Abstract
IntroductionIntensive care participants that need dialysis frequently suffer from increased risk of bleeding. Standard intermittent haemodialysis (SHD) includes anticoagulation to avoid clotting of the dialysis system. The aim of this study was to clarify which of four different low-dose anticoagulant modes was preferable in reducing the exposure to i.v. unfractionated heparin (heparin) and maintaining patency of the dialysis circuit.MethodsTwenty-three patients on SHD were included to perform haemodialysis with four modes of low-dose anticoagulation. For comparative analyses, patients served as their own control. Haemodialysis with a single bolus of tinzaparin at the start was compared to haemodialysis initiated without i.v. heparin but priming with (1) heparin in saline (H), (2) heparin and albumin in saline (HA), (3) heparin and albumin in combination with a citrate-containing dialysate (HAC), (4) saline and usinga heparin-coated filters (Evodial®). The priming fluid was discarded before dialysis started. Blood samples were collected at 0, 30 and 180 min during haemodialysis. Smaller bolus doses of heparin (500 Units/dose) were allowed during the modes to avoid interruption by clotting.FindingsThe mean activated partial thromboplastin (APTT) time as well as the doses of anticoagulation administered was highest with SHD and least with HAC and Evodial®. Mode H versus SHD had the highest rate of prematurely interrupted dialyses (33%, p = 0.008). The urea reduction rate was less with Evodial® vs. SHD (p < 0.01). One hypersensitivity reaction occurred with Evodial®. Changes in blood cell concentrations and triglycerides differed between the modes.DiscussionIf intermittent haemodialysis is necessary in patients at risk of bleeding, anticoagulation using HAC and Evodial® appeared most preferable with least administration of heparin, lowest APTT increase and lowest risk for prematurely clotted dialyzers in contrast to the least plausible H mode.
Highlights
Intensive care participants that need dialysis frequently suffer from increased risk of bleeding
The aim of this study was to clarify to what extent four different low-dose anticoagulant modes, versus standard haemodialysis, could reduce the administration of heparin while enabling dialysis
Regional citrate anticoagulation requires frequent monitoring and substitution of calcium and careful and frequent surveillance to avoid hyper- or hypocalcaemia [19].this technique so far is considered unsuitable for intermittent haemodialysis in untrained hands [8].other options may be considered for intermittent haemodialysis in patients at risk of bleeding
Summary
Intensive care participants that need dialysis frequently suffer from increased risk of bleeding. Standard intermittent haemodialysis (SHD) includes anticoagulation to avoid clotting of the dialysis system. Methods Twenty-three patients on SHD were included to perform haemodialysis with four modes of low-dose anticoagulation. In patients at risk of bleeding, while needing haemodialysis, one option is to use intravenous regional citrate infusion. This technique is so far only commercially available for continuous veno-venous haemodialysis (CVVHD) used in intensive care units and needs narrow clinical and laboratory surveillance. Except for a few centres with developed methods of narrow surveillance [4, 6, 10, 11], regional citrate anticoagulation (RCA) is considered unsuitable for intermittent haemodialysis due to the need of extensive surveillance, to avoid risk of hypo- or hypercalcaemia. Other options may be considered for intermittent haemodialysis in patients at risk of bleeding
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