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Verbout NG, Lorentz CU, Markway BD, Wallisch M, Marbury TC, Di Cera E, Shatzel JJ, Gruber A, Tucker EI. Safety and tolerability of the protein C activator AB002 in end-stage renal disease patients on hemodialysis: a randomized phase 2 trial. COMMUNICATIONS MEDICINE 2024; 4:153. [PMID: 39060370 PMCID: PMC11282208 DOI: 10.1038/s43856-024-00575-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 07/09/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND The protein C system regulates blood coagulation, inflammation, and vascular integrity. AB002 is an injectable protein C activating enzyme under investigation to safely prevent and treat thrombosis. In preclinical models, AB002 is antithrombotic, cytoprotective, and anti-inflammatory. Since prophylactic use of heparin is contraindicated during hemodialysis in some end-stage renal disease (ESRD) patients, we propose using AB002 as a short-acting alternative to safely limit blood loss due to clotting in the dialysis circuit. METHODS This phase 2, randomized, double-blind, placebo-controlled, single-dose study evaluates the safety and tolerability of AB002 administered into the hemodialysis line of ESRD patients during hemodialysis at one study center in the United States (ClinicalTrials.gov: NCT03963895). In this study, 36 patients were sequentially enrolled into two cohorts and randomized to AB002 or placebo in a 2:1 ratio. In cohort 1, patients received 1.5 µg/kg AB002 (n = 12) or placebo (n = 6); in cohort 2, patients received 3 µg/kg AB002 (n = 12) or placebo (n = 6). Patients underwent five heparin-free hemodialysis sessions over 10 days and were dosed with AB002 or placebo during session four. RESULTS Here we show that AB002 is safe and well-tolerated in ESRD patients, with no treatment-related adverse events. Clinically relevant bleeding did not occur in any patient, and the time to hemostasis at the vascular access sites is not affected by AB002. CONCLUSIONS As far as we are aware, this proof-of-concept study is the first clinical trial assessing the therapeutic potential of protein C activation. The results herein support additional investigation of AB002 to safely prevent and treat thrombosis in at-risk populations.
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Affiliation(s)
- Norah G Verbout
- Aronora, Inc., Portland, OR, USA.
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA.
| | - Christina U Lorentz
- Aronora, Inc., Portland, OR, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | | | - Michael Wallisch
- Aronora, Inc., Portland, OR, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | | | - Enrico Di Cera
- Edward A. Doisy Department of Biochemistry and Molecular Biology, School of Medicine, Saint Louis University, St. Louis, MO, USA
| | - Joseph J Shatzel
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | | | - Erik I Tucker
- Aronora, Inc., Portland, OR, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
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Ikeda S, Takahashi T, Tandoh T, Ushiyama K, Kida Y. Severe Anemia from Multiple Gastric Hyperplastic Polyps in a Hemodialysis Patient after Long-term Use of a Proton-pump Inhibitor. Intern Med 2024; 63:649-657. [PMID: 38432892 PMCID: PMC10982011 DOI: 10.2169/internalmedicine.2091-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/04/2023] [Indexed: 03/05/2024] Open
Abstract
A 90-year-old man on maintenance hemodialysis was admitted due to severe symptomatic anemia. Biopsies under esophagogastroduodenoscopy demonstrated that the cause of anemia was intermittent blood oozing from multiple gastric hyperplastic polyps. Even after successful eradication of Helicobacter pylori, he showed hypergastrinemia (480 pg/mL) owing to esomeprazole (proton-pump inhibitor) therapy for the past 4.5 years to treat reflux esophagitis. Seven months after we switched esomeprazole to famotidine (H2-receptor antagonist), those gastric polyps and anemia were remarkably ameliorated with lowered gastrin levels. This case indicates that long-term use of a proton-pump inhibitor triggers chronic hypergastrinemia, leading to gastric hyperplastic polyps and subsequent severe anemia.
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Affiliation(s)
- Shiyo Ikeda
- Department of Nephrology, Takashimadaira Chūō General Hospital, Japan
- Blood Purification Center, Takashimadaira Chūō General Hospital, Japan
| | - Toshiya Takahashi
- Department of Nephrology, Takashimadaira Chūō General Hospital, Japan
- Blood Purification Center, Takashimadaira Chūō General Hospital, Japan
| | - Toshitsugu Tandoh
- Department of Clinical Engineering, Takashimadaira Chūō General Hospital, Japan
| | - Kaori Ushiyama
- Blood Purification Center, Takashimadaira Chūō General Hospital, Japan
- Department of Nursing, Takashimadaira Chūō General Hospital, Japan
| | - Yujiro Kida
- Department of Nephrology, Takashimadaira Chūō General Hospital, Japan
- Blood Purification Center, Takashimadaira Chūō General Hospital, Japan
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Chiasakul T, Mullier F, Lecompte T, Nguyen P, Cuker A. Laboratory Monitoring of Heparin Anticoagulation in Hemodialysis: Rationale and Strategies. Semin Nephrol 2023; 43:151477. [PMID: 38290962 DOI: 10.1016/j.semnephrol.2023.151477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Unfractionated heparin (UFH) and low-molecular-weight heparins (LMWHs) are commonly used to prevent clotting of the hemodialysis extracorporeal circuit and optimize hemodialysis adequacy. There is no consensus on the optimal dosing for UFH and LMWHs during hemodialysis. In clinical practice, semiquantitative clotting scoring of the dialyzer and venous chamber may help to guide UFH and LMWH dose adjustment. Laboratory monitoring has not been shown to improve clinical outcomes and is therefore not routinely indicated in most hemodialysis patients. It might, however, be considered in select patients, such as those with extremes of body weight or history of repeated clotting or bleeding. Methods for laboratory monitoring include the activated partial thromboplastin time, activated clotting time, and antifactor Xa assays for UFH and antifactor Xa assay for LMWHs. Target ranges for anticoagulation in hemodialysis have been suggested but not clearly defined. When utilizing these tests, issues such as availability, standardization, interfering factors, and interpretation must be considered. In this narrative review, we discuss the rationale and methods of monitoring anticoagulation in hemodialysis.
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Affiliation(s)
- Thita Chiasakul
- Center of Excellence in Translational Hematology, Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
| | - François Mullier
- Namur Thrombosis and Hemostasis Center, Université Catholique de Louvain, Centre Hospitalier Universitaire UCL Namur, Hematology Laboratory, Yvoir, Belgium; Institut de Recherche Expérimentale et Clinique, Pôle Mont, Université Catholique de Louvain, Yvoir, Belgium
| | - Thomas Lecompte
- Pharmacy Department, University of Namur, Namur, Belgium; Université de Lorraine, Nancy, France
| | - Philippe Nguyen
- Hematology Laboratory, Reims University Hospital, Reims, France
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Lucca IP, Armani R, Carvalho AB, Manfredi SR, Silva MVRE, Gratão TB, Silva L, Watanabe R, Canziani ME. The effects of medium cut-off and high-flux membranes on activated clotting time of patients on hemodialysis. FRONTIERS IN NEPHROLOGY 2023; 3:1133910. [PMID: 37675344 PMCID: PMC10479637 DOI: 10.3389/fneph.2023.1133910] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 01/30/2023] [Indexed: 09/08/2023]
Abstract
Introduction The interaction between blood and dialysis membrane increases the risk of clot formation. Membrane properties can interfere with coagulation activation during dialysis. Heparin is usually used to ensure anticoagulation, which can be monitored by the Activated Clotting Time (ACT) test. The purpose of this study was to compare the ACT of patients with chronic kidney disease (CKD) undergoing hemodialysis with high-flux (HF) and medium cut-off (MCO) membranes. Methods This is a prospective, randomized, crossover study in which 32 CKD patients were dialyzed for 12 weeks with each membrane. Blood clotting measured by ACT was evaluated at the beginning, 2nd, and 4th hour of the dialysis session. Throughout the study, there were no changes in the dose or administration method of heparin. Results Patients mainly were middle-aged, non-black males on hemodialysis for eight years. Before randomization, ACT values were 132 ± 56, 195 ± 60, and 128 ± 32 seconds at pre-heparinization, 2nd and 4th hour, respectively. After 12 weeks, ACT values in HF and MCO groups were 129 ± 17, 205 ± 65 and 139 ± 38 seconds, and 143 ± 54, 219 ± 68 and 142 ± 45 seconds, respectively. An ANOVA model adjusted and unadjusted for repeated measures showed a significant time but no treatment or interaction effects. In an additional paired-sample analysis, no difference between ACT values of HF and MCO Groups was observed. Discussion and Conclusion There was no difference regarding the ACT test during dialysis therapy using HF or MCO membranes. This data suggests that no adjustment in the dose or administration method of heparin is necessary with the use of MCO dialysis membranes.
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Affiliation(s)
- Isabela Pereira Lucca
- Department of Medicine, Paulista School of Medicine, Federal University of São Paulo, São Paulo, São Paulo, Brazil
| | - Rachel Armani
- Department of Medicine, Paulista School of Medicine, Federal University of São Paulo, São Paulo, São Paulo, Brazil
- Hrim - Kidney Hospital, São Paulo, São Paulo, Brazil
| | - Aluizio B. Carvalho
- Department of Medicine, Paulista School of Medicine, Federal University of São Paulo, São Paulo, São Paulo, Brazil
- Hrim - Kidney Hospital, São Paulo, São Paulo, Brazil
| | - Silvia R. Manfredi
- Department of Medicine, Paulista School of Medicine, Federal University of São Paulo, São Paulo, São Paulo, Brazil
- Hrim - Kidney Hospital, São Paulo, São Paulo, Brazil
| | - Monique V. Rocha E. Silva
- Department of Medicine, Paulista School of Medicine, Federal University of São Paulo, São Paulo, São Paulo, Brazil
- Hrim - Kidney Hospital, São Paulo, São Paulo, Brazil
| | - Thamires B. Gratão
- Department of Medicine, Paulista School of Medicine, Federal University of São Paulo, São Paulo, São Paulo, Brazil
- Hrim - Kidney Hospital, São Paulo, São Paulo, Brazil
| | - Lidia Silva
- Department of Medicine, Paulista School of Medicine, Federal University of São Paulo, São Paulo, São Paulo, Brazil
- Hrim - Kidney Hospital, São Paulo, São Paulo, Brazil
| | - Renato Watanabe
- Department of Medicine, Paulista School of Medicine, Federal University of São Paulo, São Paulo, São Paulo, Brazil
- Hrim - Kidney Hospital, São Paulo, São Paulo, Brazil
| | - Maria Eugenia Canziani
- Department of Medicine, Paulista School of Medicine, Federal University of São Paulo, São Paulo, São Paulo, Brazil
- Hrim - Kidney Hospital, São Paulo, São Paulo, Brazil
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Wang Z, Yuan R, Li P, Huang Y, Zhao W, Zhao C. Cell-inspired selective potassium removal towards hyperkalemia therapy by microphase-isolated core-shell microspheres. Acta Biomater 2023; 157:511-523. [PMID: 36481502 DOI: 10.1016/j.actbio.2022.11.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 11/24/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
Hyperkalemia is a common metabolic problem in patients with chronic kidney disease. Although oral medications and hemodialysis are clinically applied for lowering serum potassium, the intrinsic limitations encourage alternative therapy in the trend of adsorbent-based miniaturized blood purification devices. Cells serve as the biological K+ storage units that accumulate K+ through multiple mechanisms. Inspired by cells, our strategy aims at favorable permeation and enrichment of K+ in the microsphere. We incorporate cation-affinitive groups into core-shell structures with submicron-sized phase separation. These nano-spaced side-groups cooperate to form interlinked clusters, where crown ethers with Angstrom-scale ring for size-matched complexation, while ionic sulfonic acid groups for hydrophilicity and charge-buffering. The unique structure with such non-covalent interactions facilitates K+ for permeation across the shell and binding to the core while also ensuring mechanical strength and anti-swelling durability in biofluids. The microspheres exhibit high selectivity ratios of K+ (SK/Na, SK/Ca, SK/Mg up to 9.8, 21.6, and 17.7). As column adsorbents for hemoperfusion simulation, they effectively lower elevated K+ levels to the normal range (clearance rates up to 44.4%/45.3% for hyperkalemic human serum/blood). Blood compatibility tests show low protein adsorption, preferable hemocyte compatibility, and anticoagulation property in vitro. This promising strategy has clinical potential for hyperkalemia in high-risk patients. STATEMENT OF SIGNIFICANCE: Hyperkalemia (serum potassium >5 mmol/L) is a common complication in chronic renal failure patients. The limitations of existing treatments prompt a shift to wearable artificial kidney technology for clinical convenience and efficacy. Existing treatments have limitations, and we turn to adsorbent-based miniaturized blood purification devices in the prospect of wearable artificial kidney technology. There exists a lack of ion-specific adsorbents applied in extracorporeal circuits to redress electrolyte imbalances like hyperkalemia. Inspired by cells, we aim at the favorable permeation and enrichment of K+ by microspheres. The microspheres have a microphase-isolated core-shell structure, whose nano-spaced groups form cation-affinitive clusters. Selective K+ removal and blood compatibility are achieved. We expect this strategy to enlighten alternative hyperkalemia therapy for these high-risk patients.
