Anticoagulation In Hemodialysis Patients Research Articles

Application of simplified regional citrate anticoagulation in hemodialysis patients with high risk of bleeding.

To explore the safety, effectiveness, and dialysis adequacy of simplified regional citrate anticoagulation hemodialysis (SRCA-HD) in hemodialysis patients with high risk of bleeding. From 64 hemodialysis patients, 400 cases of low blood flow (150 mL/min, dialysate flow 300 mL/min) SRCA-HD were retrospectively analyzed and subsequently referred to as the LBF-SRCA group. Then, a prospective cross-over study was performed in 24 hemodialysis patients with normal blood flow (200 mL/min, dialysate flow 500 mL/min) SRCA-HD, which was called the NBF-SRCA group. Citrate was pumped at the artery pipeline, and calcium-containing dialysate (A group: 1.25 mmol/L, B group: 1.5 mmol/L) was used. The differences in laboratory tests, pipeline and dialyzer clotting, adequacy of dialysis, and adverse events of the groups were compared. 1) In the LBF-SRCA study, the correlation between citrate dosage and serum Ca2+ level at 2 hours post-filter during dialysis was negative (r = -0.228, p < 0.05). Compared with the LBF-SRCA and NBF-SRCA-A group, the pump speed of citrate in the NBF-SRCA-B group was the highest, with 355.0 ± 19.5 mL/h, 396.3 ± 11.9 mL/h, and 407.7 ± 13.0 mL/h, respectively, p < 0.001. 2) The serum Ca2+ at 2 and 4 hours post-filter during dialysis in the NBF-SRCA-B group was closer to the physiological level and significantly higher than in the A group, with 0.80 ± 0.06 vs. 0.68 ± 0.12 mmol/L, p < 0.001; 1.03 ± 0.11 vs. 0.93 ± 0.10 mmol/L, p = 0.005, respectively. 3) Both Kt/V of the NBF-SRCA-A (1.17 ± 0.24) and B (1.22 ± 0.23) group were significantly higher than that of the LBF-SRCA group (0.94 ± 0.02), p = 0.024 and p = 0.005, respectively. 4) The efficiency of anticoagulation was higher than 95% LBF-SRCA, NBF-SRCA-A and NBF-SRCA-B groups. The total clotting in the NBF-SRCA-B group (5/24) was significantly higher than that in the A group (3/24), p = 0.005. SRCA is safe, simple, and effective in hemodialysis. The dosage of citrate can be adjusted by monitoring serum Ca2+ at 2 hours post-filter during dialysis. BFR of 200 mL/min, dialysate flow rate of 500 mL/min, and 1.5 mmol/L calcium dialysate are much safer in hemodialysis patients with a high-risk of bleeding.

Late thrombotic complications after SARS-CoV-2 infection in hemodialysis patients.

IntroductionThere is an increased risk of thrombotic complications in patients with COVID‐19. Hemodialysis patients are already at an increased risk for thromboembolic events such as stroke and pulmonary embolism. The aim of our study was to determine the incidence of late thrombotic complications (deep vein thrombosis, pulmonary embolism, stroke, new‐onset vascular access thrombosis) in maintenance hemodialysis patients after recovery from COVID‐19.MethodsWe performed a retrospective cohort study of 200 prevalent hemodialysis patients in our center at the start of the pandemic. We excluded incident patients after the cohort entry date and those who required hemodialysis for acute kidney injury, and excluded patients with less than 1 month follow‐up due to kidney transplantation or death from non‐thrombotic causes.FindingsOne‐hundred and eighty five prevalent hemodialysis patients finally met the inclusion criteria; 37 patients (17.6%) had SARS‐CoV‐2 infection, out of which 10 (27%) died during the acute phase of disease without evidence of thrombotic events. There was an increased risk of thrombotic events in COVID‐19 survivors compared to the non‐infected cohort (18.5% vs. 1.9%, p = 0.002) after a median follow‐up of 7 months. Multivariate regression analysis showed that COVID‐19 infection increased risk for late thrombotic events adjusted for age, sex, hypertension, diabetes, antithrombotic treatment, and previous thrombotic events (Odds Ratio (OR) 26.4, 95% confidence interval 2.5–280.6, p = 0.01). Clinical and laboratory markers did not predict thrombotic events.ConclusionsThere is an increased risk of late thrombotic complications in hemodialysis patients after infection with COVID‐19. Further studies should evaluate the benefit of prolonged prophylactic anticoagulation in hemodialysis patients after recovery from COVID‐19.

