Acts. First, in our study, CKD was defined solely by the level of eGFR, irrespective of the presence of hematuria or proteinuria, which may reflect glomerular damage prone to warfarin-induced glomerular bleeding. Recently, the comparison of effects of previous treatment regimens with and without 94-09-7 web warfarin on patients with IgA nephropathy suggested the detrimental effects of warfarin in patients who already sustained glomerular damage [10]. Secondly, basal levels of sCr and eGFR were not different between the WRN and non-WRN groups in our cohorts, contrary to the previous report, suggesting less severe 22948146 nature of pre-existing renal damage in our patients with WRN. The independent risk factors for the development of WRN in this study were coexisting CHF, low serum basal albumin level, and high serum AST level at post INR elevation. The mechanisms by which these risk factors increase the risk of WRN are not clear but seem to be related to higher INR after warfarinization. Since approximately 97 of warfarin becomes 
bound to plasma protein, primarily albumin, and the remaining 3 is the unbound fraction that exhibits pharmacologic effects and is metabolized and excreted from the body [11], hypoalbuminemia that results in a greater amount of the free form of warfarin may promote overanticoagulation [12,13]. Decreased metabolism of warfarin in the liver (combined with the reduction in production of coagulation factors in severe cases) and plasma volume expansion induced by CHF with resultant dilutional hypoalbuminemia may contribute to the development of WRN [14,15]. We do not have any plausible explanations about why the presence of atrial fibrillation is protective for the development ofThe impact of WRN on renal function after follow-upThe change in serum creatinine after 115103-85-0 biological activity follow-up from value within 1 week after INR.3.0 showed normal distribution (histogram not shown). Despite the similar basal renal function between the WRN and non-WRN groups, the sCr level was higher and the eGFR was lower in patients with WRN than those without WRN after follow-up. Interestingly, the INR level was still higher in patients with WRN than patients without 23727046 WRN even after follow-up, although this finding barely reached statistical significance (Table 7). While there was no difference in renal function at post INR.3.0 and follow-up in non-WRN group according to the survival of patients, the renal function in dead patients was worse both post INR.3.0 and follow-up than live patients in WRN group (Table S7).The impact of WRN on long-term mortalityLong-term mortality according to WRN is demonstrated in Table 8 and Figure 2. The actual mortality rates were 42.8 in the WRN group, 26.3 in the non-WRN group, and 29.5 in all patients over follow-up periods for the groups that were similar in duration. The increased risk of death in patients with WRN compared to patients without WRN was highest during 2 years after INR .3.0, reaching 103.8 at 1 year and 91.9 at 2 years, and 
it sharply declined thereafter (50.6 at 5 years) (Table 8, Table 9. The causes of death.Cause of death Cardiovascular Respiratory Infection MalignancyNo WRN (N, )* 38 (13.8) 17 (6.2) 15 (5.5) 93 (33.8)WRN (N, ){ 20 (18.7) 5 (4.7) 2 (1.9) 30 (28.0) 18 (16.8) 32 (29.9) 107 (100)Total (N) 58 22 17 123 80 82P-value0.233 0.570 0.170 0.278 0.217 0.Cerebrovascular 62 (22.5) Others Total 50 (18.2) 275 (100)*Percentage of the cause of death among patients without WRN. Percentage of the cause of death.Acts. First, in our study, CKD was defined solely by the level of eGFR, irrespective of the presence of hematuria or proteinuria, which may reflect glomerular damage prone to warfarin-induced glomerular bleeding. Recently, the comparison of effects of previous treatment regimens with and without warfarin on patients with IgA nephropathy suggested the detrimental effects of warfarin in patients who already sustained glomerular damage [10]. Secondly, basal levels of sCr and eGFR were not different between the WRN and non-WRN groups in our cohorts, contrary to the previous report, suggesting less severe 22948146 nature of pre-existing renal damage in our patients with WRN. The independent risk factors for the development of WRN in this study were coexisting CHF, low serum basal albumin level, and high serum AST level at post INR elevation. The mechanisms by which these risk factors increase the risk of WRN are not clear but seem to be related to higher INR after warfarinization. Since approximately 97 of warfarin becomes bound to plasma protein, primarily albumin, and the remaining 3 is the unbound fraction that exhibits pharmacologic effects and is metabolized and excreted from the body [11], hypoalbuminemia that results in a greater amount of the free form of warfarin may promote overanticoagulation [12,13]. Decreased metabolism of warfarin in the liver (combined with the reduction in production of coagulation factors in severe cases) and plasma volume expansion induced by CHF with resultant dilutional hypoalbuminemia may contribute to the development of WRN [14,15]. We do not have any plausible explanations about why the presence of atrial fibrillation is protective for the development ofThe impact of WRN on renal function after follow-upThe change in serum creatinine after follow-up from value within 1 week after INR.3.0 showed normal distribution (histogram not shown). Despite the similar basal renal function between the WRN and non-WRN groups, the sCr level was higher and the eGFR was lower in patients with WRN than those without WRN after follow-up. Interestingly, the INR level was still higher in patients with WRN than patients without 23727046 WRN even after follow-up, although this finding barely reached statistical significance (Table 7). While there was no difference in renal function at post INR.3.0 and follow-up in non-WRN group according to the survival of patients, the renal function in dead patients was worse both post INR.3.0 and follow-up than live patients in WRN group (Table S7).The impact of WRN on long-term mortalityLong-term mortality according to WRN is demonstrated in Table 8 and Figure 2. The actual mortality rates were 42.8 in the WRN group, 26.3 in the non-WRN group, and 29.5 in all patients over follow-up periods for the groups that were similar in duration. The increased risk of death in patients with WRN compared to patients without WRN was highest during 2 years after INR .3.0, reaching 103.8 at 1 year and 91.9 at 2 years, and it sharply declined thereafter (50.6 at 5 years) (Table 8, Table 9. The causes of death.Cause of death Cardiovascular Respiratory Infection MalignancyNo WRN (N, )* 38 (13.8) 17 (6.2) 15 (5.5) 93 (33.8)WRN (N, ){ 20 (18.7) 5 (4.7) 2 (1.9) 30 (28.0) 18 (16.8) 32 (29.9) 107 (100)Total (N) 58 22 17 123 80 82P-value0.233 0.570 0.170 0.278 0.217 0.Cerebrovascular 62 (22.5) Others Total 50 (18.2) 275 (100)*Percentage of the cause of death among patients without WRN. Percentage of the cause of death.