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Affiliation(s)
- Zhoujun Wang
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China
| | - Rui Yuan
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China
| | - Peiyang Li
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China
| | - Yanping Huang
- School of Chemical Engineering, Sichuan University, Chengdu 610065, China
| | - Weifeng Zhao
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China.
| | - Changsheng Zhao
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China; School of Chemical Engineering, Sichuan University, Chengdu 610065, China; Med-X Center for Materials, Sichuan University, Chengdu, 610065, China.
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De Troyer M, Wissing KM, De Clerck D, Cambier ML, Robberechts T, Tonnelier A, François K. Risk for excessive anticoagulation during hemodialysis is associated with type of vascular access and bedside coagulation testing: Results of a cross-sectional study. Front Med (Lausanne) 2022; 9:1009748. [PMID: 36590973 PMCID: PMC9794613 DOI: 10.3389/fmed.2022.1009748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
Background Recommendations and practice patterns for heparin dosing during hemodialysis show substantial heterogeneity and are scantly supported by evidence. This study assessed the variability in unfractionated heparin (UFH) dosing during hemodialysis and its clinical and biological anticoagulatory effects, and identified explanatory factors of heparin dosing. Methods Cross-sectional study assessing UFH dosing, coagulation tests - activated partial thromboplastin time (aPTT) and activated clotting time (ACT) before dialysis start, 1 h after start and at treatment end (4 h) - and measurement of residual blood compartment volume of used dialyzers. Results 101 patients, 58% male, with a median dialysis vintage of 33 (6-71) months received hemodialysis using a total UFH dose of 9,306 ± 4,079 (range 3,000-23,050) IU/session. Use of a dialysis catheter (n = 56, 55%) was associated with a 1.4 times higher UFH dose (p < 0.001) irrespective of prior access function. aPTT increased significantly more than ACT both 1 h and 4 h after dialysis start, independent of the dialysis access used. 53% of patients with catheter access and ACT ratio < 1.5, 1 h after dialysis start had simultaneous aPTT ratios > 2.5. Similar findings were present at 1 h for patients with AVF/AVG and at dialysis end for catheter use. No clinically significant clotting of the extracorporeal circuit was noted during the studied sessions. Dialyzer's blood compartment volume was reduced with a median of 9% (6-20%) without significant effect of UFH dose, aPTT or ACT measurements and vascular access type. Conclusion UFH dose adaptations based on ACT measurements frequently result in excessive anticoagulation according to aPTT results. Higher doses of UFH are used in patients with hemodialysis catheters without evidence that this reduces dialyzer clotting.
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Jin H, He M, Yang G, Xie W, Yu D, Li H, Xiao W, Li Y. A Retrospective Study of the Perioperative Period Management of Joint Arthroplasty in Patients with Chronic Kidney Disease. Orthop Surg 2022; 15:591-605. [PMID: 36453119 PMCID: PMC9891927 DOI: 10.1111/os.13589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE With the rising prevalence of chronic kidney disease (CKD) and the increasing demand for joint arthroplasty, the management of CKD patients in the perioperative period of joint arthroplasty has become an issue worthy of attention for orthopedic surgeons. This study aimed to explore comprehensive perioperative period management strategies for CKD patients. METHODS From March 2017 to August 2022, 62 patients who underwent joint arthroplasty in our hospital were included in a retrospective study, including 31 CKD patients (mean age 69.8 ± 13.4 years old) and 31 non-CKD patients (mean age 69.4 ± 14.2 years old). The outcome indicators were analyzed, including serum urea, serum creatinine, blood uric acid, hematocrit, and hemoglobin. RESULTS All patients included in the retrospective study had an average preoperative preparation time of 4.3 ± 2.6 days and an average hospitalization time of 11.0 ± 7.3 days. There were no significant differences in the changes in the serum urea values between the preoperative and postoperative measurements in the CKD patients or in the serum creatinine values and blood uric acid values (P > 0.05). The hemoglobin value in postoperative measurements was lower than in preoperative measurements in the CKD patients (P < 0.05). The hematocrit value in postoperative measurements was lower than in preoperative measurements in the CKD patients (P < 0.001). CONCLUSION Patients with CKD have distinct characteristics compared to non-CKD patients, and they generally have a higher risk for postoperative complications and adverse events. Recognition of risk factors, suitable timing of surgery, the undertaking of protective strategies, and proper management of complications are vital for managing CKD patients in the perioperative period of joint arthroplasty.
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Affiliation(s)
- Hongfu Jin
- Department of OrthopedicsXiangya Hospital, Central South UniversityChangshaHunanChina,National Clinical Research Center for Geriatric DisordersXiangya Hospital, Central South UniversityChangshaHunanChina
| | - Miao He
- Department of OrthopedicsXiangya Hospital, Central South UniversityChangshaHunanChina,National Clinical Research Center for Geriatric DisordersXiangya Hospital, Central South UniversityChangshaHunanChina
| | - Guang Yang
- Department of OrthopedicsXiangya Hospital, Central South UniversityChangshaHunanChina,National Clinical Research Center for Geriatric DisordersXiangya Hospital, Central South UniversityChangshaHunanChina
| | - Wenqing Xie
- Department of OrthopedicsXiangya Hospital, Central South UniversityChangshaHunanChina,National Clinical Research Center for Geriatric DisordersXiangya Hospital, Central South UniversityChangshaHunanChina
| | - Dengjie Yu
- Department of OrthopedicsXiangya Hospital, Central South UniversityChangshaHunanChina,National Clinical Research Center for Geriatric DisordersXiangya Hospital, Central South UniversityChangshaHunanChina
| | - Hengzhen Li
- Department of OrthopedicsXiangya Hospital, Central South UniversityChangshaHunanChina,National Clinical Research Center for Geriatric DisordersXiangya Hospital, Central South UniversityChangshaHunanChina
| | - Wenfeng Xiao
- Department of OrthopedicsXiangya Hospital, Central South UniversityChangshaHunanChina,National Clinical Research Center for Geriatric DisordersXiangya Hospital, Central South UniversityChangshaHunanChina
| | - Yusheng Li
- Department of OrthopedicsXiangya Hospital, Central South UniversityChangshaHunanChina,National Clinical Research Center for Geriatric DisordersXiangya Hospital, Central South UniversityChangshaHunanChina
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Wang H, Wang J, Feng J, Rao Y, Xu Z, Zu J, Wang H, Zhang Z, Chen H. Artificial Extracellular Matrix Composed of Heparin-Mimicking Polymers for Efficient Anticoagulation and Promotion of Endothelial Cell Proliferation. ACS APPLIED MATERIALS & INTERFACES 2022; 14:50142-50151. [PMID: 36302722 DOI: 10.1021/acsami.2c13892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Heparin-mimicking polymers have emerged as an alternative to heparin to construct effective and safe anticoagulant surfaces. However, the present heparin-mimicking polymers are usually limited to the combinations of glucose and sulfonic acid units, and the structure origin of their anticoagulant properties remains vague. Inspired by the structure of natural heparin, we synthesized a series of novel heparin-mimicking polymers (named GSAs) composed of three units, glucose, sulfonic acid, and carboxylic acid. Then, we constructed artificial extracellular matrices composed of GSAs and two typical cationic polymers, polyethyleneimine and chitosan, to investigate the anticoagulation and endothelialization of GSAs. By changing the ratio of the three units, their functions in the matrices were studied systematically. We found that an increase in the sulfonic acid content enhanced surface anticoagulant activity, an increase in glucose and sulfonic acid content promoted the proliferation of human umbilical vein vascular endothelial cells, and an increase in the carboxylic acid content inhibited the adherence of human umbilical vein vascular smooth muscle cells. This work uncovers the important role of the GSAs structure to the anticoagulation properties, which sheds new light on the design and preparation of heparin-mimicking polymers for practical engineering applications.
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Affiliation(s)
- Huanhuan Wang
- State and Local Joint Engineering Laboratory for Novel Functional Polymeric Materials, College of Chemistry, Chemical Engineering and Materials Science, Soochow University, 199 Ren'ai Road, Suzhou215123, P. R. China
| | - Jinghong Wang
- The SIP Biointerface Engineering Research Institute, Suzhou215123, P. R. China
| | - Jian Feng
- State and Local Joint Engineering Laboratory for Novel Functional Polymeric Materials, College of Chemistry, Chemical Engineering and Materials Science, Soochow University, 199 Ren'ai Road, Suzhou215123, P. R. China
| | - Yu Rao
- State and Local Joint Engineering Laboratory for Novel Functional Polymeric Materials, College of Chemistry, Chemical Engineering and Materials Science, Soochow University, 199 Ren'ai Road, Suzhou215123, P. R. China
| | - ZiYing Xu
- State and Local Joint Engineering Laboratory for Novel Functional Polymeric Materials, College of Chemistry, Chemical Engineering and Materials Science, Soochow University, 199 Ren'ai Road, Suzhou215123, P. R. China
| | - JunYi Zu
- State and Local Joint Engineering Laboratory for Novel Functional Polymeric Materials, College of Chemistry, Chemical Engineering and Materials Science, Soochow University, 199 Ren'ai Road, Suzhou215123, P. R. China
| | - Huaguang Wang
- State and Local Joint Engineering Laboratory for Novel Functional Polymeric Materials, College of Chemistry, Chemical Engineering and Materials Science, Soochow University, 199 Ren'ai Road, Suzhou215123, P. R. China
| | - Zexin Zhang
- State and Local Joint Engineering Laboratory for Novel Functional Polymeric Materials, College of Chemistry, Chemical Engineering and Materials Science, Soochow University, 199 Ren'ai Road, Suzhou215123, P. R. China
| | - Hong Chen
- State and Local Joint Engineering Laboratory for Novel Functional Polymeric Materials, College of Chemistry, Chemical Engineering and Materials Science, Soochow University, 199 Ren'ai Road, Suzhou215123, P. R. China
- The SIP Biointerface Engineering Research Institute, Suzhou215123, P. R. China
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9
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Pereira ABN, Santana LL, Rocha LDB, Cunha KDC, Rocha LSDO, Santos MCDS, Normando VMF, Torres DDC, Rocha RSB. Physical Exercise Affects Quality of Life and Cardiac Autonomic Modulation in Patients With Chronic Kidney Failure Submitted to Hemodialysis: A Randomized Clinical Trial. Percept Mot Skills 2022; 129:696-713. [DOI: 10.1177/00315125221085811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Performing physical exercise during hemodialysis has been debated regarding safety and efficacy for improving life quality for patients with chronic kidney disease (CKD). Thus, we explored the influence of physical exercise during hemodialysis on both autonomic modulation of heart rate and quality of life for patients with CKF in a randomized clinical trial. We randomly allocated participants requiring hemodialysis to an experimental exercise group (EG) and a control no-exercise group (CG) and assessed their quality of life with the Kidney Disease Quality of Life Short Form—KDQOL-SF™ 1.3 and with Polar RS800CX to monitor their heart rate variability (HRV) before and three months after the end of the exercise intervention. EG participants reported a significant increase in their quality of life ( p = .05, physical function, physical aspects, pain, emotional well-being, emotional function; p = .03, energy and fatigue) and showed HRV improvement ( p = .05, RMSSD, SDNN, and SD2; p = .004, SD1) after three months of exercise. Thus, we recommend supervised physical exercise during hemodialysis for carefully selected patients.