MO721THROMBOTIC EVENTS AFTER COVID-19 INFECTION IN HEMODIALYSIS PATIENTS*

Background and AimsThere is an increased risk of thrombotic complications in patients with COVID-19. Hemodialysis patients are already at an increased risk for thromboembolic events such as stroke and pulmonary embolism. The aim of our study was to determine the incidence of late thrombotic complications (deep vein thrombosis, pulmonary embolism, stroke, new-onset vascular access thrombosis) in maintenance hemodialysis patients after recovery from COVID-19.MethodWe performed a retrospective cohort study of 200 prevalent hemodialysis patients in our center at the start of the pandemic. We excluded incident patients after the cohort entry date and those who required hemodialysis for acute kidney injury, and excluded patients with less than 1 month follow-up due to kidney transplantation or death from non-thrombotic causes.Results185 prevalent hemodialysis patients finally met the inclusion criteria; 37 patients (17.6%) had SARS-CoV-2 infection, out of which 10 (27%) died during the acute phase of disease without evidence of thrombotic events. There was an increased risk of thrombotic events in COVID-19 survivors compared to the non-infected cohort (18.5% vs 1.9%, p=0.002) after a median follow-up of 7 months. Stroke incidence was 38.9 episodes/1000 patient-years in patients infected with SARS-CoV-2, compared to an incidence of 2.8 episodes/1000 patient-years in non-infected patients during the follow-up period. The median time from diagnosis of SARS-CoV-2 to the first thrombotic event was 62 days (interquartile range 5-118 days). Survival analysis with Kaplan-Meier curves revealed an increase in the rate of thrombotic events after SARS-CoV-2 compared to non-infected patients (see Figure 1). Mean survival from thrombotic event was 6.1±0.4 months in the COVID-infected group, compared to 6.97±0.04 months in the non-infected group (p<0.001). Multivariate regression analysis showed that COVID-19 infection increased risk for late thrombotic events adjusted for age, sex, hypertension, diabetes, antithrombotic treatment and previous thrombotic events (OR 26.4, 95% CI 2.5-280.6, p=0.01). Clinical and laboratory markers did not predict thrombotic events.MO721 Figure 1:Kaplan-Meier survival curves for freedom from thrombotic events, stratified by COVID-19 infection statusConclusionThere is an increased risk of late thrombotic complications in hemodialysis patients after infection with COVID-19. Further studies should evaluate the benefit of prolonged prophylactic anticoagulation in hemodialysis patients after recovery from COVID-19.

P1119ASSOCIATION OF VARIOUS RISK FACTORS WITH HEMODIALYZER SET CLOT INCIDENCES WHEN USING LOW DOSE UF- HEPARIN OF 400 IU BOLUS AND 400 IU INFUSION IN MAINTENANCE DIALYSIS SESSION : A CASE CONTROL STUDY

Abstract Background and Aims Efforts were made in the past to reduce the use of heparin as anticoagulation to escape from the its Sid effects like Bleeding and HIT among others. We use Low dose UF -heparin use with bolus of 400 IU and 400 IU/hour infusion as an anticoagulation in hemodialysis patients. Set clot incidences were comparable to other studies. The objectives of this study is to see aassociations of different risk factors with hemodialyzer set clot incidences using Low dose heparin Infusion protocol in maintenance haemodialysis session. Method Data were obtained from the outpatient haemodialysis unit at tertiary care Hospital in Karachi, Pakistan. UF-low dose heparin 400 I.U bolus and 400 I.U maintenance infusion protocol were given to all patient. Case to control ratio was approximately 1:4. 300 cases of set clot were taken and 1200 control sessions without set clot outcome were matched for heparin use taken from the dialysis unit. The crude odds ratios (OR’s) and adjusted ORs (aORs) for various risk factors were obtained using conditional logistic regression. Results In a prelimary part of the study the incidence of set clot was 7% (309/4000 sessions) Age, dialysis vintage, hemoglobin level, Blood flow rate and type of anti-platelet therapy were significantly associated to the incidence of set clot. Among patients having age &amp;gt; 40 yrs. the odds of set clot were 2.8 (95% CI= 1.8-4.3) as compare to the patients with age ≤ 40 yrs. The odds of set clot were 0.268(95% CI=0.081-.88) among patients with hemodialysis vintage less than 1 year as compare to those who have more than 1 year. Blood flow rate &amp;lt;350 ml/min have an odds of 1.03(95%CI=0.76-1.40) of set clot incident as compare to BFR&amp;gt;350 ml/min. Those patients with Hemoglobin &amp;lt; 9 gm/dl have odds of set clot of 0.67(95%CI =0.48-0.92) as compare to hemoglobin &amp;gt; 9 gm/dl. Off all patients ,60.36% patients were either on aspirin or clopidogrel while around 9.58% were on combine antiplatelets therapy. The odds of set clot were 4.6 (95% CI =1.9-10.8) among patients on Combine antiplatelet therapy as compare to no antiplatelet therapy. Conclusion Age, low Blood flow rate and combine antiplatelet therapy (aspirin and clopidogrel) are positively associated with set clot accidents in dialysis sessions. Dual anti platelet therapy patients are given in ischemic heart disease patients hence Blood flow pumps are kept at lower speed which can increase the risk of set clot. Lesser duration on Hemodialysis (i.e. less than 1 year) and low hemoglobin levels are protective for incidence of set clot in our study population.

