Patients with CKD may have a greater susceptibility to thromboembolism: Nephrotic range proteinuria can cause renal losses of anticoagulant factors (Antithrombin III) that lead to a thrombophilic state.
Patients with advanced CKD have an increased bleeding risk from surgical procedures as well as spontaneous GI bleeding. Additionally, uremic-related toxin exposure can lead to platelet dysfunction.
General Recommendations for Peri-Procedural Warfarin Management
Given this combination of bleeding disorders and a propensity to thrombosis that is unique in the CKD patient, decisions about anticoagulation that have a favorable risk-benefit profile in the general population may not be applicable to the patient with advanced CKD.
UFH is the parenteral anticoagulant of choice because it has a short half-life, no dose adjustment is necessary and it is easily reversible.
Fractionated low-molecular-weight heparin (LMWH), should be avoided or dose adjusted in patients with a CrCL below 30 mL/min. Monitoring of factor Xa activity has been suggested to prevent potential drug accumulation.
Warfarin should be held 3-7 days prior to most nephrology procedures.
Where bridging is indicated, recommendation is to use conventional UFH, titrated to the measured partial thromboplastin time (pTT) in hospitalized patients requiring an alternative to warfarin anticoagulation.