Platelet Abnormalities in Chronic Kidney Disease and Their Implications for Antiplatelet Therapy

2021 ◽  
pp. CJN.04100321
Author(s):  
Constance Baaten ◽  
Jonas Schröer ◽  
Juergen Floege ◽  
Nikolaus Marx ◽  
Joachim Jankowski ◽  
...  
Keyword(s):  
Chronic Kidney Disease ◽  
High Risk ◽  
Kidney Disease ◽  
Antiplatelet Therapy ◽  
Platelet Function ◽  
Treatment Strategies ◽  
Platelet Activity ◽  
High Risk Patients ◽  
Anti Platelet Therapy ◽  
Risk Patients

Patients with chronic kidney disease (CKD) display a highly increased risk of cardiovascular and thromboembolic complications, with around half of patients with advanced CKD ultimately dying of cardiovascular disease. Paradoxically, these patients also have a higher risk of hemorrhages, greatly complicating patient therapy. Platelets are central to hemostasis, and altered platelet function resulting in either platelet hyper- or hypo-reactivity may contribute to thrombotic or hemorrhagic complications. Different molecular changes have been identified that may underlie altered platelet activity and hemostasis in CKD. Here, we summarize the current knowledge on CKD-induced aberrations in hemostasis with a special focus on platelet abnormalities. We also discuss how prominent alterations in vascular integrity, coagulation as well as red blood cell count in CKD may contribute to altered hemostasis in these high-risk patients. Furthermore, with CKD patients commonly receiving anti-platelet therapy to prevent secondary atherothrombotic complications, we discuss anti-platelet treatment strategies and their risk vs. benefit in terms of thrombosis prevention, bleeding and clinical outcome depending on CKD-stage. This reveals a careful consideration of benefits vs. risks of antiplatelet therapy in CKD patients, balancing thrombotic vs. bleeding risk. Nonetheless, despite antiplatelet therapy, CKD patients remain at increased cardiovascular risk. Thus, deep insights into altered platelet activity in CKD as well as underlying mechanisms are important for the optimization and development of current and novel anti-platelet treatment strategies, specifically tailored to these high-risk patients. Ultimately, this review underlines the importance of a closer investigation of altered platelet function, hemostasis, and anti-platelet therapy in CKD patients.

scholarly journals The Impact of Pharmacist-delivered Motivational Interviewing on Chronic Kidney Disease Identification and Management in Patients with Diabetes Mellitus and Low Socioeconomic Status

2019 ◽  
Vol 10 (4) ◽  
pp. 8
Author(s):  
Keri Lillian DePatis ◽  
Catherine Harrington
Keyword(s):  
Diabetes Mellitus ◽  
Chronic Kidney Disease ◽  
High Risk ◽  
Kidney Disease ◽  
Motivational Interviewing ◽  
Urinary Albumin ◽  
Secondary Outcome ◽  
High Risk Patients ◽  
Patients With Diabetes ◽  
Risk Patients

Purpose: Chronic kidney disease (CKD) is a common complication among patients with diabetes mellitus; however, noncompliance with the recommended annual screening is common. Increased screening among high-risk patients is important to identify the early stages CKD, potentially resulting in earlier treatment, slower progression, fewer complications, and decreased healthcare expenditures. Motivational interviewing (MI) has previously been shown to be effective for various behaviors, such as smoking cessation and cholesterol level control. The objective of this study is to evaluate the effectiveness of pharmacist-delivered MI compared to typical education (TE) methods in increasing CKD screening and subsequent angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB) initiation in high-risk patient populations. Methods: Pharmacists screened diabetic patients within their chronic disease management clinic to identify patients that are at high-risk for CKD, indicated by a score of 4 or greater on the validated SCORED screening tool. High-risk patients were randomized to one of four groups to receive either one or two face-to-face education sessions from a pharmacist or student pharmacist using either MI or TE methods. Patients were then given the option to have their urine tested with a dipstick to detect albumin and creatinine, provided at no cost. The primary outcome was to determine the rate of urinary albumin testing, and the secondary outcome was to determine the rate of ACE-I or ARB initiation in patients found to have albuminuria. Results: There were no significant differences in the rates of urinary albumin screening (87% in TE vs. 100% in MI, P = 0.4828) or subsequent ACE-I/ARB initiation (100% in TE and 50% in MI, P = 1.000) between education groups. Of the high-risk patients who underwent urinary albumin screening, 54% (n=15) were found to have proteinuria Conclusions: While it appears that MI does not impact patient acceptance rates of microalbuminuria screening and ACE-I/ARB initiation, this study demonstrates the feasibility of pharmacist-delivered microalbuminuria screening in patients at high-risk for CKD in the outpatient setting.   Article Type: Practice-Based Research

