Renal thrombosis

NS AIDs Cyclooxygenases (COX-1, COX-2) l Prostaglandins l Thromboxanes l Sensitization of sensory neurons f Inhibition of spinal neurons Nonselective gastrointestinal ulcers, perforation, bleeding, renal impairment COX-2 thrombosis, myocardial infarction, stroke... 

Erythropoietin (Eprex ) is physiologically produced in the kidney and regulates proliferation of committed progenitors of red blood cells. It is used to substitute erythropoietin in severe anemias due to end stage renal disease or treatment of cancer with cytostatic agents. Side effects include hypertension and increased risk of thrombosis. 

The prototype of this class is hirudin, which was originally isolated from the salivary glands of the medicinal leech, Hirudo medicinalis. Hirudin itself is not commercially available, but recombinant technology has permitted production of hirudin derivatives, namely lepirudin and desirudin.29,38,41 Lepirudin has a short half-life of approximately 40 minutes after IV administration and 120 minutes when given SC. Elimination of lepirudin is primarily renal therefore, doses must be adjusted based on the patient s renal function. The dose should be monitored and adjusted to achieve an aPTT ratio of 1.5 to 2.5 times the baseline measurement. Lepirudin is currently approved for use in patients with HIT and related thrombosis. Up to 40% of patients treated with lepirudin will develop antibodies to the drug.29,38,41... 

Lenalidomide was approved recently for the indication of myelodysplastic syndrome where the 5q deletion is present. Since lenalidomide is an analog of thalidomide, all the same precautions must be taken to prevent phocomelia. The time to maximum lenalidomide concentrations occurs 0.5 to 4 hours after the dose. The terminal half-life ranges from 3 to 9 hours. Approximately 65% of lenalidomide is eliminated unchanged in the urine, with clearance exceeding the glomerular filtration rate. To date, no pharmacokinetic studies have been done in patients with renal dysfunction. Lenalidomide is used in the treatment of myelodysplastic syndrome and multiple myeloma. Other side effects are neutropenia, thrombocytopenia, deep vein thrombosis, and pulmonary embolus. 

Signs and Symptoms Flu-like symptoms that may progress to pneumonitis, respiratory failure, renal failure, arterial blood clots (thrombosis), cardiac arrest, and meningoencephalitis. 

POEMS is an eponym applied to patients with a variety of plasma cell dyscrasias who present with polyneuropathy, organomegaly, endocrinopathy, an M protein and skin changes this disorder is also referred to as Crow-Fukase syndrome. Additional manifestations of this disorder are pulmonary hypertension, renal failure, a predisposition to thrombosis and congestive heart failure some of these features are likely to be attributable to vascular endothelial growth factor (VEGF) and matrix metalloproteinases, which are often elevated in the plasma of these patients [43]. 

Approximately 50% of patients with meningococcal meningitis have purpuric lesions, petechiae, or both. Patients may have an obvious or subclini-cal picture of disseminated intravascular coagulation, which may progress to infarction of the adrenal glands and renal cortex and cause widespread thrombosis. 

Penicillins Proton pump inhibitors Chronic interstitial nephritis Cyclosporine Lithium Aristolochic acid Renal vasculitis, thrombosis, and cholesterol emboli ... 

Erythropoeitins are used to treat symptomatic anaemia associated with erythropoietin deficiency in chronic renal failure and to shorten the period of symptomatic anaemia in patients receiving cytotoxic chemotherapy. It is not recommended for use in cancer patients who are not receiving chemotherapy. In cancer patients, the risk of thrombosis and related complications might be increased. The haemoglobin concentration should be maintained within the range of 10-12 g/100 ml - higher concentrations should be avoided to reduce risk of complications of therapy. 

Increased susceptibility to infection and the possible development of lymphoma may result from immunosuppression. Only physicians experienced in immunosuppressive therapy and management of renal transplant patients should use sirolimus. Manage patients receiving the drug in facilities equipped and staffed with adequate laboratory and supportive medical resources. The physician responsible for maintenance therapy should have complete information needed for the follow-up of the patient. Liver transplantation-excess mortality, graft loss, and hepatic artery thrombosis (HAT) The use of sirolimus in combination with tacrolimus was associated with excess mortality and graft loss in a study in de novo liver transplant recipients. Many of these patients had evidence of infection at or near the time of death. 

Unlabeled Uses Prevention of postoperative deep vein thrombosis (DVT), protection of aortocoronary bypass grafts, reduction of graft loss after renal transplant, treatment of intermittent claudication, sickle cell disease, subarachnoid hemorrhage, diabetic microangiopathy, ischemic heart disease... 

Adverse effects include nausea, vomiting, headache, fever, abdominal pain, hyperglycemia leading to coma, hypersensitivity, renal damage, coagulation defects, thrombosis, CNS depression or hyperexcitability and acute haemorrhagic pancreatitis. 

Argatroban is a small molecule thrombin inhibitor that is FDA-approved for use in patients with HIT with or without thrombosis and coronary angioplasty in patients with HIT. It, too, has a short half-life, is given by continuous intravenous infusion, and is monitored by aPTT. Its clearance is not affected by renal disease but is dependent on liver function dose reduction is required in patients with liver disease. Patients on argatroban will demonstrate elevated INRs, rendering the transition to warfarin difficult (ie, the INR will reflect contributions from both warfarin and argatroban). (INR is discussed in detail in the discussion of warfarin administration.) A nomogram is supplied by the manufacturer to assist in this transition. 

The use of iloprost has been proposed in patients with systemic sclerosis, a disease that is often characterized by pulmonary hypertension and Raynaud s phenomenon. Three patients with systemic sclerosis who were treated with iloprost developed acute thrombotic events (3). In one case, intestinal infarction occurred 1 day after infusion of iloprost. In another patient the left kidney was not perfused 22 days after the last infusion of iloprost because of thrombosis of the left renal artery. The last patient, 9 months after the start of treatment with iloprost, and 5 days after the last infusion, had an anterolateral myocardial infarction. The authors commented that their observations did not allow them to conclude that there is a direct relation between infusion of iloprost and thrombotic events. However, they said that this possibility should be considered, and they suggested that risk factors for thromboembolism should be carefully evaluated in each patient with systemic sclerosis who is receiving iloprost. 

Bohler J, Hauenstein KH, Hasler K, Schollmeyer P. Renal vein thrombosis in a dehydrated patient on an oral contraceptive agent. Nephrol Dial Transplant 1989 4(ll) 993-5. 

Estrogen replacement therapy may have untoward effects in patients with renal disease, including an increased risk of thrombosis of dialysis access and potentially worsening of coronary artery disease, probably because the excretion of estrogens is impaired (77). 

Papaverine, because of its general depressant effect on smooth muscle, has been used in doses of 30 to 60 mg, subcutaneously and intravenously, in peripheral thrombosis and embolism, acute myocardial infarction, angina pectoris, bronchial asthma, renal and biliary colic, and other conditions in which relaxation of smooth muscle is desired. However, the therapeutic effectiveness of papaverine is questionable, and there is no established indication for its use. 

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