Analysis of bleeding risk in percutaneous renal biopsy in Tibet / 北京大学学报(医学版)

OBJECTIVE@#To observe the postoperative bleeding after percutaneous renal biopsy (PRB) in Tibet, To analyze and summarize the risk factors associated with bleeding in high altitude patients to improve the safety of surgery.@*METHODS@#A retrospective analysis of 150 cases of PRB in the Department of Nephrology, People's Hospital of Tibet Autonomous Region from May 2016 to May 2018 were carried out, and the correlations between the potential risk factors (gender, age, blood pressure, hemoglobin, platelet, serum creatinine) and postoperative bleeding events were analyzed.@*RESULTS@#During the study period, the 150 patients receiving procedure of PRB were enrolled in our hospital, with an average age of (41.2±15.6) years, of whom 58.7% (88/150) were male, 41.3% (62/150) were female, and major bleeding complications occurred in 12 biopsies (8.0%, 12/150). Six cases for men and women, respectively. The mean age in the bleeding group seemed to be higher than that in the non-bleeding group [(48.3±20.0) years vs. (40.6±15.1) years, P=0.099]. There was no significant difference in the incidence of hypertension, hemoglobinemia, urea nitrogen and prothrombin time between the two groups. The level of serum creatinine in the hemorrhage group seemed to be higher than that in the non-bleeding group (P=0.090), and the time of the hemorrhagic group was longer than that in the non-bleeding group (P=0.069). The platelet count in the bleeding group was significantly lower than that in the non-bleeding group (P < 0.05). Multivariate Logistic regression analysis showed that the prolonged activation of partial prothrombin time and lower platelet count had a relatively high risk of bleeding, which was statistically significant (P=0.079, P=0.082).@*CONCLUSION@#PRB is safe and reliable on the whole in plateau areas; Old age, low platelet count, decreased renal function and prolonged activated partial coagulation time are related to postoperative bleeding of PRB, and hyperhemoglobin is not a risk factor for bleeding. High hemoglobin is not a risk factor for postoperative bleeding of PRB at high altitude.

Living-donor Sequential ABO-incompatible Kidney Transplantation after Liver Transplantation in a Patient with Alcoholic Liver Cirrhosis and End-stage Renal Disease / 대한이식학회지

A 47-year-old man developed chronic alcoholic liver cirrhosis and end-stage renal disease. He underwent blood-type-compatible liver transplantation with a graft from his daughter. After 8 months, sequential ABO-incompatible (ABOi) kidney transplantation was performed, with his brother as the donor (A to O). The patient had anti-A antibody titers (1:256). We performed pretransplant desensitization, including administration of rituximab, mycophenolate mofetil, tacrolimus, and prednisolone 2 weeks before the scheduled transplantation, and plasmaphresis (PP) and administered an intravenous immunoglobulin injection. The patient underwent PP before kidney transplantation until the anti-A antibody titer was <1:8. The patient achieved normal renal function within 4 posttransplantation days. Postoperative bleeding (diffuse hemorrhage) requiring additional blood transfusions and radiological intervention (drainage procedure) occurred 9 days after transplantation. The patient was discharged on day 20 of hospitalization. Nine months after the kidney transplantation, the recipient's and donor's liver and kidney functions were normal. ABOi renal transplantation after liver transplantation can be successfully performed in patients with high baseline anti-ABO antibody titers after preconditioning with rituximab and PP, and quadruple immunosuppressive therapy. However, caution is required regarding an increased risk of bleeding complications.

Genomic Analysis for Preventing Complications due to Proton Pump Inhibitor and Warfarin Combination Therapy after Open-Heart Surgery / 日本心臓血管外科学会雑誌

<b>Objective</b> : Prevention of gastrointestinal bleeding is imperative in perioperative management of open-heart surgery. Although both proton pump inhibitors (PPIs) and Warfarin are often prescribed to patients following cardiac surgery, the US FDA warns that PPIs increase the international normalized ratio (INR) when used concomitantly with Warfarin, by being metabolized by cytochrome P-450 (CYP) 2C19. We assessed whether this drug interaction depends on the genotype of CYP2C19 (Extensive Metabolizer, EM ; Intermediate Metabolizer, IM ; Poor Metabolizer, PM) or the type of PPI. <b>Methods and Results</b> : In this observational prospective study, the CYP2C9, CYP2C19, and VKORC1 genotypes of 78 patients were analyzed. After excluding cases with ^*1/^*3 of the CYP2C9 genotype and those with C/T of the VKORC1 genotype, 60 patients were assigned to Warfarin+Rabeprazole (RB group, 30 cases) or Warfarin+Lansoprazole (LP group, 30 cases). Warfarin was started with an initial dose of 3 mg, and INR values were measured on days 4, 8, 14, 28, and 56. There was no significant difference in median Warfarin dose between the LP group (2.5 mg/day) and RB group (3.0 mg/day), (<i>p</i>=0.88). The time in the therapeutic range (TTR) (Rosendaal) was significantly higher in the RB group (83.7%) than in the LP group (49.4%), and the time in the over range was significantly higher in the LP group (41.9%) than in the RB group (0.0%). In the LP group, TTR values were higher in CYP2C19 Extensive Metabolizers (EMs) than in Intermediate Metabolizers (IMs) and Poor Metabolizers (PMs), but there was no statistically significant difference between them. Conversely, in the RB group, there was no difference in the values of any CYP2C19 genotype. A multivariate analysis showed that high age and low TTR were risk factors for bleeding. <b>Conclusion</b> : We consider it possible that lower TTR values in the LP group were affected by the CYP2C19 genotype. In an aging society, Rabeprazole is safer and more effective as a proton pump inhibitor after open-heart surgery.

