Apixaban in ESRD and Atrial Fibrillation

Patients with ESRD (end-stage renal disease) are usually prescribed coumadin when they need anticoagulation; the reason being that we know very little (or not at all) about the effect of new oral anticoagulants in patients with ESRD.

In this study, Siontis et al performed a retrospective cohort study of Medicare beneficiaries with ESRD and atrial fibrillation, the later an indication for anticoagulation. Outcomes were compared between patients who were treated with apixaban versus patients who were treated with warfarin. Authors examined the survival difference between the two groups for stroke or systemic embolism, major bleeding, gastrointestinal bleeding, intracranial bleeding, and death using Kaplan–Meier analyses and hazard ratios (HRs) and 95% CIs were obtained using Cox regression analyses.

Authors found that there was no difference in stroke and systemic embolism between the two groups. However, the group taking apixaban had 28% lower risk of major bleed.

While this is retrospective data, and clinical trial data is lacking, this study will support the use of new oral anticoagulants in ESRD patients.

Is Science Getting Less Bang for its Buck?

Here is an interesting article published in The Atlantic which claims that the productivity in science is declining. The investment in science is increasing but the pace of novel or truly important discoveries is decreasing. They give various reasons; I have few additional thoughts that I assume authors thought of but were not included in this piece.

1. The age of scientist at discovery is increasing due to the large volume of knowledge we ‘force’ young scientist to learn. We have formalized ‘learning’ to an extent that we feel it is obligatory for anyone to ‘know’ it all before moving forward. Just as an example, the ‘required’ courses to take are often not directly relevant to the learner’s interest or the to the topic. WE have added those without any scientific evidence that such additional courses help with discovery. We preach evidence, we prefer not to teach by science. And when we try to accumulate evidence, we do it using irrelevant outcomes. This is the problem with education in general and not with science education.

2. Truly novel discoveries happen in spurts. Discovery of zero was truly important, one may argue more important than general relativity. Perhaps discovery of algebra and calculus were also more important, and fundamental, than general relativity. But these discoveries are not ‘novel’ anymore for us. I believe new discoveries happen after we have utilized the older discoveries to close to the fullest extent. Imagine a new discovery as a new house; once we build a new house, we start filling it, decorating it, accumulating useful (and some junk) ‘stuff’. This is perhaps what happens with truly important discoveries. A truly important discovery is followed by many small discoveries over next many years until the potential of new discovery has been fully realized and then another new discovery happens.

Serum creatinine in critically ill patient

An interesting, short and sweet article in JAMA highlighting that serum creatinine increase in critically-ill patients may underestimate the degree of AKI.

They give following reasons for this underestimation:
1. Creatinine production decreases in sepsis, hence there is decreased release of creatinine and slow rise in serum creatinine
2. Critically-ill patients receive large-volume resuscitation and hence dilute serum creatinine. Of note, the volume of distribution of creatinine is about 65% of body weight.

Having said that, there does not appear to be any good alternatives for determining renal function ad GFR estimation in such population.