scholarly journals Community Pharmacy-Based eGFR Screening for Early Detection of CKD in High Risk Patients

2020 ◽  
Vol 7 ◽  
pp. 205435812092261
Author(s):  
John Papastergiou ◽  
Michelle Donnelly ◽  
Wilson Li ◽  
Robert D. Sindelar ◽  
Bart van den Bemt
Keyword(s):  
Chronic Kidney Disease ◽  
Renal Function ◽  
High Risk ◽  
Kidney Disease ◽  
Early Detection ◽  
Point Of Care ◽  
Screening System ◽  
High Risk Patients ◽  
Risk Patients

Background: Chronic kidney disease (CKD) is a condition presenting with long-term slow progression of structural and/or functional damage to the kidneys. Early detection is key to preventing complications and improving outcomes. Point-of-care estimated glomerular filtration rate (eGFR) screening technology allows for detection of abnormal kidney function in the community pharmacy setting. Objective: To evaluate the effectiveness of a community pharmacist-directed point-of-care screening program and to identify the prevalence of CKD in high-risk patients. Design: Quantitative observational. Setting: Four community pharmacies in British Columbia over a 6-month period. Patients: In all, 642 participants with at least one CKD risk factor were identified and screened. Mean age was 60 years and females accounted for 55% of the study population. Measurements: Serum creatinine was measured from peripheral blood using the HeathTab® screening system (Piccolo® Renal Function Panel with the Piccolo® blood chemistry analyzer). eGFR was calculated according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula. Methods: Patients provided a sample of peripheral blood via a self-administered finger-prick and analytical data to assess kidney function was reported including blood urea nitrogen (BUN), serum creatinine, and electrolytes by the HealthTab® screening system. Once results were available, the pharmacist conducted a comprehensive medication review with the patient and recommended certain follow-up actions if appropriate. Results: CKD risk factor included diabetes (30%), hypertension (45%), cardiovascular disease (12%), family history of kidney disease (13%), age over 55 years (68%), and an Aboriginal, Asian, South Asian, or African ethnic background (82%). A total of 11.5% of patients had eGFR values lower than 60 mL/min (abnormal renal function) and 34% had an eGFR between 60 and 89 mL/min (minimally reduced renal function). Overall pharmacists’ actions included blood pressure check (98%), education on CKD and risk factors (89%), medication review (72%), and physician follow-up (38%). Limitations included lack of follow-up beyond the 3-month study period prevented medical confirmation of CKD and limited the ability to quantify the impact of pharmacist interventions on the clinical outcomes of patients with low eGFR. Conclusion: These results illustrate the prevalence of abnormal renal function among undiagnosed, high-risk patients in the community. Pharmacists, as the most accessible healthcare practitioners, are ideally positioned to utilize novel point-of care technologies to improve access to CKD screening, facilitate follow-up, and increase awareness around the importance of early detection.