Warfarin anticoagulation in hemodialysis patients with atrial fibrillation: comparison of nephrologist-led and anticoagulation clinic-led management

BackgroundThere is conflicting evidence of benefit versus harm for warfarin anticoagulation in hemodialysis patients with atrial fibrillation. This equipoise may be explained by suboptimal Time in Therapeutic Range (TTR), which correlates well with thromboembolic and bleeding complications. This study aimed to compare nephrologist-led management of warfarin therapy versus that led by specialized anticoagulation clinic.MethodsIn a retrospective cohort of chronic hemodialysis patients from two institutions (Institution A: Nephrologist-led warfarin management, Institution B: Anticoagulation clinic-led warfarin management), we identified patients with atrial fibrillation who were receiving warfarin for thromboembolic prophylaxis. Mean TTRs, proportion of patients achieving TTR ≥ 60%, and frequency of INR testing were compared using a logistic regression model.ResultsIn Institution A, 16.7% of hemodialysis patients had atrial fibrillation, of whom 36.8% were on warfarin. In Institution B, 18% of hemodialysis patients had atrial fibrillation, and 55.5% were on warfarin. The mean TTR was 61.8% (SD 14.5) in Institution A, and 60.5% (SD 15.8) in Institution B (p-value 0.95). However, the proportion of patients achieving TTR ≥ 60% was 65% versus 43.3% (Adjusted OR 2.22, CI 0.65–7.63) and mean frequency of INR testing was every 6 days versus every 13.9 days in Institutions A and B respectively.ConclusionsThere was no statistical difference in mean TTR between nephrologist-led management of warfarin and that of clinic-led management. However, the former achieved a trend toward a higher proportion of patients with optimal TTR. This improved therapeutic results was associated with more frequent INR monitoring.

Subcutaneous Enoxaparin for Therapeutic Anticoagulation in Hemodialysis Patients

BackgroundInformation regarding dosing of low-molecular-weight heparins (LMWH) for therapeutic anticoagulation in hemodialysis (HD) patients is limited. The aim of this study was to retrospectively compare the safety and efficacy of enoxaparin versus unfractionated heparin (UFH) for therapeutic anticoagulation in HD patients. Materials and MethodsThis retrospective chart review evaluated HD patients treated with subcutaneous enoxaparin that were matched based on the indication for anticoagulation with patients treated with intravenous UFH to achieve therapeutic anticoagulation. Primary outcome measures included 30-day incidence of thromboembolic events and major bleeding. Secondary outcomes included rehospitalization within 30days, length of stay, and mortality. ResultsOne hundred sixty-four patients were evaluated, 82 in each group. The average daily dose of enoxaparin used to target therapeutic levels was 0.7±0.2mg/kg/day (range=0.4-1). Comparing enoxaparin to UFH, there was no significant difference in major bleeding (6.1% vs 11%, p=0.4) or thromboembolism (0% vs 2.4%, p=0.5). Hospital length of stay was shorter in the enoxaparin group (20±53.8 vs 28.9±44.5days, p=0.02); there was no significant difference between groups in mortality or readmission. Adjusting for risk factors for bleeding there was a slight but statistically non-significant difference between enoxaparin versus UFH (OR=0.77, 95%CI: 0.2-3.5, p=0.73). ConclusionsThese findings suggest that therapeutic dosing of enoxaparin, in doses that ranged from 0.4-1mg/kg/day, was as safe as intravenous UFH in providing therapeutic anticoagulation in stable patients requiring chronic hemodialysis.

Warfarin use in hemodialysis patients with atrial fibrillation: decisions based on uncertainty.

