hematology consult is essential. Prophylactic coagulation factor replacement is crucial in these patients in order to avoid bleeding complications, but on the other hand, these factors were also associated with thrombotic complications. Historically, bare-metal stents were preferred over drug-eluting stents in view of the shorter duration of dual antiplatelets therapy (DAPT). Currently, some trials have demonstrated the safety of new-generation drug-eluting stents in patients with elevated bleeding risk, where DAPT use is limited to four weeks. The radial artery is the preferred access and was found to have less bleeding complications when compared to the femoral access. Anticoagulation with heparin is the safest in view of antidote availability and shorter half-life. Bivalirudin has also been used in some case reports, while GP2b3a inhibitors are usually avoided except in a high thrombus burden. Close peri procedural follow-up is important with patient education about symptoms of bleed. Carefully and individually tailored antithrombotic and factor replacement therapy is required to overcome these clinically challenging situations. Early screening for cardiovascular risk factors and considering early intervention and management might help to improve the general health status of this population and reduce morbidity.