O90
Major Bleeding in Incident Hemodialysis Patients: A single centre study
Suzanne Forbes, Neil Ashman
Department of Nephrology and Transplantation, Royal London Hospital, London
Background:
ESRD is associated with increased risk of bleeding related to uraemia, platelet
dysfunction, hypergastrinaemia, and potentially anticoagulation and the dialysis
process. In prevalent haemodialysis (HD) patients in our centre (publication pending),
major bleeding occurs in 1.33 per patient years at risk (comparable to North American
data at 2.5%). However all published analyses looking at bleeding risk in dialysis
patients exclude incident (<90days) patients. Intuitively the risk of bleeding at this
time would be greatest and an understanding of the early risk of bleeding associated
with HD would aid us in decisions regarding dialysis anticoagulation and the use of
antiplatelet agents. We set out to report bleeding rates over this early period.
Methods:
We performed an observational retrospective single centre study of all HD new
starters of any cause over a 74 month period up until March 2013. Those dialysing for
<1week, those having HD for delayed graft function or new transfers already
established on HD were excluded. Bleeding was defined as ‘major’ using
International Society of Thrombosis and Haemostasis criteria, or as any bleed
requiring admission. Minor bleeds were also captured.
Results:
1540 patients in total were analysed. The majority of these dialysed for a minimum of
90 days. In total 364 patient-at-risk years were studied. All patients were
anticoagulated on HD with the low-molecular weight heparin, tinzaparin. The median
age was 57 with a pre-HD eGFR of 6.52ml/min/1.73m2. 973 were male and 517 were
diabetic. Starting access was a catheter in 1256 patients and 699 were on at least one
antiplatelet agent.
Within the first 90 days of HD there were 188 bleeding events reported in 177
patients. Of these 95 were major, 2 fatal. The average age of patients with a bleed was
57. 161 of them had a catheter, 59 were on antiplatelet agents and 82 were unknown
to our service prior to first HD.
Thus the rate for major bleeding in incident patients within 90 days of starting HD
was calculated at 15.9 per at-risk patient year. If the need for hospital admission is
also included in the definition of ‘major’ this rate rises to 26.1. And grouping together
all major and minor bleeds in this population yields an incident rate per at-risk patient
year of 51.4.
Conclusion:
We have previously shown prevalent bleeding rates in our unit to be similar to that
reported elsewhere. In comparison with this prevalent rate, we now show early
bleeding risk to be significantly higher. This data should prompt increased caution
with regards the use of antiplatelets and aid prescription of anticoagulant therapy
during dialysis at this time. Furthermore this data forms a proposal to examine
registry-wide incident bleeding across the UK.