Dose Of Low Molecular Weight Heparin Research Articles

Weight-adjusted versus fixed dose heparin thromboprophylaxis in hospitalized obese patients: A systematic review and meta-analysis

Background: Fixed dose unfractionated or low molecular weight heparin is the recommended treatment for venous thromboembolism (VTE) prevention in hospitalized patients. However, its efficacy has been questioned in obese population. Results of previous studies on weight-adjusted doses of heparin for VTE prevention are contradictory. Different anticoagulant regimens are used in clinical practice, but their role remains to be elucidated.Aims: To clarify the efficacy and safety of weight-adjusted dose heparin for VTE prevention in obese subjects hospitalized for medical and surgical conditions.Methods: Twelve studies were identified as reporting VTE occurrence, major or minor bleeding and anti-Xa levels. A random-effect meta-analysis was conducted to derive odds ratios (OR) comparing fixed vs weight adjusted-doses heparins on VTE occurrence, bleeding, anti-Xa levels. Medical and surgical patients, prospective vs retrospective and quality of studies were extracted for moderators and meta-regression analysis.Results: Weight-adjusted dose heparin administration was not associated with reduced VTE occurrence (6320/13317 patients, OR 1.03, 95% C.I. 0.79 to 1.35), nor increased bleeding (5840/10906 patients, OR 0.84, 95% C.I. 0.65 to 1.08), but it was associated with higher anti-Xa levels (284/294 patients, ES 2.04, 95% C.I. 1.16 to 2.92, p<0.0001). A significant heterogeneity was present for comparison of anti-Xa levels (I2=94%, p=0.0001) but not for VTE occurrence or bleeding (I2=7.6% and 12.8% respectivel). None of the moderators explained the heterogeneity of the results among primary studies.Conclusion: Weight-adjusted dose as compared to fixed-dose of heparins in the prevention of VTE in obese patients was not associated with a lower risk of VTE nor a higher risk of bleeding.

Use of low-molecular weight heparin, transfusion and mortality in COVID-19 patients not requiring ventilation.

It is still debated whether prophylactic doses of low-molecular- weight heparin (LMWH) are always effective in preventing Venous Thromboembolism (VTE) and mortality in COVID-19. Furthermore, there is paucity of data for those patients not requiring ventilation. We explored mortality and the safety/efficacy profile of LMWH in a cohort of Italian patients with COVID-19 who did not undergo ventilation. From the initial cohort of 422 patients, 264 were enrolled. Most (n = 156, 87.7%) received standard LMWH prophylaxis during hospitalization, with no significant difference between medical wards and Intensive Care Unit (ICU). Major or not major but clinically relevant hemorrhages were recorded in 13 (4.9%) patients: twelve in those taking prophylactic LMWH and one in a patient taking oral anticoagulants (p: n.s.). Thirty-nine patients (14.8%) with median age 75 years. were transfused. Hemoglobin (Hb) at admission was significantly lower in transfused patients and Hb at admission inversely correlated with the number of red blood cells units transfused (p < 0.001). In-hospital mortality occurred in 76 (28.8%) patients, 46 (24.3%) of whom admitted to medical wards. Furthermore, Hb levels at admittance were significantly lower in fatalities (g/dl 12.3; IQR 2.4 vs. 13.3; IQR 2.8; Mann–Whitney U-test; p = 0.001). After the exclusion of patients treated by LMWH intermediate or therapeutic doses (n = 32), the logistic regression showed that prophylaxis significantly and independently reduced mortality (OR 0.31, 95% CI 0.13–0.85). Present data show that COVID-19 patients who do not require ventilation benefit from prophylactic doses of LMWH.

LOW MOLECULAR WEIGHT HEPARIN AT HIGH DOSE IMPACTS ON OUTCOME OF COVID-19 HOSPITALIZED PATIENTS, WHILE STANDARD DOSE DOESN’T

