RESUMEN
PURPOSE: Hyperkalemia more commonly affects patients with a glomerular filtration rate of less than 60 mL/min. Using intravenous (IV) insulin to shift potassium intracellularly may cause hypoglycemia, requiring additional treatment or longer hospitalization. Literature on insulin dosing in this context is limited, with one previous study indicating that 5 units of IV insulin might be as effective and result in less hypoglycemia than the standard dose of 10 units of IV insulin. The hyperkalemia treatment pathway at our institution was revised in May 2018 to include a reduced-dose option (5 units of insulin) for patients with end-stage renal disease. This study aimed to compare the prevalence of hypoglycemia between patients who received standard-dose vs reduced-dose IV insulin. METHODS: This single-center, retrospective, quasi-experimental study evaluated the impact of revision of the hyperkalemia treatment pathway by assessing rates of hypoglycemia during the 6 months before and after implementation of the revised pathway. The primary endpoint was prevalence of hypoglycemia, defined as a blood glucose level of less than or equal to 70 mg/dL. RESULTS: There was no statistically significant difference in the occurrence of hypoglycemia when comparing the pre- and postimplementation groups (36 [17.7%] patients vs 34 [18.7%] patients; P = 0.7924). The postimplementation group had a statistically significant lower reduction in potassium levels after treatment than the preimplementation group (mean [interquartile range], -0.9 [-1.3, -0.5] mEq/L vs -0.6 [-1.2, -0.2] mEq/L; P = 0.0095). Baseline potassium levels were similar between the groups. CONCLUSION: Administration of reduced-dose IV insulin for treatment of hyperkalemia was significantly less effective in lowering serum potassium levels and did not decrease prevalence of hypoglycemia. When accounting for potential confounders, the only variable that was associated with hypoglycemia was pretreatment glucose level.
Asunto(s)
Hiperpotasemia , Hipoglucemia , Glucemia , Humanos , Hiperpotasemia/diagnóstico , Hiperpotasemia/tratamiento farmacológico , Hiperpotasemia/epidemiología , Hipoglucemia/inducido químicamente , Hipoglucemia/diagnóstico , Hipoglucemia/tratamiento farmacológico , Insulina , Potasio , Estudios RetrospectivosRESUMEN
Apixaban is prescribed for stroke prevention in nonvalvular atrial fibrillation (NVAF) in patients with varying degrees of renal dysfunction. While pharmacokinetic data support apixaban in severe renal impairment, clinical safety outcomes data are limited. This retrospective cohort analysis was conducted to evaluate the safety of apixaban in patients with NVAF and renal impairment. A total of 340 patients with NVAF receiving apixaban 5 mg or 2.5 mg twice daily were included for analysis; 287 preserved renal function (pRF: CrCl ≥ 25 ml/min and SCr ≤ 2.5 mg/dl) and 53 impaired renal function (iRF: CrCl < 25 ml/min and/or SCr > 2.5 mg/dl). The primary endpoint was major bleeding in patients taking apixaban 5 mg. Secondary endpoints included major bleeding with apixaban 2.5 mg and minor bleeding in both groups. There was no difference in major bleeding events in the 5 mg pRF group (4.41%) versus iRF group (3.57%) (P = 0.66). Similar rates occurred between the 2.5 mg pRF and iRF groups. Minor bleeding events were similar regardless of renal function. The incidence of bleeding in the 5 mg group was 11.45% with pRF versus 10.71% with iRF (P = 0.6). In the 2.5 mg group, bleeding incidence was 10% with pRF versus 16% with iRF (P = 0.47). There were no observed differences in bleeding between groups with pRF or iRF, regardless of apixaban dose. Because patients with severe renal impairment were excluded from original trials, this study contributes clinical safety outcomes to the limited data for use of apixaban in this patient population.
Asunto(s)
Fibrilación Atrial/tratamiento farmacológico , Inhibidores del Factor Xa/administración & dosificación , Enfermedades Renales/fisiopatología , Riñón/fisiopatología , Pirazoles/administración & dosificación , Piridonas/administración & dosificación , Accidente Cerebrovascular/prevención & control , Administración Oral , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico , Esquema de Medicación , Inhibidores del Factor Xa/efectos adversos , Femenino , Hemorragia/inducido químicamente , Humanos , Enfermedades Renales/complicaciones , Enfermedades Renales/diagnóstico , Masculino , Persona de Mediana Edad , Pirazoles/efectos adversos , Piridonas/efectos adversos , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/etiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Vancomycin-associated (VA) acute kidney injury (AKI) is being increasingly recognized. A distinct pattern of rapid rise in serum creatinine (sCr) during VA-AKI has occasionally been observed. However, such scenarios remain underreported. METHODS: We conducted an online survey at the American Society of Nephrology Communities forum and reviewed publications of VA-AKI via PubMed or Google searching for cases of precipitous AKI (those with rise in sCr ≥1.5 mg/dL/day) attributable to vancomycin. RESULTS: We identified 12 original cases compiled from 6 different hospitals and 4 published cases (n = 16; 38% women, age 43.5 ± 16 years, weight 108 ± 23 kg, body mass index 35 ± 7 kg/m2) of precipitous AKI observed shortly after large cumulative doses of VA (8.8 ± 5 g). The median steepest 24-h rise in sCr was 2.6 mg/dL (range 1.5-3.5 mg/dL) and the slope of the initial 48-h sCr rise was greater than that of a control AKI (non-VA, n = 48) group (2.03 ± 0.1 vs. 0.62 ± 0.0 mg/dL/day; p < 0.0001). The steep rise in sCr in the VA-AKI was not accompanied by anuria. Overt rhabdomyolysis was absent in all cases. Further, in 3 precipitous VA-AKI cases, simultaneous serum cystatin C values did not rise precipitously, suggesting that the reductions in glomerular filtration rate were overestimated by the sCr increase. CONCLUSIONS: VA-AKI can manifest with a precipitous rise in sCr shortly after a high cumulative dose of vancomycin. True toxic tubular injury overrepresented by the sCr rise is postulated.
