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Buccianti G, Valenti G, Lorenz M, Cresseri D, Strada E, Nazzari M. Kinetics of Anti-Xa Activity during Combined Defibrotide - Heparin Administration in Hemodialysis. Int J Artif Organs 2018. [DOI: 10.1177/039139889001300707] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Defibrotide, a polydesoxyribonucleotide derivative with antithrombotic and fibrinolytic activity, capable of inducing the release of PGI2 from vascular endothelia, was proposed as an alternative to standard heparin coverage during blood dialysis for patients at risk of bleeding. The original procedure featured the preliminary washing of the dialysis circuit with heparin, which was then recirculated and eliminated, and the two drugs, heparin and defibrotide, are known to interact with each other. The purpose of this present study was to explore the ex-vivo heparin activity (assessed as anti-Xa activity) in diverse hemodialysis models using defibrotide (800 mg intravenous, in 4 bolus injections) and various dosages of heparin. Anti-Xa activity is negligible in dialysis conducted with defibrotide alone. When the circuit was prewashed with heparin (5000 and 2500 IU), there was evident anti-Xa activity (0.3-0.5 U/ml) in the first 30-60 minutes of dialysis; continuous heparin infusion (500 U/hour) resulted in high anti-Xa activity levels at the end of dialysis. Thus the best hemodialysis procedure for patients at high risk of bleeding should be one utilizing only defibrotide, or defibrotide plus small amounts of calcium heparin infused at the rate of 500 U/hour for not more than two hours.
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Affiliation(s)
- G. Buccianti
- Dialysis Department, 1st Medical Clinic, University of Milan, Milan
| | - G. Valenti
- Dialysis Department, 1st Medical Clinic, University of Milan, Milan
| | - M. Lorenz
- Dialysis Department, 1st Medical Clinic, University of Milan, Milan
| | - D. Cresseri
- Dialysis Department, 1st Medical Clinic, University of Milan, Milan
| | - E. Strada
- Dialysis Department, 1st Medical Clinic, University of Milan, Milan
| | - M. Nazzari
- Medical Department, Crinos S.p.A., Villa Guardia, Como - Italy
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2
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Tew CJ, Lane DA, Thompson E, Ireland H, Curtis JR. Relationship between ex vivo anti-proteinase (factor Xa and thrombin) assays and in vivo anticoagulant effect of very low molecular weight heparin, CY222. Br J Haematol 2008. [DOI: 10.1111/j.1365-2141.1988.00335.x] [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]
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3
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Starke R, Mackie I, Drummond O, MacGregor I, Harrison P, Machin S. Prion protein in patients with renal failure. Transfus Med 2006; 16:165-8. [PMID: 16764594 DOI: 10.1111/j.1365-3148.2006.00662.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We previously found elevated levels of prion protein (PrP(C)) in the blood plasma of 16 patients with renal failure. We studied a further 20 patients with renal failure, and all had a significantly higher PrP(C) concentration than healthy normal subjects (P < 0.0001). Renal dialysis did not remove plasma PrP(C) in these patients. Because dialysis patients receive heparin during dialysis, which could potentially bind to PrP(C), the concentration of PrP(C) was measured in patients receiving heparin for cardiopulmonary bypass and was found to be similar to normal controls. We also studied several other groups with chronic illnesses and found that patients with thrombotic thrombocytopenic purpura and sickle cell anaemia had normal plasma PrP(C) levels, but that those with beta-thalassaemia had slightly elevated levels of plasma PrP(C). This suggests that the observations in renal failure were not just part of a generalized response to chronic illness or acute phase reaction. The mechanism of elevated plasma PrP(C) levels in renal disease is unknown, but this shows that plasma PrP(C) is not a specific marker of neurological disease or Creutzfeldt-Jakob disease.
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Affiliation(s)
- R Starke
- Department of Haematology, University College London, London, UK.
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4
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Koutsikos D, Fourtounas C, Kapetanaki A, Dalamanga A, Tzanatos H, Agroyannis B, Kopelias I, Bosiolis B, Rammos G, Bovoleti O, Sallum G, Darema M. A cross-over study of a new low molecular weight heparin (Logiparin) in hemodialysis. Int J Artif Organs 1996; 19:467-471. [PMID: 8841845 DOI: 10.1177/039139889601900807] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
The safety and effectiveness of a low molecular weight heparin (LMWH) of 4500 +/- 1500 Daltons were evaluated in eight hemodialysis (HD) patients, in comparison with unfractionated heparin (UFH). In phase A of the study 3000 +/- 500 anti-factor Xa (AFXa) IU of LMWH were administered in bolus for the three consecutive HD sessions of a week. In phase B, 10000 +/- 2500 IU of UFH were administered to the same patients for the same time. Were observed no significant differences in hematocrit (Ht), platelets (Pt), fibronogen (FG) and prothrombin time (PT). Whole blood activated coagulation time (WBACT) was more prolonged with LMWH, 24 and 48 hours (start of next session) after administration (p < 0.05), and less prolonged at 5, 60, 120, 180, 240 min compared to UFH (p < 0.001). The activated partial thromboplastin time (APTT) and AFXa activity were more prolonged with UFH at 60 and 240 min (p < 0.001). The clinical effectiveness of the two preparations was similar as judged by thrombus formation and compression time. In conclusion, the present study found no real differences between LMWH and UFH, except for prolongation of WBACT 24 and 48 hours after the administration of LWMH. This probably indicates a cumulative effect of the LMWH and needs further investigation.
