Clinical outcome of patients with venous thromboembolism and renal insufficiency

Summary

There is little information on the clinical outcome of patients with venous thromboembolism and renal insufficiency. RIETE is an ongoing, prospective registry of consecutive patients with acute, objectively confirmed, symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE). In this analysis we analyzed the three-month outcome in patients with creatinine clearance (CrCl) <30 ml/min. As of March 2007, 1,037 of the 18,251 (5.7%) patients enrolled in RIETE had CrCl <30 ml/min. During the three-month study period these patients had an increased incidence of fatal bleeding, fatal PE, and overall death compared to those with CrCl >30 ml/min. Of the 579 patients presenting with clinically overt PE, 52 (9.0%) died of the initial PE, 13 (2.2%) of recurrent PE, and nine (1.6%) died of bleeding complications. During the first 15 days of therapy the 10% incidence of fatal PE was 10-fold their 1.0% of fatal bleeding. From day 16 to 90, the 1.0% rate of fatal PE was not significantly higher than the 0.5% of fatal bleeding. Of the 458 DVT patients with CrCl <30 ml/min, 14 (3.1%) had fatal bleeding and only one (0.2%) died of PE. In patients with CrCl <30 ml/min presenting with clinically overt PE the main threat is PE itself. On the contrary, in those with DVT the main threat is bleeding.

Keywords

Venous thromboembolism - renal insufficiency - anticoagulant therapy

• References

• 1 Büller HR, Agnelli G, Hull RD. et al. Antithrombotic therapy for venous thromboembolic disease. The seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004; 126: 401S-428S.
• 2 Grand’Maison A, Charest A, Geerts WH. Anticoagulant use in patients with chronic renal impairment. Am J Cardiovasc Drugs 2005; 5: 291-305.
• 3 Monreal M, Falgá C, Valle R. et al. and the RIETE investigators. Venous thromboembolism in patients with renal insufficiency: Findings from the RIETE Registry. Am J Med 2006; 119: 1073-1079.
• 4 Arcelus JI, Monreal M, Caprini JA. et al. The management and outcome of acute venous thromboembolism: a prospective registry including 4011 patients. J Vasc Surg 2003; 38: 916-922.
• 5 Monreal M, Suárez C, González Fajardo JA. et al. and the RIETE investigators. Management of patients with acute venous thromboembolism: Findings from the RIETE Registry. J Pathophysiol Haemost Thromb 2003; /2004 33: 330-334.
• 6 Monreal M, Falgá C, Valdés M. et al. for the RIETE Investigators. Fatal pulmonary embolism and fatal bleeding in cancer patients with venous thromboembolism: Findings from the RIETE registry. J Thromb Haemost 2006; 4: 1950-1956.
• 7 Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976; 16: 31-41.
• 8 Lim W, Dentali F, Eikelboom JW. et al. Meta-analysis: Low-molecular-weight heparin and bleeding in patients with severe renal insufficiency. Ann Intern Med 2006; 144: 673-684.
• 9 Goodman SG, Cohen M, Bigonzi F. et al. Randomized trial of low molecular weight heparin (enoxaparin) versus unfractionated heparin for unstable coronary artery disease: one-year results of the ESSENCE Study. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q Wave Coronary Events. J Am Coll Cardiol 2000; 36: 693-698.
• 10 Cohen M, Demers C, Gurfinkel EP. et al. A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group. N Engl J Med 1997; 337: 447-452.
• 11 Gerlach AT, Pickworth KK, Seth SK. et al. Enoxaparin and bleeding complications: A review in patients with and without renal insufficiency. Pharmacotherapy 2000; 20: 771-775.
• 12 Spinler SA, Inverso SM, Cohen M. et al. Safety and efficacy of unfractionated heparin versus enoxaparin in patients who are obese and patients with severe renal impairment: Analysis from the ESSENCE and TIMI 11B studies. Am Heart J 2003; 146: 33-41.
• 13 Thorevska N, Amoateng-Adjepong Y, Sabahi R. et al. Anticoagulation in hospitalized patients with renal insufficiency. A comparison of bleeding rates with unfractionated heparin vs enoxaparin. Chest 2004; 125: 856-863.
• 14 Farooq V, Hegarty J, Chandrasekar T. et al. Serious adverse incidents with the usage of low molecular weight heparins in patients with chronic kidney disease. Am J Kidney Dis 2004; 43: 531-537.