Development of best practice statements for anticoagulation in advanced kidney disease using the modified Delphi method

BACKGROUND: Patients with advanced kidney disease (estimated glomerular filtration rate [eGFR] < 30 mL/min/1.73 m2) are known to have an increased risk of venous thromboembolic events and increased likelihood of atrial fibrillation alongside an increased risk of bleeding. People with advanced kidney disease are often excluded from randomised controlled trials (RCTs) of anticoagulants, leaving gaps in the evidence base and practice variation. This study aimed to achieve consensus on anticoagulant use in advanced kidney disease to inform national prescribing guidance. METHODS: A modified Delphi approach was used to achieve consensus on statements relating to anticoagulant use in advanced kidney disease. Three Delphi rounds were predefined, with two rounds of questionnaires followed by online discussion in round three. Panel members included UK experts from the fields of cardiology, nephrology and haematology, who were asked to rate 160 statements with appropriateness and consensus defined by RAND methodology. RESULTS: Twenty-one experts completed rounds one and two of the Delphi. For round three, 11 experts joined a Microsoft Teams discussion. Following round three, there were 72 statements with consensus agreement for inclusion in the guideline, including dose reduction recommendations for therapeutic light molecular weight heparin (LMWH), recommendation for off-label apixaban use in non-valvular atrial fibrillation, and trough anti-Xa level monitoring with therapeutic LMWH. Forty-two statements with consensus disagreement for exclusion and 27 with unequivocal consensus. These statements could be used to develop research recommendations. CONCLUSION: This study has led to consensus agreement on a number of statements relating to anticoagulant use in advanced kidney disease in the UK that can be used in national guidance.