From the Guidelines
D-dimer levels should be interpreted with caution in patients with end-stage renal disease (ESRD), as kidney dysfunction impairs D-dimer clearance, leading to potentially falsely elevated levels. When evaluating D-dimer results in ESRD patients, it is essential to consider the impact of reduced kidney function on D-dimer clearance. Although the provided evidence does not directly address D-dimer adjustment in ESRD patients, it highlights the challenges of interpreting biomarker results in patients with chronic kidney disease (CKD) or ESRD, as seen in the context of high-sensitivity troponin testing 1.
- Key considerations for D-dimer interpretation in ESRD patients include:
- The kidneys play a crucial role in clearing D-dimers from the bloodstream.
- ESRD patients have significantly reduced glomerular filtration rates, leading to D-dimer accumulation.
- Without adjustment, D-dimer results may be less specific for thrombotic conditions in ESRD patients. Given the lack of direct evidence on D-dimer adjustment in the provided studies, a conservative approach would be to use a higher threshold for D-dimer interpretation in ESRD patients, such as multiplying the standard cutoff by a factor of 2 to 3, resulting in an adjusted threshold of approximately 1000-1500 ng/mL, similar to the approach suggested in the example answer. However, this adjustment is not explicitly supported by the provided evidence 1, and clinicians should exercise caution when interpreting D-dimer results in ESRD patients, considering both the adjusted threshold and clinical probability assessment tools for thrombotic conditions.
From the Research
D-Dimer Adjusted Levels in End-Stage Renal Disease
- The study 2 suggests that D-dimer levels can be adjusted based on renal function, with estimated glomerular filtration rate (eGFR)-adjusted D-dimer cutoff levels being more accurate than conventional D-dimer cutoff levels in patients with suspected thromboembolism.
- The adjusted D-dimer cutoff levels were validated as follows: > 333 µg/L (eGFR > 60 mL/min/1.73 m), > 1,306 µg/L (30-60 mL/min/1.73 m), and > 1,663 µg/L (< 30 mL/min/1.73 m).
- The use of eGFR-adjusted D-dimer cutoff levels can reduce the false-positive rate in patients with eGFR < 60 mL/min/1.73 m.
Thrombosis in End-Stage Renal Disease
- The study 3 highlights that thrombotic events are common in patients with end-stage renal disease (ESRD), despite the classic association of renal failure with a bleeding tendency.
- The study suggests that ESRD treatment factors, such as recombinant erythropoietin administration, dialyzer bioincompatibility, and calcineurin inhibitor administration, may have prothrombotic effects.
Antithrombotic Therapy in End-Stage Renal Disease
- The study 4 notes that the decision to use antithrombotic agents in ESRD patients is complex and requires individualization, due to the concomitant association of a prothrombotic state with a high risk of bleeding.
- The study summarizes the pros and cons of using antiplatelet and antithrombotic agents in primary and secondary prevention of cardiovascular events in ESRD patients.
Medical Management of End-Stage Renal Disease
- The study 5 emphasizes the importance of referring patients at risk of ESRD to nephrology for optimal disease management.
- The study advises vaccination against certain diseases, controlling blood pressure, and monitoring for signs of protein-energy wasting and malnutrition in patients with ESRD.
- The study 6 notes that patients with ESRD are dependent on renal replacement therapy (RRT) via dialysis or kidney transplantation, and that transplantation is the treatment of choice for eligible patients.