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Affiliation(s)
- D Koutsikos
- Department of Nephrology, Aretaieon University Hospital, Athens-Greece
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5
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Cella G, Vertolli U, Naso A, Vianello A, Rampin E, Sbarai A, Boeri G, Strauss WE. Tissue factor pathway inhibitor (TFPI) activity in uremic patients during hemodialysis. Thromb Res 1996; 81:671-7. [PMID: 8868518 DOI: 10.1016/0049-3848(96)00044-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We studied tissue factor pathway inhibitor (TFPI) activity during hemodialysis in 10 uremic patients who were not receiving anticoagulant for at least 120 minutes. TFPI activity before dialysis was normal (patients 107 +/- 5.8%, controls 104 +/- 4.5%). During extracorporeal circuit it rose progressively with a statistically significant difference, reaching a plateau between 60 and 120 minutes. Since thrombin induces a marked redistribution and release of TFPI from stimulated endothelial cells and platelets contain about 10% of TFPI activity that is secreted following activation it is possible that thrombin-induced release of TFPI by endothelium and platelets could account for the increased TFPI we found during hemodialysis. To investigate this possibility we measured during dialysis beta-thromboglobulin (beta-TG), thrombin-antithrombin complex (TAT) and prothrombin fragment 1.2 (F 1.2). The increased levels of beta-TG, TAT and F1.2 we noted during extracorporeal circuit are in keeping with this concept. One hundred eighty minutes after initiation of dialysis, by which time all patients were receiving heparin there was a further increase in TFPI (to more than 200% of baseline), due to the presence of the glycosaminoglycan. This was due the previously reported displacement by heparin of the major intravascular pool of TFPI, from endothelial cell surfaces.
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Affiliation(s)
- G Cella
- Hematology, University of Padua, Italy
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7
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Hafner G, Swars H, Ehrenthal W, Schinzel H, Weilemann LS, Prellwitz W. The control of anti-coagulation in acute dialyses with sensitive laboratory parameters. Scand J Clin Lab Invest 1992; 52:289-96. [PMID: 1332180 DOI: 10.1080/00365519209088361] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
In seven patients who had to be dialysed between four and 13 times due to acute renal failure, low molecular weight heparin (LMWH) Fragmin was used for anticoagulation. According to dose-finding studies, 80-90 U kg-1 body weight of LMWH as a single bolus were administered initially, producing dose-related levels of 0.3-1.5 anti-factor Xa U ml-1 in plasma. Apart from the anti-Xa activity in the plasma, the thrombin anti-thrombin III complex (TAT complex) and a fibrin degradation product (D-dimer) were measured as parameters of a coagulation activation. A sufficient anti-coagulation during dialysis was supposed to exist at a normal range (5.0 micrograms l-1 or below) of TAT complex. Pathological TAT concentrations at the end of dialysis indicated the requirement of an increased dose for the next dialysis. These concentrations reflected a need for more heparin if, for example, inflammation, indicated by increasing C-reactive protein levels (CRP), occurred. The increase of TAT complex and D-dimer during dialysis showed a good agreement (p less than 0.001). Due to a single bolus application before dialysis, one measurement of TAT at the end of the dialysis was sufficient. The determination of the TAT complex concentration enabled a heparinization better adapted to the clinical situation of intensive-care patients undergoing acute dialyses, so that the coagulation system was not additionally activated by the extracorporeal circulation.
