Enoxaparin versus unfractionated heparin for venous thromboembolism prophylaxis in renally impaired ICU patients

Abstract

Introduction Intensive care unit (ICU) patients with renal insufficiency are more likely to develop venous thromboembolism and are at an increased risk for bleeding. There is conflicting data on whether enoxaparin or unfractionated heparin (UFH) is preferred for preventing thromboembolism in this population. Therefore, the purpose of this study was to evaluate the safety of prophylactic enoxaparin versus UFH in ICU patients with renal impairment. Methods We conducted a single‐center, retrospective cohort study of ICU patients with renal impairment who received venous thromboembolism prophylaxis with either enoxaparin or UFH. Patients were included if they were at least 18 years of age, had renal impairment (acute kidney injury, severely decreased renal function, or end‐stage renal disease), and an ICU length of stay ≥72 h. The primary outcome was the proportion of patients experiencing a major bleeding event, including fatal bleed, symptomatic bleed in a critical area, or bleeding causing a ≥2 g/dl decrease in hemoglobin leading to a transfusion of ≥2 units of packed red blood cells. Results A total of 460 patients were included in the study. Of these, 231 received enoxaparin and 229 received UFH. In the unadjusted analysis, there was no difference in major bleeding events observed with enoxaparin compared to UFH (29.4% vs. 22.3%; p = 0.08) or rates of venous thromboembolism (4.3% vs. 3.5%; p = 0.64), respectively. After adjusting for confounding factors, enoxaparin showed a significant increase in major bleeding (OR: 1.84; 95% CI: 1.11 – 3.04; p = 0.02). Conclusion Thromboprophylaxis with enoxaparin in critically ill patients with renal impairment was associated with an increased risk of major bleeding compared to UFH.

Risk of bleeding with factor Xa inhibitors versus unfractionated heparin in patients with acute kidney injury

“…A single‐center retrospective study evaluating enoxaparin versus UFH for VTE prophylaxis in critically ill patients with impaired renal function noted that the use of enoxaparin was associated with an increased risk of major bleeding compared with UFH. It should be noted, however, that this study included patients with AKI, severely decreased renal function, and ESRD 9 . A recent study evaluating bleeding events in hospitalized patients receiving apixaban found no difference in the rate of major bleeding events between patients with and without AKI, although the study may have been underpowered.…”

“…Baseline patient characteristics are represented in Table 1. The median hospital length of stay was 6 [3-9.5] versus 8 [5][6][7][8][9][10][11][12][13][14] days in the factor Xa inhibitor group compared with the UFH group, respectively (p < 0.001). Chronic kidney disease was common, present in 50.8% of factor Xa inhibitor patients and 43.6% of UFH patients.…”

“…It should be noted, however, that this study included patients with AKI, severely decreased renal function, and ESRD. 9 A recent study evaluating bleeding events in hospitalized patients receiving apixaban found no difference in the rate of major bleeding events between patients with and without AKI, although the study may have been underpowered. The absolute rates of major bleeding were 7.8% in the AKI group versus 3.4% in patients without AKI (p = 0.15).…”

Indian Society of Critical Care Medicine Consensus Statement for Prevention of Venous Thromboembolism in the Critical Care Unit

“…In a retrospective, single-center, cohort study including 460 ICU patients with renal impairment, DVT prophylaxis was administered with either enoxaparin or UFH, it was found that use of enoxaparin for thromboprophylaxis in renally impaired critically ill patients, was associated with an increase in major bleeding events compared to UFH. 76 …”

The Impact of Continuous Veno-Venous Hemodiafiltration on the Efficacy of Administration of Prophylactic Doses of Enoxaparin: A Prospective Observational Study

“…Current pharmacological thromboprophylaxis in the ICU setting is based on either unfractionated heparin (UFH) or low-molecular-weight heparins (LMWHs). Extensive studies have shown that LMWHs are as effective as UFH in reducing the incidence of thrombotic complications in critically ill patients, but carry less risk of bleeding, and heparin-induced thrombocytopenia (HIT) than UFH [ 5 ]; therefore, LMWHs are more readily used anticoagulant agents in the ICU population. Enoxaparin, dalteparin, and tinzaparin are widely used LMWH agents [ 6 ].…”