Safety and Efficacy of Therapeutic Anticoagulation with Subcutaneous Unfractionated Heparin in Patients with Renal Failure

Therapeutic anticoagulation poses a significant challenge in patients with renal failure, particularly those with more advanced disease requiring renal replacement therapy. Although there are several therapeutic options, it is still unclear which is the safest and most effective, as available evidence is heterogeneous.[1] [2] Patients with renal impairment are at increased risk of both bleeding and thrombosis; hence, anticoagulation is often associated with unfavorable patient outcomes. A recent review focusing on patients with renal failure and pulmonary embolism (PE) showed an overall mortality rate of 30% in individuals with an estimated glomerular filtration rate (eGFR) <30 mL/min, compared with 10% in those with normal eGFR.[3] In a comprehensive multicenter cohort study evaluating the validity of bleeding scores in PE patients, an eGFR below 60 mL/min emerged as a predictor of early major bleeding in multivariate analysis.[4] Of the included patients, over half were treated with low-molecular-weight heparin (LMWH), whereas the remaining group was divided equally between unfractionated heparin (UFH) and direct oral anticoagulation (DOAC). A minority of patients received thrombolysis or invasive clot retrieval. Another study, involving 2,784 cases, examined the prognostic significance of renal function in acute PE, revealing a higher prevalence of bleeding within 30 days in patients with impaired renal function (8%) compared with those without (5%). Of these bleeding events 1.1% were fatal bleeding in patients with eGFR <30 mL/min compared with 0.3% without renal impairment.[5]