Relationship between Chronic Kidney Disease, Time-in-Therapeutic Range, and Adverse Outcomes in Atrial Fibrillation: A post hoc Analysis from the AMADEUS Trial

<b><i>Background:</i></b> The benefit of anticoagulation therapy in atrial fibrillation (AF) and chronic kidney disease (CKD) remains controversial. We aimed to evaluate the impact of renal function on the quality of anticoagulation control, and the effects of both these factors on outcomes in AF. <b><i>Methods:</i></b> Post hoc analysis of the AMADEUS trial. Trial-related outcomes were adjudicated and we studied the composite of first stroke/major bleeding/all-cause mortality, ischaemic stroke, major bleeding, all-cause mortality, and cardiovascular mortality. <b><i>Results:</i></b> We included 2,282 vitamin K antagonist (VKA)-treated patients {<i>n</i> = 787 (34.5%) females; median age 72 (interquartile ranges [IQR] 64–77) years}. Median follow-up was 365 (IQR 189–460) days. There were 1,922 (84.2%) non-CKD and 360 (15.8%) CKD patients. Renal function was inversely correlated with time-in-therapeutic range (<i>r</i> = −0.047, <i>p</i> = 0.025). There was no statistical difference in terms of crude study outcomes based on renal function. Multivariable regression analysis demonstrated that moderate renal failure with estimated glomerular filtration rate of less than 60 mL/min/1.73 m² (<i>p</i> = 0.032) and percentage of time-in-therapeutic range (<i>p</i> = 0.011) were independent predictors for the composite outcome of stroke, major bleeding, and all-cause mortality. <b><i>Conclusion:</i></b> Deteriorated renal function has a small negative impact on the quality of anticoagulation control with VKA which is linked to poor outcomes in AF. However, moderate renal failure itself was an independent risk factor for increased risk of stroke, major bleeding, and all-cause mortality amongst patients with AF.

Biochemical Parameters of Diabetes Ketoacidosis in patients with End-Stage Kidney Disease and Preserved Renal Function

Introduction Differences in biochemical parameters of diabetic ketoacidosis in patients with end-stage kidney disease (ESKD) has not been established. Accordingly, we assessed the relationship between degree of metabolic acidosis and ß -hydroxybutyrate in patients ESKD (eGFR &lt;15 mL/min/1.73 m 2), moderate renal failure (eGFR 15-60) or preserved renal function (eGFR &gt;60). Methods This observational study included adults (18-80 years) with DKA, admitted to Emory University Hospitals between 01/01/2006 to 12/31/2016. DKA and renal stages were confirmed on admission laboratory values. Results Admission bicarbonate levels (13.9±5 vs 13.4±5.3 vs 13.8±4.2 mmol/L, p=0.7), and pH levels (7.2±0.3 vs 7.2±0.2 vs 7.2±0.2, p=0.8) were similar among groups. Patients with ESKD had lower mean ß -hydroxybutyrate (4.3±3.3 vs 5.6±2.9 vs 5.9±2.5 mmol/L, p=0.01), but higher admission glucose (852±340.4 vs 714.6±253.3 mg/dL vs 518±185.7 mg/dL, p &lt;0.01), anion gap (23.4±7.6 vs 23±6.9 vs 19.5±4.7 mmol/L, p &lt;0.01), and osmolality (306±20.6 vs 303.5± vs 293.1±3.1mOsm/kg, p&lt;0.01), compared to patients with moderate renal failure and preserved renal function. The sensitivity of ß-hydroxybutyrate &gt;3 mmol/L for diagnosing DKA by bicarbonate level &lt;15 and &lt;18 mmol/L was 86.9% and 72% in ESKD, 89.3% and 83.7% in moderate renal failure and 96.2% and 88.3% in preserved renal function. In patients with ESKD, the corresponding ß-hydroxybutyrate with bicarbonate levels &lt;10, 10-15, &lt;18 mmol/L were 5.5, 3.9, 3.0 mmol/L, respectively. Conclusions Significant metabolic differences were found among DKA patients with different levels of renal function. In patients with ESKD, a ß-hydroxybutyrate level &gt; 3 mmol/L may assist with confirmation of DKA diagnosis.

Diagnosis and Therapy of Atrial Fibrillation in Geriatric Patients

Atrial fibrillation is very common in most old patients who need an adapted therapy due to their comorbidities. Before initiating an antiarrhythmic therapy, possible adverse effects, especially iatrogenic proarrhythmia, and extracardiac side-effects, must be considered. In geriatric patients with atrial fibrillation, heart rate control is the most frequent therapy. Oral anticoagulation plays a vital role in the therapy, but anticoagulation in old patients, who had a bleeding or stroke event, is challenging. Available data favor the use of anticoagulation in old patients with atrial fibrillation and suggest the use of direct oral coagulants, in most cases, over the use of vitamin K antagonists. However, a gap exists in the knowledge regarding the optimal dose in very old patients, particularly in patients with mild-to-moderate renal failure, with very low or high body mass index, and in those receiving medications with a high risk of metabolic interactions.

A Clinical and Electrophysiological Study of Peripheral Neuropathies in Predialysis Chronic Kidney Disease Patients and Relation of Severity of Peripheral Neuropathy with Degree of Renal Failure

ABSTRACT Objective: To study the prevalence, clinical features, electrophysiological features, and severity of peripheral neuropathy in predialysis chronic kidney disease (CKD) patients with respect to severity of renal failure and presence of diabetes mellitus. Materials and Methods: Between May 2015 and December 2016, 200 predialysis CKD patients were assessed prospectively. Results: The prevalence of peripheral neuropathy in predialysis CKD patients in the present study was 45% based on clinical symptoms and 90% electrophysiologically. Mean age of 200 predialysis CKD patients who participated in the study was 53.2 ± 13.2 years. One hundred and thirty-six (68%) patients were male and 64 (32%) patients were female. Mean duration of disease was 2.2 ± 1.6 years. Nearly 45% patients of patients had asymptomatic peripheral neuropathy in the present study, which was more common in mild-to-moderate renal failure group. One hundred twenty-six patients (63%) had definite damage and 54 patients (27%) had early damage. In mild-to-moderate renal failure (n = 100) and severe renal failure patients (n = 100), 88% and 92% had significant peripheral neuropathy, respectively. Most common nerves involved were sural nerve, median sensory nerve, and ulnar sensory nerve. Diabetic patients (97%) showed more severe and high prevalence of peripheral neuropathy when compared to nondiabetic patients (83%). Most common patterns were pure axonal sensorimotor neuropathy and mixed sensorimotor neuropathy. Conclusion: Peripheral neuropathy is common in predialysis patients, prevalence and severity of which increases as renal failure worsens. Predialysis patients with diabetes show higher prevalence and severity of peripheral neuropathy when compared with nondiabetics.

Rivaroxaban in non valvular atrial fibrillation: subgroups analysis

After the ROCKET AF study main paper several subgroups analysis were recently published. These studies are useful to better evaluate the rivaroxaban efficacy and safety in different clinical conditions. Here the subgroup analysis of patients with moderate renal failure, heart failure and diabetes are presented. Post hoc data on patients who underwent an electrical or pharmacological cardioversion during ROKET AF follow up were available and here we analyze also the results of the first randomized study on electrical cardioversion in patients treated with new oral anticolagulants: the X-VeRT trial. A metanalysis of all the studies with rivaroxaban (one on stroke prevention in atrial fibrillation, two on acute coronary syndromes, four on deep venous thrombosis prophylaxis and two on pulmonary embolism treatment) with respect to the risk of myocardial infarction is examined.