I work in an anticoagulation clinic and have observed that end-stage renal disease (ESRD) patients on dialysis have labile international normalized ratios (INR) while on warfarin. Is there a strategy to help ensure that patients receiving hemo- or peritoneal dialysis maintain therapeutic anticoagulation while on warfarin therapy for deep venous thrombosis (DVT) or hypercoagulable states? Are there recommendations for enoxaparin (Lovenox) with this patient population?—RONNIE GLADDEN, FNP, Decatur, Ga.

The question concerning the enoxaparin bridge is interesting. Enoxaparin should not be used with dialysis patients because it cannot be monitored. A nephrologist told me that this topic is on the cutting edge of current trials, as it appears that warfarin increases mortality of dialysis patients. However, until this is proven, you can use heparin if the control has become difficult and the patient’s CHADS2 score is >2.—Maria Kidner, DNP, FNP-BC (143-2)

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