Objective: COVID-19 is a new disease caused by pandemic SARS-CoV-2, that involves multiple organs and can cause a potentially fatal respiratory distress syndrome. Accumulating evidence point out that an “endothelitis” due to a cytokines storm causes intravascular thrombosis, especially in the lungs, and is related to the poor outcome. We tested possible relationships between anticoagulant treatment and/or administration of low molecular weight heparin (LMWH) at different doses and outcome in a population of 258 COVID-19 patients admitted from February 28th to April 30th, 2020 to General Medicine ward of the Hospital of Montichiari (Brixia, Italy). Design and method: A group of 258 consecutive patients (174 males and 84 females, mean age 71 years +/- 14) was included in the present study. In 168 patients, high-flow oxygen was required (Venturi mask), 6 patients needed orotracheal intubation and 20 were given continuous positive pressure oxygen therapy (CPAP). Patient were treated (unless a pulmonary embolism was detected) with different doses of prophylactic LMWH, according to emerging evidence during pandemic period. As of June 10th, 65 deaths had been observed. Survival curves were calculated according to Kaplan-Meier method. Comparison between groups was performed with Breslow and Mantel-Cox test. Results: LMWH at standard dose (4000 IU once daily) didn’t reduce mortality compared to no treatment (p = ns), while LMWH at a higher dose than usual prophylactic dose (enoxaparin 6000 IU once daily or 4000 IU bid) was associated with better outcome (p &lt; 0.001 vs untreated and treated with standard dose). Significance was confirmed adding patients treated with oral anti-coagulant (OAC)for any reason. None of the patients treated with LMWH at higher doses or OAC died. Conclusions: The administration of subcutaneous LMWH at a higher dose than indicated for deep vein thrombosis prophylaxis is associated with a better outcome in patients with SARS-CoV-2 pneumonia, confirming some emerging evidence.

ROTEM Analyses of Low Molecular heparin effects with Vitro Induced Thrombocytopenia

Background: Thrombocytopenia is correlated to hemorrhagic complications in patients with low molecular weight heparin (LMWH) thromboprophylaxis. Aims: The aims of our study were to investigate an experimentally induced in vitro thrombocytopenia and then adding 2 types of LMWHs in vitro. Our hypothesis was that a platelet depleted whole blood sample could reflect a stronger synergistic anticoagulative effect of in vitro added LMWH than in the non-manipulated blood. Method: Two venous citrated blood samples were consecutively drawn from 8 patient’s gynaecologic cancer and normal routine coagulation laboratory analyses immediately preopewratively. One of the two samples had its buffy coat pipetted away into a separate tube. Half of the buffy coat was returned to the same sample (treated sample). 3x500 μl of blood from the non-treated sample was added to 3 separate microtubes and corresponding for the treated sample. Thromboprophylactic doses corresponding to an in vivo peak effect 0.5 anti-Xa international units/ml of tinzaparin and enoxaparin were added both to untreated and treated samples – 2 microtubes were unheparinized (treated/untreatedsample). All samples were analysed with rotational thromboelastometry (ROTEM). Results: Wilcoxon matched-pairs signed rank tests of the in-group differences between non-non-treated and treated samples showed no significant differences (p≤0.05) for any of the parameters analysed with the ROTEM-INTEM reagent regardless of heparinization or not. Calculation of non-parametric spearman correlation for clotting time (CT) vs. platelet count (PLC) were not significant for any group. Tinzaparin was clearly observed to prolong CT in the buffy-coat lowered blood from two patients. Conclusions: Our results corroborate previous research that ROTEM cannot detect anticoagulative effects of low dose LMWH in patients with normal PLC. In two patients there was a clear prolongation of clot initiation after tinzaparin that warrants further studies on a more developed in vitro induced thrombocytopenia model.

Use of plasmapheresis in treatment of patients with unfavorable anamnestic pregnancy outcomes coupled to antiphospholipid antibodies

