ORLANDO, FL USA (UroToday.com) - As the urologic community works to embrace wide-spread and regular use of perioperative chemical venous thromboembolism (VTE) prophylaxis for inpatients, emerging data reveal that a large proportion of symptomatic VTE events after abdominal and pelvic cancer surgery occur following hospital discharge.
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Recent guidelines (NCCN, NICE, NHMRC) by a number of leading national and international organizations have recommended extended pharmacological venous thromboembolism prophylaxis (EPVTEP) following radical cystectomy (RC), for 4 weeks. However, experience with this strategy in RC patients is largely lacking. Importantly, low molecular weight heparin (LMWH) is renally cleared, and patients with renal deterioration risk bioaccumulation and the potential for hemorrhagic complications. Whereas RC patients often experience dehydration and secondary renal insufficiency following hospital discharge, authors thought to quantitate the risk of clinically significant renal function deterioration following RC, which could result in supratherapeutic levels of LMWH and an increased risk of bleeding events.
Patients who underwent RC between 2006 and 2011 were identified from the institutional registry. Estimated glomerular filtration rate (eGFR) was calculated and categorized as preoperative, discharge, and nadir. Perioperative eGFR trends in patients who would have been candidates for EPVTEP were evaluated. A total of 304 patients with eGFR > 30 ml/min/1.73m2 at the time of hospital discharge were included in the analysis as potentially eligible for EPVTEP. The majority of patients were Caucasian (90%) and male (73%), with a median age of 69 years (IQR: 61-76). The readmission rate for the entire cohort was 32%. Nearly half of the patients (43%) exhibited a decline in eGFR following discharge. Importantly, 13.0% of patients (n=40/304), who would have qualified for EPVTEP at discharge, experienced a nadir eGRF below the 30 ml/min/1.73m2 threshold where LMWH would have become supratherapeutic. The odds ratio for developing an eGFR < 30 mL/min/1.73m2 was 9.1 (95% CI 4.3-19.3, p < 0.001), when comparing those with a discharge GFR ≥ 60 mL/min/1.73m2 to those with a discharge GFR < 60 mL/min/1.73m2.
The conclusion from this study is that nearly half of the patients (43%) undergoing RC experience an eGFR decline following discharge. In those who would have been candidates for EPVTEP, over 10% experienced an eGFR which would have rendered LMWH supratherapeutic and potentially would have placed the patient at risk for clinically significant bleeding. While post-operative VTE following RC is a recognized concern, a better understanding of risks of EPVTEP is needed before this strategy is universally adopted in patients undergoing RC. Until these risks are better delineated, we propose that EPVTEP be reserved for patients with discharge eGFR > 60 ml/min/1.73m2.
Click HERE to view the poster from this session
Click HERE to listen to Reza Mehrazin, MD, one of the authors of this study
Presented by Reza Mehrazin, MD at the American Urological Association (AUA) Annual Meeting - May 16 - 21, 2014 - Orlando, Florida USA
Fox Chase Cancer Center, Philadelphia, PA USA
Written by Reza Mehrazin, MD, medical writer for UroToday.com