Tranexamic acid reduces blood loss during stone surgery

Chandigarh :  Kidney stone is an increasingly common problem with a current world-wide incidence of 12%. Percutaneous nephrolithotomy (PCNL) endoscopic stone surgery is a minimally invasive procedure for removal of renal and upper ureteral stone.  Kidneys receive 25 % of blood that heart pumps in to body. Bleeding is a significant morbidity during PCNL with reports quoting an average hemoglobin drop ranging from 2. – 3.3 gm/dl. As a result, 1-11% of patients overall and 2-33% of those with staghorn calculi, require blood transfusion. ). Blood loss and associated blood transfusion increases patients morbidity and hospital stay, even mortality. It increases further intervention and increases cost of treatment.  Blood is a precious commodity and its judicious use increases its availability for life threatening condition.

A study was conducted by Dr. Santosh Kumar et al from Department of Urology, PGIMER, Chandigarh to evaluate the safety and efficacy of the anti-fibrinolytic agent tranexamic acid in reducing blood loss and surgical complication in patients undergoing PCNL. Dr. Santosh Kumar concluded from the study that the use of tranexamic acid is effective in reducing blood loss in PCNL and is associated with less intra-operative and peri-operative complications. Its use is safe. Therefore peri-opertive administration of tranexamic acid may be advised for those patients in whom there is no contraindication. It is likely to be beneficial in those cases, in whom prolonged operative time is anticipated for Percutaneous Nephrolithotomy( endoscopic stone surgery).

This study Tranexamic acid reduces blood loss in percutaneous nephrolithotomy: a prospective randomized controlled study.Published in  The Journal of urology Impact factor. 4.02. Best urology journal from USA.

This was highlighted in the international health news by Will Boggs, MD Reuters Health Reuters Health Information

Tranexamic Acid May Cut Blood Loss in Percutaneous Nephrolithotomy

Nov 06, 2012

By Will Boggs, MD

NEW YORK (Reuters Health) Nov 06 – The antifibrinolytic drug tranexamic acid helped reduce blood loss in percutaneous nephrolithotomy (PCNL) in a recent randomized trial.

One of the researchers, Dr. Santosh Kumar from Postgraduate Institute of Medical Education and Research, Chandigarh, India told Reuters Health, “One should use tranexamic acid in PCNL if there is no contraindication. I personally started using it in my patients and was amazed by seeing the results, when after PCNL the urethral catheter is draining clear urine.”

Dr. Kumar and colleagues tested tranexamic acid vs no tranexamic acid in 200 patients undergoing PCNL for renal stone disease.

As reported online November 1st in The Journal of Urology, patients in the treatment group received a gram of tranexamic acid at the start of the procedure, followed by three doses of 500 mg orally at eight-hour intervals.

Mean estimated blood loss was significantly lower with vs without tranexamic acid (1.39 vs 2.31 g/dL; p<0.0001). The need for blood transfusion was also lower in the treatment group (2% vs 11%; p=0.018), as was the overall complication rate (33% vs 59%; p=0.0002). The tranexamic acid group also had shorter mean operative times and hospital stays, but its complete stone clearance rate was no better than in the control group (91% vs 82%; p=0.06).

“The theoretical concern associated with the use of tranexamic acid is its potential for inducing thromboembolic events,” the researchers note. “None of the participants in the previous various studies and in our prospective randomized study had symptomatic deep vein thrombosis, pulmonary embolism, or myocardial infarction.”

Dr. Antti Rannikko from Helsinki University Central Hospital, Finland, who has published research on the use of tranexamic acid in surgical settings, told Reuters Health, “We’ve used tranexamic acid for quite some time in Finland for various indications and it seems to be very well tolerated and safe. Tranexamic acid sounds like an addition to the armamentarium that is good to have around. It is very cheap and well tolerated. Especially it might be handy for the ones just starting PCNL as it may reduce bleeding and make the operation easier.”

“These findings are not surprising, since this is not the first application of tranexamic acid in the setting of urology,” Dr. Giovanni Landoni from IRCCS San Raffaele Hospital, Milan, Italy told Reuters Health. “All applications of tranexamic acid in urologic surgery concern interventions in which an increased fibrinolysis (caused by release of fibrinogen activators from the surrounding tissues) is associated with a prevalent microvascular bleeding. Considering the mechanism of action of this drug, these situations are the most suitable for the use of tranexamic acid.”

“Tranexamic acid is effective and probably safe not only in cardiac surgery, where it is commonly used, but also in many other different settings,” Dr. Landoni concluded. “Physicians should consider studying this drug in any situation where bleeding could be due at least in part to excessive fibrinolysis.” But while tranexamic acid has been shown in several surgical studies to reduce blood loss, in the U.S. the oral formulation is approved only for the treatment of heavy menstrual bleeding. The injectable formulation is approved in patients with hemophilia for short-term use to reduce or prevent hemorrhage and reduce the need for replacement therapy during and following tooth extraction.


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