Heparin Dose Adjustment in The Prescence of Renal Impairment
Heparin Dose Adjustment in The Prescence of Renal Impairment
Heparin Dose Adjustment in The Prescence of Renal Impairment
Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient
characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased
susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.
If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good
practice to record these and communicate them to others involved in the care of the patient.
Version Number: 5
Does this version include
Yes
changes to clinical advice:
Date Approved: 8th July 2020
Important Note:
The Intranet version of this document is the only version that is maintained.
Any printed copies should therefore be viewed as ‘Uncontrolled’ and as such, may not necessarily contain the
latest updates and amendments.
CLINICAL GUIDELINE
Important Note:
The Intranet version of this document is the only version that is maintained.
Any printed copies should therefore be viewed as ‘Uncontrolled’ and as such, may not necessarily contain
the latest updates and amendments.
Heparin and heparin-like anticoagulants (unfractionated heparin (UFH), low molecular weight heparins (LMWH) and
the pentasaccharide, fondaparinux) vary considerably in their glycosaminoglycan composition, specifically their
average chain size (UFH > LMWH > fondaparinux). Even within the LMWH group there can be subtle differences in
average chain size (tinzaparin > dalteparin > enoxaparin). These differences have important effects both on the
antithrombin-mediated target specificity and dependence on renal clearance – smaller heparins having a higher
anti-factor Xa: anti-factor IIa ratio and a greater dependence on renal clearance. The latter is very relevant when
prescribing these agents, either at prophylactic or therapeutic doses, for patients with substantially reduced kidney
function (CrCl<30mL/min) as observational data demonstrate clinically important increase in bleeding complications
of anticoagulation in this group of patients. For this reason, in-patients in the NHS GGC renal unit with chronic
kidney disease and CrCl <30mL/min do not routinely receive pharmaceutical thromboprophylaxis when admitted for
non-operative reasons unless there are other risk factors for thrombosis.
Within NHS GGC the heparin agent of choice may vary between treatment and prophylaxis and for different
indications – please consult NHS GGC Formulary or Therapeutics Handbook for preferred agent of choice. Based
on relevant SPC guidance and limited additional literature the following recommendations are offered.
There are different concentrations of UFH currently available – only the 1000 units/ml preparation should be used at
all times to reduce the risk of dose errors and serious clinical incidents.
For dose adjustments in adult patients with very low or very high body weight,
refer to GGC guideline on Staffnet – Clinical Guideline Repository
CrCl (ml/min)
GGC CrCl calculator available here
Within NHS GGC the LMWH of choice for use during haemodialysis is subject to regular review. Please seek advice
from renal team before prescribing.
When LMWH is used for haemodialysis anticoagulation, routine monitoring of anti-Xa activity is not required.
Authors: Dr Emily McQuarrie, Cristina Coelho and Kathryn McCormick on behalf of NHS GGC Thrombosis
Committee (with input from Dr Catherine Bagot)
Approved by: Medicines Utilisation Sub-Committee, NHS GGC ADTC
Review date: July 2023