Appointment utilization as a trigger for palliative care introduction: A retrospective cohort study

2019 ◽  
Vol 33 (4) ◽  
pp. 457-461
Author(s):  
Zlatana Nenova ◽  
John Hotchkiss
Keyword(s):  
Chronic Kidney Disease ◽  
Palliative Care ◽  
Cohort Study ◽  
High Risk ◽  
Kidney Disease ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
High Risk Patients ◽  
Risk Of Death ◽  
Risk Patients

Background: Chronic kidney disease palliative care guidelines would benefit from more diverse and objectively defined health status measures. Aim: The aim is to identify high-risk patients from administrative data and facilitate timely and uniform palliative care involvement. Design: It is a retrospective cohort study. Setting/participants: In total, 45,368 Veterans, with chronic kidney disease Stage 3, 4, or 5, were monitored for up to 6 years and categorized into three groups, based on whether they died, started dialysis, or avoided both outcomes. Results: Patient’s appointment utilization was a significant predictor for both outcomes. It separated individuals into low, medium, and high appointment utilizers. Among the low appointment utilizers, the risk of death did not change significantly, while the risk of dialysis increased. Medium appointment utilizers had a stable risk of death and a decreasing risk of dialysis. Significant appointment utilization (above 31 visits during the baseline year) helped high-risk patients avoid both outcomes of interest—death and dialysis. Conclusion: Our model could justify the creation of a novel palliative care introduction trigger, as patients with medium demand for care may benefit from additional palliative care evaluation. The trigger could facilitate the uniformization of conservative treatment preparations. It could prompt messages to a managing physician when a patient crosses the threshold between low and medium appointment utilization. It may also aid in system-level policy development. Furthermore, our results highlight the benefit of significant appointment utilization among high-risk patients.

scholarly journals Perceived Susceptibility to Chronic Kidney Disease among High-risk Patients Seen in Primary Care Practices

2009 ◽  
Vol 24 (10) ◽  
pp. 1123-1129 ◽  
Author(s):  
L. Ebony Boulware ◽  
Kathryn A. Carson ◽  
Misty U. Troll ◽  
Neil R. Powe ◽  
Lisa A. Cooper
Keyword(s):  
Primary Care ◽  
Chronic Kidney Disease ◽  
High Risk ◽  
Kidney Disease ◽  
Perceived Susceptibility ◽  
High Risk Patients ◽  
Risk Patients ◽  
Care Practices ◽  
Primary Care Practices

TWILIGHT: A Randomized Trial of Ticagrelor Monotherapy Versus Ticagrelor Plus Aspirin Beginning at 3 Months in High-risk Patients Undergoing Percutaneous Coronary Intervention

2020 ◽  
Vol 14 ◽  
Author(s):  
Johny Nicolas ◽  
Usman Baber ◽  
Roxana Mehran
Keyword(s):  
Percutaneous Coronary Intervention ◽  
High Risk ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Coronary Intervention ◽  
Bleeding Events ◽  
High Risk Patients ◽  
Risk Of Death ◽  
Percutaneous Coronary ◽  
Risk Patients

A P2Y12 inhibitor-based monotherapy after a short period of dual antiplatelet therapy is emerging as a plausible strategy to decrease bleeding events in high-risk patients receiving dual antiplatelet therapy after percutaneous coronary intervention. Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention (TWILIGHT), a randomized double-blind trial, tested this approach by dropping aspirin at 3 months and continuing with ticagrelor monotherapy for an additional 12 months. The study enrolled 9,006 patients, of whom 7,119 who tolerated 3 months of dual antiplatelet therapy were randomized after 3 months into two arms: ticagrelor plus placebo and ticagrelor plus aspirin. The primary endpoint of interest, Bleeding Academic Research Consortium type 2, 3, or 5 bleeding, occurred less frequently in the experimental arm (HR 0.56; 95% CI [0.45–0.68]; p<0.001), whereas the secondary endpoint of ischemic events was similar between the two arms (HR 0.99; 95% CI [0.78–1.25]). Transition from dual antiplatelet therapy consisting of ticagrelor plus aspirin to ticagrelor-based monotherapy in high-risk patients at 3 months after percutaneous coronary intervention resulted in a lower risk of bleeding events without an increase in risk of death, MI, or stroke.

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