iCliniq logo

Ask a Doctor Online Now

HomeHealth articlesanticoagulationWhat Is the Importance of Anticoagulation in Chronic Kidney Disease?

Anticoagulation in Chronic Kidney Disease

Verified dataVerified data
0

5 min read

Share

Anticoagulation is important in patients with chronic kidney disease as they are at increased risk of thromboembolic events. Read further to know more.

Published At November 10, 2022
Reviewed AtAugust 23, 2023

Introduction:

Chronic kidney disease (CKD) patients are at an increased risk of thromboembolic events due to the hypercoagulable state of the blood as a result of altered homeostatic mechanisms. More than 15 % of patients with CKD are at an increased risk of atrial fibrillation as a result of increased platelet activity and pro-inflammatory events. Oral anticoagulants play a major role in preventing such complications and increasing the survival rates of patients with chronic kidney disease. Each anticoagulant shares unique pharmacological properties; hence it is important for the nephrologist to have a wide knowledge of these drugs to select the appropriate anticoagulant for the respective patients.

What Is Chronic Kidney Disease?

The gradual loss of kidney function characterizes chronic kidney disease. This results in the build-up of waste products and excess fluid in the body. In the early stages, it would not produce any symptoms. The symptoms appear as the disease advances, producing harmful effects on the body.

What Are the Causes of Chronic Kidney Disease?

The causes of chronic kidney disease include:

  • Diabetes mellitus.

  • Hypertension.

  • Vesicoureteral reflux (irregular urine flow from the bladder back up the ureters that link the bladder to the kidneys).

  • Interstitial nephritis (inflammation of the spaces between tubules of the kidney).

  • Glomerulonephritis (refers to damaged glomeruli or small filters present inside the kidneys).

  • Kidney stones.

  • Polycystic kidney disease (a hereditary condition where groups of cysts form inside the kidneys, making the kidneys grow larger and lose their functioning).

  • Inherited kidney diseases (also known as autosomal dominant polycystic kidney disease).

  • Prostate hypertrophy (age-related prostate gland enlargement that may make it difficult to urinate).

  • Pyelonephritis (inflammation of the kidneys occurring due to bacterial infection).

What Are the Stages of Chronic Kidney Disease Based on the Estimated Glomerular Filtration Rate?

Chronic kidney disease can be categorized into five stages based on the eGFR (estimated glomerular filtration rate), and they are as follows:

  • Stage 1 (Normal or High): When the eGFR value is greater than or equal to 90.

  • Stage 2 (Mild Reduction): When the eGFR value is between 60 to 89.

  • Stage 3a (Mild to Moderate Reduction): When the eGFR value is between 45 to 59.

  • Stage 3b (Moderate to Severe Reduction): When the eGFR value is between 30 to 44.

  • Stage 4 (Severe Reduction): When the eGFR value is between 15 to 29.

  • Stage 5 (Most Severe Reduction): When the eGFR value is less than 15.

What Are the Symptoms of Chronic Kidney Disease?

The symptoms include:

  • Nausea.

  • Vomiting.

  • Fatigue and weakness.

  • Loss of appetite.

  • Muscle cramps.

  • Urinating more or less.

  • Decreased mental sharpness.

  • Swelling of feet and ankles.

  • Pruritus (itching).

  • High blood pressure (hypertension).

  • Shortness of breath.

  • Chest pain.

What Are Anticoagulants?

Anticoagulants are medicines that help to prevent blood from clotting. They are usually indicated in patients with high chances of clot formation, such as cardiac patients and patients with a history of stroke.

Why Is Anticoagulation Important in Patients with Chronic Kidney Disease?

In patients with chronic kidney disease, there is altered homeostasis of the body, causing uremia (increased uric acid in the blood), anemia (decreased red blood cell count), abnormal mineral metabolism, systemic inflammation, activation of the renin-angiotensin-aldosterone system, and platelet hyperactivity. All the above-discussed factors have an impact on the cardiovascular system, increasing the hypercoagulability of the blood resulting in clot formation and increasing the chances of thrombosis (blood clots blocking arteries and veins) and embolism (sudden blockage of arteries due to a foreign body or clots).

What Is the Pathogenesis of Hypercoagulation in Patients With Chronic Kidney Disease?

The pathogenesis in the blood hypercoagulability of patients with chronic kidney disease includes three components called Virchow's triad. The factors include:

  • Stasis and turbulent flow of the blood.