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Affiliation(s)
| | | | | | - Katiane Da Costa Cunha
- Department of Morphology and Physiological Sciences, University of Pará State, Belém, Brazil
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10
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Garg R, Parikh MP, Chadalvada P, Singh A, Sanaka K, Ahuja KR, Aggarwal M, Veluvolu R, Vignesh S, Rustagi T. Lower rates of endoscopy and higher mortality in end-stage renal disease patients with gastrointestinal bleeding: A propensity matched national study. J Gastroenterol Hepatol 2022; 37:584-591. [PMID: 34989024 DOI: 10.1111/jgh.15771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/16/2021] [Accepted: 12/22/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Patients with end-stage renal disease (ESRD) on hemodialysis are considered to be at higher risk of gastrointestinal bleeding (GIB) as compared with those without renal disease (NRD). We conducted a population-based study using the National Inpatient Sample (NIS) database to study the outcomes of GIB in ESRD. METHODS Patients admitted with GIB (upper and lower) from 2005 to 2013 were extracted from the NIS database using ICD-9 codes. Patients were divided into NRD and ESRD groups, and a 1:1 propensity matched analysis was performed. Various outcomes were compared in both groups, and subgroup analysis based on the timing of endoscopy was also performed. RESULTS A total of 218 032 patients were included in the study. There was an increase in inpatient admissions among ESRD patients with GIB with significant reduction in mortality (P < 0.001). In-hospital mortality, length of stay, and total costs were significantly higher in ESRD patients as compared with NRD. ESRD patients were less likely to undergo endoscopic evaluation compared with NRD (P < 0.001). Late endoscopy (> 48 h) was associated with increased need for transfusion and health-care utilization but without a significant difference in mortality as compared with early endoscopy. On multivariate analysis, endoscopy was associated with significantly lower rate of mortality in ESRD patients with GIB (odds ratio 0.28, P < 0.0001). CONCLUSION End-stage renal disease patients with GIB had a significantly higher rate of mortality and a higher health-care utilization with a lower rate of endoscopic evaluation. Endoscopy was associated with a lower mortality rate on multivariate analysis.
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Affiliation(s)
- Rajat Garg
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Malav P Parikh
- Department of Gastroenterology, SUNY Downstate Health Sciences University, New York, New York, USA
| | - Pravallika Chadalvada
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Krishna Sanaka
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Keerat R Ahuja
- Department of Cardiology, Tower Health, Philadelphia, Pennsylvania, USA
| | - Manik Aggarwal
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rajesh Veluvolu
- Department of Gastroenterology, SUNY Downstate Health Sciences University, New York, New York, USA
| | - Shivakumar Vignesh
- Department of Gastroenterology, SUNY Downstate Health Sciences University, New York, New York, USA
| | - Tarun Rustagi
- Department of Gastroenterology, University of New Mexico, Albuquerque, New Mexico, USA
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11
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Fisher C, Shao H, Ho CH. Improved hemocompatibility of polysulfone hemodialyzers with Endexo® surface modifying molecules. J Biomed Mater Res B Appl Biomater 2021; 110:1335-1343. [PMID: 34951744 DOI: 10.1002/jbm.b.35003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 11/19/2021] [Accepted: 12/13/2021] [Indexed: 11/09/2022]
Abstract
Anticoagulation therapy is widely used to reduce clotting during hemodialysis (HD), but may cause adverse effects in end-stage kidney disease patients. A new hemodialyzer with a membrane modified by surface modifying molecule was developed to improve hemocompatibility that aimed to reduce the need for anticoagulation during dialysis treatments. We compared membrane surface characteristics and in vitro hemocompatibility of the new hemodialyzer to the standard polysulfone (PSF) hemodialyzer membrane. Scanning electron microscopy, contact angle measurement (68° ± 3° test vs. 41.6° ± 6° control), and X-ray photoelectron spectrometry measurement for fluorine atomic % (7.4% ± 0.4% test vs. not detectable control), showed that the membrane surface was modified with surface modifying macromolecule (SMM1) but maintained membrane structure and surface hydrophilicity. Zeta potential of the blood-contacting surface showed that the absolute surface charge was reduced at neutral pH (-3.3 mV ± 1.1 mV test vs. -15.6 mV ± 1.0 mV control). Platelet count reduction was significantly less for the SMM1-modified dialyzer (40.88% ± 21.89%) compared to the standard PSF dialyzer (62.62% ± 34.13%), along with Platelet Factor 4 (1824.10 ng/ml ± 436.26 ng/ml test vs. 2479.00 ng/ml ± 852.96 ng/ml control). These studies demonstrate the successful incorporation of SMM1 into the new hemodialyzer with the expected results. Our in vitro experiments indicate that the SMM1-modified hemodialyzers could improve hemocompatibility compared to standard PSF hemodialyzers and have the potential to minimize the patient's anticoagulant requirements during HD. Additional research with SMM1 additives incorporated into the entire dialysis circuit and use in a clinical settings are required to confirm these promising findings.
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Affiliation(s)
- Colleen Fisher
- Biosciences Department, Fresenius Medical Care North America Global Research and Development, Ogden, Utah, USA
| | - Hui Shao
- Product Development Department, Fresenius Medical Care North America Global Research and Development, Ogden, Utah, USA
| | - Chih-Hu Ho
- Biosciences Department, Fresenius Medical Care North America Global Research and Development, Ogden, Utah, USA
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12
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Lee HW, An JN, Lee HS, Song YR, Kim HJ, Kim SG, Kim JK. Neutrophil extracellular traps and heparin-induced antibodies contribute to vascular access thrombosis in hemodialysis patients. Kidney Res Clin Pract 2021; 40:712-723. [PMID: 34370931 PMCID: PMC8685352 DOI: 10.23876/j.krcp.21.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/03/2021] [Indexed: 11/05/2022] Open
Abstract
Background Anti-heparin/platelet factor 4 (PF4) antibodies may trigger severe thrombotic complications in hemodialysis (HD) patients. Tetrameric PF4 has a high affinity for extracellular DNA, which is a key component of neutrophil extracellular traps (NETs); therefore, the interactions between anti-heparin/PF4 antibodies and NETs can contribute to prothrombotic events. Methods Anti-heparin/PF4 antibody levels were measured by enzyme-linked immunosorbent assay and an optical density > 1.8 was regarded as clinically significant. We additionally measured serum nucleosome levels as representative markers of NETs, and the contributions of anti-heparin/PF4 and increased serum nucleosome levels to the primary functional patency loss of vascular access was assessed. Results The frequency of anti-heparin/PF4 antibodies was significantly higher in incident HD patients compared to prevalent HD patients (23.6% vs. 7.7%). Serum nucleosome levels, as well as the white blood cell counts, neutrophil counts, and high- sensitivity C-reactive protein levels, were significantly higher in anti-heparin/PF4 antibody-positive patients compared to the control. Platelet counts tended to be lower in the patients with anti-heparin/PF4 of >1.8 than in the controls. Relative risk calculations showed that the presence of anti-heparin/PF4 antibodies increased the risk of primary functional patency failure by 4.28-fold, and this risk increased further with higher nucleosome levels. Furthermore, in the anti-heparin/PF4 antibody-positive group, the time to first vascular intervention was much shorter, and the risk of repeated intervention was higher, compared to the controls. Conclusion In incident HD patients, the presence of anti-heparin/PF4 antibodies was associated with increased NET formation; this could be a strong predictor of vascular access complications
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Affiliation(s)
- Hoi Woul Lee
- Department of Clinical Immunology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Jung Nam An
- Department of Internal Medicine and Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Hyung Seok Lee
- Department of Internal Medicine and Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Young Rim Song
- Department of Internal Medicine and Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Hyung Jik Kim
- Department of Internal Medicine and Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Sung Gyun Kim
- Department of Clinical Immunology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea.,Department of Internal Medicine and Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Jwa-Kyung Kim
- Department of Clinical Immunology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea.,Department of Internal Medicine and Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
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13
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Gupta A, Zimmerman D. Complications and challenges of home hemodialysis: A historical review. Semin Dial 2021; 34:269-274. [PMID: 33609415 DOI: 10.1111/sdi.12960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Home hemodialysis (HHD) has evolved as a preferred and safe kidney replacement modality over the past six decades. Despite advances in technological aspects of HHD, potential complications still pose a challenge to health care givers, patients, and their families. In this narrative review, we describe vascular access and cannulation, anticoagulation, nutritional, residual kidney function, psychosocial, technique failure, and machine/procedural-related complications. Addressing these problems is essential for favorable patient outcomes.
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Affiliation(s)
- Ankur Gupta
- Department of Medicine, Whakatane Hospital, Whakatane, New Zealand
| | - Deborah Zimmerman
- Division of Nephrology, The Ottawa Hospital, University of Ottawa, Ottawa, Canada
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14
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Heparin-mimicking semi-interpenetrating composite membrane with multiple excellent performances for promising hemodialysis. J Memb Sci 2021. [DOI: 10.1016/j.memsci.2020.118740] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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Claudel SE, Miles LA, Murea M. Anticoagulation in hemodialysis: A narrative review. Semin Dial 2020; 34:103-115. [PMID: 33135208 DOI: 10.1111/sdi.12932] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/28/2020] [Accepted: 10/11/2020] [Indexed: 12/18/2022]
Abstract
Systemic anticoagulation in maintenance hemodialysis (HD) has historically been considered necessary to maintain the extracorporeal circuit (ECC) and preserve dialysis efficiency. Unfractionated heparin (UFH) is the most commonly used anticoagulant due to low cost and staff familiarity. Despite widespread use, there is little standardization of heparin dosing protocols in the United States. Although the complication rates with UFH are low for the general population, certain contraindications have led to exploration in alternative anticoagulants in patients with end-stage kidney disease (ESKD). Here we review the current evidence regarding heparin dosing protocols, complications associated with heparin use, and discuss alternatives to UFH including anticoagulant-free routine HD.
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Affiliation(s)
- Sophie E Claudel
- Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Lauren A Miles
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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16
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Liang M, Wu Y, Su N, Liu Y, Lin W, Li S, Zhong W, Jiang Z. Prevalence, associated factors and cardiocerebral vascular prognosis of anaemia among patients on chronic haemodialysis in South Guangdong, China. J Int Med Res 2020; 48:300060520965791. [PMID: 33203278 PMCID: PMC7683930 DOI: 10.1177/0300060520965791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/21/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To assess the prevalence, associated factors and cardiocerebral vascular prognosis of anaemia in patients undergoing haemodialysis. METHODS This multicentre, retrospective, observational cohort study included patients on maintenance haemodialysis in South Guangdong, China. Anaemia in haemodialysis was defined as haemoglobin (Hb) <90 g/l. A proportion of patients were enrolled in a follow-up of the cardiocerebral vascular prognosis. RESULTS A total of 1161 patients were enrolled and 938 were followed-up for cardiocerebral vascular events. Of 1161 patients, 250 (21.5%) had anaemia and 524 (45.1%) had an Hb level of 100-120 g/l. Adjusted multivariate logistic regression analysis demonstrated that frequency of dialysis ≤ twice weekly, hypoalbuminaemia and use of unfractionated heparin were independent factors associated with anaemia. Kaplan-Meier survival curve analysis for no myocardial infarction was 100%, 100%, 100% and 100% after 3, 6, 9 and 12 months, respectively, in patients with Hb < 90 g/l; compared with 97%, 95%, 93% and 93%, respectively, in patients with Hb ≥ 130 g/l. Adjusted Cox proportional hazards regression demonstrated that Hb ≥ 130 g/l was an independent risk factor for myocardial infarction. CONCLUSION Anaemia is highly prevalent among patients undergoing haemodialysis in South Guangdong and requires careful management.