Aim: to evaluate efficacy of plasmapheresis combined with low molecular weight heparins (LMWH) and acetylsalicylic acid (ASA).Materials and Methods. 327 plasmapheresis sessions were performed for 75 patients: 17 (22.6 %) patients during preparation for pregnancy, 11 (19.0 %) pregnant women in the first trimester, 33 (56.9 %) pregnant women in the second trimester, and 34 (58.6 %) pregnant women in the third trimester. Study inclusion criteria were as follows: high titers of antiphospholipid antibodies (APA) as well as included non-inclusion criteria in pregnant women with miscarriages and unfavorable anamnestic pregnancy outcome. 36 (62.1 %) women had pregnancy loss in anamnesis. All patients received low-dose ASA and LMWH therapy; 15 (25.86 %) pregnant women also received courses of intravenous immunoglobulins in the first and second trimesters.Results. 47 pregnant women had delivery, whereas 10 of women had pregnancy in progress. Term delivery was in 40 (85.1 %) patients, so that 23 (48.9 %) pregnant women had delivery per vias naturales. The average weight of the fetus was 3364.00 ± 393.76 g, height - 52.13 ± 1.82 cm. In 100 % cases, Apgar score was 8 points. 24 (51.1%) pregnant women had delivery via cesarean section. The average blood loss comprised 528.64 ± 166.10 ml. The average fetal weight in group after surgical delivery was 2982.14 ± 582.88 g, average height - 49.14 ± 4.09 cm, the Apgar score - 7.69 ± 0.47 points. Preterm births were observed in 7 (14.9%) cases, all via cesarean section. In 1 case, early fetal death was at gestational age of 8/9 weeks; according to the karyotyping data, a fetal chromosomal abnormality was detected. No severe obstetric complications were observed.Conclusions. Combining plasmapheresis with low dose LMWH and ASA therapy demonstrated high efficacy in treating obstetric APS manifested as high percentage of favorable pregnancy outcomes and low number of obstetric complications.

Spinal Cord Stimulator Trial in a Patient on Chronic Warfarin Therapy

Background: Spinal cord stimulation (SCS) is a rapidly growing interventional treatment modality in chronic pain. Pain physicians are faced with the decision on how to manage patients on anticoagulation therapy given the risk of epidural hematomas. Case Report: We describe a patient with a history of atrial fibrillation and prior pulmonary embolism on chronic anticoagulation. The patient was planned to undergo an SCS trial, but was unable to discontinue all anticoagulation during the length of the trial. Utilizing a multidisciplinary approach, the patient discontinued warfarin 5 days prior to the procedure and began a therapeutic dose of low molecular weight heparin (LMWH). The final dose of LMWH was given 24 hours before the trial procedure. The patient then started prophylactic dosing of LMWH 24 hours after the trial procedure and continued that regimen for the course of the SCS trial. The last dose of prophylactic LMWH was given 24 hours before removal of the trial leads and the patient restarted 3 days of therapeutic LMWH along with resuming his normal anticoagulation regimen after lead removal. The patient was able to undergo a successful SCS trial and will be pursuing a SCS implant with further anticoagulation management. Conclusion: This case demonstrates a possible strategy for managing patients who requiring anticoagulation therapy during the course of their SCS trial phase. Although a single-electrode array proved to be efficacious, using 2 electrode arrays improves the anatomic coverage of the painful areas and allows for greater optionality in electrode selections to avoid plasticity. Key words: Spinal cord stimulation, anticoagulation, chronic pain, post laminectomy syndrome

Massive Perivillous Fibrinoid Degeneration of Placenta/ Maternal Floor Infarct: A Case Report

AbstractPlacental pathology can be a cause of early severe FGR leading to perinatal morbidity and mortality with repercussions in future pregnancies. A diagnosis of a placental lesion on ultrasound should have a detailed clinical and histopathological correlation for better management in next pregnancy. We present a case report of “placental massive perivillous fibrinoid degeneration/maternal floor infarction (MPFD)” with very large avascular placenta. This can lead to fetal growth restriction (FGR) and other complications for the fetus. It is also known to be associated with antiphospholipid syndrome. Management with low dose aspirin and low molecular weight heparin achieves good results.

Effect of unfractionated heparin and low molecular weight heparin on the clotting of platelet-reduced whole blood: an in-vitro study utilizing thromboelastography.