  • Endothelial injury to the walls of the blood vessels.

  • Increased platelet activity (hypercoagulability).

All three factors would contribute to the initiation of inflammation and increase the coagulation activity of the platelets. Another important factor that would increase the risk of coagulation in chronic kidney disease patients is uremia. Increased uric acid levels in the blood would increase the levels of clotting factors such as fibrinogen, thrombomodulin, von Willebrand factor, etc., resulting in atherosclerosis and arterial stiffness, thereby contributing to cardiovascular complications.

What Is the Frequency of Complications Due to Hypercoagulability in Patients With Chronic Kidney Disease?

Studies report that the risk in predialysis patients with chronic kidney disease ranges from four percent to 21 %. In patients with pre-existing ST-elevation myocardial infarction, the risk increases to 30 %. The risk of thromboembolism is estimated to be 29 % in patients with mild CKD and may increase up to 134 % in patients under dialysis for CKD treatment. As compared to the general population, patients with CKD are at a 2.5 to 5.5 times higher risk for thromboembolic events.

What Are the Anticoagulants Used in Patients With Chronic Kidney Disease?

The commonly used oral anticoagulants in chronic kidney disease patients include Warfarin, Dabigatran, Rivaroxaban, Apixaban, etc. These drugs require dose adjustment in patients with CKD based on their pharmacological properties.

  • Warfarin: Warfarin is a vitamin-K-dependent factor inhibitor. It is metabolized by the CYP2C9 enzyme that breaks down the Warfarin complex. No renal dose adjustment is required in the case of Warfarin in patients with CKD, as kidneys are not involved in the metabolism of Warfarin. It is nondialyzable, and its binding to the effector is not reversible.

  • Dabigatran: Dabigatran is a direct thrombin inhibitor, which is metabolized by the esterase enzyme. Renal dose adjustment is needed in the case of Dabigatran, as 80 % of the drug is excreted by the kidneys. It is dialyzable, and its binding to the effector is reversible.

  • Rivaroxaban: Rivaroxaban is a free and clot-bound factor Xa inhibitor. Renal dose adjustment is essential in Rivaroxaban as 66 % of the drug is excreted by the kidneys, and the rest, 36 %, remains unchanged with minimal excretion in feces. It is nondialyzable, and its binding to the effector is reversible.

  • Apixaban: Apixaban is a free and clot-bound factor Xa inhibitor. It is metabolized in the liver by an enzyme called CYP3A4. 25 % of the drug is excreted by the kidneys, and the rest is in feces. No renal dose adjustment is required in the case of Apixaban. A small amount of it is dialyzable, and its binding to the effector is reversible.

What Is the Necessary Dose Adjustment Required in Patients With Chronic Kidney Disease?

  • Warfarin: It usually does not require any dose adjustment as it is not metabolized by the kidneys. But it is essential to alter the dose based on the estimated glomerular filtration rate values.

  • Dabigatran: When the eGFR values are above 50, then 150 mg of Dabigatran can be given twice daily. When the eGFR values are below 30, and above 15, then 75 mg of Dabigatran can be given twice daily. In the case of patients with end-stage renal disease and eGFR less than 15, it is not recommended to prescribe Dabigatran.

  • Rivaroxaban: When the eGFR values are above 50, then 20 mg of Rivaroxaban can be given once daily. When the eGFR values are below 30, and above 15, then 15 mg of Rivaroxaban can be given once daily. In the case of patients with end-stage renal disease and eGFR less than 15, it is not recommended.

  • Apixaban: When the eGFR values are above 50, then 5 mg of Apixaban can be given twice daily. When the eGFR values are below 30, and above 15, then 2.5 mg of Apixaban can be given twice daily. In the case of patients with end-stage renal disease, adding an eGFR of less than 15 is not recommended.

Conclusion:

Anticoagulation is one of the vital steps in treating patients with chronic kidney disease, as patients with CKD are at a 2.5 to 5.5 times higher risk of developing thromboembolic and cardiovascular complications. It is important to put them under anticoagulants to decrease platelet hyperactivity and reduce the hypercoagulability of the blood. Prophylactic anticoagulants would help them survive better and reduce unnecessary complications.

Frequently Asked Questions

1.

What Anticoagulant Is Safe for People With CKD?