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Affiliation(s)
- Mengjun Liang
- Department of Nephrology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong Province, China
| | - Yong Wu
- Department of Nephrology, Huizhou Municipal Central Hospital, Huizhou, Guangdong Province, China
| | - Ning Su
- Department of Nephrology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong Province, China
| | - Ying Liu
- Department of Nephrology, Huizhou Municipal Central Hospital, Huizhou, Guangdong Province, China
| | - Weiping Lin
- Department of Nephrology, Huizhou Municipal Central Hospital, Huizhou, Guangdong Province, China
| | - Siyi Li
- Department of Nephrology, Huizhou Municipal Central Hospital, Huizhou, Guangdong Province, China
| | - Weiqiang Zhong
- Department of Nephrology, Huizhou Municipal Central Hospital, Huizhou, Guangdong Province, China
| | - Zongpei Jiang
- Department of Nephrology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong Province, China
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17
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Kato C, Oakes M, Kim M, Desai A, Olson SR, Raghunathan V, Shatzel JJ. Anticoagulation strategies in extracorporeal circulatory devices in adult populations. Eur J Haematol 2020; 106:19-31. [PMID: 32946632 DOI: 10.1111/ejh.13520] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/27/2020] [Accepted: 08/31/2020] [Indexed: 12/16/2022]
Abstract
Extracorporeal circulatory devices such as hemodialysis and extracorporeal membrane oxygenation can be lifesaving; however, they are also prone to pathologic events including device failure, venous and arterial thrombosis, hemorrhage, and an accelerated risk for atherosclerotic disease due to interactions between blood components and device surfaces of varying biocompatibility. While extracorporeal devices may be used acutely for limited periods of time (eg, extracorporeal membrane oxygenation, continuous venovenous hemofiltration, therapeutic apheresis), some patients require chronic use of these technologies (eg, intermittent hemodialysis and left ventricular assist devices). Given the substantial thrombotic risks associated with extracorporeal devices, multiple antiplatelet and anticoagulation strategies-including unfractionated heparin, low-molecular-weight heparin, citrate, direct thrombin inhibitors, and direct oral anticoagulants, have been used to mitigate the thrombotic milieu within the patient and device. In the following manuscript, we outline the current data on anticoagulation strategies for commonly used extracorporeal circulatory devices, highlighting the potential benefits and complications involved with each.
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Affiliation(s)
- Catherine Kato
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Michael Oakes
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Morris Kim
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Anish Desai
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Sven R Olson
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA.,Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Vikram Raghunathan
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Joseph J Shatzel
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA.,Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
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18
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Wang Z, Sun W, Wei Z, Bao J, Song X, Li Y, Ji H, Zhang J, He C, Su B, Zhao W, Zhao C. Selective potassium uptake via biocompatible zeolite-polymer hybrid microbeads as promising binders for hyperkalemia. Bioact Mater 2020; 6:543-558. [PMID: 32995679 PMCID: PMC7498761 DOI: 10.1016/j.bioactmat.2020.08.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/19/2020] [Accepted: 08/24/2020] [Indexed: 02/05/2023] Open
Abstract
Patients with chronic kidney disease are at high risk of hyperkalemia that is associated with various life-threatening complications. Treatments primarily rely on orally administered potassium binding agents, along with low curative effects and various side effects. Herein, direct serum potassium uptake was realized via zeolite–heparin-mimicking-polymer hybrid microbeads. The preparation process involved the synthesis of the heparin-mimicking polymer via the in situ cross-linking polymerization of acrylic acid and N-vinylpyrrolidone in polyethersulfone solution, the fabrication of microbeads via zeolite-mixing, electro-spraying and phase-inversion, and the subsequent aqueous-phase modifications based on ion-exchange and metal-leaching. An ultra-high (about 88%) amount of zeolite could be incorporated and well locked inside the polymer matrix. Potassium uptake capability was verified in water, normal saline and human serum, showing high selectivity and fast adsorption. The microbeads exhibited satisfying blood compatibility, negligible hemolysis ratio, prolonged clotting time, inhibited contact activation, and enhanced antifouling property toward serum proteins and cells. The proposed approach toward zeolite–heparin-mimicking-polymer hybrid microbeads provided a cheap, efficient and safe treatment protocol of hyperkalemia for the high-risk patients. Zeolite–heparin-mimicking-polymer hybrid microbeads were prepared for potassium uptake. An ultra-high (~88%) amount of zeolite could be well locked inside the polymer matrix. Potassium uptake by microbeads exhibited high selectivity and fast adsorption. The microbeads exhibited excellent blood compatibility. The proposed method is cheap, efficient and safe to treat hyperkalemia.
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Affiliation(s)
- Zhoujun Wang
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, 610065, China
| | - Wei Sun
- Laboratory Department of General Hospital of Western Theatek Command, Chengdu, 610000, China
| | - Zhiwei Wei
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, 610065, China
| | - Jianxu Bao
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, 610065, China
| | - Xin Song
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, 610065, China
| | - Yupei Li
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, 610041, China.,Institute for Disaster Management and Reconstruction, Sichuan University, Chengdu, 610207, China
| | - Haifeng Ji
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, 610065, China
| | - Jue Zhang
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, 610065, China
| | - Chao He
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, 610065, China
| | - Baihai Su
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, 610041, China.,Institute for Disaster Management and Reconstruction, Sichuan University, Chengdu, 610207, China
| | - Weifeng Zhao
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, 610065, China
| | - Changsheng Zhao
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, 610065, China.,College of Chemical Engineering, Sichuan University, Chengdu, 610065, China.,College of Biomedical Engineering, Sichuan University, Chengdu, 610064, China
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19
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Bansal S, Pergola PE. Current Management of Hyperkalemia in Patients on Dialysis. Kidney Int Rep 2020; 5:779-789. [PMID: 32518860 PMCID: PMC7270720 DOI: 10.1016/j.ekir.2020.02.1028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 02/07/2023] Open
Abstract
Patients with end-stage renal disease (ESRD) on maintenance dialysis have a high risk of developing hyperkalemia, generally defined as serum potassium (K+) concentrations of >5.0 mmol/l, particularly those undergoing maintenance hemodialysis. Currently, the key approaches to the management of hyperkalemia in patients with ESRD are dialysis, dietary K+ restriction, and avoidance of medications that increase hyperkalemia risk. In this review, we highlight the issues and challenges associated with effective management of hyperkalemia in patients undergoing maintenance dialysis using an illustrative case presentation. In addition, we examine the potential nondialysis options for the management of these patients, including use of the newer K+ binder agents patiromer and sodium zirconium cyclosilicate, which may reduce the need for the highly restrictive dialysis diet, with its own implication on nutritional status in patients with ESRD, as well as reducing the risk of potentially life-threatening hyperkalemia.
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Affiliation(s)
- Shweta Bansal
- Division of Nephrology, UT Health at San Antonio, San Antonio, Texas, USA
| | - Pablo E Pergola
- Division of Nephrology, UT Health at San Antonio, San Antonio, Texas, USA.,Renal Associates, P.A., San Antonio, Texas, USA
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20
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Ashby D, Borman N, Burton J, Corbett R, Davenport A, Farrington K, Flowers K, Fotheringham J, Andrea Fox RN, Franklin G, Gardiner C, Martin Gerrish RN, Greenwood S, Hothi D, Khares A, Koufaki P, Levy J, Lindley E, Macdonald J, Mafrici B, Mooney A, Tattersall J, Tyerman K, Villar E, Wilkie M. Renal Association Clinical Practice Guideline on Haemodialysis. BMC Nephrol 2019; 20:379. [PMID: 31623578 PMCID: PMC6798406 DOI: 10.1186/s12882-019-1527-3] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 12/15/2022] Open
Abstract
This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: "what does good quality haemodialysis look like?"The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to - most of this is freely available online, at least in summary form.A few notes on the individual sections: 1. This section is about how much dialysis a patient should have. The effectiveness of dialysis varies between patients because of differences in body size and age etc., so different people need different amounts, and this section gives guidance on what defines "enough" dialysis and how to make sure each person is getting that. Quite a bit of this section is very technical, for example, the term "eKt/V" is often used: this is a calculation based on blood tests before and after dialysis, which measures the effectiveness of a single dialysis session in a particular patient. 2. This section deals with "non-standard" dialysis, which basically means anything other than 3 times per week. For example, a few people need 4 or more sessions per week to keep healthy, and some people are fine with only 2 sessions per week - this is usually people who are older, or those who have only just started dialysis. Special considerations for children and pregnant patients are also covered here. 3. This section deals with membranes (the type of "filter" used in the dialysis machine) and "HDF" (haemodiafiltration) which is a more complex kind of dialysis which some doctors think is better. Studies are still being done, but at the moment we think it's as good as but not better than regular dialysis. 4. This section deals with fluid removal during dialysis sessions: how to remove enough fluid without causing cramps and low blood pressure. Amongst other recommendations we advise close collaboration with patients over this. 5. This section deals with dialysate, which is the fluid used to "pull" toxins out of the blood (it is sometimes called the "bath"). The level of things like potassium in the dialysate is important, otherwise too much or too little may be removed. There is a section on dialysate buffer (bicarbonate) and also a section on phosphate, which occasionally needs to be added into the dialysate. 6. This section is about anticoagulation (blood thinning) which is needed to stop the circuit from clotting, but sometimes causes side effects. 7. This section is about certain safety aspects of dialysis, not seeking to replace well-established local protocols, but focussing on just a few where we thought some national-level guidance would be useful. 8. This section draws together a few aspects of dialysis which don't easily fit elsewhere, and which impact on how dialysis feels to patients, rather than the medical outcome, though of course these are linked. This is where home haemodialysis and exercise are covered. There is an appendix at the end which covers a few aspects in more detail, especially the mathematical ideas. Several aspects of dialysis are not included in this guideline since they are covered elsewhere, often because they are aspects which affect non-dialysis patients too. This includes: anaemia, calcium and bone health, high blood pressure, nutrition, infection control, vascular access, transplant planning, and when dialysis should be started.
