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Thongdee C, Lumkul L, Wongyikul P, Spilles N, Laonapaporn B, Patumanond J, Phinyo P. Optimal volume for the draw-and-return methods to enhance activated partial thromboplastin time ratio accuracy in hemodialysis patients with central venous catheters. Heliyon 2024; 10:e28651. [PMID: 38590898 PMCID: PMC11000023 DOI: 10.1016/j.heliyon.2024.e28651] [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: 08/10/2023] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/10/2024] Open
Abstract
Background Significant errors of activated partial thromboplastin time (aPTT) ratio were frequently observed in blood sampling from central venous dialysis catheter (CVC) of hemodialysis (HD) patients. Following the draw-and-return methods, initial blood withdrawal from the catheter before sampling can reduce the error, but the optimal withdrawal volume remains undetermined. Aim The objective of this study is to determine the optimal blood withdrawal volume for the draw-and-return methods to improve aPTT ratio accuracy in hemodialysis patients with CVC. Methods A prospective study was conducted in patients receiving HD via CVC. Four blood samples were collected from each patient, involving a peripheral venipuncture and three draw-and-return samples (10 ml, 20 ml and 25 ml groups). The aPTT ratio of a peripheral sample was used as a reference to determine the aPTT ratio accuracy for each draw-and-return group. Subsequently, the agreement was illustrated using modified Bland-Altman plot. Results A total of 1,000 samples were obtained from 250 patients. The patients had a mean age of 59.6 ± 15.4 years, with 17.2% using citrate as the CVC's locking agent. The adjusted accuracies of the aPTT ratio varied significantly among the three withdrawal volumes (p-value <0.001). The 25 ml group demonstrated the highest accuracy (43.2%; 95%CI, 38.0-48.4), followed by the 20 ml group (30.0%; 95%CI, 24.9-35.2), and the 10 ml group (18.0%; 95%CI, 12.8-23.2). Additionally, using citrate as a locking agent provided more than 80.0% aPTT ratio accuracy, whereas heparin demonstrated inferior accuracy even in the 25 ml withdrawal group. Conclusion The optimal blood withdraw volume for the draw-and-return methods concluded at 20 ml for citrate locked-CVC and 25 ml for heparin which significantly improved aPTT ratio accuracies. Applying citrate as a locking agent provides clear benefits for aPTT ratio monitoring, while peripheral venipuncture is recommended in cases of heparin-locked CVC.
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Affiliation(s)
- Chitrada Thongdee
- Dialysis Center, Nopparat Rajathanee Hospital, Ministry of Public Health, Bangkok, Thailand
| | - Lalita Lumkul
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Multidisciplinary Technology for Advanced Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pakpoom Wongyikul
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nantana Spilles
- Dialysis Center, Nopparat Rajathanee Hospital, Ministry of Public Health, Bangkok, Thailand
| | - Boonruksa Laonapaporn
- Dialysis Center, Nopparat Rajathanee Hospital, Ministry of Public Health, Bangkok, Thailand
| | - Jayanton Patumanond
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Multidisciplinary Technology for Advanced Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Natale P, Palmer SC, Ruospo M, Longmuir H, Dodds B, Prasad R, Batt TJ, Jose MD, Strippoli GF. Anticoagulation for people receiving long-term haemodialysis. Cochrane Database Syst Rev 2024; 1:CD011858. [PMID: 38189593 PMCID: PMC10772979 DOI: 10.1002/14651858.cd011858.pub2] [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] [Indexed: 01/09/2024]
Abstract
BACKGROUND Haemodialysis (HD) requires safe and effective anticoagulation to prevent clot formation within the extracorporeal circuit during dialysis treatments to enable adequate dialysis and minimise adverse events, including major bleeding. Low molecular weight heparin (LMWH) may provide a more predictable dose, reliable anticoagulant effects and be simpler to administer than unfractionated heparin (UFH) for HD anticoagulation, but may accumulate in the kidneys and lead to bleeding. OBJECTIVES To assess the efficacy and safety of anticoagulation strategies (including both heparin and non-heparin drugs) for long-term HD in people with kidney failure. Any intervention preventing clotting within the extracorporeal circuit without establishing anticoagulation within the patient, such as regional citrate, citrate enriched dialysate, heparin-coated dialysers, pre-dilution haemodiafiltration (HDF), and saline flushes were also included. