D-dimer to rule out pulmonary embolism in renal insufficiency

Am J Med. 2014 Apr;127(4):343-7. doi: 10.1016/j.amjmed.2013.12.003. Epub 2013 Dec 16.

Abstract

Background: D-dimer levels are often elevated in renal insufficiency. The diagnostic accuracy of D-dimer to rule out pulmonary embolism in patients with renal insufficiency is unclear.

Methods: We evaluated the data of patients presenting to our Emergency Department and receiving computed tomography angiography to rule out pulmonary embolism with measurement of D-dimer and creatinine. Glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration formula.

Results: There were 1305 patients included; 1067 (82%) had an estimated glomerular filtration rate (eGFR) exceeding 60 mL/min, 209 (16%) 30-60 mL/min, and 29 (2%) <30 mL/min. One hundred fifty-two patients (12%) had D-dimer below 500 μg/L. eGFR (R = -0.1122) correlated significantly with D-dimer (P <.0001). One hundred sixty-nine patients (13%) were found to have pulmonary embolism. Sensitivity of D-dimer for patients with an eGFR >60 mL/min was 96% (confidence interval [CI], 0.93-0.99) and 100% (CI, 100-100) for those with 30-60 mL/min, while specificity decreased significantly with impaired renal function. Area under the curve of the receiver operating characteristic for D-dimer was 0.734 in patients with an eGFR of >60 mL/min, and 0.673 for 30-60 mL/min.

Conclusions: D-dimer levels were elevated in patients with an eGFR <60 mL/min, but proved to be highly sensitive for the exclusion of pulmonary embolism. However, because almost all patients with impaired renal function had elevated D-dimer irrespective of the presence of pulmonary embolism, studies should be performed to determine renal function-adjusted D-dimer cutoffs.

Keywords: CT angiography; D-dimer; Emergency; Pulmonary embolism; Renal insufficiency.

MeSH terms

  • Aged
  • Female
  • Fibrin Fibrinogen Degradation Products / analysis*
  • Humans
  • Male
  • Middle Aged
  • Pulmonary Embolism / blood*
  • Pulmonary Embolism / diagnosis*
  • Pulmonary Embolism / etiology
  • Renal Insufficiency / complications
  • Retrospective Studies

Substances

  • Fibrin Fibrinogen Degradation Products
  • fibrin fragment D