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Affiliation(s)
- G Hafner
- Institute of Clinical Chemistry, Johannes Gutenberg University, Mainz, Germany
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8
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Barrowcliffe TW. LMW heparin: relationship between antithrombotic and anticoagulant effects. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1992; 313:205-20. [PMID: 1332437 DOI: 10.1007/978-1-4899-2444-5_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- T W Barrowcliffe
- National Institute for Biological Standards and Control, Potters Bar, UK
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9
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Diéval J, Morinière P, Gross S, d'Azemar P, Fournier A, Delobel J. Influence of thromboembolism prophylaxis by low molecular weight heparin CY 216 (Fraxiparine) on several parameters of haemostasis in patients under dialysis and receiving either unfractionated heparin or CY 216. Thromb Res 1990; 58:555-60. [PMID: 2166971 DOI: 10.1016/0049-3848(90)90301-r] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The hemorrhagic risk of an association of the low molecular weight (LMWH), Fraxiparine injected intravenously at the dose of 7.500 AXalCU or of unfractionated heparin (UFH) injected intravenously at the usual dose used during hemodialysis (3.750 +/- 1.280 IU + 1.000 IU after 2 hours of dialysis) to the subcutaneous administration once daily of a thromboembolism preventive dose of Fraxiparine (7.500 AXalCU) was evaluated on the modification of the following hemostasis parameters: thrombin time, activated partial thromboplastin time (APTT), anti Xa activity, in 13 uremic patients on hemodialysis. The association of intravenous and subcutaneous Fraxiparine prevented efficiently the clotting of the extracorporeal circulation without inducing a detectable antithrombinic activity. In contrast, the association of I.V. UFH to subcutaneous Fraxiparine induced a significant increase of the thrombin time and of the APTT, so explained by the activity of UFH. It is concluded that subcutaneous Fraxiparine at the thromboembolism preventive dose can be associated as well to I.V. Fraxiparine as to UFH without increasing the potential hemorrhagic risk. Nevertheless the association of SC and IV Fraxiparine 7.500 AXalC u seems preferable to the association of SC Fraxiparine with UFH.
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Affiliation(s)
- J Diéval
- Laboratory of Haematology, CHR Amiens, France
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Hamano S, Komatsu H, Ikeda S, Takahashi K, Oguma Y, Sakuragawa N. Beneficial effect of low molecular weight heparin on the hemodialysis model in dogs. Thromb Res 1989; 55:439-49. [PMID: 2554525 DOI: 10.1016/0049-3848(89)90052-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The effect of FR-860, one of low molecular weight heparins, was investigated on the hemodialysis model in dogs for comparison with that of conventional unfractionated heparin (UF-heparin). In a bolus injection model, FR-860 at 12.5-100 U/kg prolonged the dialysis time (the time until the arterial circuit pressure reaching 500 mmHg) in a dose-dependent manner and UF-heparin at 50 U/kg also prolonged it. Additionally, FR-860 (12.5-50 U/kg/hr) and UF-heparin (25 and 50 U/kg/hr) continuously inhibited the rise of the arterial circuit pressure in an infusion model. In both models, the efficacy of FR-860 was more potent than that of UF-heparin. FR-860 and UF-heparin decreased the amount of blood loss remaining in the dialyzer in the infusion model. During hemodialysis, both FR-860 and UF-heparin showed activated plasma anti-F.Xa activity, prolongation of aPTT and such of thrombin time in a dose-dependent manner in those models. However, FR-860 was higher in anti-F.Xa activity and weaker in prolongation of aPTT and thrombin time than UF-heparin. These results suggest that FR-860 is more beneficial in in efficacy and higher in safety against the bleeding risk than UF-heparin hemodialysis.
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Affiliation(s)
- S Hamano
- Central Research Laboratories, Kissei Pharmaceutical Co. Ltd., Matsumoto, Japan
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LANE DA, TEW C, IRELAND H, FLYNN A, CURTIS J. Heparin and Low Molecular Weight Heparin(oid)s as Anticoagulants in Hemodialysis for Chronic Renal Failure. Ann N Y Acad Sci 1989. [DOI: 10.1111/j.1749-6632.1989.tb22535.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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12
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Tew CJ, Lane DA, Thompson E, Ireland H, Curtis JR. Relationship between ex vivo anti-proteinase (factor Xa and thrombin) assays and in vivo anticoagulant effect of very low molecular weight heparin, CY222. Br J Haematol 1988; 70:335-40. [PMID: 2849981 DOI: 10.1111/j.1365-2141.1988.tb02491.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
There is uncertainty as to which activities of unfractionated heparin (UFH) and low MW heparin are responsible for their anticoagulant and antithrombotic properties. We have sought to answer this question by examining plasma samples taken during a recently conducted dose-finding study of the low MW heparin, CY222, in haemodialysis for chronic renal failure. In this study, in vivo anticoagulant effect was assessed by measurement of plasma FPA levels. UFH was administered as a dose of 5000 iu bolus + 1,500 iu/h maintenance infusion, while the effects of three doses of CY222 were studied (10,000, 15,000 and 20,000 Institute Choay anti-factor Xa u bolus, all with 1,500 Institute Choay anti-factor Xa u/h maintenance infusion). Anti-factor Xa levels were determined by chromogenic substrate assay. Anti-thrombin levels were determined by chromogenic substrate assay and by quantitation of catalysed thrombin-inhibitor complexes (using autoradiography). Analysis of the results indicate that plasma fibrinopeptide A (FPA) levels correlate with anti-factor Xa (r = -0.45) and anti-thrombin (substrate) (r = -0.63) levels of UFH, but only with the anti-factor Xa levels (r = -0.41) of CY222. These results suggest that the anti-factor Xa assay is currently the most suitable assay for monitoring low MW heparins such as CY222 in humans.
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Affiliation(s)
- C J Tew
- Department of Haematology, Charing Cross and Westminster Hospital and Medical School, London
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