Anticoagulation Bridging for Patients with Severe Renal Impairment or End Stage Renal Disease

NHS Borders clinical guidelines
NHS Borders

Adapted from RIE renal unit guidance February 2020; updated November 2023

Patients with a creatinine clearance <30ml/min who require therapeutic parenteral anticoagulation:

  • for anticoagulation bridging when Warfarin treatment is initiated or restarted, or
  • in AKI when creatinine clearance ,30ml/minute

Should be assessed on a case-by-case basis and choice of anticoagulant should take into account the patient's thrombosis and bleeding risk.

The risks and benefits for unfractionated Heparin infusion (UFH) and reduced treatment dose Dalteparin should be considered

Unfractionated heparin infusion:

  • does not depend on renal clearance,
  • shorter half-life
  • can be fully reversed in the event of
  • dependence on a continuous intravenous infusion of UFH can prolong hospital
  • Can be challenging to monitor and maintain anticoagulation in therapeutic range

(Guidance for initiating UFH infusion can be found on NHS Borders Anticoagulant microsite )

Low molecular weight heparin (LMWH)

  • is a more convenient option and with appropriate monitoring, can be a suitable alternative

In these cases, the use of LMWH is short term until INR is therapeutic (if warfarinising) which usually takes about 5 to 7 days; or until creatinine clearance > 30ml/min and the clinical decision is made to change to oral anticoagulation (generally with apixaban or Edoxaban) It is important to note that use of treatment dose LMWH for prolonged periods in renal impairment may lead to accumulation therefore increasing the risk of bleeding.

 

Low to Moderate Thrombosis Risk

A reduced dose of Dalteparin to 2/3 of the full treatment dose can be considered for the following indications where creatinine clearance is <30ml/min:

  1. Atrial fibrillation
  2. Anticoagulation for deep vein thrombosis (DVT) or pulmonary embolism (PE). To ensure therapeutic anticoagulation is achieved, anti-factor Xa levels should be measured and dose of Dalteparin adjusted if indicated.

Dose calculation

Dose calculation Anti-factor Xa monitoring Warfarin

Dalteparin 130units/kg

Please round to nearest available syringe:

  • 5,000units
  • 7,500units
  • 10,000units
  • 12,500units
  • 15,000units
  • 18,000units

After 3rd dose

This must be done 2-4 hours after dose administration to achieve an accurate peak level

(Target 0.5-1.0 units/ml)

Repeat on day 10 if treatment still ongoing

Outpatients:

Restart at usual dose

 

Inpatients:

May be restarted at higher dose – please discuss with senior medical staff

Editorial Information

Last reviewed: 30/11/2023

Next review date: 01/11/2026

Author(s): Leith L, Morrison R .

Version: V3

Author email(s): Rhona.morrison@nhs.scot, liz.leitch@nhs.scot.

Co-Author(s): Morrison R.

Approved By: Area Drugs & Therapeutic Committee

Reviewer name(s): Morrison R, Metcalfe W.