MP559BRIDGING ANTICOAGULATION IN CKD PATIENTS IN THE COMMUNITY: WALKING THROUGH THE FOG. A PRACTICAL APPROACH

Abstract

Introduction and Aims: Chronic oral anticoagulation frequently requires interruption for various reasons . Whether or not to bridge with heparin is a common clinical dilemma. The evidence to inform decision making is limited . The dilemma is more with patients with advanced kidney impairment as impaired kidney function is associated with increased risks of stroke and of bleeding associated with the use of anticoagulation . Aim : To develop and implement a practical bridging algorithm for advanced CKD patients, easy and safe to be applied in the community. Methods: In January 2015 a suggested bridging algorithm launched in the quality and safety meeting of the renal department at University Hospital of Wales. This algorithm based on an audit in which all patients were bridged in hospital and with unfractionated heparin. We started to apply this algorithm for patients in the community using LMWH in the period betweenMay and December 2015. This necessitated adding more details and some modifications to the algorithm to be more practical . Results: We bridged our first eleven cases as a pilot group. Nine patients were on HDF in satellite units and two pre- dialysis patients . All are on long term anticoagulation with warfarin, six with AF, two PE , one AF and TIA , one DVT and one CVA . Five of them bridged for permecath removal, five for AVF formation and one for fistuloplasty. The principles of the algorithm are as follows: First : Descicion making: based on risk stratification for thrombosis (low, moderate and high risk) and risk of bleeding due to the procedure. CHADS2 score used to stratify AF patients while the criteria adopted by American Cardiology College of Physicians (ACCP) used to stratify VTE patients. Patients with metallic heart valves and patients who have a high risk for significant bleeding postoperatively were excluded from outpatient bridging. As AF patients' CHADS2 scores were above 2 and VTE patients' were less than 12 months , all were for eligible for bridging. Second : Essential Communications : vascular access nurses arranged dates and booked procedures , communicated with district nurses, dialysis unit staff and patients to provide all the informations. For proper communication information sheets designed to be sent to district nurses and patients including INR request for the day before the procedure. Sheets included contact details for relevant staff. Third: LMWH(enoxaparin) prescribed at a therapeutic dose 1mg/kg/day to be given SC. SC route was selected as enoxaparin is dialyzable by HDF. Dialysis units informed to give the dose on Dialysis days while district nurses in the non dialysis days. Diabetic & PE patients self administered LMWH. Doses ranged between 60 -80 mg /day for 6-8 days . No bleeding events or prolonged post dialysis bleeding recorded. Fourth: Warfarin stopped 5 days before procedures, INR checked and therapeutic LMWHcontinued till the day before the procedure. INR rechecked the day before the procedure. Fifth: No LMWHthe morning of the procedure. In high risk patients prophylactic LMWH administered 8-12 hours after procedure. Warfarin started in the evening and therapeutic LMWHrestarted the next morning . Sixth : Stop LMWH when INR is therapeutic. The average number of days to complete bridging was eight days. We saved about eighty eight days of hospital bed occupancy. This enabled beds for other patients. This saved about £ 15,400 (provided that cost of bed per day is £175). Conclusions: Bridgning can be implemented safely in outpatient cirumstances. It needs proper case selection with good risk evaluation and proper communication with all the health personnel involved in this patient care.