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Affiliation(s)
- Damien Ashby
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England.
| | - Natalie Borman
- Wessex Kidney Centre, Portsmouth NHS Trust, Portsmouth, England
| | - James Burton
- University Hospitals of Leicester NHS Trust, Leicester, England
| | - Richard Corbett
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England
| | | | - Ken Farrington
- Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, England
| | - Katey Flowers
- Wessex Kidney Centre, Portsmouth NHS Trust, Portsmouth, England
| | | | - R N Andrea Fox
- School of Nursing and Midwifery, University of Sheffield, Sheffield, England
| | - Gail Franklin
- East & North Hertfordshire NHS Trust, Stevenage, England
| | | | | | - Sharlene Greenwood
- Renal and Exercise Rehabilitation, King's College Hospital, London, England
| | | | - Abdul Khares
- Haemodialysis Patient, c/o The Renal Association, Bristol, UK
| | - Pelagia Koufaki
- School of Health Sciences, Queen Margaret University, Edinburgh, Scotland
| | - Jeremy Levy
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England
| | - Elizabeth Lindley
- Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, England
| | - Jamie Macdonald
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
| | - Bruno Mafrici
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | | | - Kay Tyerman
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Enric Villar
- Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, England
| | - Martin Wilkie
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England
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21
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Jegatheswaran J, Hundemer GL, Massicotte-Azarniouch D, Sood MM. Anticoagulation in Patients With Advanced Chronic Kidney Disease: Walking the Fine Line Between Benefit and Harm. Can J Cardiol 2019; 35:1241-1255. [PMID: 31472820 DOI: 10.1016/j.cjca.2019.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 12/23/2022] Open
Abstract
Chronic kidney disease affects more than 3 million Canadians and is highly associated with cardiovascular diseases that require anticoagulation, such as atrial fibrillation and venous thromboembolism. Patients with chronic kidney disease are at a problematic crossroads; they are at high risk of thrombotic conditions requiring anticoagulation and bleeding complications due to anticoagulation. The limited high-quality clinical evidence to guide decision-making in this area further compounds the dilemma. In this review, we discuss the physiology and epidemiology of bleeding and thrombosis in patients with kidney disease. We specifically focus on patients with advanced kidney disease (estimated glomerular filtration rate ≤ 30 mL/min) or who are receiving dialysis and focus on the nephrologist perspective regarding these issues. We summarize the existing evidence for anticoagulation use in the prevention of stroke with atrial fibrillation and provide practical clinical recommendations for considering anticoagulation use in this population. Last, we examine specific scenarios such as the use of a glomerular filtration rate estimating equation and dosing, the use of existing prediction tools for stroke and hemorrhage risk, current patterns of anticoagulation use (including during the dialysis procedure), and vascular calcification with vitamin K antagonist use in patients with chronic kidney disease.
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Affiliation(s)
| | - Gregory L Hundemer
- Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Manish M Sood
- Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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22
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Chronic Kidney Disease Increases Cerebral Microbleeds in Mouse and Man. Transl Stroke Res 2019; 11:122-134. [PMID: 31055735 PMCID: PMC6957561 DOI: 10.1007/s12975-019-00698-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 01/28/2019] [Accepted: 02/22/2019] [Indexed: 01/07/2023]
Abstract
Brain microbleeds are increased in chronic kidney disease (CKD) and their presence increases risk of cognitive decline and stroke. We examined the interaction between CKD and brain microhemorrhages (the neuropathological substrate of microbleeds) in mouse and cell culture models and studied progression of microbleed burden on serial brain imaging from humans. Mouse studies: Two CKD models were investigated: adenine-induced tubulointerstitial nephritis and surgical 5/6 nephrectomy. Cell culture studies: bEnd.3 mouse brain endothelial cells were grown to confluence, and monolayer integrity was measured after exposure to 5–15% human uremic serum or increasing concentrations of urea. Human studies: Progression of brain microbleeds was evaluated on serial MRI from control, pre-dialysis CKD, and dialysis patients. Microhemorrhages were increased 2–2.5-fold in mice with CKD independent of higher blood pressure in the 5/6 nephrectomy model. IgG staining was increased in CKD animals, consistent with increased blood–brain barrier permeability. Incubation of bEnd.3 cells with uremic serum or elevated urea produced a dose-dependent drop in trans-endothelial electrical resistance. Elevated urea induced actin cytoskeleton derangements and decreased claudin-5 expression. In human subjects, prevalence of microbleeds was 50% in both CKD cohorts compared with 10% in age-matched controls. More patients in the dialysis cohort had increased microbleeds on follow-up MRI after 1.5 years. CKD disrupts the blood–brain barrier and increases brain microhemorrhages in mice and microbleeds in humans. Elevated urea alters the actin cytoskeleton and tight junction proteins in cultured endothelial cells, suggesting that these mechanisms explain (at least in part) the microhemorrhages and microbleeds observed in the animal and human studies.
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Dai Y, Dai S, Xie X, Ning J. Immobilizing argatroban and mPEG-NH2 on a polyethersulfone membrane surface to prepare an effective nonthrombogenic biointerface. JOURNAL OF BIOMATERIALS SCIENCE-POLYMER EDITION 2019; 30:608-628. [PMID: 30907698 DOI: 10.1080/09205063.2019.1595891] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Yanling Dai
- Department of Nephrology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Siyuan Dai
- Department of Nephrology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Xiaohui Xie
- Department of Nephrology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jianping Ning
- Department of Nephrology, Xiangya Hospital of Central South University, Changsha, Hunan, China
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Voinova M, Repin N, Sokol E, Tkachuk B, Gorelik L. Physical Processes in Polymeric Filters Used for Dialysis. Polymers (Basel) 2019; 11:E389. [PMID: 30960373 PMCID: PMC6473866 DOI: 10.3390/polym11030389] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/06/2019] [Accepted: 02/12/2019] [Indexed: 01/03/2023] Open
Abstract
The key physical processes in polymeric filters used for the blood purification include transport across the capillary wall and the interaction of blood cells with the polymer membrane surface. Theoretical modeling of membrane transport is an important tool which provides researchers with a quantification of the complex phenomena involved in dialysis. In the paper, we present a dense review of the most successful theoretical approaches to the description of transport across the polymeric membrane wall as well as the cell⁻polymer surface interaction, and refer to the corresponding experimental methods while studying these phenomena in dialyzing filters.
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Affiliation(s)
- Marina Voinova
- Department of Physics, Chalmers University of Technology, 41296 Gothenburg, Sweden.
- Department of Industrial and Biomedical Electronics, Kharkiv Polytechnical Institute, National Technical University, 61002 Kharkov, Ukraine.
| | - Nikolay Repin
- Department of Cryomorphology, Institute for Problems of Cryobiology and Cryomedicine, 61015 Kharkov, Ukraine.
| | - Evgen Sokol
- Department of Industrial and Biomedical Electronics, Kharkiv Polytechnical Institute, National Technical University, 61002 Kharkov, Ukraine.
| | - Bogdan Tkachuk
- Department of Hemodialysis, Municipal Noncommercial Enterprise of Kharkiv Regional Council "Regional Medical Clinical Center of Urology and Nephrology n.a. V.I. Shapoval", 61037 Kharkov, Ukraine.
| | - Leonid Gorelik
- Department of Physics, Chalmers University of Technology, 41296 Gothenburg, Sweden.
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26
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Minasyan H, Flachsbart F. Blood coagulation: a powerful bactericidal mechanism of human innate immunity. Int Rev Immunol 2019; 38:3-17. [DOI: 10.1080/08830185.2018.1533009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Hayk Minasyan
- Private laboratory, Immunology Microbiology, Yerevan, Armenia
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Brunelli SM, Cohen DE, Marlowe G, Liu D, Njord L, Van Wyck D, Aronoff G. Safety and efficacy of heparin during dialysis in the context of systemic anticoagulant and antiplatelet medications. J Nephrol 2019; 32:453-460. [PMID: 30604148 DOI: 10.1007/s40620-018-00576-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 12/18/2018] [Indexed: 10/27/2022]
Abstract
Heparin is widely used to prevent coagulation during hemodialysis. Although systemic anticoagulants and antiplatelet agents are commonly prescribed in the hemodialysis population, the safety and efficacy of heparin in the presence of these medications is unclear. This retrospective cohort study considered adult hemodialysis patients treated in the United States (August 2015-July 2017). For each month, patients were ascribed a three-part exposure status (heparin use, anticoagulant use, antiplatelet agent use) based on electronic health records. Outcomes included anemia measures, peri-treatment bleeding and clotting, and hospitalization for gastrointestinal (GI) bleeding. Within systemic medication exposure categories, associations of heparin use were examined using adjusted generalized linear, negative binomial, or Poisson models. Across all systemic medication exposures, heparin use was associated with lower erythropoiesis stimulating agent (ESA) dose, higher hemoglobin levels, and lower monthly intravenous (IV) iron dose; lower rates of clotting during treatment and hospitalization for GI bleeding; and similar rates of peri-treatment bleeding. Associations with respect to ESA, IV iron, hemoglobin, and clotting were approximately twofold more potent in the absence of a systemic anticoagulant; the presence of an antiplatelet agent had little impact. Neither medication type influenced associations between heparin use and peri-treatment or GI bleeding. These results suggest that heparin use is safe and effective in the presence and absence of systemic anticoagulants and antiplatelet agents. Clinical judgment must be applied to assess bleeding risk in individual patients; however, the decision to withhold heparin should not solely be based upon the concurrent use of anticoagulant or antiplatet agents.
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Affiliation(s)
- Steven M Brunelli
- DaVita Clinical Research, 825 South 8th Street, Minneapolis, MN, 55404, USA. .,DaVita Institute for Patient Safety, Inc, Denver, CO, USA.
| | - Dena E Cohen
- DaVita Clinical Research, 825 South 8th Street, Minneapolis, MN, 55404, USA.,DaVita Institute for Patient Safety, Inc, Denver, CO, USA
| | - Gilbert Marlowe
- DaVita Clinical Research, 825 South 8th Street, Minneapolis, MN, 55404, USA.,DaVita Institute for Patient Safety, Inc, Denver, CO, USA
| | - Daniel Liu
- DaVita Institute for Patient Safety, Inc, Denver, CO, USA
| | - Levi Njord
- DaVita Institute for Patient Safety, Inc, Denver, CO, USA
| | - David Van Wyck
- DaVita Institute for Patient Safety, Inc, Denver, CO, USA
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28
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Preparation and evaluation of a self-anticlotting dialyzer via an interface crosslinking approach. J Memb Sci 2018. [DOI: 10.1016/j.memsci.2018.05.056] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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29
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Walder A, Müller M, Dahdal S, Sidler D, Devetzis V, Leichtle AB, Fiedler MG, Popp AW, Lippuner K, Vogt B, Uehlinger D, Huynh-Do U, Arampatzis S. The effect of a previous created distal arteriovenous-fistula on radial bone DXA measurements in prevalent renal transplant recipients. PLoS One 2018; 13:e0200708. [PMID: 30048464 PMCID: PMC6061984 DOI: 10.1371/journal.pone.0200708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 07/02/2018] [Indexed: 11/18/2022] Open
Abstract
Background Accelerated bone loss occurs rapidly following renal transplantation due to intensive immunosuppression and persistent hyperparathyroidism. In renal transplant recipients (RTRs) due to the hyperparathyroidism the non-dominant forearm is often utilized as a peripheral measurement site for dual-energy x-ray absorptiometry (DXA) measurements. The forearm is also the site of previous created distal arteriovenous fistulas (AVF). Although AVF remain patent long after successful transplantation, there are no data available concerning their impact on radial bone DXA measurements. Methods In this cross-sectional study we performed DXA in 40 RTRs with preexisting distal AVF (RTRs-AVF) to assess areal bone mineral density (aBMD) differences between both forearms (three areas) and compared our findings to patients with chronic kidney disease (CKD, n = 40), pre-emptive RTRs (RTRs-pre, n = 15) and healthy volunteers (n = 20). In addition, we assessed relevant demographic, biochemical and clinical aspects. Results We found a marked radial asymmetry between the forearms in RTRs with preexisting AVF. The radial aBMD at the distal AVF forearm was lower compared to the contralateral forearm, resulting in significant differences for all three areas analyzed: the Rad-1/3: median (interquartile range) in g/cm2, Rad-1/3: 0.760 (0.641–0.804) vs. 0.742 (0.642, 0.794), p = 0.016; ultradistal radius, Rad-UD: 0.433 (0.392–0.507) vs. 0.420 (0.356, 0.475), p = 0.004; and total radius, Rad-total: 0.603 (0.518, 0.655) vs. 0.599 (0.504, 0.642), p = 0.001). No such asymmetries were observed in any other groups. Lower aBMD in AVF forearm subregions resulted in misclassification of osteoporosis. Conclusions In renal transplant recipients, a previously created distal fistula may exert a negative impact on the radial bone leading to significant site-to-site aBMD differences, which can result in diagnostic misclassifications.