BackgroundWarfarin prescribing patterns for hemodialysis patients with atrial fibrillation vary widely amongst nephrologists. This may be due to a paucity of guiding evidence, but also due to concerns of increased risks of warfarin use in this population. The literature lacks clarity on the balance of warfarin therapy between prevention of thrombotic strokes and the increased risks of bleeding in hemodialysis patients with atrial fibrillation.MethodsWe performed a survey of Canadian Nephrologists, assessing warfarin prescribing practice, and measured the certainty in making these choices.ResultsRespondents were consistently uncertain about warfarin use for atrial fibrillation. This uncertainty increased with a history of falls or starting hemodialysis, even when a high CHADS2 or CHA2DS2VASc score was present. The majority of respondents agreed that clinical equipoise existed about the use of oral anticoagulation in hemodialysis patients with atrial fibrillation (72.2%) and that the results of a randomized controlled trial would be relevant to their practice (98.2%).ConclusionsA randomized controlled trial of warfarin use in hemodialysis patients with atrial fibrillation would clarify the risks and benefits of warfarin use in this population.

Dermatan sulfate: an alternative to unfractionated heparin for anticoagulation in hemodialysis patients

Unfractionated heparin (UFH) is the standard anticoagulant in regular dialysis treatments (RDTs), despite the fact that it may induce thrombocytopenia, dyslipidemia, allergy and osteoporosis. Dermatan sulfate (DS) selectively inhibits thrombin, does not inhibit F-Xa and does not interfere with platelets (PLTS). Here we described an original protocol for the use of DS as anticoagulant in RDT and compared its effects with those of UFH. In 102 patients, 7,254 RDTs were performed using DS for anticoagulation (DS-phase) and 5,707 with UFH (UFH-phase). DS was supplied as initial bolus (80 ± 12 mg) and continuous infusion (14 ± 7 mg/hour). With UFH, the initial bolus was 1,475 ± 141 IU and continuous infusion 576 ± 349 IU/hour. Activated partial thromboplastin time and its ratio were measured at least monthly, both before (pre-RDT APTT ratio) and after (post-RDT APTT ratio) RDT sessions. With 41 of 102 patients, both DS and UFH doses were not changed during study phases (stable patients). In this subset, the coefficient of variation (CV) of all pre-RDT APTT ratio and post-RDT APTT ratio values was calculated. In DS and UFH phases, post-RDT APTT ratio increased by 61% and 50%, respectively, by comparison with pre-RDT APTT ratio (p<0.001). PLTS count was lower in the UFH than in the DS phase (p<0.01). In stable patients, post-RDT APTT ratio CV was lower in the DS than in the UFH phase (p<0.001), which indicates a more predictable anticoagulant effect of DS compared with UFH. DS appeared as effective as UFH for anticoagulation in RDT. It can reliably be considered as an alternative approach especially in cases of thrombocytopenia or other adverse effects of UFH.

The effect of heparinized catheter lock solutions on systemic anticoagulation in hemodialysis patients

Hemodialysis catheter thrombosis is associated with loss of catheter patency, catheter-related bacteremia and sepsis. To limit these risks, many renal units use heparin as a catheter-locking solution. In this study we investigate the effect of different concentrations of heparin catheter lock solution on systemic anticoagulation in an investigator-blinded randomized study of patients with non-tunneled (temporary) central venous catheters. 28 consecutive patients requiring insertion of a temporary non-tunneled dual lumen central venous hemodialysis catheter were randomly allocated to receive either heparin 5,000 IU/ml or heparin 1,000 IU/ml as catheter lock solutions. The primary outcome measure was the difference in activated partial thromboplastin time (APTT) at 10 minutes following catheter locking with heparin 5,000 IU/ml and heparin 1,000 IU/ml. Secondary outcomes included intradialytic blood flow rates, catheter removal due to insufficient hemodialysis blood flow to maintain hemodialysis and catheter-related bacteremia. 13 patients were randomized to the heparin 1,000 IU/ml group with 15 patients randomized to the heparin 5,000 IU/ml group. There was a statistically significant increase in APTT at 10 minutes between groups with median +22.2% (range 0 - 210) rise in APTT in the heparin 1,000 IU/ml group compared with +373.7% (range 133 - 800) in the heparin 5,000 IU/ml group (p < 0.001). There was no statistically significant difference between groups with the secondary outcomes of intradialytic blood flow, catheter failure rates and catheter-related bacteremia rates. Heparin 1,000 IU/ml catheter lock solution confers a significantly lower risk of systemic heparinization than heparin 5,000 IU/ml without any overtly detrimental effect on intradialytic blood flow, catheter failure rates and catheter-related bacteremia rates.

