Trough anti-Xa activity after intermediate dose nadroparin for thrombosis prophylaxis in critically ill patients with COVID-19 and acute kidney injury.

Our objective was to assess the incidence of drug bioaccumulation in critically ill COVID-19 patients with AKI receiving intermediate dose nadroparin for thrombosis prophylaxis. We conducted a Prospective cohort study of critically ill COVID-19 patients. In patients on intermediate dose nadroparin (5700 IU once daily) we assessed the incidence of bioaccumulation (trough anti-Xa level > 0.2 IU/mL) stratified according to presence of AKI. We quantified this association using multilevel analyses. To assess robustness of our observations, we explored the association between AKI and anti-Xa activity in patients receiving high dose nadroparin (> 5700 IU). 108 patients received intermediate dose nadroparin, of whom 24 had AKI during 36 anti-Xa measurements. One patient with AKI (4.2% [95%CI 0.1-21%]) and 1 without (1.2% [95%CI 0.03-6.5%]) developed bioaccumulation (p = 0.39). Development of AKI was associated with a mean increase of 0.04 (95%CI 0.02-0.05) IU/ml anti-Xa activity. There was no statistically significant association between anti-Xa activity and AKI in 51 patients on high dose nadroparin. There were four major bleeding events, all in patients on high dose nadroparin. In conclusion, Bioaccumulation of an intermediate dose nadroparin did not occur to a significant extent in critically ill patients with COVID-19 complicated by AKI. Dose adjustment in AKI may be unnecessary.

Impact of COVID-19 pandemic on the quality and performance of haemostasis laboratories

Background : The high incidence of thrombotic events in patients with COVID-19 affects healthcare worldwide and results in an increased workload in haemostasis laboratories. Especially D-dimer, haemostatic parameters and anti-Xa tests are expected to be analysed more frequently. However, the impact of this increase in assay requests on the quality of performance in haemostasis laboratories remains unclear. Aims : To evaluate the impact of the COVID-19 pandemic on the quality performance and management of haemostasis laboratories. Methods : The impact on the quality of performance was studied using external quality assessment (EQA) data from 2019 and 2020 derived from ECAT surveys. A questionnaire was sent to Dutch haemostasis laboratories to identify challenges and management strategies during the COVID-19 pandemic with focus on D-dimer, anti-Xa, factor VIII and fibrinogen. Furthermore, the number of assays performed in 2019 and 2020 was collected from four Dutch hospitals, located in regions with different disease incidence. Results : No differences in response rate nor the quality of the measurements were observed between the EQA surveys in 2019 and 2020 (Table 1). Fifty-five percent of the laboratories observed a more than 25% increase in test requests for anti-Xa and D-dimer assays in 2020 compared to 2019. Twenty-seven percent also experienced this increase in requested fibrinogen assays. Additionally, 84% of the respondents indicated to experience increased work pressure and increased absenteeism in 71% of the participating laboratories was observed. Evaluation of the number of assays performed over the year showed extreme peaks in anti-Xa assays (144 -772%) in all four hospitals and D-dimer assays (368%, 670%) in the two hospitals that are located in areas with high disease incidence. Conclusions : The enormous increase in work pressure and test requests, especially for D-dimer assays and anti-Xa activity, did not affect the quality of performance within haemostatic laboratories during the COVID-19 pandemic.