What is the recommended thromboprophylaxis for a patient with a hip fracture and impaired renal function, specifically with an estimated Glomerular Filtration Rate (EGFR) indicating severe renal impairment?

From the Guidelines

For patients with hip fractures and severe renal impairment (eGFR of 17.7), unfractionated heparin (UFH) is the recommended thromboprophylaxis option. The typical regimen is 5,000 units of UFH administered subcutaneously every 8-12 hours, starting preoperatively if surgery is delayed and continuing for at least 10-14 days postoperatively, or until the patient is fully mobile. Low molecular weight heparins (LMWHs) like enoxaparin should be avoided or used with extreme caution and dose adjustment in severe renal impairment as they are primarily cleared by the kidneys and can accumulate, increasing bleeding risk, as noted in studies such as 1.

UFH is preferred because it's cleared through non-renal mechanisms and can be more easily monitored and reversed if necessary. For extended prophylaxis beyond hospitalization (up to 35 days), which is often recommended for hip fracture patients, options include switching to adjusted-dose warfarin with close INR monitoring (target 2.0-3.0) or continuing UFH if outpatient administration is feasible. Mechanical prophylaxis with intermittent pneumatic compression devices should be used as adjunctive therapy, especially when pharmacological prophylaxis must be temporarily interrupted. Regular monitoring of renal function, complete blood counts, and clinical assessment for signs of bleeding or thrombosis is essential throughout the treatment period.

Some studies, such as 1, discuss the use of factor Xa inhibitors like rivaroxaban, but these are generally not recommended for patients with severe renal impairment due to their renal elimination and potential for accumulation. Similarly, fondaparinux, another factor Xa inhibitor, is contraindicated in patients with severe renal insufficiency, as stated in 1. More recent guidelines, such as those from 1, emphasize the importance of thromboprophylaxis in hospitalized patients, including those with cancer, but also highlight the preference for UFH over LMWH in patients with severe renal impairment.

Key considerations in the management of these patients include:

• Monitoring renal function closely
• Adjusting anticoagulation doses as necessary
• Using mechanical prophylaxis when possible
• Regularly assessing for signs of bleeding or thrombosis
• Considering the patient's overall clinical condition and risk factors for VTE and bleeding.

From the FDA Drug Label

In patients with CrCl <30 mL/min, rivaroxaban exposure and pharmacodynamic effects are increased compared to patients with normal renal function There are limited clinical data in patients with CrCl 15 to <30 mL/min; therefore, observe closely and promptly evaluate any signs or symptoms of blood loss in these patients. There are no clinical data in patients with CrCl <15 mL/min (including patients on dialysis); therefore, avoid the use of XARELTO in these patients

The patient's eGFR is 17.7, which is less than 15 mL/min, and according to the label, there are no clinical data in patients with CrCl <15 mL/min. Therefore, the recommended action is to avoid the use of XARELTO in this patient 2.

From the Research

Thromboprophylaxis for Hip Fracture with Severe Renal Impairment

The recommended thromboprophylaxis for a patient with a hip fracture and impaired renal function, specifically with an estimated Glomerular Filtration Rate (EGFR) of 17.7, is not directly addressed in the provided studies. However, the following points can be considered:

• The studies 3, 4, 5 discuss the efficacy and safety of rivaroxaban for thromboprophylaxis after hip fracture surgery, but they do not provide specific guidance for patients with severe renal impairment.
• A study 6 found that decreasing EGFR is associated with an increased risk of hip fracture, but it does not provide information on thromboprophylaxis.
• Another study 7 found that lower estimated glomerular filtration rate levels are an independent predictor of acute kidney injury after hip fracture surgery, highlighting the importance of considering renal function when managing patients with hip fractures.

Key Considerations

• The patient's severe renal impairment (EGFR of 17.7) should be taken into account when selecting a thromboprophylaxis regimen.
• The studies provided do not offer specific guidance on the use of Xarelto (rivaroxaban) in patients with severe renal impairment.
• It is essential to consult the prescribing information for Xarelto and consider the patient's individual factors, such as renal function, when determining the appropriate thromboprophylaxis dose.

Available Thromboprophylaxis Options

• Aspirin and rivaroxaban have been compared as thromboprophylaxis options after hip fracture surgery 4.
• Rivaroxaban has been shown to be effective and safe in patients with lower limb fractures 3, 5.
• However, the optimal thromboprophylaxis regimen for patients with severe renal impairment remains unclear based on the provided studies.