Background and purposePlatelet function testing prior to flow diversion procedures, although initially heavily debated, has seen a substantial increase in its adoption to assess the risk of operative and perioperative thrombotic and hemorrhagic events. This meta-analysis was conducted to assess platelet function testing, particularly the VerifyNow Platelet Reactivity Unit (PRU) assay, for a relationship between the reported assay PRU value and thrombotic and hemorrhagic events.Materials and methodsThe currently available literature (2013–2018) was surveyed with PubMed and Google Scholar searches. Included studies were those for which there were at least 30 cases during the study period, for which VerifyNow platelet reactivity unit values were obtained prior to the procedures and for which intraoperative and perioperative adverse events were noted. PRU value cut-offs ranging from >200 to >240 comprised the hyporesponse group while values ranging from <60 to <70 comprised the hyper-response group. The data were subject to statistical analysis to assess the relationship between PRU values and thrombotic and hemorrhagic events. The collected data were subsequently statistically analyzed to assess for publication bias.ResultsThe searches yielded 27 studies, of which 12 met the inclusion criteria for the meta-analysis. The meta-analysis included data from 1464 reported Pipeline cases. The study included 273 men and 1177 women with a mean age across the analyzed procedures of 58 years (range 25–85). After loading with antiplatelet medications, preprocedural platelet hyper-responsiveness was associated with a greater incidence of hemorrhagic events with an increased absolute risk of 12%, but showed no relationship with thrombotic events. Preprocedural platelet hyporesponsiveness was associated with a greater incidence of thrombotic events with an absolute risk of 15%, but showed no relationship with hemorrhagic events.ConclusionsVerifyNow PRU values that correspond to platelet hyporesponse or hyper-response to dual antiplatelet therapy are associated with a higher risk of thrombotic and hemorrhagic events, respectively. Thus, the PRU value may offer some predictive value for these events.
Background The renal angina index (RAI) is a useful tool for risk-stratification of acute kidney injury (AKI) in critically ill children. We evaluated the performance of a modified adult RAI (mRAI) for the risk-stratification of AKI in critically ill adults. Methods We used two independent ICU cohorts: 13,965 adult patients from the University of Kentucky (UKY) and 4,789 from UT Southwestern (UTSW). The mRAI included: diabetes, presence of sepsis, mechanical ventilation, pressor/inotrope use, percentage change in SCr in reference to admission SCr (ΔSCr), and fluid overload percentage within the first day of ICU admission. The primary outcome was AKI stage ≥2 at Day 2-7. Performance and reclassification metrics were determined for the mRAI score compared to ΔSCr alone. Results The mRAI score outperformed ΔSCr and readjusted probabilities to predict AKI stage ≥2 at Day 2-7: C-statistic: UKY 0.781 vs. 0.708 (IDI 2.2%) and UTSW 0.766 vs. 0.696 (IDI 1.8%), p<0.001 for both. In the UKY cohort, only 3.3% of patients with mRAI score <10 had the AKI event, while 16.4% of patients with mRAI score of ≥ 10 had the AKI event (NPV 96.8%). Similar findings were observed in the UTSW cohort as part of external validation. Conclusions In critically ill adults, the adult mRAI score determined within the first day of ICU admission outperformed changes in SCr for the prediction of AKI stage ≥2 at Day 2-7 of ICU stay. The modified adult RAI is a feasible tool for AKI risk-stratification in adult patients in the ICU.
Background:In patients with cirrhosis and acute kidney injury (AKI), longer time to AKI-recovery may increase the risk of subsequent major-adverse-kidney-events (MAKE). Aims:To examine the association between timing of AKI-recovery and risk of MAKE in patients with cirrhosis.Methods: Hospitalised patients with cirrhosis and AKI (n = 5937) in a nationwide database were assessed for time to AKI-recovery and followed for 180-days. Timing of AKI-recovery (return of serum creatinine <0.3 mg/dL of baseline) from AKI-onset was grouped by Acute-Disease-Quality-Initiative Renal Recovery consensus: 0-2, 3-7, and >7-days. Primary outcome was MAKE at 90-180-days. MAKE is an accepted clinical endpoint in AKI and defined as the composite outcome of ≥25% decline in estimated-glomerular-filtration-rate (eGFR) compared with baseline with the development of de-novo chronic-kidney-disease (CKD) stage ≥3 or CKD progression (≥50% reduction in eGFR compared with baseline) or new haemodialysis or death.Landmark competing-risk multivariable analysis was performed to determine the independent association between timing of AKI-recovery and risk of MAKE.Results: 4655 (75%) achieved AKI-recovery: 0-2 (60%), 3-7 (31%), and >7-days (9%).Cumulative-incidence of MAKE was 15%, 20%, and 29% for 0-2, 3-7, >7-days recovery groups, respectively. On adjusted multivariable competing-risk analysis, compared to 0-2-days, recovery at 3-7 and >7-days was independently associated with an increased risk for MAKE: sHR 1.45 (95% CI 1.01-2.09, p = 0.042), sHR 2.33 (95% CI 1.40-3.90, p = 0.001), respectively. Conclusion:Longer time to recovery is associated with an increased risk of MAKE in patients with cirrhosis and AKI. Further research should examine interventions to shorten AKI-recovery time and its impact on subsequent outcomes.
Background and Purpose: Flow diversion with the Pipeline Embolization Device (PED; Medtronic, Minneapolis, MN) has become increasingly utilized in the treatment of otherwise difficult to manage wide-necked aneurysms. Variations in the propensity for hemorrhagic and thrombotic complications during these procedures has been attributed to differences in location as defined be an anterior circulation versus a posterior circulation location. This meta-analysis was conducted to assess and fully characterize the relationship between these aneurysm locations and thrombotic and hemorrhagic events. Materials and Methods: The currently available literature (2013 - 2018) was surveyed with PubMed and Google Scholar searches. Included studies were those for which aneurysm locations were accurately reported and for which intra and perioperative adverse events were noted. The data was subject to statistical analysis to assess the relationship between an anterior or posterior circulation location and thrombotic or hemorrhagic events. The collected data was subsequently statistically analyzed to assess for publication bias. Results: The searches yielded 49 studies, of which 34 met the inclusion criteria for this meta-analysis. The current meta-analysis assessed 4060 anterior circulation pipeline procedures for hemorrhagic complications, and 3100 for thrombotic complications. This study also assessed 608 posterior circulation pipeline procedures for hemorrhagic events, and 582 for thrombotic events. An anterior circulation location was associated with a 3% absolute risk of hemorrhagic events (CI: 0.02 - 0.04), and a 4% absolute risk of thrombotic events (CI: 0.04 - 0.05). A posterior circulation location was associated with a 6% absolute risk of hemorrhagic complications (CI: 0.04 - 0.08) and showed a greater 13% absolute risk of thrombotic events (CI: 0.10 - 0.16). Conclusions: A posterior circulation aneurysm location is associated with a higher propensity for both thrombotic and hemorrhagic events compared to an anterior circulation location. Thrombotic complications are almost twice as likely compared to hemorrhagic complications in the posterior location.
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