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Affiliation(s)
- Anna Walder
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Suzan Dahdal
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Daniel Sidler
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Vasilios Devetzis
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Alexander B. Leichtle
- Center of Laboratory Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Martin G. Fiedler
- Center of Laboratory Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Albrecht W. Popp
- Department of Osteoporosis, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Kurt Lippuner
- Department of Osteoporosis, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Bruno Vogt
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Dominik Uehlinger
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Uyen Huynh-Do
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Spyridon Arampatzis
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
- * E-mail:
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Miller CM, Xu Y, Kudrna KM, Hass BE, Kellar BM, Egger AW, Liu J, Harris EN. 3-O sulfation of heparin leads to hepatotropism and longer circulatory half-life. Thromb Res 2018; 167:80-87. [PMID: 29793137 DOI: 10.1016/j.thromres.2018.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 04/20/2018] [Accepted: 05/15/2018] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Heparins are common blood anticoagulants that are critical for many surgical and biomedical procedures used in modern medicine. In contrast to natural heparin derived from porcine gut mucosa, synthetic heparins are homogenous by mass, polymer length, and chemistry. MATERIALS & METHODS Stable cell lines expressing the human and mouse Stabilin receptors were used to evaluate endocytosis of natural and synthetic heparin. We chemoenzymatically produced synthetic heparin consisting of 12 sugars (dodecamers) containing 14 sulfate groups resulting in a non-3-O sulfated structure (n12mer). Half of the n12mer was modified with a 3-O sulfate on a single GlcNS sugar producing the 3-O sulfated heparin (12mer). Wildtype (WT), Stabilin-1 knock-out (KO), and Stabilin-2 KO C57BL/6 mice were developed and used for metabolic studies and provided as a source for primary liver sinusoidal endothelial cells. RESULTS & CONCLUSIONS Human and mouse Stabilin-2 receptors had very similar endocytosis rates of both the 12mer and n12mer, suggesting that they are functionally similar in primary cells. Subcutaneous injections of the n12mer and 12mer revealed that the 12mer had a much longer half-life in circulation and a higher accumulation in liver. The n12mer never accumulated in circulation and was readily excreted by the kidneys before liver accumulation could occur. Liver sinusoidal endothelial cells from the Stabilin-2 KO mice had lower uptake rates for both dodecamers, whereas, the Stabilin-1 KO mice had lower endocytosis rates for the 12mer than the n12mer. 3-O sulfation of heparin is correlated to both a longer circulatory half-life and hepatotropism which is largely performed by the Stabilin receptors.
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Affiliation(s)
- Colton M Miller
- Dept. of Biochemistry, University of Nebraska, Lincoln, NE 68588, United States
| | - Yongmei Xu
- Dept. of Pharmacy and Natural Products, University of North Carolina, Chapel Hill, NC 27099, United States
| | - Katrina M Kudrna
- Dept. of Biochemistry, University of Nebraska, Lincoln, NE 68588, United States
| | - Blake E Hass
- Dept. of Biochemistry, University of Nebraska, Lincoln, NE 68588, United States
| | - Brianna M Kellar
- Dept. of Biochemistry, University of Nebraska, Lincoln, NE 68588, United States
| | - Andrew W Egger
- Dept. of Biochemistry, University of Nebraska, Lincoln, NE 68588, United States
| | - Jian Liu
- Dept. of Pharmacy and Natural Products, University of North Carolina, Chapel Hill, NC 27099, United States
| | - Edward N Harris
- Dept. of Biochemistry, University of Nebraska, Lincoln, NE 68588, United States.
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Wang H, Li J, Liu F, Li T, Zhong Y, Lin H, He J. Enhanced hemocompatibility of flat and hollow fiber membranes via a heparin free surface crosslinking strategy. REACT FUNCT POLYM 2018. [DOI: 10.1016/j.reactfunctpolym.2018.01.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Nahain AA, Ignjatovic V, Monagle P, Tsanaktsidis J, Ferro V. Heparin mimetics with anticoagulant activity. Med Res Rev 2018; 38:1582-1613. [PMID: 29446104 DOI: 10.1002/med.21489] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 12/16/2017] [Accepted: 01/12/2018] [Indexed: 01/10/2023]
Abstract
Heparin, a sulfated polysaccharide belonging to the glycosaminoglycan family, has been widely used as an anticoagulant drug for decades and remains the most commonly used parenteral anticoagulant in adults and children. However, heparin has important clinical limitations and is derived from animal sources which pose significant safety and supply problems. The ever growing shortage of the raw material for heparin manufacturing may become a very significant issue in the future. These global limitations have prompted much research, especially following the recent well-publicized contamination scandal, into the development of alternative anticoagulants derived from non-animal and/or totally synthetic sources that mimic the structural features and properties of heparin. Such compounds, termed heparin mimetics, are also needed as anticoagulant materials for use in biomedical applications (e.g., stents, grafts, implants etc.). This review encompasses the development of heparin mimetics of various structural classes, including synthetic polymers and non-carbohydrate small molecules as well as sulfated oligo- and polysaccharides, and fondaparinux derivatives and conjugates, with a focus on developments in the past 10 years.
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Affiliation(s)
- Abdullah Al Nahain
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Vera Ignjatovic
- Haematology Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Paul Monagle
- Haematology Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.,Department of Clinical Haematology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - John Tsanaktsidis
- CSIRO Materials Science and Engineering, Clayton South, Victoria, Australia
| | - Vito Ferro
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia
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Yuan S, Qian Y, Tan D, Mo D, Li X. Therapeutic plasma exchange: A prospective randomized trial to evaluate 2 strategies in patients with liver failure. Transfus Apher Sci 2018; 57:253-258. [PMID: 29571962 DOI: 10.1016/j.transci.2018.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 02/01/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare two means of performing therapeutic plasma exchange (TPE) in patients with liver failure. METHOD This open-label monocentric randomized trial, conducted in a single prestigious general healthcare facility, recruited liver failure patients with an indication to receive artificial liver support therapy for TPE. All patients underwent TPE procedures and were administered in a random sequence: heparin-free or systemic heparinization with unfractionated heparin. The primary endpoint was completion of TPE sessions, and the secondary endpoints included the safety and efficacy. RESULTS In the period of the studying, there were 164 patients being recruited in and underwent total of 398 randomized TPEs: 168 with unfractionated heparin and 230 with heparin-free. In unfractionated heparin group, there were 3 cases (1.79%) being interrupted due to uncontrollable intraoperative pulmonary hemorrhages and gastrointestinal bleeding. In heparin-free group, 228 (99.13%) were completed successfully and 2 of them (0.87%) were switched from heparin-free to unfractionated heparin eventually. No significant differences were found between the two groups for either RRs or IRs (P > 0.05). CONCLUSION Heparin-free regimen is feasible and safer than systemic heparinization with unfractionated heparin in the process of TPEs in patients with liver failure.
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Affiliation(s)
- Su'e Yuan
- Xiangya Hospital Central South University, Changsha, Hunan Province, China; Xiangya Nursing School Central South University, Changsha, Hunan Province, China.
| | - Yun Qian
- Xiangya Hospital Central South University, Changsha, Hunan Province, China
| | - De'ming Tan
- Xiangya Hospital Central South University, Changsha, Hunan Province, China
| | - Dan Mo
- Xiangya Hospital Central South University, Changsha, Hunan Province, China
| | - Xue'bing Li
- Xiangya Hospital Central South University, Changsha, Hunan Province, China
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Vanommeslaeghe F, Van Biesen W, Dierick M, Boone M, Dhondt A, Eloot S. Micro-computed tomography for the quantification of blocked fibers in hemodialyzers. Sci Rep 2018; 8:2677. [PMID: 29422614 PMCID: PMC5805764 DOI: 10.1038/s41598-018-20898-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 01/24/2018] [Indexed: 01/13/2023] Open
Abstract
A novel technique based on micro-CT scanning is developed to quantify coagulation in fibers of hemodialyzers. This objectivation is needed to allow accurate assessment of thrombogenicity of dialyzers used during hemodialysis, for example when comparing different strategies to avoid coagulation and/or fiber blocking. The protocol allowed imaging at a resolution of 25 µm, making it possible to count the open, non-coagulated fibers in a non-invasive way. In 3 fresh, non-used FX600 hemodialyzers, patent fiber counts were extremely consistent (10748 ± 2). To illustrate the potential of this technique, different dialysis parameters currently used as surrogates for fiber blocking were evaluated during 20 hemodialysis sessions. After dialysis, the FX600 dialyzers were visually scored for clotting, dried and subsequently weighed and scanned. The number of patent fibers (10003 [8763,10330], range 534–10692) did not correlate with any of the recorded surrogate parameters. Micro-CT scanning is a feasible, objective, non-invasive, accurate and reproducible tool for quantification of the degree of fiber blocking in a hemodialyzer after use, making it a potential gold standard for use in studies on fiber blocking during renal replacement therapies.
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Affiliation(s)
| | - Wim Van Biesen
- Nephrology Department, Ghent University Hospital, Ghent, Belgium
| | - Manuel Dierick
- UGCT, Department of Subatomic and Radiation Physics, Ghent University, Ghent, Belgium
| | - Matthieu Boone
- UGCT, Department of Subatomic and Radiation Physics, Ghent University, Ghent, Belgium
| | - Annemieke Dhondt
- Nephrology Department, Ghent University Hospital, Ghent, Belgium
| | - Sunny Eloot
- Nephrology Department, Ghent University Hospital, Ghent, Belgium
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Hibi A, Kasugai T, Kamiya K, Kamiya K, Kominato S, Ito C, Miura T, Koyama K. Successful Recovery from Spontaneous Spinal Epidural Hematoma in a Patient Undergoing Hemodialysis. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:1357-1364. [PMID: 29259148 PMCID: PMC5745891 DOI: 10.12659/ajcr.905953] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Patient: Male, 70 Final Diagnosis: Spontaneous spinal epidural hematoma Symptoms: Abdominal pain • chest pain • complete paraplegia Medication: — Clinical Procedure: Conservative management Specialty: Nephrology
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Affiliation(s)
- Arata Hibi
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Takahisa Kasugai
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Keisuke Kamiya
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Keisuke Kamiya
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Satoru Kominato
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, Kariya, Aichii, Japan
| | - Chiharu Ito
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Toshiyuki Miura
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Katsushi Koyama
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, Kariya, Aichi, Japan
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Murea M, Russell GB, Daeihagh P, Saran AM, Pandya K, Cabrera M, Burkart JM, Freedman BI. Efficacy and safety of low-dose heparin in hemodialysis. Hemodial Int 2017; 22:74-81. [DOI: 10.1111/hdi.12563] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology; Wake Forest School of Medicine; Winston-Salem North Carolina USA
| | - Gregory B. Russell
- Department of Internal Medicine, Section on Nephrology; Wake Forest School of Medicine; Winston-Salem North Carolina USA
| | - Pirouz Daeihagh
- Department of Internal Medicine, Section on Nephrology; Wake Forest School of Medicine; Winston-Salem North Carolina USA
| | - Anita M. Saran
- Department of Internal Medicine, Section on Nephrology; Wake Forest School of Medicine; Winston-Salem North Carolina USA
| | - Karan Pandya
- Department of Internal Medicine, Section on Nephrology; Wake Forest School of Medicine; Winston-Salem North Carolina USA
| | - Mark Cabrera
- Department of Internal Medicine, Section on Nephrology; Wake Forest School of Medicine; Winston-Salem North Carolina USA
| | - John M. Burkart
- Department of Internal Medicine, Section on Nephrology; Wake Forest School of Medicine; Winston-Salem North Carolina USA
| | - Barry I. Freedman
- Department of Internal Medicine, Section on Nephrology; Wake Forest School of Medicine; Winston-Salem North Carolina USA
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Safadi S, Albright RC, Dillon JJ, Williams AW, Alahdab F, Brown JK, Severson AL, Kremers WK, Ryan MA, Hogan MC. Prospective Study of Routine Heparin Avoidance Hemodialysis in a Tertiary Acute Care Inpatient Practice. Kidney Int Rep 2017; 2:695-704. [PMID: 29142987 PMCID: PMC5678923 DOI: 10.1016/j.ekir.2017.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 02/28/2017] [Accepted: 03/08/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction Extracorporeal circuit (EC) anticoagulation with heparin is a key advance in hemodialysis (HD), but anticoagulation is problematic in inpatients at risk of bleeding. We prospectively evaluated a heparin-avoidance HD protocol, clotting of the EC circuit (CEC), impact on dialysis efficiency, and associated risk factors in our acute care inpatients who required HD (January 17, 2014 to May 31, 2015). Methods HD sessions without routine EC heparin were performed using airless dialysis tubing. Patients received systemic anticoagulation therapy and/or antiplatelets for non-HD indications. We observed patients for indications of CEC (interrupted HD session, circuit loss, or inability to return blood). The primary outcome was CEC. Logistic regression with generalized estimating equations assessed associations between CEC and other variables. Results HD sessions (n = 1200) were performed in 338 patients (204 with end-stage renal disease; 134 with acute kidney injury); a median session was 211 minutes (interquartile range [IQR]: 183−240 minutes); delivered dialysis dose measured by Kt/V was 1.4 (IQR: 1.2 Kt/V 1.7). Heparin in the EC was prescribed in only 4.5% of sessions; EC clotting rate was 5.2%. Determinants for CEC were temporary catheters (odds ratio [OR]: 2.8; P < 0.01), transfusions (OR: 2.4; P = 0.04), therapeutic systemic anticoagulation (OR: 0.2; P < 0.01), and antiplatelets (OR: 0.4; P < 0.01). CEC was associated with a lower delivered Kt/V (difference: 0.39; P < 0.01). Most CEC events during transfusions (71%) occurred with administration of blood products through the HD circuit. Discussion We successfully adopted heparin avoidance using airless HD tubing as our standard inpatient protocol. This protocol is feasible and safe in acute care inpatient HD. CEC rates were low and were associated with temporary HD catheters and transfusions. Antiplatelet agents and systemic anticoagulation were protective. ClinicalTrials.gov Identifier:NCT02086682.
