Thesis (M.S.)--University of Missouri-Columbia, 2004. / Typescript. Vita. Includes bibliographical references. Also available on the Internet.

Thesis (M.S.)--University of Missouri-Columbia, 2004. / Typescript. Vita. Includes bibliographical references. Also available on the Internet.

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INTRODUCTION Apixaban has revolutionized anticoagulation in patients with atrial fibrillation in preventing strokes. Anticoagulant-induced nephropathy with warfarin is well known, but nephropathy with apixaban is a rare entity, and here we present a case of Apixaban-induced nephropathy. Case Description A 71-year-old patient with a medical history of persistent atrial fibrillation on apixaban, Ischemic cardiomyopathy, and chronic kidney disease stage (CKD) IIIa presented to the hospital with complaints of dyspnea and hemoptysis and tea-colored urine of three-day duration. On admission, the patient had acute kidney injury (AKI) on CKD, Methicillin sensitive Staphylococcus aureus (MSSA) bacteremia, and elevated international normalized ratio (INR) and apixaban were held. The hemoptysis worsened and prompted bronchoscopy revealing diffuse alveolar hemorrhage. The urinalysis showed gross hematuria with high red blood cell (RBC) count and 1+ proteinuria presumed secondary to MSSA associated glomerulonephritis. Evaluation for coagulopathy with serum mixing studies and autoimmune workup has been unremarkable. The patient's coagulopathy was considered secondary to decreased clearance of apixaban with AKI on CKD. However, the patient's kidney function continued to worsen, needing continuous renal replacement therapy and a kidney biopsy for a definitive diagnosis for his decline in kidney function. Kidney biopsy revealed IgA dominant infection associated glomerulitis with one out of hundred glomeruli with the crescent formation and signs of anticoagulant induced nephropathy with several intratubular RBC casts out of proportion to the degree of glomerular injury causing acute tubular damage. The patient's INR improved on dialysis. However, he continued to be oliguric before being terminally extubated. DISCUSSION With the increasing incidence of atrial fibrillation and the use of oral anticoagulants, it is vital to have anticoagulant induced as a differential in patients presenting with supra therapeutic INR and AKI. Apixaban-induced nephropathy is a subset of anticoagulant-induced nephropathy and an uncommon cause of the acute decline in kidney function needing dialysis. Prompt recognition and treatment will prevent further deterioration in kidney function and possible improvement.

This thesis deals with the mechanics of the Intra-Aortic Balloon Pump (IABP), the most widely used temporary cardiac assist device, whose beneficial action is based on the principle of counterpulsation. The investigation is carried out in vitro in increasingly more realistic setups, including a mock circulatory system with physiological distribution of peripheral resistance and compliance in which IABP counterpulsation was simulated. Pressure and flow measurements show the effect of variables such as intra-luminal pressure, angle and aortic compliance on balloon hemodynamics. These data are complemented by results on the duration of balloon inflation and deflation obtained by means of high-speed camera visualisation. Furthermore, wave intensity analysis is carried out and it is identified as a possible alternative method for the assessment of IABP performance. This work includes two prototypes of intra-aortic balloons of novel shape with the balloon chamber tapering both from and toward the balloon tip. In clinical terms, with reference to the semi-recumbent position in which patients assisted with the IABP are nursed in the intensive care unit, the results presented in this thesis indicate that operating the balloon at an angle compromises the benefit of counterpulsation when assessed in vitro.

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