Treatment of venous thromboembolism with concomitant thrombocytopenia is challenging. The platelet threshold for safe administration of anticoagulants is under debate, with minimum platelet count of 50 × 109/l being recommended as the safe cutoff. However, some evidence suggests administration of anticoagulants may still be safe at platelet levels of 30 × 109/l. Therefore, we developed an in-vitro thromboelastography (TEG) study to examine the effect of therapeutic or prophylactic levels of unfractionated heparin (UFH) and low molecular weight heparin (LMWH) on the clotting profile of platelet-reduced whole blood. Using magnetic bead-based antibody chromatography, platelets were removed to achieve platelet-depleted blood (<10 × 109/l of platelets). Platelet-depleted blood was then mixed with whole blood to produce blood samples with platelet counts of 30 × 109, 50 × 109 and 150 × 109/l. These blood samples were incubated with therapeutic or prophylactic levels of UFH or LMWH in disposable TEG cups. Clotting was initiated with 10 mmol/l calcium and optimized tissue factor levels for each anticoagulant used (2.25 pmol/l for UFH and 2.05 pmol/l for LMWH). Clotting was monitored by TEG at 37 °C for 180 min. The following TEG parameters were evaluated: R (time to clot), maximum amplitude (strength of clot) and area under the curve in 15 min (overall speed and strength of the clot at 15 min of clotting). No statistically significant differences were observed between platelet counts of 30 × 109 and 50 × 109/l for R, maximum amplitude or area under the curve in 15 min for most of the therapeutic and prophylactic doses of UFH and LMWH tested in this study. Use of anticoagulants compromised all of the TEG parameters relative to a normal platelet count of 150 × 109/l, in a dose dependent manner. The current study demonstrates that in-vitro clotting is impaired with use and increasing doses of anticoagulants. Despite this observation, we did not observe a significant difference in clotting between platelet levels of 30 × 109 and 50 × 109/l. Overall, this work provides further insight in the debated use of anticoagulants in patients with venous thromboembolism and concomitant thrombocytopenia, and provides support for possible use of anticoagulants at lower platelet thresholds.

Diagnosis and treatment of disseminated intravascular coagulation in COVID-19 patients: a scoping review.

BackgroundDisseminated intravascular coagulation (DIC) is noted in severe cases of coronavirus disease 2019 (COVID-19). Recently, a number of studies evaluating the diagnosis and treatment of DIC in COVID-19 patients have been reported.ObjectiveThe aim of this study is to identify existing gaps where further research is needed on the diagnosis and treatment of DIC complicated by COVID-19.MethodsWe used the PRISMA Extension for Scoping Reviews. MEDLINE, CENTRAL, WHO-ICTRP, ClinicalTrial.gov and PROSPERO were searched from their inception to 6 October 2020.ResultsSeven studies were selected; five were already published and two are ongoing. DIC was diagnosed using the International Society on Thrombosis and Hemostasis (ISTH) DIC score (n = 4) and the sepsis-induced coagulopathy (SIC) DIC score (n = 5). Seven studies examined the effectiveness of low molecular weight heparin (LMWH); of these, four studies used a prophylactic dose and five used a therapeutic dose of LMWH. A prophylactic dose of unfractionated heparin (UFH) was investigated in two studies.ConclusionStudies on DIC diagnostic criteria and anticoagulants were limited to the ISTH or SIC scores and heparinoids, particularly LMWH. Further studies are needed to compare these with other available DIC scoring systems and anticoagulants.

Efficacy and Safety of D-dimer, Weight, and Renal Function-Adjusted Thromboprophylaxis in Patients with Coronavirus Disease 2019 (COVID-19).

The activation of inflammatory and coagulation pathways, leading to hypercoagulability with reduced fibrinolysis, has emerged as pivotal mechanism in development of acute respiratory failure and thrombosis in patients with severe coronavirus disease 2019 (COVID-19).[1] Although thrombosis is a major complication in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the optimal thromboprophylaxis regimen in these patients is unknown. High rates of thrombosis, especially in those admitted to intensive care, are usually reported despite standard or even intensified thromboprophylaxis with low molecular weight heparin (LMWH). The uncertainty has been reflected in the diverse recommendations in local, national, and international guidelines.[2] [3] [4] Early studies reported that elevated D-dimer values were associated with magnified risk of thrombosis,[5] and this has been confirmed in subsequent studies,[6] even in those in which the thrombosis rate was found to be low.[7] D-dimer has also been a reliable predictor of a poor outcome, and although it is not established that these two observations are linked, large and small vessel thrombosis is prominent in the pulmonary circulation both ante- and postmortem.[8] The prominence of large and small vessel thrombosis in the pathophysiology of COVID-19 and its high frequency despite standard or sometimes increased intensity LMWH suggests that intensified prophylaxis may be beneficial. However, any benefit from this approach would need to be balanced against a possible increase in bleeding complications. The use of intensified versus standard dose LMWH is being investigated in several clinical trials, although only recently initiated in the United Kingdom. Pending the results of such studies, individual National Health Service (NHS) Trusts have developed local thromboprophylaxis guidelines for COVID-19.

Ethnic differences in thromboprophylaxis for COVID-19 patients: should they be considered?