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Affiliation(s)
- Sami Safadi
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert C Albright
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - John J Dillon
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Amy W Williams
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Fares Alahdab
- Division of Preventive, Occupational, and Aerospace Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Julie K Brown
- Nursing Practice Resources Division, Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - Amanda L Severson
- Medical Nephrology Division, Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - Walter K Kremers
- Division and Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Mary Ann Ryan
- Medical Nephrology Division, Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - Marie C Hogan
- Division of Preventive, Occupational, and Aerospace Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Vlachopanos G, Ghalli FG. Antithrombotic medications in dialysis patients: a double-edged sword. J Evid Based Med 2017; 10:53-60. [PMID: 28276631 DOI: 10.1111/jebm.12235] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 09/20/2016] [Indexed: 01/11/2023]
Abstract
In the clinical context of end-stage renal disease (ESRD), thrombosis and bleeding risks are simultaneously increased and may have devastating consequences. While anticoagulant and antiplatelet drugs are indispensable for the prevention of thromboembolic events, the significantly higher bleeding risk makes their handling extremely complicated. In ESRD, they are frequently administered for a wide array of conditions. For example, atrial fibrillation is quite common in ESRD and warrants the use of anticoagulants like warfarin. Unfractionated heparin and low molecular weight heparins are typically used for clotting prevention in the hemodialysis extracorporeal circuit. The antithrombotics use dilemma has worsened because ESRD patients have been excluded from major clinical trials that defined standard indications, contraindications and optimal management of these medications. That limits our knowledge and results in that the process of decision-making depends on weaker data. Besides the substantial bleeding risk, warfarin may also increase cardiovascular risk because it is implicated in the pathogenesis of vascular calcifications in ESRD. The present article attempts to offer a comprehensive overview of practical considerations for the use of the most common antithrombotic medications in ESRD linking them, at the same time, to the best available evidence from randomized controlled trials and observational studies.
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Affiliation(s)
| | - Farid Girgis Ghalli
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, United Kingdom
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Islam MS, Hassan ZA, Chalmin F, Vido S, Berrada M, Verhelst D, Donnadieu P, Moranne O, Esnault VLM. Vitamin E-Coated and Heparin-Coated Dialyzer Membranes for Heparin-Free Hemodialysis: A Multicenter, Randomized, Crossover Trial. Am J Kidney Dis 2016; 68:752-762. [PMID: 27344212 DOI: 10.1053/j.ajkd.2016.05.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 05/08/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Hemodialysis requires effective anticoagulation to avoid blood circuit clotting. In patients at high risk for bleeding, several alternative methods have been developed. STUDY DESIGN Multicenter, prospective, randomized, crossover study evaluating the noninferiority of vitamin E-coated compared with heparin-coated dialyzers in a 4-hour heparin-free hemodialysis strategy. SETTINGS & PARTICIPANTS 32 adult long-term hemodialysis patients from 2 French hemodialysis units with well-functioning fistulas or double-lumen catheters. INTERVENTION Patients were randomly allocated to a first period using either vitamin E- or heparin-coated dialyzers. After a washout period of 2 hemodialysis sessions, each patient was switched to the alternative dialyzer for a second period. Each study period started with 2 hemodialysis sessions with reduced heparin dose (50% and 25% of usual heparin dose, respectively, for sessions 1 and 2) followed by 2 heparin-free sessions. OUTCOMES The primary end point was the percentage of successful study periods, defined as no circuit-clotting event leading to premature interruption of any of the 4 dialysis sessions. Secondary end points included total number and cumulative duration of hemodialysis sessions without clotting, number of saline solution flushes, dialysis circuit bubble trap status and dialyzer membrane status by visual inspection, and dialysis adequacy. RESULTS The percentage of success with vitamin E-coated dialyzers (25/32 study periods [78%]) was not inferior to that with heparin-coated dialyzers (26/32 study periods [81%]). Visual inspection showed equal numbers of clean dialysis circuit bubble traps (vitamin E-coated, 34/121; heparin-coated, 32/120), whereas clean fiber bundles were more frequently noted with the vitamin E-coated compared with heparin-coated dialyzers (25/121 vs 2/120; P=0.002). LIMITATIONS Results may not extrapolate to critically ill patients. Differences in dialyzer transparency may account for visual inspection scores. CONCLUSIONS The success rate of 4-hour heparin-free hemodialysis sessions is lower than that previously claimed in uncontrolled studies. Vitamin E-coated and heparin-coated dialyzers exposed patients to similar and unacceptable high failure rates. Further studies are required to improve heparin-free hemodialysis.
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Affiliation(s)
| | | | - Florence Chalmin
- Nephrology Department, Pasteur University Hospital of Nice, Nice, France
| | - Sandor Vido
- Nephrology Department, Pasteur University Hospital of Nice, Nice, France
| | - Mohamed Berrada
- Nephrology Department, Pasteur University Hospital of Nice, Nice, France
| | - David Verhelst
- Nephrology Department, General Hospital of Avignon, Avignon, France
| | | | - Olivier Moranne
- Nephrology Department, Pasteur University Hospital of Nice, Nice, France
| | - Vincent L M Esnault
- Nephrology Department, Pasteur University Hospital of Nice, Nice, France; Nice Sophia-Antipolis University, Nice, France
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Leung KCW, Tai DJ, Ravani P, Quinn RR, Scott-Douglas N, MacRae JM. Citrate vs. acetate dialysate on intradialytic heparin dose: A double blind randomized crossover study. Hemodial Int 2016; 20:537-547. [DOI: 10.1111/hdi.12433] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/29/2016] [Indexed: 11/28/2022]
Affiliation(s)
| | - Davina J. Tai
- Cumming School of Medicine; University of Saskatchewan
| | | | - Rob R. Quinn
- Cumming School of Medicine; University of Calgary
| | | | - Jennifer M. MacRae
- Cumming School of Medicine; University of Calgary
- Department of Cardiac Sciences; University of Calgary
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Ockhuis D, Kyriacos U. Renal unit practitioners' knowledge, attitudes and practice regarding the safety of unfractionated heparin for chronic haemodialysis. Curationis 2015; 38. [PMID: 26841913 PMCID: PMC6091600 DOI: 10.4102/curationis.v38i1.1447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 06/03/2015] [Accepted: 05/18/2015] [Indexed: 11/18/2022] Open
Abstract
Background Chronic haemodialysis for adult patients with end-stage kidney failure requires a patent extracorporeal circuit, maintained by anticoagulants such as unfractionated heparin (UFH). Incorrect administration of UFH has safety implications for patients. Objectives Firstly, to describe renal practitioners’ self-reported knowledge, attitudes and practice (KAP) regarding the safe use of UFH and its effects; secondly, to determine an association between KAP and selected independent variables. Method A cross-sectional descriptive survey by self-administered questionnaire and non-probability convenience sampling was conducted in two tertiary hospital dialysis units and five private dialysis units in 2013. Results The mean age of 74/77 respondents (96.1%), was 41.1 years. Most (41/77, 53.2%) had 0–5 years of renal experience. The odds of enrolled nurses having poorer knowledge of UFH than registered nurses were 18.7 times higher at a 95% Confidence Interval (CI) (1.9–187.4) and statistically significant (P = 0.013). The odds of delivering poor practice having ≤ five years of experience and no in-service education were 4.6 times higher at a 95% CI (1.4–15.6), than for respondents who had ≥ six years of experience (P = 0.014) and 4.3 times higher (95% CI 1.1–16.5) than for respondents who received in-service education (P = 0.032), the difference reaching statistical significance in both cases. Conclusion Results suggest that the category of the professional influences knowledge and, thus, safe use of UFH, and that there is a direct relationship between years of experience and quality of haemodialysis practice and between having in-service education and quality of practice.
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Affiliation(s)
- Debra Ockhuis
- Faculty of Health Sciences, Department of Health and Rehabilitation Sciences, University of Cape Town.
