HHE 2018 | Page 57

AE Anticoagulant effect AT Antithrombin FPX Fondaparinux LMWH Low molecular weight heparin UFH Unfractionated heparin VKA Vitamin K antagonist

Anti-Xa Anti-factor Xa activity aPTT Activated prothrombin time FPX Fondaparinux INR International normalised ratio LMWH Low molecular weight heparin od Once daily UFH Unfractionated heparin VKA Vitamin K antagonist

Outside the setting of elective joint arthroplasty , meaningful subgroup analyses of patients with CKD are rare . Therefore , recommendations derived from joint replacement surgeries are considered references for postoperative VTE prevention also in other indications .

Many of those – elderly – patients with CKD undergoing surgery are on long-term anticoagulation therapy prior to the operation due to AF or VTE . Nowadays , most of these patients receive DOACs . Yet , there still is a relevant proportion of patients treated with VKA for these indications or others . Although minor procedures can be performed in most patients while on trough levels of DOACs or in the lower part of the therapeutic INR-range , major surgeries or interventions with an increased risk of haemorrhage require normal hemostasis . For DOACs an interruption for 2 – 5 days ( Table 2 ) depending on the specific DOAC as well as on renal function seems to be a safe strategy . Bridging of VKA anticoagulation by LMWH in the context of AF has recently become a matter of discussion . 15 Yet , it needs to be stressed that in patients with sRI or ERD , having a clear cut indication for anticoagulation therapy , bridging via application of UFH may be less convenient , but safer than the use of LMWH . Postoperative anticoagulation in these patients may be initiated with a prophylactic dose for some days before – stepwise – escalation to the therapeutic dose , depending on the postoperative bleeding risk .

Full dose anticoagulation therapy in patients with CKD and VTE Prospective randomised trials in general populations with VTE have demonstrated that anticoagulation therapy significantly decreases recurrent VTE to a larger extend than it increases hemorrhagic complications . 6 This beneficial effect of treatment has been confirmed in observational studies and registries . In large registration studies patients with acute VTE ( or AF ) and mRI have been included and subgroup analysis demonstrated a comparable ‘ net-benefit ’ of therapeutic anticoagulation with numerically higher rates of thromboembolic events and bleeding complications compared with patients with a GFR > 60ml / min . 5-7 However , patients with sRI or CHD were largely excluded .

Thus , prospective evidence as well as systematic reviews and meta-analyses for patients suffering from sRI or ESRD / CHD and acute VTE are not available . However , tens of thousands of patients with AF and CHD treated with warfarin have been analysed with heterogeneous results . 6 , 17 Thus , any clear benefit of VKA in the CHD

57 HHE 2018 | hospitalhealthcare . com

As long as GFR is > 30ml / min , standard dosages of LMWH or most DOACs can safely be applied