UK prescribing practice of anticoagulants in patients with chronic kidney disease: a nephrology and haematology-based survey

Abstract

A survey to gain insight into anticoagulant prescribing practice in the setting of chronic kidney disease (CKD) across the UK was disseminated via renal and haematology networks. Areas of anticoagulant use included patients with venous thromboembolism (VTE), requiring thromboprophylaxis for VTE, Atrial Fibrillation (AF) and nephrotic syndrome.An online-survey was disseminated via British Haematology Society, UK Kidney Association, and Renal Pharmacy Group over a five month period. All responses were voluntary and anonymous.Among 117 responses there were 49 nephrology doctors, 47 renal pharmacists and 20 haematology clinicians. A specialist multidisciplinary team to discuss the specific anticoagulant management of these patients was only available to 3% (4/117) respondents. Renal function estimate used for anticoagulant dosing was mainly Cockcroft-Gault for pharmacists and haematology but lab-based estimates were used by nephrology doctors. Therapeutic dose of Low Molecular Weight Heparin was mostly likely to be reduced by one-third when used for VTE treatment, with the majority of units undertaking anti-Xa monitoring in CKD stage 5 and dialysis. Direct-acting Oral Anticoagulants are being used in patients with nephrotic syndrome, those with CKD stage 5 and on dialysis for VTE and AF in the absence of license in these indications.This survey highlighted the significant differences between anticoagulant prescribing in CKD between two professional specialties and marked variation between centres in anticoagulant management strategies employed for these patients. With gaps still existing in the evidence base and answers to these not expected within the next few years, development of a best-practice guideline would be warranted to support clinicians in this field.

Thromboembolism in nephrotic syndrome: controversies and uncertainties

“…The uncertainty with use of anticoagulation was demonstrated in a European survey undertaken by the European Rare Kidney Disease Registry (ERKnet) in 2019 (personal correspondence with Professor Wetzels), where 27% of specialist units did not routinely use any prophylactic anticoagulation. Similar variation was seen in a recent United Kingdom survey where varying levels of albumin cut-off were used to decide upon prophylactic anticoagulation, with other risks factors, such as primary cause of NS and degree of proteinuria not always being included in the decision [ 43 ].…”

“…Despite the very limited number of studies, serum albumin, although not the only risk factor, appears to have been used as the main surrogate marker to determine the use of prophylactic anticoagulation in patients with NS. This was also seen in the ERKnet and UK surveys with 50% and 100%, respectively, of units responding that they would use anticoagulation with a serum albumin levels of <20 g/L [ 43 ]. Given the bleeding potential in patients with NS, its assessment should also be undertaken and used as part of the decision-making process when initiating anticoagulation.…”

“…Given the bleeding potential in patients with NS, its assessment should also be undertaken and used as part of the decision-making process when initiating anticoagulation. Bleeding risk assessment was considered in anticoagulant decision making of 89% respondents from the UK survey [ 43 ]. The authors propose the factors to consider when making decisions about prophylactic anticoagulation in Figure 2 .…”

Longitudinal Analysis of Prophylactic Anticoagulation in Primary Nephrotic Syndrome: Low Incidence of Thromboembolic Complications

“…Another recent survey of 117 combined UK nephrologists, renal pharmacists, and haematologists reported that over 80% use a combination of sAlb and bleeding risk when considering initiation of PAC. The most frequent anticoagulants used were warfarin or therapeutic LMWH when sAlb was <20 g/dL, and surprisingly, 25% reported using a direct oral anticoagulant (DOAC) [ 14 ].…”

Assessment of nephrology disease reporting to territory care hospital in Guntur, a prospective observational study

“…The kidneys are vulnerable to infection by blood borne microorganisms because of their high blood flow (20% of cardiac output). Objective hemodynamic examination is essential for proper therapy in several of these situations, including AKI and hyponatremia (1) .Agricultural communities, particularly manual laborers in dry, low land regions of Central America, Sri Lanka, and Southern India, are the main populations affected by chronic kidney disease of unknown origin, which is a progressive tubulointerstitial nephropathy (2) .Using the renal and hematology networks, a survey was circulated to gather insight on anticoagulant prescribing practice in the context of chronic kidney disease (CKD) throughout the UK (3) .The goal of this study was to identify the pattern of renal disease among kids who visited the hospital's pediatric nephrology clinic (4) .Here, an unbiased transcriptomic-driven method was employed to discover genomic pathways shared by subgroups of individuals with either focal segmental glomerulosclerosis or minimal change illness (FSGS) (5) .…”