Original Investigation
Pathogenesis and Treatment of Kidney Disease
Venous Thromboembolism in Patients With Reduced Estimated GFR: A Population-Based Perspective

https://doi.org/10.1053/j.ajkd.2011.06.021Get rights and content

Background

An increased frequency of venous thromboembolism (VTE) has been shown in patients with decreased kidney function measured by decreased estimated glomerular filtration rate (eGFR). However, present practices with respect to VTE prevention and management in patients with decreased eGFR in general population settings are uncertain.

Study Design

Observational study.

Setting & Participants

Community investigation of 1,509 metropolitan Worcester, MA, residents with a validated VTE in 1999, 2001, and 2003 with further follow-up for up to 3 years.

Predictor

Patients with VTE classified further according to eGFR on presentation: <30, 30-59, 60-89, or ≥90 mL/min/1.73 m2 (reference group).

Outcomes

Recurrent VTE, major bleeding episodes, and all-cause mortality.

Measurements

Demographic and clinical characteristics, treatment practices, and study outcomes were extracted from patients' hospital and outpatient medical records; eGFR was estimated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation.

Results

Patients with VTE with eGFR <30 mL/min/1.73 m2 were at increased risk of recurrent VTE (HR, 1.83; 95% CI, 1.03-3.25), major bleeding episodes (HR, 2.30; 95% CI, 1.28-4.16), and all-cause mortality (HR, 1.70; 95% CI, 1.12-2.57) during a 3-year follow-up. Patients with decreased eGFR also presented with more comorbid conditions and were less likely to be discharged on any form of anticoagulant therapy (72.6%, 81.0%, 82.1%, and 87.3% for eGFR <30, 30-59, 60-89, and ≥90 mL/min/1.73 m2, respectively; P < 0.001).

Limitations

Decreased eGFR status is presumed based on creatinine values on clinical presentation. The impact of drug dosage, timing, type of anticoagulant therapy, and medication adherence on study outcomes could not be evaluated.

Conclusions

Severe decreases in eGFR are associated with increased risk of long-term recurrent VTE, bleeding, and total mortality in patients with VTE. A greater frequency of serious comorbid conditions, difficulties implementing available management strategies, and suboptimal VTE prophylaxis during hospital admissions likely contributed to our findings.

Section snippets

Study Design, Sampling, and Data Abstraction

The Worcester Venous Thromboembolism Study is an ongoing population-based surveillance study examining the descriptive epidemiology of VTE, including its magnitude, prophylaxis, and management strategies; in-hospital and post-discharge outcomes; and long-term recurrence, bleeding, and all-cause mortality rates, in residents from a large central New England metropolitan area.1, 2, 14 The catchment area for this study included all 12 hospitals serving residents of the Worcester, MA, standard

Demographic and Clinical Characteristics

Of 1,509 patients with confirmed VTE, 122 had eGFR <30 mL/min/1.73 m2, 432 had eGFR of 30-59 mL/min/1.73 m2, 575 had eGFR of 60-89 mL/min/1.73 m2, and the rest (n = 380) had eGFR ≥90 mL/min/1.73 m2. The prevalence of decreased eGFR (<60 mL/min/1.73 m2) in our total study sample essentially was similar across the 3 study years; 37.7% of patients had decreased eGFR in 1999; 36.8%, in 2001; and 35.7%, in 2003 (P = 0.8). At initial VTE presentation, deep vein thrombosis was most common in patients

Discussion

The incidence and prevalence of kidney disease have nearly doubled during the past decade, presently affecting more than 20 million Americans.18, 19, 20 Given the increasing magnitude of this disease, the frequency with which these patients are hospitalized, and increased bleeding risk associated with most anticoagulants, better understanding of the clinical profile, current management, and outcomes of patients with decreased kidney function who are at risk of and/or develop VTE is needed.

In

Acknowledgements

Support: This research study is supported by a grant from the National Heart, Lung, and Blood Institute (R01-HL70283). Dr Spencer is supported by a Career Investigator Award from the Heart and Stroke Foundation of Ontario.

Financial Disclosure: The authors declare that they have no relevant financial interests.

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    Originally published online August 29, 2011.

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