Thromboembolic events contribute to morbidity and mortality in coronavirus disease 2019 (COVID-19). As a result, thromboprophylaxis using low-molecular-weight heparin (LMWH) is universally recommended for hospitalized patients based on multiple guidelines. However, ethnic differences with respect to thrombogenicity have been reported and the incidence of thromboembolic events is considered to be lower in the Asian population. Despite the importance of thromboprophylaxis, bleeding is also a side effect that should be considered. We examine the data relating to potential ethnic differences in thrombosis and bleeding in COVID-19. Although sufficient data is not yet available, current evidence does not oppose routine anticoagulant use and thromboprophylaxis using a standard dose of LMWH for admitted patients regardless of ethnicity based on our review.

Şiddetli COVİD-19 Hastalarında DMAH (Düşük Molekül Ağırlıklı Heparin) Doz Farklılıklarının Etkileri

Objective: The most prominent clinical finding in severe COVID-19 patients is endothelial damage. For these reasons, active administration of anticoagulants (such as heparin) is recommended to patients with severe COVID-19. The purpose of this study is to investigate the effects of different doses of low-molecular weight heparin (LMWH) on severe COVID-19 patients. Methods: This study was performed retrospectively in intensive care unit of a tertiary referral hospital. PCR (polymerase chain reaction) positive (+) patients were included in the study. Patients’ demographic data, length of stay in the hospital and intensive care unit, laboratory values (D-dimer, CRP, creatinine) on the last day of intensive care stay, mortality and invasive mechanical ventilator needs were recorded. Group O: consisted of patients not receiving anticoagulants, and Group 1 received a single daily dose of 40 mg enoxaparin sodium (equivalent to 4000 anti-Xa IU), and Group 2 received 2 daily doses of 1 mg/kg enoxaparin sodium. Results: A total of 191 patients were included in the study. 45% of the patients were female (n: 86), 55% were male. The mean age was found to be 67.6 ± 13.8. Patient numbers; group 0: 12, group 1: 90, group 2: 89. 7-day mortality was 50% in group 0, 22.2% in group 2, and 23.5% in group 3 (p value &lt;0.05). Conclusion: In a recent lung dissection report in critically ill patient with COVID-19; occlusion of pulmonary small vessels and formation of microthrombosis have been demonstrated. Prophylactic doses of LMWH are used more frequently. Some studies have suggested that septic patients may benefit from early diagnosis and specific treatment. As a result; in severe COVID-19 patients with limited mobilization, all doses of LMWH reduce morbidity and mortality.

Comparison of standard prophylactic and preemptive therapeutic low molecular weight heparin treatments in hospitalized patients with COVID-19.

Anticoagulant treatment approach in patients with COVID-19 is not well studied and not standardized. We aimed to compare the effects of standard prophylactic and pre-emptive therapeutic Low-Molecular-weight Heparin (LMWH) treatment approaches on mortality in patients with COVID-19. This retrospective and single-centre study includes patients aged ≥ 18 years, who were diagnosed with COVID-19 and treated with LMWH during the hospital stay. Therapeutic dose of LMWH was defined as 1 mg/kg subcutaneously twice daily and prophylactic dose of LMWH was defined as 40 mg subcutaneously once daily. Among the 336 patients diagnosed with COVID-19 pneumonia, 115 patients, who received LMWH were included in the study. The mean age was 58.6 ± 13.3 and 58 (50.4 %) of the patients were male. Sixty-nine (60 %) of the patients were treated with prophylactic and 46 (40 %) therapeutic LMWH.In-hospital mortality was not different between patients treated therapeutic LMWH and prophylactic LMWH by the multivariate regression analysis (OR=2.187, 95% CI 0.484-9.880, p=0.309) and the propensity score modelling (OR=1.586, 95% CI 0.400-6.289, p=0.512.)CONCLUSION: Clinicians should consider the potential risks and benefits of standard prophylactic and pre-emptive therapeutic LMWH. Therefore, anticoagulant therapy should be individualized in patients with COVID-19 (Tab. 3, Ref. 28).

