Venous thrombosis and CKD : IS there a connection?

Cancer can lead to increased risk of clots and DVTs. Many cancer patients also have decreased GFR. Does GFR alone increase the risk of DVTS or blood clots?

Ocak et al answered this question in a recent publication in Circulation in 2014.

Pro-coagulant factors were reviewed in patients with varied degree of GFR compared to a cohort of normal GFR patients with venous thrombosis.

Factor VIII and VWF levels were increased with each percentile category drop in GFR.  The odds of having a venous clot also increased independent of other risk factors( DM, Factor V leiden, malignancy, arterial thrombosis, BMI, immobilization, surgery, steroids use) with drop in GFR.

Adjustment of those factor levels did attenuate the odds ratio related to GFR.  The authors did conclude that impaired kidney function affects venous thrombosis risk via concurrently raised factor VIII and von Willebrand factor levels. 

In both the Longitudinal Investigation of Thromboembolism Etiology (LITE) and Prevention of Renal and Vascular End-Stage Disease (PREVEND) study, chronic kidney disease was associated with an increased risk of venous thrombosis. This study showed the pathophysiologic mechanism perhaps why this happens. 

New York Society of Nephrology Fellows Night Event: Please submit abstracts

         NYSN Fellows Night

                                 Date: May 20th 2015

                                       Location:

                   The New York Academy of Medicine

                     1216 Fifth Avenue (103rd Street)

                              New York, NY 10029

Abstract Submission: April 28th, 2015

Abstract Acceptance Notice: May 6th, 2015

Abstract Guidelines:

1)      Page Length –Please describe their project in NO MORE than 300 words

2)      Fellow must present their own work in which they made a significant contribution.

3)      Research Mentor should be a member of the NYSN with paid dues. Dues are $100.00 and should be send to Dr. Enver Akalin, Montefiore Medical center, 111 East 210th street, Kidney Transplant Program, Bronx, NY 10467.

4)      Please identify the research into one of two categories: Clinical Or Basic

5)      Mentor/advisor name has to be part of the abstract.

6)      Please submit your abstracts to kjhaveri@nshs.edu when ready.

7)      Top Clinical and Basic research abstracts will be selected for ORAL presentation on May 20th evening

a.      Presentation: Power Point

b.      Presentation Length: 8 minutes

c.      Questions / Answers: 4 minutes

d.      Abstract presentations will be judged based on the following:

i.      Research Question / Knowledge about the topic

ii.     Study Design / Data Presentation

iii.    Interpretation of Data / Responses to Questions

e.      Prizes - First place and Second places will be awarded in BOTH categories.

8)      Alison Norris Nephrology Fellow Award: Third year in a row, this award will be given the paper that is focused on some psychosocial/ethical aspect of the care of kidney patients.

Kenar Jhaveri, MD

Program Chair

NYSN

Tyrosine Kinase Inhibitors vs Anti VEGF therapy: What does the podocyte see?

Anti VEGF therapy has been known to cause proteinuric renal disease. A recent study published in Medicine has the largest single center series looking at biopsy proven findings of Anti VEGF and tyrosine kinase inhibitor therapies.

Some interesting points:

Most patients were biopsied for proteinuria

TMA was the most common biopsy finding if the drug used was an anti VEGF or TRAP agent, 50% of which were only renal limited.

Minimal Change disease/FSGS was the most common finding associated with tyrosine kinase inhibitors along with interstitial or tubular disease.  

This is an interesting observation that was not reported before. It appears that the VEGF inhibitors are strictly likely to behave like pre eclampsia like syndromes but the TKIs are more likely to cause a pure nephrotic syndrome like GN.  None had gotten steroids. It might be interesting to see if these drug induced MCD respond to steroids and hence we can then continue the agent for good cancer treatment.

Hypertension and proteinuria resolved following drug discontinuation and antihypertensive agents.

No patient developed severe renal failure requiring dialysis. 

SiteGPR: A website for renal dosing of medications

Dosing of drugs in renal disease is a common topic of discussion. A nice website tool that helps manage that better is here.
http://sitegpr.com/index.php

SiteGPR presents evidence-based recommendations on drugs dosage adjustments in patients with renal insufficiency.

In addition, it has a long list of medications that are linked with renal toxicity.
A great tool to be used.

Nephtangles: The nephrology interface with ABIM MOC

As we are all aware of the increased requirements from ABIM in the last few years for board certification.  What are we to do? Sit tight and wait for a final decision? Is MOC here to stay or to go? What is our role as a practicing physician.

I urge all to read Nephtangles blog
http://nephtangles.blogspot.com/

The blog has multiple posts highlight some important developments in the last few months on this very important topic.

Blood Transfusions and AKI following CABG: Does age of PRBCs matter?

Blood transfusions have been linked with risk of AKI following cardiac surgery. Anemia and number of PRBCs transfusion are independent risk factors for development of AKI post CABG, Catalytic iron can produce oxidative stress, surrogate for hypotension and a “sick patient” and age of PRBCs maybe the culprit? In addition, PRBCs have been linked with non renal adverse outcomes such as 16% increase risk of mortality post CABG, risk of sepsis and pneumonia and risk of increased length of intubation.

A recent study called RECESS trial just published in NEJM looked at the age of PRBCS and risk of outcomes following CABG. RECESS was a randomized trial at multiple sites from 2010 to 2014 looking at patients 12 years of age or older who had complex cardiac surgery and were likely to undergo transfusion of red cells were randomly assigned to receive leukocyte-reduced red cells stored for 10 days or less (shorter-term storage group) or for 21 days or more (longer-term storage group) for all intraoperative and postoperative transfusions.

The primary outcome was the change in Multiple Organ Dysfunction Score (MODS; range, 0 to 24, with higher scores indicating more severe organ dysfunction) from the preoperative score to the highest composite score through day 7 or the time of death or discharge.Overall results showed that the duration of PRBCS storage was not associated with MODS events. In addition, adverse events did not differ significantly between groups except that hyperbilirubinemia was more common in the longer-term storage group.

What about renal outcomes? In the supplementary sections, the renal outcomes are mentioned and there was no difference in both arms. Serious renal adverse events in both arms were also similar. So AKI risk might still exist due to PRBCs transfusion risk but it’s not due to the age of the PRBCS. 

Acute Kidney Injury Associated with Cardiac Surgery

Here is a slide share of a talk I gave on AKI in the cardiac surgery unit.