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42
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Kobrin S. How Does a Patient's Primary Renal Disease Impact Chronic Dialysis Management? Semin Dial 2015; 28:464-6. [DOI: 10.1111/sdi.12398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Sidney Kobrin
- Department of Medicine; University of Pennsylvania School of Medicine; Philadelphia Pennsylvania
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43
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Tai DJ, Leung K, Ravani P, Quinn RR, Scott-Douglas N, MacRae JM. The effect of citrate dialysate on intradialytic heparin dose in haemodialysis patients: study design of a randomised controlled trial. BMC Nephrol 2015; 16:147. [PMID: 26303208 PMCID: PMC4548909 DOI: 10.1186/s12882-015-0144-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 08/13/2015] [Indexed: 11/25/2022] Open
Abstract
Background Unfractionated heparin is the most common anticoagulant used in haemodialysis (HD), although it has many potential adverse effects. Citrate dialysate (CD) has an anticoagulant effect which may allow reduction in cumulative heparin dose (CHD) compared to standard acetate dialysate (AD). Methods This double-blinded, randomised, cross-over trial of chronic haemodialysis patients determines if CD allows reduction in CHD during HD compared with AD. After enrolment, intradialytic heparin is minimised during a two-week run-in period using a standardised protocol based on a visual clotting score. Patients still requiring intradialytic heparin after the run-in period are randomised to two weeks of HD with AD followed by two weeks of CD (Sequence 1) or two weeks of HD with CD followed by two weeks of AD (Sequence 2). The primary outcome is the change in CHD with CD compared with AD. Secondary outcomes include metabolic and haemodynamic parameters, and dialysis adequacy. Discussion This randomised controlled trial will determine the impact of CD compared with AD on CHD during HD. Trial registration ClinicalTrials.gov NCT01466959
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Affiliation(s)
- Davina J Tai
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
| | - Kelvin Leung
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Pietro Ravani
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
| | - Robert R Quinn
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
| | | | - Jennifer M MacRae
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Kessler M, Moureau F, Nguyen P. Anticoagulation in Chronic Hemodialysis: Progress Toward an Optimal Approach. Semin Dial 2015; 28:474-89. [PMID: 25913603 DOI: 10.1111/sdi.12380] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Appropriate anticoagulation for hemodialysis (HD) requires a subtle balance between under- and over-heparinization to prevent extracorporeal circuit (ECC) clotting and bleeding, respectively. We discuss five key issues relating to anticoagulation therapy for chronic HD in adults following a review of relevant literature published since 2002: (i) options for standardization of anticoagulation in HD settings. The major nephrology societies have issued low evidence level recommendations on this subject. Interventional studies have generally investigated novel low-molecular weight heparins and provided data on safety of dosing regimens that cannot readily be extrapolated to clinical practice; (ii) identification of clinical and biological parameters to aid individualization of anticoagulation treatment. We find that use of clinical and biological monitoring of anticoagulation during HD sessions is currently not clearly defined in routine clinical practice; (iii) role of ECC elements (dialysis membrane and blood lines), dialysis modalities, and blood flow in clotting development; (iv) options to reduce or suppress systemic heparinization during HD sessions. Alternative strategies have been investigated, especially when the routine mode of anticoagulation was not suitable in patients at high risk of bleeding or was contraindicated; (v) optimization of anticoagulation therapy for the individual patient. We conclude by proposing a standardized approach to deliver anticoagulation treatment for HD based on an individualized prescription prepared according to the patient's profile and needs.
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Affiliation(s)
- Michèle Kessler
- Department of Nephrology, University Hospital, Vandœuvre-les-Nancy, France
| | | | - Philippe Nguyen
- Department of Hematology, University Hospital, Reims, France
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45
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Fu SS, Ning JP, Liao XH, Fu X, Yang ZB. Preparation and characterization of a thrombin inhibitor grafted polyethersulfone blending membrane with improved antithrombotic property. RSC Adv 2015. [DOI: 10.1039/c5ra16515f] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A thrombin inhibitor grafted polyethersulfone membrane with improved antithrombotic property.
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Affiliation(s)
- Shuang-Shuang Fu
- Department of Nephrology
- Xiangya Hospital of Central South University
- Changsha 410008
- P. R. China
| | - Jian-Ping Ning
- Department of Nephrology
- Xiangya Hospital of Central South University
- Changsha 410008
- P. R. China
| | - Xiao-Hua Liao
- Department of Nephrology
- Xiangya Hospital of Central South University
- Changsha 410008
- P. R. China
| | - Xiao Fu
- Department of Nephrology
- Xiangya Hospital of Central South University
- Changsha 410008
- P. R. China
| | - Zheng-Bo Yang
- Department of Nephrology
- Xiangya Hospital of Central South University
- Changsha 410008
- P. R. China
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46
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Shen JI, Mitani AA, Winkelmayer WC. Heparin use in hemodialysis patients following gastrointestinal bleeding. Am J Nephrol 2014; 40:300-7. [PMID: 25341418 DOI: 10.1159/000367901] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 08/23/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Heparin is commonly given during hemodialysis (HD). Patients undergoing HD have a high rate of gastrointestinal bleeding (GIB). It is unclear whether or when it is safe to give heparin after acute GIB. We describe the patterns and safety of heparin use with outpatient HD following an acute GIB. METHODS We identified patients aged ≥ 67 who, from 2004-2008, experienced GIB requiring hospitalization within 2 days of receiving maintenance HD with heparin. We used Cox regression to estimate the risk of recurrent GIB and death associated with receiving heparin the day they resumed outpatient HD post-GIB. RESULTS Of the 1,342 patients who had GIB, 1,158 (86%) received heparin at a median dose of 4,000 units with their first outpatient HD session after discharge from GIB. On average, their post-GIB doses were slightly lower than their pre-GIB doses (mean change: -214 ± 3,266 units, p < 0.02). However, only 27% of patients had a decrease in their dose, while 21% had their dose increased. We did not find an increased risk of death or recurrent GIB associated with using heparin post-GIB (HR; 95% confidence interval (CI), for death: 1.01; 0.69-1.48; for recurrent GIB: 0.78; 0.39-1.57). CONCLUSIONS The vast majority of these high-risk patients received heparin on the very first day they resumed outpatient HD post-GIB, and the majority at unchanged doses to those received pre-GIB. Even if the practice was not associated with increased risks of death or re-bleeding, it highlights an area for possible system-based improvement to the care for patients on HD.
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Affiliation(s)
- Jenny I Shen
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, Calif., USA
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47
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Shen JI, Montez-Rath ME, Mitani AA, Erickson KF, Winkelmayer WC. Correlates and variance decomposition analysis of heparin dosing for maintenance hemodialysis in older US patients. Pharmacoepidemiol Drug Saf 2014; 23:515-25. [PMID: 24677688 DOI: 10.1002/pds.3595] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 12/24/2013] [Accepted: 01/14/2014] [Indexed: 11/11/2022]
Abstract
PURPOSE Heparin is commonly used to anticoagulate the hemodialysis (HD) circuit. Despite the bleeding risk, no American standards exist for its administration. We identified correlates and quantified sources of variance in heparin dosing for HD. METHODS We performed a cross-sectional study of patients aged 67 years or older who underwent HD with heparin on one of two randomly chosen days in 2008 at a national chain of dialysis facilities. Using a mixed effects model with random intercept for facility and fixed patient and facility characteristics, we examined heparin dosing at patient and facility levels. RESULTS The median heparin dose among the 17 722 patients treated in 1366 facilities was 4000 (25th-75th percentile: 2625-6000) units. In multivariable-adjusted analyses, higher weight, longer session duration, catheter use, and dialyzer reuse were significantly associated with higher heparin dose. Dose also varied considerably among census divisions. Of the overall variance in dose, 21% was due to between-facility differences, independent of facilities' case mix, geography, size, or rurality; 79% was due to differences at the patient level. The patient and facility characteristics in our model explained only 25% of the variance at the patient level. CONCLUSIONS Despite the lack of standards for heparin administration, we noted patterns of use, including weight-based and time-dependent dosing. Most of the variance was at the patient level; however, only a quarter of it could be explained. The high amount of unexplained variance suggests that factors other than clinical need are driving heparin dosing and that there is likely room for more judicious dosing of heparin.
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Affiliation(s)
- Jenny I Shen
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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Abstract
Optimization of renal replacement therapy (RRT) for severe acute kidney injury (AKI) has been intensively studied over the last decade. Several large recently published randomized trials have clarified uncertainties regarding dialysis modality selection as well as dialysis dosage. This information will help inform decision makers regarding resource allocation and establishment of treatment targets. The decision to initiate dialysis remains a clinical one, based on individual patient needs. Despite technological advances in renal replacement therapy, AKI continues to be associated with poor outcomes.
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Affiliation(s)
- Emily Christie
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Liu XL, Wang XZ, Liu XX, Hao D, Jaladat Y, Lu F, Sun T, Lv CJ. Low-dose heparin as treatment for early disseminated intravascular coagulation during sepsis: A prospective clinical study. Exp Ther Med 2013; 7:604-608. [PMID: 24520253 PMCID: PMC3919907 DOI: 10.3892/etm.2013.1466] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Accepted: 10/17/2013] [Indexed: 11/20/2022] Open
Abstract
The present study aimed to investigate whether low-dose heparin improves the condition of patients suffering from early disseminated intravascular coagulation (pre-DIC) during sepsis. In total, 37 patients were randomly divided into low-dose heparin intervention and control groups. The heparin group received a low-dose of heparin for 5–7 days, while the other group received only saline. The two groups were treated for sepsis. Blood samples were collected at various times and acute physiology and chronic health evaluation (APACHE)-II scores were recorded at day 1 and 7. In addition, the number of days applying mechanical ventilation and in the intensive care unit (ICU) were recorded, as well as the 28-day mortality rate. APACHE-II scores in the two groups decreased following treatment, however, scores in the heparin group decreased more significantly. Prothrombin fragment and thrombin-antithrombin complex levels in the heparin group were significantly decreased. In addition, the number of days applying a ventilator was fewer and the total stay in ICU was significantly shorter compared with the control group. Significantly fewer complications were observed in the heparin group, however, there was no significant difference in the 28-day mortality rate. In conclusion, low-dose heparin improves the hypercoagulable state of sepsis, which subsequently reduces the incidence of DIC or multiple organ dysfunction syndrome, decreasing the number of days of mechanical ventilation and hospitalization.
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Affiliation(s)
- Xiao-Li Liu
- Department of Respiratory Disease, Hospital of Binzhou Medical University, Binzhou, Shandong 256603, P.R. China
| | - Xiao-Zhi Wang
- Department of Respiratory Disease, Hospital of Binzhou Medical University, Binzhou, Shandong 256603, P.R. China
| | - Xiu-Xiang Liu
- Department of Respiratory Disease, Hospital of Binzhou Medical University, Binzhou, Shandong 256603, P.R. China
| | - Dong Hao
- Department of Respiratory Disease, Hospital of Binzhou Medical University, Binzhou, Shandong 256603, P.R. China
| | - Yasaman Jaladat
- Department of Otolaryngology-HNS, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Feng Lu
- Department of Respiratory Disease, Hospital of Binzhou Medical University, Binzhou, Shandong 256603, P.R. China
| | - Ting Sun
- Department of Respiratory Disease, Hospital of Binzhou Medical University, Binzhou, Shandong 256603, P.R. China
| | - Chang-Jun Lv
- Department of Respiratory Disease, Hospital of Binzhou Medical University, Binzhou, Shandong 256603, P.R. China
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Tovar AMF, Teixeira LAC, Rembold SM, Leite M, Lugon JR, Mourão PAS. Bovine and porcine heparins: different drugs with similar effects on human haemodialysis. BMC Res Notes 2013; 6:230. [PMID: 23763719 PMCID: PMC3688204 DOI: 10.1186/1756-0500-6-230] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 06/07/2013] [Indexed: 01/21/2023] Open
Abstract
Background Heparins from porcine and bovine intestinal mucosa differ in their structure and also in their effects on coagulation, thrombosis and bleeding. However, they are used as undistinguishable drugs. Methods We compared bovine and porcine intestinal heparin administered to patients undergoing a particular protocol of haemodialysis. We compared plasma concentrations of these two drugs and also evaluated how they affect patients and the dialyzer used. Results Compared with porcine heparin, bovine heparin achieved only 76% of the maximum plasma concentration as IU mL-1. This observation is consistent with the activities observed in the respective pharmaceutical preparations. When the plasma concentrations were expressed on weight basis, bovine heparin achieved a maximum concentration 1.5 fold higher than porcine heparin. The reduced anticoagulant activity and higher concentration, on weight basis, achieved in the plasma of patients under dialysis using bovine instead of porcine heparin did not affect significantly the patients or the dialyzer used. The heparin dose is still in a range, which confers security and safety to the patients. Discussion Despite no apparent difference between bovine and porcine intestinal heparins in the haemodialysis practice, these two types of heparins should be used as distinct drugs due to their differences in structure and biological effects. Conclusions The reduced anticoagulant activity achieved in the plasma of patients under dialysis using bovine instead of porcine heparin did not affect significantly the patients or the dialyzer.
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Affiliation(s)
- Ana M F Tovar
- Laboratório de Tecido Conjuntivo, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
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