Covid-19 cases developing dyspnea under anticoagulant treatment

Coronavirus disease 2019 (COVID-19) infection is thought to increase thrombotic events by activating coagulation system and making endothelial damage. The frequency of severe acute respiratory syndrome coronavirus 2 pneumonia and pulmonary embolism has drawn attention. There are recommendations for prophylactic low-molecular-weight heparin (LMWH) for COVID-19 at hospitalized patients. However, there is no consensus regarding the duration and doses of LMWH given with COVID-19 treatment. We presented three cases of pulmonary embolism at different times of COVID-19 infection who were diagnosed with pulmonary embolism under anticoagulant treatment. Subsegmental thrombus was detected in computed thoracic pulmonary angiography in all cases and treated with LMWH in the hospital, two cases were discharged with warfarin and one case with LMWH. Care should be taken in dyspnea that develops in the of COVID-19 infection, especially in terms of subsegmental pulmonary embolism. This paper shows that COVID-19 is an important risk factor for venous thromboembolism and the duration and dose of anticoagulant treatment should be re-evaluated.

Safety of Preoperative Low-Molecular-Weight Heparin in Patients Who Underwent Hepatectomy

Background: Although international guidelines advocate preoperative venous thromboembolism (VTE) chemoprophylaxis for hepatectomy, there are still safety concerns. Methods: We conducted a medical chart review of patients who underwent hepatectomy from 2016 to 2020 in a tertiary hospital in Thailand. Our center has applied preoperative chemoprophylaxis protocols with low-molecular-weight heparin (LMWH) since 2018. The rates of post-hepatectomy hemorrhage (PHH) were compared between patients receiving and those not receiving preoperative LMWH. Results: Of 204 patients who underwent hepatectomy, 186 were eligible for the analysis. Moreover, 48% were included in the LMWH group. Major hepatectomies accounted for approximately 50% in both LMWH and No-LMWH groups. The overall PHH rate was 3.8% and was not different between the LMWH (4.4%) and No-LMWH groups (3.1%). PHH was significantly associated with intraoperative blood transfusion > 2 units and post-hepatectomy liver failure. Postoperative VTE developed in 0.5% of patients. Conclusion: No association between PHH and preoperative VTE prophylaxis for hepatectomies was found. Although half of patients in this study underwent major hepatectomies, the PPH rate was low. A single dose of preoperative LMWH plus mechanical thromboprophylaxis may be appropriate in populations with low incidence of VTE. Funding Information: None. Declaration of Interests: None. Ethics Approval Statement: This study was approved by the Prince of Songkla University Hospital Ethics Committee (approval no. REC. 63443101).

Life-threatening hematomas in COVID-19 patients.

The COVID-19 pandemic has caused over 1.75 million deaths in the world to date. Although the leading cause of mortality is respiratory disorders and thromboembolic pathologies, other rare pathologies may also increase mortality and morbidity. In our study, we aimed to examine life-threatening hematomas, risk factors, and management during COVID-19. Institutional center (a third level pandemic center) database was searched for patients hospitalized for COVID-19 during 10 months period between March 11, 2020, and December 17, 2020, retrospectively. Patients with bleeding symptoms/signs were de-tected. Patients with gastrointestinal system bleeding were excluded from the study. Patients with hematomas were included in the study. Eleven of a total 5484 patients had hematomas (0.2%). Median age was 76 (min-max: 56-90). Seven (63.6%) patients were male and 4 (36.4%) were female. All patients had at least one comorbidities, been under treatment dose of low-molecular-weight hep-arin (LMWH) and severe or critical COVID-19 disease. Seven retroperitoneal hematomas, two rectus sheath hematomas, one breast hematoma, and in one patient both retroperitoneal and breast hematomas were diagnosed. Angiographic arterial embolization was applied to 5 (45.5%) patients. Overall mortality rate in patients with bleeding complications was 54.5% (n=6), and the male-to-female ratio was 66.7% (n=4) versus 33.3% (n=2). Hematomas are rare, but mortality increasing phenomena in COVID-19 patients. Age, male gender, severe or critical COVID-19 disease, comorbidities, and treatment dose of LMWH may be risk factors. New onset of abdominal/back pain and ecchymotic skin lesions may be signs of bleeding in this patient group. Mortality can be reduced by early diagnosis of hematoma and interventional methods.

