Abstract 10113: Improving Safety of Direct Oral Anticoagulant Dosing in Patients with Advanced Chronic and End-Stage Renal Disease

Introduction: Direct oral anticoagulants have become a mainstay in therapy for venous thromboembolism as well as mitigation of stroke and systemic embolism risk in atrial fibrillation. Although guidelines have been put forth for dose reduction in renal impairment, significant inconsistency in dosing practices exists. No study has directly evaluated the dosing practice of apixaban and rivaroxaban in those with advanced chronic kidney disease (stage 4 and 5) and end-stage renal disease at a quaternary care institution. Methods: We screened 853 patients from 1/1/2017 to 3/21/2020 with advanced chronic kidney disease and end-stage renal disease and identified 312 patients on either apixaban or rivaroxaban. Clinical data collected include anticoagulation indication, dosing, serum creatinine, age, weight, and creatinine clearance (calculated by the Cockcroft-Gault equation). Results: A total of 312 patients were studied (268 apixaban, 44 rivaroxaban). Among all patients with advanced chronic kidney disease and end-stage renal disease, a total of 123 patients (46%) were incorrectly dosed with apixaban compared to 17 patients (38%) with rivaroxaban. Among those with advanced chronic kidney disease, 57 patients (41%) were dosed incorrectly with apixaban compared to 10 patients (27%) with rivaroxaban. Among those with end-stage renal disease, 66 patients (50%) were dosed incorrectly with apixaban. (Figure 1). Conclusion: We demonstrate that there is significant variance in the dosing practice of direct oral anticoagulants among patients with advanced chronic kidney disease and end-stage renal disease. We hope to develop a checklist within the electronic medical record to promote adherence to guidelines when determining whether a patient requires dose reduction in the setting of renal dysfunction. Further investigation is being carried out to determine differences in outcomes among those properly dosed and those incorrectly dosed.