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to November 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-randomised controlled studies (quasi-RCTs) evaluating anticoagulant agents administered during HD treatment in adults and children with kidney failure. DATA COLLECTION AND ANALYSIS Two authors independently assessed the risk of bias using the Cochrane tool and extracted data. Treatment effects were estimated using random effects meta-analysis and expressed as relative risk (RR) or mean difference (MD) with 95% confidence intervals (CI). Evidence certainty was assessed using the Grading of Recommendation, Assessment, Development and Evaluation approach (GRADE). MAIN RESULTS We included 113 studies randomising 4535 participants. The risk of bias in each study was adjudicated as high or unclear for most risk domains. Compared to UFH, LMWH had uncertain effects on extracorporeal circuit thrombosis (3 studies, 91 participants: RR 1.58, 95% CI 0.46 to 5.42; I2 = 8%; low certainty evidence), while major bleeding and minor bleeding were not adequately reported. Regional citrate anticoagulation may lower the risk of minor bleeding compared to UFH (2 studies, 82 participants: RR 0.34, 95% CI 0.14 to 0.85; I2 = 0%; low certainty evidence). No studies reported data comparing regional citrate to UFH on risks of extracorporeal circuit thrombosis and major bleeding. The effects of very LMWH, danaparoid, prostacyclin, direct thrombin inhibitors, factor XI inhibitors or heparin-grafted membranes were uncertain due to insufficient data. The effects of different LMWH, different doses of LMWH, and the administration of LMWH anticoagulants using inlet versus outlet bloodline or bolus versus infusion were uncertain. Evidence to compare citrate to another citrate or control was scant. The effects of UFH compared to no anticoagulant therapy or different doses of UFH were uncertain. Death, dialysis vascular access outcomes, blood transfusions, measures of anticoagulation effect, and costs of interventions were rarely reported. No studies evaluated the effects of treatment on non-fatal myocardial infarction, non-fatal stroke and hospital admissions. Adverse events were inconsistently and rarely reported. AUTHORS' CONCLUSIONS Anticoagulant strategies, including UFH and LMWH, have uncertain comparative risks on extracorporeal circuit thrombosis, while major bleeding and minor bleeding were not adequately reported. Regional citrate may decrease minor bleeding, but the effects on major bleeding and extracorporeal circuit thrombosis were not reported. Evidence supporting clinical decision-making for different forms of anticoagulant strategies for HD is of low and very low certainty, as available studies have not been designed to measure treatment effects on important clinical outcomes.
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Affiliation(s)
- Patrizia Natale
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, Universityof Foggia, Foggia, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Marinella Ruospo
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | | | - Benjamin Dodds
- School of Medicine, University of Tasmania, Hobart, Australia
| | - Ritam Prasad
- Department of Haematology/Pathology, Royal Hobart Hospital, Hobart, Australia
| | - Tracey J Batt
- Department of Haematology, Westmead Hospital, Westmead, Australia
| | - Matthew D Jose
- School of Medicine, University of Tasmania, Hobart, Australia
| | - Giovanni Fm Strippoli
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Boldt D, Busse L, Chawla LS, Flannery AH, Khanna A, Neyra JA, Palmer P, Wilson J, Yessayan L. Anticoagulation practices for continuous renal replacement therapy: a survey of physicians from the United States. Ren Fail 2023; 45:2290932. [PMID: 38073554 PMCID: PMC11001369 DOI: 10.1080/0886022x.2023.2290932] [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] [Received: 09/11/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND During continuous renal replacement therapy (CRRT), anticoagulants are recommended for patients at low risk of bleeding and not already receiving systemic anticoagulants. Current anticoagulants used in CRRT in the US are systemic heparins or regional citrate. To better understand use of anticoagulants for CRRT in the US, we surveyed nephrologists and critical care medicine (CCM) specialists. METHODS The survey contained 30 questions. Respondents were board certified and worked in intensive care units of academic medical centers or community hospitals. RESULTS 150 physicians (70 nephrologists and 80 CCM) completed the survey. Mean number of CRRT machines in use increased ∼30% from the pre-pandemic era to 2022. Unfractionated heparin was the most used anticoagulant (43% of estimated patients) followed by citrate (28%). Respondents reported 29% of patients received no anticoagulant. Risk of hypocalcemia (52%) and citrate safety (42%) were the predominant reasons given for using no anticoagulant instead of citrate in heparin-intolerant patients. 84% said filter clogging was a problem when no anticoagulant was used, and almost 25% said increased transfusions were necessary. Respondents using heparin (n = 131) considered it inexpensive and easily obtainable, although of moderate safety, citing concerns of heparin-induced thrombocytopenia and bleeding. Anticoagulant citrate dextrose solution was the most used citrate. Respondents estimated that 37% of patients receiving citrate develop hypocalcemia and 17% citrate lock. CONCLUSIONS Given the increased use of CRRT and the lack of approved, safe, and effective anticoagulant choices for CRRT in the US, effective use of current and other anticoagulant options needs to be evaluated.