Arterial Versus Venous Port Site Administration of Nadroparin for Preventing Thrombosis of Extracorporeal Blood Circuits in Patients Receiving Hemodiafiltration Treatment

IntroductionAdministration of low-molecular-weight heparins (LMWHs) is necessary for preventing extracorporeal circuit thrombosis during hemodialysis. A substantial amount of LMWH is removed with online hemodiafiltration (OL-HDF) when administered through the inlet site of the extracorporeal circuit. Consequently, administration of LMWH at the outlet site appears to be more efficient. In this study we aimed to compare the effects of nadroparin calcium (NAD) administered through the outlet versus the inlet port site in postdilution OL-HDF and assess the NAD dose reduction.MethodsForty-nine hemodialysis patients were included in 3 consecutive 6-week studies as follows: phase I, inlet port line; phase II, outlet port line; and phase III, outlet port line with reduced dose. We evaluated clotting in the hemodialyzer and venous bubble trap, the dialysis dose (Kt/V), and substitution volume.ResultsThirty four percent, 63%, and 66% were categorized as “white” during phases I, II, and III, respectively. During phases I, II, and III, 75%, 93%, and 95% of the venous bubble traps were “clean,” and 9%, 0.6%, and 0.4% of the dialyzers clotted, respectively. Average NAD dose was 0.43 ml during phase I and 0.3 ml during phase II. During phase III, the LMWH dose was reduced by 33% to 50% in 15 patients. In phase III, Kt/V improved from 1.64 to 1.75 and substitution volume increased from 20.18 to 21.96 L.ConclusionsWhen using OL-HDF, a single administration of NAD at the outlet port line allows for a significant dose reduction and was associated with improved dialysis performance.

Bozulmuş DNA Metilasyonuyla İlişkili olumsuz gebelik sonuçları: Olgu sunumu

The methylenetetrahydrofolate reductase (MTHFR) gene encodes an enzyme called MTHFR involved in the processes of DNA methylation and chromosome segregation. MTHFR polymorphisms are associated with DNA methylation disorders including congenital malformations and chromosomal abnormalities, and various obstetrical complications such as miscarriage, fetal growth retardation, preeclampsia, preterm labor, etc. Herein, we have reported a patient with compound heterozygous MTHFR polymorphisms in whom different type of adverse pregnancy outcomes (1. blighted ovum, 2. preterm delivery, and 3. pregnancy with a fetus having anencephaly and meningocele going together with 46, XX, del (13) (q22)) were observed in her previous 3 pregnancies. She was referred to our hospital during her third pregnancy for prenatal diagnosis. Her fourth baby was born healthy at 37th gestational week after having necessary precautions. Low dose low molecular weight heparin and low-dose acetylsalicylic acid were added to patient-specific management protocol immediately after the confirmation of her fourth pregnancy. In conclusion, DNA methylation enzyme pathway disorders are associated with adverse gestational outcomes.

Дозирование низкомолекулярных гепаринов и анти-фактор Xa активность у пациентов с новой коронавирусной инфекцией COVID-19.

Дозирование низкомолекулярных гепаринов и анти-фактор Xa активность у пациентов с новой коронавирусной инфекцией COVID-19.

Prevention of thromboembolism in spinal cord injury -S1 guideline

IntroductionTraumatic and non-traumatic spinal cord injury bears a high risk for thromboembolism in the first few months after injury. So far, there is no consented guideline regarding diagnostic and prophylactic measures to prevent thromboembolic events in spinal cord injury. Based on a Pubmed research of related original papers and review articles, international guidelines and a survey conducted in German-speaking spinal cord injury centers about best practice prophylactic procedures at each site, a consensus process was initiated, which included spinal cord medicine experts and representatives from medical societies involved in the comprehensive care of spinal cord injury patients. The recommendations comply with the German S3 practice guidelines on prevention of venous thromboembolism.RecommendationsSpecific clinical or instrument-based screening methods are not recommended in asymptomatic SCI patients. Based on the severity of neurological dysfunction (motor completeness, ambulatory function) low dose low molecular weight heparins are recommended to be administered up to 24 weeks after injury. Besides, mechanical methods (compression stockings, intermittent pneumatic compression) can be applied. In chronic SCI patients admitted to the hospital, thromboembolism prophylactic measures need to be based on the reason for admission and the necessity for immobilization.ConclusionsRecommendations for thromboembolism diagnostic and prophylactic measures follow best practice in most spinal cord injury centers. More research evidence needs to be generated to administer more individually tailored risk-adapted prophylactic strategies in the future, which may help to further prevent thromboembolic events without causing major side effects. The present article is a translation of the guideline recently published online (https://www.awmf.org/uploads/tx_szleitlinien/179-015l_S1_Thromboembolieprophylaxe-bei-Querschnittlaehmung_2020-09.pdf).