Catheter-Directed Thrombolysis with a Continuous Infusion of Low-Dose Urokinase for Non-Acute Deep Venous Thrombosis of the Lower Extremity

OBJECTIVE: We wanted to evaluate the feasibility of catheter-directed thrombolysis with a continuous infusion of low-dose urokinase for treating non-acute (less than 14 days) deep venous thrombosis of the lower extremity. MATERIALS AND METHODS: The clinical data of 110 patients who were treated by catheter-directed thrombolysis with a continuous infusion of low-dose urokinase for lower extremity deep venous thrombosis was analysed. Adjunctive angioplasty or/and stenting was performed for the residual stenosis. Venous recanalization was graded by pre- and post-treatment venography. Follow-up was performed by clinical evaluation and Doppler ultrasound. RESULTS: A total of 112 limbs with deep venous thrombosis with a mean symptom duration of 22.7 days (range: 15-38 days) were treated with a urokinase infusion (mean: 3.5 million IU) for a mean of 196 hours. After thrombolysis, stent placement was performed in 25 iliac vein lesions and percutaneous angioplasty (PTA) alone was done in five iliac veins. Clinically significant recanalization was achieved in 81% (90 of 112) of the treated limbs; complete recanalization was achieved in 28% (31 of 112) and partial recanalization was achieved in 53% (59 of 112). Minor bleeding occurred in 14 (13%) patients, but none of the patients suffered from major bleeding or symptomatic pulmonary embolism. During follow-up (mean: 15.2 months, range: 3-24 months), the veins were patent in 74 (67%) limbs. Thirty seven limbs (32%) showed progression of the stenosis with luminal narrowing more than 50%, including three with rethrombosis, while one revealed an asymptomatic iliac vein occlusion; 25 limbs (22%) developed mild post-thrombotic syndrome, and none had severe post-thrombotic syndrome. Valvular reflux occurred in 24 (21%) limbs. CONCLUSION: Catheter-directed thrombolysis with a continuous infusion of low-dose urokinase combined with adjunctive iliac vein stenting is safe and effective for removal of the clot burden and for restoration of the venous flow in patients with non-acute lower extremity deep venous thrombosis.

A Renal Perforating Artery Mistaken for Arterial Bleeding after Percutaneous Renal Biopsy: A Case Report

Perirenal hematoma after a renal biopsy is a common complication that usually resolves spontaneously, but this rarely requires transfusions or surgical/radiological intervention. We report here on a case of a renal perforating artery that was mistaken for renal arterial bleeding in a 53-year-old woman who was complicated with perirenal hematoma after undergoing a percutaneous renal biopsy. On the color and pulsed wave Doppler ultrasonography, linear blood flow was seen in the perirenal hematoma, which extended perpendicularly from the renal parenchyma into the perirenal space, and this linear blood flow exhibited an arterial pulse wave. On CT angiography, the renal perforating artery was demonstrated as a curvilinear vessel coursing tangentially to the renal margin and we decided that it was a pseudolesion caused by the renal perforating artery. A renal perforating artery may be mistaken for renal arterial bleeding after a percutaneous renal biopsy. A renal perforating artery and arterial bleeding can be differentiated by the location and shape seen on a color Doppler examination and the pulse waves characteristics.

