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Anticoagulants in Children with Renal Impairment: A Narrative Review
Amy L Kiskaddon1,2,3,4,5, Daniel M Witt6, Marisol Betensky2,7
1Division of Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Insights
Managing anticoagulation in children with kidney disease requires careful consideration of drug pharmacokinetics due to renal elimination. Limited evidence exists for pediatric dose adjustments of many anticoagulant medications.
Area of Science:
- Pediatric Nephrology
- Pharmacology
- Hematology
Background:
- Venous thromboembolism (VTE) is a significant cause of illness and death in children with kidney disease.
- Effective VTE treatment and prevention necessitate understanding various anticoagulant agents.
- Many anticoagulants are renally eliminated, requiring careful management in patients with impaired kidney function.
Purpose of the Study:
- To review the pharmacokinetics of key anticoagulants in pediatric patients with renal impairment.
- To highlight challenges in selecting, dosing, and monitoring anticoagulants in this population.
- To address the limited evidence for pediatric renal dose adjustments.
Main Methods:
- Review of pharmacokinetic data for specific anticoagulants in children with renal dysfunction.
- Analysis of factors influencing anticoagulant selection, dosing, and monitoring.
- Examination of existing literature on renal dose adjustments in pediatric patients.
Main Results:
- Pharmacokinetic alterations in children with renal impairment impact anticoagulant efficacy and safety.
- Limited pediatric-specific data exists for many anticoagulants, complicating dose adjustments.
- Individualized approaches are necessary due to variable renal impairment and bleeding risks.
Conclusions:
- Anticoagulation management in pediatric renal impairment is complex due to pharmacokinetic changes and data limitations.
- Further research is needed to establish evidence-based guidelines for pediatric anticoagulant dosing in renal disease.
- Clinicians must carefully weigh bleeding risks and renal function for each child.
Abstract:
Venous thromboembolism is a common cause of morbidity and mortality in children with renal disease. To properly treat and prevent thromboembolism in this patient population, it is important to be familiar with the multitude of anticoagulant agents currently available. Many anticoagulant drugs undergo some extent of renal elimination. There are important considerations for the selection, dosing, and monitoring of anticoagulant drugs for patients with renal impairment due to various pharmacokinetic alterations that may occur. While there are data to help guide dosing and monitoring in adults, evidence regarding renal dose adjustment of many anticoagulant drugs in children are limited. For the clinician, anticoagulation management in children with renal impairment presents unique challenges. In addition to considering overall bleeding risk, the extent of renal impairment may vary by patient, making a one-size-fits-all approach to managing these patients difficult. These factors, combined with limited data, can make managing anticoagulation in children with renal impairment a challenge. Therefore, the focus of this review will be to describe the pharmacokinetics of the following anticoagulants in children with impaired renal function: unfractionated heparin, enoxaparin, dalteparin, rivaroxaban, apixaban, edoxaban, fondaparinux, bivalirudin, argatroban, dabigatran, and warfarin.
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