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Affiliation(s)
- David Boldt
- Department of Anesthesiology and Perioperative Medicine, UCLA Healthcare System and David Geffen School of Medicine, Los Angeles, CA, USA
| | - Laurence Busse
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA, USA
| | | | - Alexander H. Flannery
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Ashish Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, School of Medicine, Wake Forest University, Winston-Salem, NC, USA
- Perioperative Outcomes and Informatics Collaborative, Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Javier A. Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - James Wilson
- Department of Nephrology, UCLA Healthcare System and David Geffen School of Medicine, Los Angeles, CA, USA
| | - Lenar Yessayan
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Vanommeslaeghe F, Van Biesen W, François K. Detection and Scoring of Extracorporeal Circuit Clotting During Hemodialysis. Semin Nephrol 2023; 43:151474. [PMID: 38267348 DOI: 10.1016/j.semnephrol.2023.151474] [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: 01/26/2024]
Abstract
Maintaining patency of the extracorporeal hemodialysis (HD) circuit is a prerequisite to perform HD. Unfractionated heparin and low-molecular-weight heparins are the most used anticoagulants in maintenance HD, but their administration comes with a major trade-off of bleeding complications. This narrative review article discusses technical factors impacting on HD circuit patency, such as tubings, dialyzer membranes, priming practices, and treatment settings. Strategies for monitoring extracorporeal circuit clotting during and after treatment are also reviewed, as these are essential tools for optimizing anticoagulation.
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Affiliation(s)
| | - Wim Van Biesen
- Department of Nephrology, Ghent University Hospital, Gent, Belgium
| | - Karlien François
- Department of Nephrology and Arterial Hypertension, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
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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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Laursen SH, Boel L, Brandi L, Christensen JH, Vestergaard P, Hejlesen OK. Implementation of a coagulation component into a phosphate kinetics model in haemodialysis therapy: A tool for detection of clotting problems? Exp Physiol 2023; 108:1325-1336. [PMID: 37566800 PMCID: PMC10996865 DOI: 10.1113/ep091201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023]
Abstract
A coagulation component should be considered in phosphate kinetics modelling because intradialytic coagulation of the extracorporeal circuit and dialyser might reduce phosphate removal in haemodialysis. Thus, the objective of this study was to add and evaluate coagulation as an individual linear clearance reduction component to a promising three-compartment model assuming progressive intradialytic clotting. The model was modified and validated on intradialytic plasma and dialysate phosphate samples from 12 haemodialysis patients collected during two treatments (HD1 and HD2) at a Danish hospital ward. The most suitable clearance reduction in each treatment was identified by minimizing the root mean square error (RMSE). The model simulations with and without clearance reduction were compared based on RMSE and coefficient of determination (R2 ) values. Improvements were found for 17 of the 24 model simulations when clearance reduction was added to the model. The slopes of the clearance reduction were in the range of 0.011-0.632/h. Three improvements were found to be statistically significant (|observed z value| > 1.96). A very significant correlation (R2 = 0.708) between the slopes for HD1 and HD2 was found. Adding the clearance reduction component to the model seems promising in phosphate kinetics modelling and might be explained, at least in part, by intradialytic coagulation. In future studies, the model might be developed further to serve as a potentially useful tool for the quantitative detection of clotting problems in haemodialysis. NEW FINDINGS: What is the central question of this study? The aim was to add an intradialytic coagulation component to a modified version of a promising three-compartment phosphate kinetics model. The hypothesis was that circuit and dialyser clotting can be modelled by an individual linear phosphate clearance reduction component during haemodialysis treatment. What is the main finding and its importance? Improvements were found for 17 of 24 model simulations when clearance reduction was added to the model. Thus, the kinetics model seems promising and could be a useful tool for the quantitative detection of clotting problems in haemodialysis patients.
