Autopsy reports indicated low incidence of venous thromboembolism (VTE) in end stage renal disease (ESRD) compared to the general population. ESRD associated platelet dysfunction and bleeding propensity are cited as reasons ESRD patients are not at risk for VTE, and, therefore not candidates for VTE prophylaxis. Recent reports suggest VTE is more common in ESRD than previously thought, and ESRD patients who develop VTE have risk factors similar to the general population. Guidelines for prevention of VTE do not address ESRD. The purpose of this study was to identify risk of VTE and prophylaxis patterns for ESRD patients admitted through the Emergency Department (ED).
We reviewed medical records for admissions through the ED in an urban, teaching hospital for one month in 2003 as part of a study of ED utilization of VTE prophylaxis. Inclusion criteria were a diagnosis of ESRD and a minimum length of stay of two days. ESRD VTE risk was stratified based on a modified Caprini Risk Assessment tool. Patients with moderate to high risk were considered in need of VTE prophylaxis. Appropriate prophylaxis was considered as medical (heparin or low molecular weight heparin) or mechanical prophylaxis. Patients with an admission international normalized ratio (INR) of 1.3 or greater or platelet count less than 100,000 were assessed as not requiring additional VTE prophylaxis.
Thirty of 414 patients met inclusion criteria. Twenty of the 30 patients (67%) were at moderate or higher risk for VTE and considered in need of VTE prophylaxis; 30% of these patients were actively prophylaxed (Table 1Table 1:
Rate of ProphylaxisPatientsPercentAppropriate Decisions Made Regarding VTE Prophylaxis16/3053%Indications for Prophylaxis20/3067%Required Active VTE Prophylaxis and Received it.6/2030%). High risk was associated with a lower probability of appropriate prophylaxis (p<0.04) (Table 2Table 2:
Prophylaxis by Risk LevelRisk LevelNumber Appropriately Prophylaxed*Required Active Prophylaxis and Received it.Low –Moderate Risk8/10 (80%)0/2 (0%)High –Very High Risk8/20 (40%)6/18 (33%)*
Includes patients that did not require prophylaxis and did not receive it, and patients requiring prophylaxis who received it.
20 of 30 patients had indications for PX (6/20 or 30% received PX). Higher risk was associated with a lower robability of appropriate PX, p<0.04.).
The 30% rate of VTE prophylaxis in the ESRD group appears consistent with general ED admissions. Lower risk appropriately received non-treatment, whereas treatment is neglected in high risk ESRD patients.
ESRD patients have multiple risk factors for VTE. Future research needs to establish true risk and develop ESRD VTE prophylaxis guidelines.
G.W. Hergenroeder, None.