Low Dose of Argatroban Saline Flushes Anticoagulation in Hemodialysis Patients With High Risk of Bleeding

Anticoagulation in hemodialysis (HD) patients with high risk of bleeding is still an intractable problem. A total of 80 HD sessions with high risk of bleeding were completed with either heparin-free (HF) or low dose of argatroban saline flushes (LASF) anticoagulation. Clinical clot formation in the pipeline and dialyzer was inspected to evaluate the local anticoagulation efficiency; prothrombin time (PT), activated partial thromboplastin time (aPTT), and D-dimer were tested to investigate the influence on the whole body coagulation system; urea reduction ratio (URR) and Kt/V were used to evaluate the efficiency of dialysis. Comparing with HF, LASF showed a satisfactory efficiency in reducing the clot formation and the URR and Kt/V of it were also higher. Low dose of argatroban saline flushes is a feasible and safe alternative anticoagulation protocol in HD patients with high risk of bleeding.

Rx Report

Rx Report

Thromboembolism and anticoagulant management in hemodialysis patients: A practical guide to clinical management

The need for anticoagulation in dialysis patients is common and the incidence of venous thromboembolism (VTE) and atrial fibrillation in this population is high. While direct data are lacking on the management of anticoagulation in dialysis patients, careful weighing of risks and benefits on the basis of evidence from other populations is crucial. VTE should be managed with adjusted dose warfarin for most patients. Placement of an inferior vena cava filter is a reasonable option for those patients with unacceptable bleeding risks. Studies are ongoing to assess the safety of some low-molecular-weight heparins (LMWH), which may potentially be useful for long-term anticoagulation in hemodialysis patients. In atrial fibrillation the available data on risk of bleeding, risk of stroke, and patient preferences should all be taken into account when considering long-term anticoagulation. We have constructed an evidence model to help quantitate the risks and benefits for an individual patient. The impact of dialysis on risk of bleeding is such that the risk of bleeding will outweigh the benefit in many patients, and anticoagulation will not be used: in some of these patients aspirin therapy may be an alternative. Finally, ‘in the area of prevention of graft and access thrombosis, some randomized controlled trials are available, but none have to date shown benefit from anticoagulation for primary or secondary prevention of thrombosis, and the risk of bleeding in these studies was high.

Heparin-associated antiplatelet antibodies increase morbidity and mortality in hemodialysis patients

Patients are frequently exposed to heparin during hemodialysis (HD) to prevent thrombosis of the extracorporeal circuit. Other groups with frequent heparin exposures have a high rate of development of heparin-associated antiplatelet antibodies (HAAb). We sought to define the prevalence of HAAb in HD patients and evaluate their effects. A chart listing of all patients undergoing HD at our tertiary care institution during a six-year period was obtained. Charts of patients who tested positive for HAAb were reviewed. A cohort of randomly selected HD patients who tested negative for HAAb was analyzed as a control group. In our sample, 3.7% of HD patients were positive for HAAb. Morbidity, as defined by thromboembolic (TEC) or hemorrhagic complications, was higher in the HAAb-positive group compared with the control patients (60% vs 8.7%, P < .05), and the mortality rate (mortality directly related to TECs) was also higher in the HAAb-positive patients (28.6% vs 4.35%, P < .05). Contrary to reports of HAAb in patients undergoing HD without increased morbidity and mortality, we found significant increases in both morbidity and mortality. The elevated morbidity and mortality may represent ongoing endothelial and platelet activation from repeated heparin exposures. Reduced morbidity and mortality will likely require early recognition of HAAb and alteration of anticoagulation in HD patients.

The risk of anticoagulation in hemodialysis patients.

The risks of intermittent anticoagulation with heparin for hemodialysis and longterm anticoagulation with warfarin to prevent clotting of arteriovenous shunts were assessed in a group of 125 home dialysis patients. Over a 7-year period, there were nine bleeding complications attributable to heparin anticoagulation for an incidence of one complication for every 40 patient year on dialysis. In contrast, 20 of 48 patients anticoagulated with warfarin for an average of 2 years each, had a total of 50 hemorrhagic complications requiring 542 days in the hospital and 15 operative procedures. Concersion to an alternative form of vascular access, the internal arteriovenous fistula, obviated the need for warfarin therapy and its unacceptably high complication rate in this population of patients.