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Affiliation(s)
- Sisse H. Laursen
- The Danish Diabetes AcademyOdense University HospitalOdenseDenmark
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
- Department of NursingUniversity College of Northern DenmarkAalborgDenmark
- Steno Diabetes Center North DenmarkAalborg University HospitalAalborgDenmark
- Clinical Nursing Research UnitAalborg University HospitalAalborgDenmark
| | - Lise Boel
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
| | - Lisbet Brandi
- Department of Cardiology, Nephrology and EndocrinologyNordsjællands HospitalHillerødDenmark
| | | | - Peter Vestergaard
- Steno Diabetes Center North DenmarkAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Department of EndocrinologyAalborg University HospitalAalborgDenmark
| | - Ole K. Hejlesen
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
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Harvey B, Lafrance JP, Elftouh N, Vallée M, Laurin LP, Nadeau-Fredette AC. Single-Bolus Tinzaparin Anticoagulation in Extended Hemodialysis Session: A Feasibility Study. KIDNEY360 2023; 4:641-647. [PMID: 36921585 PMCID: PMC10278850 DOI: 10.34067/kid.0000000000000098] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 02/07/2023] [Indexed: 03/17/2023]
Abstract
Key Points A single bolus of tinzaparin is effective for 8-hour hemodialysis session. Eight-hour simulation sessions with anti-Xa monitoring are useful to adjust tinzaparin dose. Background Few studies have assessed the use of low-molecular weight heparins for anticoagulation during extended hemodialysis (HD) sessions. This study aimed to evaluate the efficacy of a single bolus of tinzaparin for anticoagulation of the extracorporeal circuit and dialyzer in 8-hour HD sessions. Methods This single-center study included all patients who underwent a single 8-hour simulation session as part of their nocturnal home HD training between 2009 and 2020. Tinzaparin was delivered as a single-bolus injection at time 0 with dosing on the basis of doubling of standard 4-hour session dose. Tinzaparin efficacy was examined using visual observations (score 1–4) of the dialyzer and venous bubble trap at the end of dialysis and using anti-Xa measured at 15 and 30 minutes and 1, 2, 4, 6, and 8 hours after HD start. Results Forty-seven patients were included. The mean tinzaparin dose was 107±20 IU/kg. Anti-Xa levels peaked at 15 minutes with 1.3±0.4 IU/ml and progressively declined reaching 0.9±0.3 IU/ml at 1 hour, 0.4±0.21 IU/ml at 4 hours, and 0.15±0.15 IU/ml at 8 hours. After the 8-hour session, none of the patients had severe clotting of their dialyzer or venous chamber. Moderate blood clotting was observed in the dialyzer of 6 patients (20%) and in the venous chamber of 22 patients (61%). On the basis of the simulation results, tinzaparin dose was increased in 27 patients (58%) with a mean home-discharge dose of 123±28 IU/kg. Conclusions This study shows that anti-Xa levels stabilized rapidly after administration of tinzaparin for 8-hour HD. Administration of a single-bolus tinzaparin at the start of an 8-hour dialysis session seemed effective, although dose adjustment may be required.
