Renally Impaired Patients

Renally Impaired Patients

Renal impairment is common in hospitalised patients1,2

Distribution of Renal Function in Medical Patients

As can be seen in the pie chart above, a quarter of medical inpatients have some degree of renal impairment (Stage ≥3).1,2

VTE treatment with UFH is associated with higher mortality rates than LMWH in patients with renal impairment3*

In one study, compared with LMWH, initial VTE treatment with UFH in patients with severe renal impairment (CrCl <30 ml/min) resulted in:3

  • significantly higher mortality
  • higher rates of fatal PE

*P<0.05 vs. LMWH

VTE risk in renally impaired patients4–6

While patients with VTE who have renal insufficiency are at higher risk of both fatal bleeding and fatal pulmonary embolism (PE)4, an analysis of this group found the risk of fatal PE far exceeded the risk of fatal bleeding.5

Incidence of Fatal PE and Bleeding in Patients with Renal Insufficiency

A post hoc analysis of the CLOT study found high-dose, extended treatment with Fragmin® significantly reduced the risk of recurrent VTE in cancer patients with renal impairment. Compared with VKA, Fragmin® significantly reduced risk of recurrent VTE in patients with cancer and renal impairment (p=0.01) while exhibiting a comparable safety profile.6    

Time to first recurrent VTE during the 6-month study period for patients with renal impairment

Advantages of LMWH vs UFH

The advantages of VTE treatment with LMWH compared with UFH in renal impairment7–11

  • More predictable anticoagulant response7,8
  • Better bioavailability at low doses7,8
  • Dose-independent clearance mechanism7
  • Longer half-life7,8
  • Lower incidence of bleeding complications8
  • Lower incidence of heparin-induced thrombocytopenia (HIT)8,9
  • Decreased tendency to produce osteopenia on prolonged administration10
  • Ease of administration8,11
  • No daily anticoagulation monitoring in the majority of patients8
  • Outpatient use8

 LMWHs are not clinically interchangeable11

LMWH = low-molecular-weight heparin; PE= pulmonary embolism; UFH = unfractioned heparin; VKA = vitamin K antagonists; VTE = venous thromboembolism;

Monitoring anti-Xa levels

References

1. Schmid P et al. Swiss Med Wkly 2007;137:514.
2. Schmid P et al. Swiss Med Wkly 2009;139:438–452.
3. Trujillo-Santos J et al. Am J Med 2013;126:425–434.
4. Schmid P et al. Swiss Med Wkly 2009;139:438–452.
5. Monreal M et al. Am J Med 2006;119:1073–1079.
6. Woodruff S et al. J Thromb Thrombolysis 2016;42:494–504.
7. Weitz JI. N Eng J Med 1997;337:688–698.
8. Quader MA et al. J Am Coll Surg 1998;187:641–658.
9. Warkentin TE et al. N Eng J Med 1995;332:1330–1335.
10. Pineo GF and Hull RD. Eur J Med Res 2004;9:215–224.
11. Fragmin SmPC [Surgical Thromboprophylaxis (2,500 IU and 5,000 IU syringes)]. Available at: https://www.medicines.org.uk/emc/product/4246 and https://www.medicines.org.uk/emc/product/4247

*Including, but not limited to: congestive cardiac failure (NYHA class III or IV), acute respiratory failure or acute infection, who also have a predisposing risk factor for VTE such as age over 75 years, obesity, cancer or previous history of VTE.~
†In patients with chronic renal insufficiency or acute renal failure.

PP-FRA-GBR-0174.  June 2019