Name: Deep vein thrombosis (DVT) prophylaxis agent selection in patients with acute kidney injury
Start: 2025-04-24T09:10:00-0400
End: 2025-04-24T09:25:00-0400

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Thursday April 24, 2025 9:10am - 9:25am EDT

Athena I

Title: Deep vein thrombosis (DVT) prophylaxis agent selection in patients with acute kidney injury

Authors: Jacob Powell, Lauren Chambers, Joseph Davis

Objective: To assess differences in bleed risk and clinical outcomes between enoxaparin and unfractionated heparin for the use of DVT prophylaxis in the setting of acute kidney injury

Background: Venous thromboembolisms (VTE) are a significant contributor to morbidity and mortality in hospitalized patients. The American Society of Hematology (ASH) and American College of Chest Physicians recommend pharmacological prophylaxis for acutely or critically ill patients. Reduced kidney function can impair anticoagulant elimination, increasing the risk of bleeding. However, thrombosis and bleeding are both common in patients with acute kidney injury (AKI). Proper dosing is critical to avoid drug accumulation. Enoxaparin is prescribed for DVT prophylaxis at 40 mg daily, while unfractionated heparin (UFH) is given at 5,000 mg 2-3 times daily. In patients with reduced kidney function (creatinine clearance <30 ml/min), enoxaparin is reduced to 30 mg daily. UFH does not require renal dose adjustments. There is insufficient data to lead one to favor enoxaparin over UFH in this patient population. The objective of this research project is to assess differences in bleed risk and clinical outcomes between enoxaparin and UFH for the use of DVT prophylaxis in the setting of AKI. Results from this study will help to guide providers in agent selection for DVT prophylaxis in patients with AKI.

Methods: This study was a single center, retrospective, observational review conducted at ECU Health Medical Center (ECHMC). This study included patients with a creatinine clearance (CrCl) <30 ml/min who had developed an AKI, defined by an increase in serum creatinine (SCr) by ≥0.3 mg/dL, within 48 hours of admission. Patients included received DVT prophylaxis with enoxaparin or UFH for at least 48 hours after admission and during AKI. Patients were excluded if they received both agents, were admitted to a trauma, surgery, or orthopedic service, or had end stage kidney disease (ESKD) receiving dialysis within 30 days of admission. Patients weighing <45kg were likewise excluded from this study. The primary outcome in this study was the incidence of major bleeding between each medication within 30 days of admission. Secondary outcomes included in-hospital mortality, length of stay, daily cost of medications, incidence of minor bleeding, and development of thrombus within 30 days of admission.

Results: A total of 130 patients were included for analysis, with 36 (28%) receiving enoxaparin and 94 (72%) receiving UFH. Baseline characteristics were largely similar between groups, with some notable exceptions. Patients in the UFH group had a significantly higher median weight (77.1 kg vs. 65.6 kg; p=0.0003) and body mass index (27.3 kg/m² vs. 22.2 kg/m²; p=0.0006) compared to those receiving enoxaparin. Additionally, patients receiving UFH had higher median SCr levels on admission (p<0.0001), higher peak SCr during AKI (p<0.0001), and lower median CrCl during AKI (p=0.0005). There was no statistically significant difference in the primary outcome of major bleeding between enoxaparin and UFH groups (5.6% vs. 2.1%; RR 2.611, 95% CI 0.3819–17.854; p=0.3067). Similarly, there were no significant differences in secondary outcomes, including in-hospital mortality, length of stay, incidence of minor bleeding, or thrombus formation within 30 days of admission. However, UFH was associated with a significantly higher median drug cost per day compared to enoxaparin (p<0.001).

Conclusion: This study found no increased risk of bleeding with enoxaparin in patients with AKI. While underpowered to detect statistical significance, this study provides additional data on enoxaparin use in this patient population without increased risk of safety concerns. Larger studies are needed to confirm these findings.

Contact Information: Jacob.Powell@ecuhealth.org

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Kayla Lawlor

CVICU Pharmacist, Emory University Hospital

Dr. Kayla Lawlor is a Cardiothoracic/Vascular Surgical Intensive Care Pharmacist at Emory University Hospital in Atlanta, Georgia. She received her Bachelors in Science in Food Science and Human Nutrition at the University of Florida in 2012 and her Doctorate of Pharmacy from University... Read More →

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