Unfractionated heparin (UFH) is recommended because, even in patients with severe renal impairment at high hemorrhagic risk, its short half-life enables the anticoagulant effect to wear off within 1 to 4 hours.

2.

Can Someone With Renal Problems Use Blood Thinners?

Blood thinners can make bleeding more likely, which is problematic for people already at high risk, such as those with kidney illnesses.

3.

Why Is LMWH Not Recommended in CKD?

It has been recommended that patients with a creatinine clearance of 30 mL/min or less (0.50 mL/s) be prohibited from treatment with low-molecular-weight (LMW) heparin or have anti-factor Xa heparin level monitoring undertaken due to the possibility of accumulation of anticoagulant action.

4.

Is Heparin Effective for CKD?

Heparin anticoagulation is safe in nondialysis-dependent CKD; however, it is still difficult in hemodialysis patients.

5.

In CKD, Is Apixaban Safe?

There is little evidence that apixaban benefits AF patients with CKD who are not on dialysis. However, according to this study, apixaban reduces the risk of an ischemic stroke or SE by 26% in people with AF who have CKD and 37% in people with advanced CKD.

6.

Which Drugs Should People With CKD Stay Away From?

Medications to avoid in chronic kidney disease are:
 - Nonsteroidal anti-inflammatory medicines (NSAIDs) are painkillers.
 - Proton pump inhibitors (PPIs).
 - Cholesterol-lowering drugs (statins).
 - Antibiotics.
 - Drugs for diabetes.
 - Antacids.
 - Herbal supplements and vitamins.
 - Contrast dye.

7.

Is Enoxaparin Safe for Use in CKD?

Numerous sources have proven that people with renal impairment who use enoxaparin have a higher risk of bleeding. These safety studies appear to be the driving force behind fine-tuning renal dose recommendations for individuals with CrCl (creatine clearance) levels less than 50 mL/min and varied degrees of renal impairment.

8.

What Is the Initial Course of Action for CKD?

In individuals with albuminuria, ACE (angiotensin converting enzymes) inhibitors and ARBs (angiotensin receptor blockers) have been shown to reduce the course of CKD and are regarded as first-line therapy.

9.

Is Tranexamic Acid Not Advised for People With CKD?

No, tranexamic acid is not safe for patients with CKD. Tranexamic acid displaces plasminogen from the fibrin surface to provide antifibrinolytic effects. Due to reports of ureteric clots and abrupt renal failure from cortical necrosis, chronic renal impairment is considered a relative contraindication to administering tranexamic acid.

10.

Is Fondaparinux Safe for Use in CKD?

Due to the higher risk of bleeding, fondaparinux is contraindicated in patients with severe renal impairment and renal failure. The kidney is known to be the principal organ used to eliminate fondaparinux. Patients with a creatinine clearance of less than 50 ml/min have a higher risk of bleeding and should be managed carefully.

11.

What Causes Hypercoagulability in CKD?

Increased fibrinogen levels in CKD patients directly contribute to the hypercoagulable state since it acts as a compensatory mechanism to regulate hemostasis in the presence of documented platelet dysfunction in CKD.

12.

Can Someone With CKD Take Warfarin?

According to evidence from randomized controlled trials, Warfarin and direct oral anticoagulants (DOACs) are effective and secure treatments for mild to moderate CKD.

13.

Is Vitamin D Harmful to Those With CKD?

No, Vitamin D supplementation is used in patients with CKD. In CKD, 25-(OH)-vitamin D supplementation is advised at the onset of the condition, including calcitriol replacement starting in Stage 3.
Source Article IclonSourcesSource Article Arrow
Dr. Samer Sameer Juma Ali Altawil
Dr. Samer Sameer Juma Ali Altawil

Urology

Tags:

chronic kidney diseaseanticoagulation
Community Banner Mobile
By subscribing, I agree to iCliniq's Terms & Privacy Policy.

Source Article ArrowMost popular articles

Ask your health query to a doctor online

Nephrology

*guaranteed answer within 4 hours

Disclaimer: No content published on this website is intended to be a substitute for professional medical diagnosis, advice or treatment by a trained physician. Seek advice from your physician or other qualified healthcare providers with questions you may have regarding your symptoms and medical condition for a complete medical diagnosis. Do not delay or disregard seeking professional medical advice because of something you have read on this website. Read our Editorial Process to know how we create content for health articles and queries.

This website uses cookies to ensure you get the best experience on our website. iCliniq privacy policy