Risk of Renal Failure Shown to Increase After Lytic Therapy for Acute DVT

July 26, 2021—The Society for Vascular Surgery (SVS) announced the publication of findings from a large single-center retrospective study demonstrating that the risk of acute kidney injury (AKI) after pharmacomechanical thrombolysis (PMT) for lower extremity deep vein thrombosis (DVT) is as high as 22%.

Karim M. Salem, MD, et al published the study in Journal of Vascular Surgery: Venous and Lymphatic Disorders (2021;9:868-873).

As noted by SVS, there has been significant clinical success with hemolysis, but it can lead to AKI with unknown longer-term implications. In the study, the investigators aimed to characterize the rate of AKI after PMT and identify those patients at the greatest risk.

“Recent evidence has suggested that catheter-direct therapy (CDT) in the setting of acute iliofemoral DVT improves vein patency and postthrombotic severity with an equivocal risk of bleeding,” commented Dr. Salem in the SVS press release.

Dr. Salem continued, “Catheter thrombolysis can be accomplished by dripping thrombolytic agents through a multiside-hole catheter over several hours or using PMT devices. Plenty of evidence has supported the use of PMT over catheter thrombolysis because PMT can achieve fast lytic therapy at a lower tissue plasminogen activator (tPA) dose. Aggressive PMT, however, can cause hemolysis, which can result in AKI.”

As summarized in the SVS announcement, the study investigators studied the records of 137 patients who underwent PMT for acute iliofemoral DVT between 2007 and 2018 at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania. Patient characteristics include mean age, 47+/-17 years; male, 50%; preoperative creatinine, 0.99 mg/dL. Thirty (22%) of the 137 patients developed postoperative AKI, defined as a creatinine 1.5 times baseline.

The investigators reported that multivariable analysis demonstrated the following three significant risks factors for the development of AKI:

• Bilateral DVT (odds ratio [OR], 4.35; P = .008)
• Single-session PMT (OR, 3.05, P = .046)
• Female sex (OR, 2.85; P = .046)

Of the 30 patients who did develop AKI, two progressed to severe renal failure (glomerular filtration rate < 30 mL/min), and one required long-term hemodialysis.

“Contemporary studies have reported the results of more rapid and aggressive thrombolysis protocols that can be completed in a single session,” stated Dr. Salem. “This approach has been associated with a development of acute renal failure owing to the hemolysis caused by the PMT devices. Our focus was to identify the preoperative factors that might influence our decision to pursue aggressive single-stage intervention versus multistage CDT. With the results of the present study, we avoid single-stage intervention in women with bilateral extensive DVT to minimize the risk of postoperative AKI.”

This study adds significant knowledge to understanding the risks of lytic therapy in patients with iliofemoral DVT, noted SVS in the press release.