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Affiliation(s)
- Benoît Harvey
- Division of Nephrology, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada
| | - Jean-Philippe Lafrance
- Division of Nephrology, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada
- Maisonneuve-Rosemont Hospital Research Center, Montreal, Quebec, Canada
| | - Naoual Elftouh
- Maisonneuve-Rosemont Hospital Research Center, Montreal, Quebec, Canada
| | - Michel Vallée
- Division of Nephrology, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada
| | - Louis-Philippe Laurin
- Division of Nephrology, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada
- Maisonneuve-Rosemont Hospital Research Center, Montreal, Quebec, Canada
| | - Annie-Claire Nadeau-Fredette
- Division of Nephrology, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada
- Maisonneuve-Rosemont Hospital Research Center, Montreal, Quebec, Canada
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8
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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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9
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Hemoperitoneum complicating an oocyte puncture in a chronic hemodialysis patient. J Nephrol 2022; 35:2433-2435. [PMID: 35239174 DOI: 10.1007/s40620-022-01270-8] [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: 10/25/2021] [Accepted: 02/01/2022] [Indexed: 10/18/2022]
Abstract
We report the case of a 31-year-old patient on chronic hemodialysis for 17 years, after two failed kidney grafts, presently on daily home hemodialysis. She underwent follicle puncture for oocyte retrieval in the context of an in vitro fertilization program. This procedure was complicated by hemoperitoneum, requiring transfusion of 2 units of packed red blood cells and 2 units of fresh-frozen plasma, as well as an emergency laparoscopy to drain the hemoperitoneum and perform local hemostasis of the ovarian bleeding. This complication occurred following the patient's routine hemodialysis session, performed with the usual systemic anticoagulation with unfractionated heparin. The evolution was favorable and there was no recurrence of bleeding or sequelae. A later hematology workup did not reveal any pathology of hemostasis that might have favored bleeding. This case may underline how, even though assisted reproductive procedures are increasingly performed in patients on dialysis, special care should be taken when these procedures are performed in this fragile population.
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10
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Movement is Life-Optimizing Patient Access to Total Joint Arthroplasty: Chronic Kidney Disease Disparities. J Am Acad Orthop Surg 2022; 30:1064-1068. [PMID: 35427242 DOI: 10.5435/jaaos-d-21-00919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/09/2022] [Indexed: 02/01/2023] Open
Abstract
Approximately 15% of the American adults have chronic kidney disease (CKD). Rates of CKD are higher in underserved communities: It is highest in African Americans (16%) and Hispanic individuals (14%). African Americans are more than 3 times as likely compared with their White counterparts to develop end-stage kidney disease, requiring dialysis or a kidney transplant. Rates of CKD are higher in the geriatric and socioeconomic disadvantaged populations, groups with higher rates of hip and knee osteoarthritis and with comorbidities, including obesity, diabetes mellitus, heart disease, and hypertension. CKD of any stage is associated with increased postoperative readmission, complications, and mortality. Patients on hemodialysis after total joint arthroplasty are at increased risk for complications, including periprosthetic joint infection, and given the reduction in risk after kidney transplant, there is varying opinion regarding whether patients on hemodialysis are safe arthroplasty candidates.
