RESUMEN
BACKGROUND: Vascular access by dialysis graft or fistula is of major importance for hemodialysis treatment. Vascular access occlusion is one main reason for hospitalization of patients on hemodialysis. Thrombophilic risk factors are discussed as one cause for occlusion. The aim of this study was to determine if the presence of thrombophilic factors is associated with a reduced survival rate of vascular dialysis access. PATIENTS AND METHODS: The following thrombophilic parameters were measured in every hemodialysis patient from five outpatient dialysis centers in Berlin: antithrombin, protein C, protein S, prothrombin mutation (G20210A), factor V mutation (G1691A), lupus anticoagulant, anticardiolipin antibodies, factor VIII, plasminogen activator inhibitor, homocysteine and lipoprotein(a). Vascular access characteristics such as vascular access material (PTFE graft or native fistula) and location were also recorded. Each patient's medical history was documented. RESULTS: 199 patients with a total of 499 vascular accesses in the past (311 native fistulas (62.3 %) and 188 PTFE grafts (33.7 %)) were included in this study. The type of vascular access played an important role, with mean survival times of 34.2 months for native fistulas versus 9.5 months for grafts. There was at least one thrombophilic risk factor present in 69.8 % of the patients. In the univariate analysis thrombophilia had a significant influence on vascular access survival. The effect persisted throughout the multivariate analysis. Multivariate Cox analysis showed that the presence of thrombophilic factors was associated with a 43 % (mild) to 105 % (severe thrombophilia) increased risk of occlusion of the vascular access, corresponding to a 45 % to 68 % reduction of native access survival time. The influence of thrombophilia was evident in fistulas as well as in PTFE grafts. CONCLUSIONS: Thrombophilia plays a role in vascular accesses survival in patients on hemodialysis. In hemodialysis patients with recurrent occlusions of vascular access thrombophilia testing should be performed.
Asunto(s)
Derivación Arteriovenosa Quirúrgica/efectos adversos , Implantación de Prótesis Vascular/efectos adversos , Oclusión de Injerto Vascular/etiología , Fallo Renal Crónico/terapia , Diálisis Renal , Trombofilia/complicaciones , Trombosis/etiología , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Femenino , Predisposición Genética a la Enfermedad , Alemania , Oclusión de Injerto Vascular/sangre , Oclusión de Injerto Vascular/genética , Oclusión de Injerto Vascular/fisiopatología , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Análisis Multivariante , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Trombofilia/sangre , Trombofilia/genética , Trombosis/sangre , Trombosis/genética , Trombosis/fisiopatología , Factores de Tiempo , Grado de Desobstrucción Vascular , Adulto JovenRESUMEN
BACKGROUND AND PURPOSE: Patients with stroke are at substantial risk of thromboembolic complications and therefore require antithrombotic prophylaxis. To show the noninferiority of the low-molecular-weight heparin certoparin to unfractionated heparin (UFH) for the prevention of thromboembolic complications, we performed a randomized, double-blind, active-controlled multicenter trial in patients with acute ischemic stroke. METHODS: Overall, 545 patients were randomized within 24 hours of stroke onset to treatment with certoparin (3000 U anti-Xa OD; n=272) or UFH (5000 U TID; n=273) for 12 to 16 days. Patients with paresis of a leg and an National Institutes of Health Stroke Scale score of 4 to 30 points were included. The primary end point was a composite outcome of proximal deep vein thrombosis, pulmonary embolism, or death related to venous thromboembolism during treatment. Computed tomography was performed at trial entry, after 7 days, and when clinical deterioration occurred. RESULTS: The per-protocol analysis revealed 17 (7.0%) primary events in the certoparin group compared with 24 (9.7%) in the UFH group, thereby demonstrating noninferiority (P=0.0011), confirmed by intention-to-treat analysis (6.6% versus 8.8%; P=0.008). Major bleeding occurred during treatment in 3 patients allocated to certoparin (1.1%) and 5 patients allocated to UFH (1.8%). CONCLUSIONS: Certoparin (3000 U anti-Xa OD) is at least as effective and safe as UFH (TID) for the prevention of thromboembolic complications in patients with acute ischemic stroke.
Asunto(s)
Heparina de Bajo-Peso-Molecular/uso terapéutico , Heparina/uso terapéutico , Accidente Cerebrovascular/tratamiento farmacológico , Tromboembolia/tratamiento farmacológico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Método Doble Ciego , Humanos , Isquemia/terapia , Persona de Mediana Edad , Modelos Estadísticos , Embolia Pulmonar/tratamiento farmacológico , Embolia Pulmonar/mortalidad , Riesgo , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/patología , Tromboembolia/mortalidad , Tromboembolia/patología , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Trombosis de la Vena/tratamiento farmacológicoAsunto(s)
Cardiología/normas , Trombosis/prevención & control , Alemania , Humanos , Sociedades MédicasRESUMEN
We examined the impact of treatment with ramipril versus other angiotensin-converting enzyme (ACE) inhibitors on clinical outcome in unselected patients of the prospective multicenter registry Maximal Individual Therapy of Acute Myocardial Infarction PLUS registry (MITRA PLUS). Of 14,608 consecutive patients with ST-elevation acute myocardial infarction, 4.7% received acute therapy with ramipril, 39.0% received other ACE inhibitor therapy, and 56.3% received no ACE inhibitor therapy. In a multivariate analysis, the treatment with ramipril compared with the treatment without ACE inhibitors was associated with a significantly lower hospital mortality and a lower rate of nonfatal major adverse coronary and cerebrovascular events. Compared with other generic ACE inhibitors, ramipril therapy was independently associated with a significantly lower hospital mortality (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.32 to 0.90) and a lower rate of nonfatal major adverse coronary and cerebrovascular events (OR 0.65, 95% CI 0.46 to 0.93), but not with a lower rate of heart failure at discharge (OR 0.79, 95% CI 0.50 to 1.27).