Anticoagulation

Anticoagulation in Renal Failure

Patients with chronic kidney disease (CKD) present a dilemma in that they are simultaneously prothrombotic and haemorrhagic. Special consideration should be given to anticoagulation in these patients given the relatively high risk of bleeding complications. If in doubt, treatment options should be discussed with the Haematology team……

 

Unfractionated Heparin (UFH)

For inpatients with significant renal impairment, unfractionated heparin (UFH) is often the treatment of choice for initiating anticoagulation, especially when bleeding risk is high…. 

Link to UFH protocol

 

Low Molecular Weight Heparin (LMWH)

In instances where treatment with UFH is problematic, for example when there are difficulties with intravenous access or where the patient could otherwise be discharged from hospital, the use of sub-cutaneous low molecular weight heparins (LMWH) has become increasingly popular.  Whilst there have previously been concerns regarding the accumulation of these agents in renal failure, this can be monitored by measurement of a LMWH assay. LMWHs are now used in our unit for anticoagulation where warfarin is contra-indicated, or for the purposes of bridging anticoagulation.

Link to LMWH protocol

 

Warfarin

Despite increasing use of LMWHs for anticoagulation, warfarin is still the treatment of choice for many patients with CKD, including those on haemodialysis. The guidelines for initiating warfarin therapy in these patients differs slightly, and so care should be taken when prescribing loading doses. Patients on haemodialysis who have achieved therapeutic anticoagulation usually continue to have an INR check once weekly. The responsibility for warfarin prescribing varies across the 3 dialysis units in NHS Lothian, and the local unit policy should be referred to appropriately (see links below).

?Link to warfarin protocols – Fennerty vs. Haemodialysis

Warfarin (Edinburgh Royal Infirmary)

Warfarin (Western General Hospital)

Warfarin (St. John’s Hospital)

 

Novel / Direct Oral Anticoagulants

The Novel / Direct Oral Anticoagulants (NOAC / DOAC) comprise of direct Factor Xa inhibitors (apixaban, rivaroxaban, darexaban and edoxaban) and direct thrombin inhibitors (dabigatran). Whilst some of these agents are licensced for use in for patients with a mild-moderate degree of renal impairment, they may require dose adjustment if eGFR is <30ml/min/m2 , and are generally not recommended when eGFR is <15ml/min/m2. Their use in advanced kidney disease should be carefully considered and discussed with the Haematology team should their be any concerns.

Link to NOAC / DOAC protocols 

 

Alternative Anticoagulants

In situations where thrombotic risk is high but it is not possible to use heparins, alternative agents are required – treatment in these situations is usually directed by the Haematology team.

Heparin-Induced Thrombocytopenia (HIT) – where antibodies are formed against heparin when it is bound to platelet factor 4 (PF4)  – is a condition which results in widespread platelet activation and is associated with a very high risk of arterial and venous thromboses. The 4T scoring system can be used to predict risk of HIT – the score is based upon severity of thrombocytopenia, timing of thrombocytopenia in relation to heparin use, presence of thrombosis, and presence of alternative explanation for thrombocytopenia (reference). 

Because HIT is associated with a high risk of thrombosis, treatment comprises of formal anticoagulation. In NHS Lothian, this is usually with IV argatroban or oral warfarin. Often patients are commenced on IV argatroban whilst warfarin is initiated and a therapeutic INR achieved. Argatroban should only be initiated under specialist advice and requires close monitoring.

Link to Argatroban protocol

 

VTE Prophylaxis in Renal Failure

 

 

 

Acknowledgements:   Lorna Thomson, Mariana Dimova and Neil Turner were the main authors for this page; first published in November 2001. It was updated by Ashley Simpson in 2019. The last modified date is shown in the footer.