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Sudusinghe D, Riddell A, Gandhi T, Chowdary P, Davenport A. Increased risk of dialysis circuit clotting in hemodialysis patients with COVID-19 is associated with elevated FVIII, fibrinogen and D-dimers. Hemodial Int 2022; 27:38-44. [PMID: 36081392 PMCID: PMC9537782 DOI: 10.1111/hdi.13046] [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: 03/01/2022] [Revised: 08/09/2022] [Accepted: 08/23/2022] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Severe COVID-19 infections increase the risk of thrombotic events and Intensive Care Units reported increased extracorporeal circuit clotting (ECC) in COVID-19 patients with acute kidney injury. We wished to determine whether hemodialysis (HD) patients with COVID-19 also have increased risk of circuit clotting. METHODS We reviewed coagulation studies and HD records, 4 weeks before and after COVID-19 polymerase chain reaction detection in HD patients between April 2020 and June 2021. FINDINGS Sixty-eight (33.5%) of 203 HD patients with COVID-19, 65% male, mean age 64.9 ± 15.3 years, experienced some circuit clotting, and no clotting recorded prior to positive test results. In those who experienced ECC, prothrombin, activated partial thromboplastin or thrombin times were not different, whereas median factor VIII (273 [168-419] vs. 166 [139-225] IU/dl, p < 0.001), D-dimers (2654 [1381-6019] vs. 1351 [786-2334] ng/ml, p < 0.05), and fibrinogen (5.6 ± 1.4 vs. 4.9 ± 1.4 g/L, p < 0.05) were greater. Antithrombin (94 [83-112] vs. 89 [84-103] IU/dl), protein C (102 [80-130] vs. 86 [76-106] IU/dl), protein S (65 [61-75] vs. 65 [52-79] IU/dl) and platelet counts (193 [138-243] vs. 174 [138-229] × 109 /L) did not differ. On multivariable logistic analysis, circuit clotting was associated with log factor VIII (odds ratio [OR] 14.8 (95% confidence limits [95% CL] 1.12-19.6), p = 0.041), fibrinogen (OR 1.57 [95% CL 1.14-21.7], p = 0.006) and log D dimer (OR 4.8 [95% CL 1.16-12.5], p = 0.028). DISCUSSION Extracorporeal circuit clotting was increased within 4 weeks of testing positive for COVID-19. Clotting was associated with increased factor VIII, fibrinogen and D-dimer, suggesting that the risk of circuit clotting was related to the inflammatory response to COVID-19.
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Affiliation(s)
- Dinesha Sudusinghe
- Department of Physiology, Faculty of Medical SciencesUniversity of Sri JayewardenepuraNugegodaSri Lanka
| | - Anne Riddell
- Haemophilia and Thrombosis Laboratory (Health Services Laboratories)Royal Free HospitalLondonUK,Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK
| | - Tejas Gandhi
- Haemophilia and Thrombosis Laboratory (Health Services Laboratories)Royal Free HospitalLondonUK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK,Research Department of HaematologyCancer Institute UCLLondonUK
| | - Andrew Davenport
- Department of Renal Medicine, Royal Free Hospital, Faculty of Medical SciencesUniversity College LondonLondonUK
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12
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Tan QZ, Mai YF, Jiao HH, Xiong RJ, Liu Y, Lin L, Cui LW, Pai P. Quality improvement project to enhance heparin safety in patients with haemodialysis in China. BMJ Open Qual 2022; 11:bmjoq-2021-001665. [PMID: 35393293 PMCID: PMC8996018 DOI: 10.1136/bmjoq-2021-001665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 03/31/2022] [Indexed: 11/03/2022] Open
Affiliation(s)
- Qiu-Zhen Tan
- Department of Medicine, Division of Nephrology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yan-Fen Mai
- Department of Medicine, Division of Nephrology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Hai-Hong Jiao
- Department of Medicine, Division of Nephrology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Ren-Jie Xiong
- Department of Medicine, Division of Nephrology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yu Liu
- Department of Medicine, Division of Nephrology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Li Lin
- Clinical Service Department, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Li-Wen Cui
- Department of Medicine, Division of Nephrology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Pearl Pai
- Department of Medicine, Division of Nephrology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China .,Department of Medicine, Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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13
