Fadi Kayali

Venous Thromboembolism in Patients Hospitalized with Nephrotic Syndrome

PURPOSE Whether pulmonary embolism in patients with the nephrotic syndrome is caused by deep venous thrombosis or renal vein thrombosis is controversial. To determine which is the likely cause of pulmonary embolism in patients with the nephrotic syndrome, we investigated data from the National Hospital Discharge Survey. METHODS The number of patients discharged from nonfederal short-stay hospitals in the United States with a diagnostic code of nephrotic syndrome, deep venous thrombosis, renal vein thrombosis, and pulmonary embolism was obtained using ICD-9-M (International Classification of Diseases, Ninth Revision, Clinical Modification) codes. RESULTS From 1979 to 2005, 925,000 patients were discharged from hospitals with the nephrotic syndrome and 898,253,000 patients did not have the nephrotic syndrome. With the nephrotic syndrome, 5000 (0.5%) had pulmonary embolism, 14,000 (1.5%) had deep venous thrombosis, and fewer than 5000 had renal vein thrombosis. The relative risk of pulmonary embolism comparing patients with the nephrotic syndrome to those who did not have it was 1.39, and the relative risk of deep venous thrombosis was 1.72. Among patients aged 18-39 years, the relative risk of deep venous thrombosis was 6.81. From 1991-2005, after venous ultrasound was generally available, the relative risk of deep venous thrombosis (all ages) was 1.77. CONCLUSION The nephrotic syndrome is a risk factor for venous thromboembolism. This is strikingly apparent in young adults. Renal vein thrombosis was uncommon. Therefore, pulmonary embolism, if it occurs, is likely to be due to deep venous thrombosis and not renal vein thrombosis.

Gadolinium-Enhanced Magnetic Resonance Angiography for Detection of Acute Pulmonary Embolism: An In-depth Review

STUDY OBJECTIVE To review the published experience with gadolinium-enhanced magnetic resonance angiography (MRA) for the detection of acute pulmonary embolism (PE) in order to test the hypothesis that gadolinium-enhanced MRA may be potentially sensitive and specific enough to include it among diagnostic alternatives in the evaluation of patients with suspected PE. METHODS Studies were identified by searching MEDLINE for trials that used gadolinium-enhanced MRA to diagnose acute PE based on the visualization of an intraluminal filling defect or a cutoff vessel, using pulmonary angiography as a reference standard. RESULTS Twenty-eight investigations were identified in which MRA was used to diagnose PE. Only three studies, however, met the criteria for inclusion in the analysis. In these three case series, the sensitivity of gadolinium-enhanced MRA ranged from 77 to 100%, and the specificity ranged from 95 to 98%. CONCLUSION Gadolinium-enhanced MRA may be a useful diagnostic alternative in some patients with suspected acute PE, particularly if they have an elevated creatinine level, have an allergy to radiographic contrast material, or should, if possible, avoid exposure to ionizing radiation.

Catheter-directed thrombolysis (intrathrombus injection) in treatment of deep venous thrombosis: a systematic review.

Methods of delivery of thrombolytic agents for massive or limb threatening deep venous thrombosis (DVT) include a systemic infusion, local–regional administration, and catheter‐directed therapy (tip of catheter placed inside the thrombus). We evaluated the effectiveness of catheter‐directed therapy and compared the results with randomized clinical trials of systemic and local–regional thrombolytic therapy. Many who used catheter‐directed thrombolysis used balloon angioplasty, stents, or thrombectomy in addition. Pooled data showed higher rates of complete early opening of occluded veins with catheter‐directed thrombolysis alone, 90%, or with catheter‐directed thrombolysis often followed by adjunct therapy, 76%, than with a systemic infusion, 28%, or local–regional administration, 20%. The prevalence of postthrombotic syndrome was lower with catheter‐directed combined with adjunct therapy, 26%, compared with 56% and 69%, respectively. Rates of any bleeding were higher with catheter‐directed thrombolytic therapy, but bleeding was usually minor. In conclusion, the data suggest that catheter‐directed thrombolytic therapy may be more beneficial than systemic or local regional administration. An advantage is that it lends itself to adjunct treatment following the administration of thrombolytic agents if the thrombolysis is inadequate.

Mortality From Acute Pulmonary Embolism According to Season

BACKGROUND Varying observations have been made on seasonal differences of mortality from acute pulmonary embolism (PE). METHODS The number of deaths each year from PE, from 1980 through 1998, based on death certificates, was obtained from the US National Center for Health Statistics Multiple Cause-of-Death Files. RESULTS Acute PE as the cause of death ranged from 0.91 to 1.03 PE deaths per quarter per 100,000 population. Small differences were statistically significant due to the large number of patients evaluated. Quarterly mortality rates from PE in the northeast, south, midwest, and west, where seasonal weather varies widely, showed no meaningful seasonal differences. CONCLUSION Mortality rates from PE do not vary to a meaningful extent according to season.