Asunto(s)
Lesión Renal Aguda/inducido químicamente , Antibacterianos/efectos adversos , Creatinina/sangre , Vancomicina/efectos adversos , Lesión Renal Aguda/sangre , Adulto , Estudios de Cohortes , Colorimetría , Femenino , Humanos , Masculino , Espectrometría de Masas , Persona de Mediana EdadRESUMEN
BACKGROUND: Current guidelines make no specific recommendations on the selection of direct oral anticoagulants for the prevention and treatment of venous thromboembolism in patients with end-stage renal disease (ESRD) receiving hemodialysis. Based on these guidelines, warfarin remains the anticoagulant of choice in these patients. OBJECTIVE: To compare bleeding rates in patients receiving apixaban or warfarin with ESRD undergoing chronic hemodialysis. METHODS: This was a single-center, retrospective, institutional review board-approved cohort analysis. Patients with ESRD undergoing chronic hemodialysis and receiving anticoagulation therapy with either apixaban or warfarin were included in this study. All data were collected from paper charts and electronic medical records and included documentation of bleeding events and related interventions. The primary outcome of this study was clinically relevant major bleeding events. Secondary outcomes included clinically relevant nonmajor bleeding events and minor bleeding events. RESULTS: A total of 160 patients were included in this study (warfarin group, n = 120; apixaban group, n = 40). There were 7 major bleeding events in the warfarin group compared with zero in the apixaban group ( P = 0.34). There were similar rates of clinically relevant nonmajor bleeding events (12.5% vs 5.8%, P = 0.17) and minor bleeding (2.5% vs 2.5%, P = 0.74) events in patients receiving apixaban and warfarin. CONCLUSIONS: There were no observed differences in bleeding rates in patients receiving apixaban compared with those receiving warfarin. Apixaban may be a cautious consideration in hemodialysis patients until there is further insight into the effect of subsequent, multiple doses on drug accumulation and clinical outcomes.
Asunto(s)
Anticoagulantes/efectos adversos , Hemorragia/inducido químicamente , Pirazoles/efectos adversos , Piridonas/efectos adversos , Warfarina/efectos adversos , Anciano , Anciano de 80 o más Años , Anticoagulantes/uso terapéutico , Femenino , Humanos , Fallo Renal Crónico/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tromboembolia Venosa/tratamiento farmacológico , Warfarina/uso terapéuticoRESUMEN
A 57-year-old woman presented to the hospital after a 40-day acaloric (water-only) fast, which was motivated by her Christian beliefs and Pentecostal affiliation. She exhibited hyponatremia on admission, and developed hypokalemia, hypophosphatemia and hypomagnesemia during refeeding. The authors are unaware of other published case reports describing medical and religious aspects of prolonged fasting by Christians for spiritual reasons. Nevertheless, this practice is advocated by some Pentecostal and non-Pentecostal sources, and may be more common than is widely recognized.
Asunto(s)
Ayuno/fisiología , Ayuno/psicología , Religión , Desequilibrio Hidroelectrolítico/diagnóstico , Desequilibrio Hidroelectrolítico/psicología , Agua/administración & dosificación , Femenino , Humanos , Persona de Mediana Edad , Desequilibrio Hidroelectrolítico/etiologíaAsunto(s)
Miocarditis/diagnóstico , Pericarditis/diagnóstico , Rickettsia rickettsii/aislamiento & purificación , Fiebre Maculosa de las Montañas Rocosas/complicaciones , Síndrome de Respuesta Inflamatoria Sistémica/diagnóstico , Adulto , Taponamiento Cardíaco/etiología , Taponamiento Cardíaco/cirugía , Ecocardiografía/métodos , Electrocardiografía/métodos , Tratamiento de Urgencia/métodos , Femenino , Estudios de Seguimiento , Humanos , Miocarditis/etiología , Pericardiocentesis/métodos , Pericarditis/etiología , Medición de Riesgo , Fiebre Maculosa de las Montañas Rocosas/diagnóstico , Índice de Severidad de la Enfermedad , Síndrome de Respuesta Inflamatoria Sistémica/etiología , Síndrome de Respuesta Inflamatoria Sistémica/terapia , Factores de Tiempo , Troponina T/sangreRESUMEN
Central sleep apnea is an important but frequently missed clinical diagnosis. The purpose of this clinical case series is to demonstrate that in a subset of patients with central sleep apnea, inpatient telemetry ECG recordings may reveal a consistent relationship between changes in sinus rate, AV conduction, and the presence and rate of respiratory artifact that should raise the clinical suspicion of central sleep apnea. In the three presented cases, marked sinus bradycardia or AV block was followed by the simultaneous occurrence of abrupt acceleration of heart rate and the appearance of rapid micro-oscillations consistent with respiratory artifact. These changes suggested central sleep apnea characterized by bradycardia during the apneic spells followed by awakening of the breathing center and postvagal tachycardia. In each case, central sleep apnea was confirmed by visual observation of the patient, documentation of arterial desaturations during episodes of bradycardia, and in two, by a subsequent sleep study. Physicians should be aware of the potential and significance of these electrocardiographic disturbances in patients with central sleep apnea.