From the Guidelines
For patients with an eGFR of 14 mL/min, apixaban is the most suitable direct oral anticoagulant (DOAC) option, with a reduced dose of 2.5 mg twice daily, as it has the lowest renal clearance of 27% compared to other DOACs 1. When considering anticoagulation options for patients with severe impaired renal function, it is crucial to prioritize those that do not heavily rely on renal clearance to minimize the risk of drug accumulation and bleeding.
- Key considerations include:
- The percentage of renal clearance for each DOAC, as indicated in Table 6 of the 2018 European Heart Rhythm Association practical guide 1.
- The recommendation for dose adjustment based on renal function, with apixaban being approved for use in patients with severe CKD (Stage 4, i.e., a CrCl of 15–29 mL/min) with a reduced dose regimen.
- Other anticoagulants like rivaroxaban, edoxaban, and dabigatran have higher renal clearance rates, making them less ideal for patients with an eGFR of 14 mL/min.
- Warfarin, which is metabolized by the liver, can be an alternative option with close INR monitoring, but its use requires careful consideration of the patient's overall clinical profile.
- Unfractionated heparin (UFH) is another option that does not rely on renal clearance and can be monitored with aPTT levels, but its use is typically reserved for specific clinical scenarios due to its intravenous administration and need for close monitoring.
- It is essential to note that the management of anticoagulation in patients with severe renal impairment should be individualized, taking into account the patient's specific risk factors, comorbidities, and the clinical context, as highlighted in the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1.
From the Research
Anticoagulants for Severe Impaired Renal Function
The following anticoagulants can be considered for use in patients with an estimated Glomerular Filtration Rate (eGFR) of 14, indicating severe impaired renal function:
- Unfractionated heparin, which is the preferred anticoagulant for use in most patients with severe renal impairment, although its use is associated with increased bleeding in this population 2, 3
- Argatroban, which does not require dose adjustment with renal dysfunction, but close monitoring of anticoagulation is recommended when administered in patients with severe chronic renal impairment 3
- Warfarin, which may require dose reduction in patients with severe kidney impairment, with a reduction of 19% in warfarin dose requirements compared to patients with no/mild kidney impairment 4
- Apixaban, which has been shown to be effective in preventing stroke or systemic embolism and reducing mortality in patients with atrial fibrillation, regardless of renal function, and may be associated with less major bleeding events across all ranges of eGFRs 5
Considerations for Anticoagulant Use
When using anticoagulants in patients with severe impaired renal function, the following considerations should be taken into account:
- Dose adjustment may be necessary for some anticoagulants, such as warfarin and low-molecular-weight heparins 6, 2, 3, 4
- Close monitoring of anticoagulation is recommended when using anticoagulants in patients with severe renal impairment 2, 3
- The risk of bleeding and thromboembolic complications should be carefully weighed when selecting an anticoagulant for use in patients with severe impaired renal function 6, 2, 3