The Therapeutic Efficacy and the Bleeding Complications of Urokinase and Alteplase in Patients with Massive Pulmonary Thromboembolism / 결핵및호흡기질환

BACKGROUND: The efficacy of several thrombolytic agents for treating massive pulmonary thromboembolism (PTE) has been reported to be similar. However, the difference of the bleeding complications caused by two commonly used thrombolytic agents in PTE patients is not well known. The aim of this study was to compare the therapeutic efficacy and the bleeding complications between urokinase and recombinant tissue-type plasminogen activatior(rt-PA, alteplase) in a Korean medical center. METHODS: We retrospectively reviewed the clinical data of the patients who were treated with thrombolytic agents(urokinase and alteplase) because of massive PTE. RESULTS: A total of 40 patients were included: 16 (40%) treated with urokinase and 24 (60%) with alteplase. The patients treated with alteplase showed a shorter duration of using vasopressor agents than did the patients who were given urokinase, but the duration of mechanical ventilation, the length of the ICU stay and the hospital stay were not different between the thrombolytic agents. Five patients treated with urokinase and eight patients treated with alteplase died (p=0.565): One patient in the urokinase group and four patients in the alteplase group died due to pulmonary thromboembolism. Bleeding complications after thrombolysis were observed in 3 patients(7.5%) treated with urokinase and in 11 (27.5%) patients treated with alteplase (p=0.079). Major bleeding complication occurred in 2 patients who were treated with alteplase. CONCLUSION: Urokinase seems to have fewer bleeding complications with an equivalent efficacy, as compared to alteplase, in Korean patients who suffer with massive pulmonary thromboembolism.

Clinical Experiences of Intravenous Urokinase in Acute Myocardial Infarction / 대한내과학회지

OBJECTIVES: The most important therapeutic strategy in acute myocardial infarction(AMI) is early recanalization of infarct-related artery(IRA). In Korea the commonly used method for recanalization is urokinase infusion in early phase of disease. But total dosage and method of urokinase infusion are still arbitary. Thus this study was undertaken to evaluate the patency rate of infarct-related artery by urokinase in AMI patients. METHODS: 42 acute myocardial infarction patients were treated with intravenous urokinase(40.000U/kg in 32 patients, 3,00,000U in 10 patients). IRA patency was evaluated with coronary angiography at 90 minutes and 7-10 days after intravenous urokinase. The clinical findings and coronary angiographic findings according to dose of urokinase or pain to time for urokinase injection were analysed prospectively. RESULTS: Mean pain to Door time was 251 minutes and door to urokinase time was 74 minutes. Early patiency of IRA was 61.8%(21/42) and no difference was observed between the dosage of intravenous urokinase. In open IRA group(21 patients) the reocclusion was not observed at 7-10 days later. The ejection fraction on admission was similiar in patent or non-patent IRA group, but follow up ejection fraction was significantly lower in closed IRA group than open IRA group(P=0.0185). Life- threatened bleeding complications were developed in 2 cases(4.8%, I intracranial hemorrhage, 1 gastrointestinal bleeding). CONCLUSION: IRA patency was achieved in 61.8% of acute myocardial infarction by intravenous urokinase as evaluated by coronary angiography. The patency of IRA at 90 minutes was important in preserving the global left ventricular function in early recovery phase of acute myocardial infarction. But large, prospective study may be needed to determine optimal and effective intravenous urokinase dosage in acute myocardial infarction.

Successful Coronary Stent Implantation without Systemic Heparin Therapy: Use of Local Heparin Delivery

BACKGROUND: Acute or subacute stent thrombosis, bleeding complications and restenosis remain major clinical concerns in coronary stenting despite high pressure inflation and intravascular ultrasound guidance. A new strategy of local heparin delivery may maintain sustained local concentration and limit systemic complications. To observe the feasibility and efficacy of local heparin delivery in stenting, local heparin deliveries were performed in stented patients. METHOD: Heparin was delivered(5,000 Units, 1.0ml/min over 10 min) using the Dispatch Catheter, after predilation of target lesons in 10 patients(4 unstable angina, 6 acute myocardial infarction, mean age 52+/-7 yr) in the left anterior descending artery without systemic heparin loading. After local heparin delivery. Palmaz-Schatz stents were placed using standard methods. APTT and CK were checked at 1hr, 3hrs and 24 hrs after local heparin delivery and stenting. Follow-up coronary angiograms were done at 48 hrs and 6 months after stenting. RESULTS: All patients had no ischemic symptoms or ECG changes during and after local heparin delivery. All APTT and CK values were unchanged at 3 hrs and 24 hrs after local heparin delivery and stenting. Follow-up quantitative coronary angiograms at 48 hrs and 6 months showed all stents patent, with TIMI III distal flow, and without intra-stent thrombus(%diameter stenosis : 79.4+/-4.2% before predilation, 32.9+/-7.7% after predilation, 32.4+/-13.1% after local delivery, 14.2+/-2.3% immediately after stenting, 13.9+/-2.5% at 48 hrs and 21.7+/-8.8% at 6 months after stenting). CONCLUSION: Intracoronary stenting may be performed safely and effectively without systemic heparin therapy by using local heparin prior to stent implantation. Long-term stent patency and lack of coronary events appear favorable.