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Riddell A, Chowdary P, Davenport A. The effect of SARS-Co-V2 infection on prothrombotic and anticoagulant factors in dialysis patients. Artif Organs 2022; 46:1328-1333. [PMID: 35167146 PMCID: PMC9111238 DOI: 10.1111/aor.14206] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/11/2022] [Accepted: 02/01/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Patients with COVID-19 infection are at increased risk of thrombosis. We wished to determine whether this was is due to an increase in prothrombotic or reduction in anticoagulant factors, and whether heparin would be an appropriate anticoagulant. METHODS We measured routine coagulation and prothrombtic factors in dialysis patients after a positive COVID-19 test between March 2020 -April 2021. RESULTS Routine coagulation tests were measured in 227 dialysis patients, 148 males (65.2%), median age 67.5 (53.8-77.0) years. The international normalised ratio was prolonged in 11.5%, activated partial thromboplastin time in 48.5%, thrombin time in 57%. Factor VIII was increased in 59.1%, fibrinogen in 73.8%, and D-dimer 95.5%. Protein C was reduced in 15.3%, protein S in 28%, and antithrombin (AT) in 12.1%. Two patients were Lupus anticoagulant positive , and two Factor VLeiden positive. Factor VIII levels increased with clinical disease; outpatients 159 (136-179) IU/dL, hospitalised but not ventilated 228 (167-311) IU, ventilated 432 (368-488) IU/dL (p<0.01). Overall 75% had an AT level ≥ 88 IU/dL (reference range 79-106), but only 11.7% of non-hospitalised patientscompared to 45% of those who died, p<0.01, Fibrinogen,D-dimers, proteins S or C did not differ with clinical disease severity, whether patients required hospital admission or not and between survivors and those who died. CONCLUSION COVID-19 dialysis patients have increased levels of fibrinogen and D-Dimers, but only factor VIII levels in the clotting profile increased with clinical disease severity increasing systemic hypercoagulability. AT concentrations are maintained and as such should not compromise anticoagulation with heparins.
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Affiliation(s)
- Anne Riddell
- Haemophilia & Thrombosis Laboratory (Health Services Laboratories), Royal Free Hospital, London, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia & Thrombosis Centre, Royal Free Hospital.,Research Department of Haematology, Cancer Institute UCL
| | - Andrew Davenport
- UCL Department of Nephrology, Royal Free Hospital, Faculty of Medical Sciences, University College London, London, UK
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14
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Bi X, Zhang Q, Zhuang F, Ding F. A mathematical estimation for quantified calcium supplementation during intermittent hemodialysis using regional citrate anticoagulation. Artif Organs 2022; 46:1122-1131. [PMID: 34978734 DOI: 10.1111/aor.14164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Regional citrate anticoagulation has been recommended as an alternative of anticoagulation for patients at high risk of bleeding undergoing intermittent hemodialysis. Precise calcium supplementation is important for the safety of regional citrate anticoagulation. In this study we aimed to develop a possible method to optimize calcium supplementation for regional citrate anticoagulation in intermittent hemodialysis. METHODS The investigation consisted of a pilot study and a validation study. 18 patients undergoing intermittent hemodialysis anticoagulated by citrate and Six types of filters were included in the pilot study. The ionized calcium levels were monitored and maintained in the targeted range. Calcium-free dialysate was used in the study. After linear regression analysis of the clearance of non-protein bound calcium and calculating the ratio of the non-protein bound calcium concentration to total calcium concentration, we developed a mathematical model for estimation of extracorporeal circuit calcium removal. Another 8 maintenance hemodialysis patients (12 sessions) were enrolled in the validation study to validate the new version of the calcium supplementation approach. RESULTS In the pilot study, positive correlations were found between the clearance of non-protein bound calcium and the hematocrit-adjusted clearance of creatinine and phosphate given in the dialyzer leaflet (R2 =0.31, p=0.0165). The ratio of the non-protein bound calcium concentration to total calcium concentration at the pre-filter point after infusion of citrate were constant about 0.75. In the validation study, we found that the systemic ionized calcium levels were stably maintained in the safe range and no filter clotting occurred during the hemodialysis when we used the new model of calcium supplementation. CONCLUSIONS We developed a possible method to quantify calcium supplementation for intermittent hemodialysis anticoagulated by citrate which may help to avoid negative calcium balance and reduce the incidence of complications.
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Affiliation(s)
- Xiao Bi
- Division of Nephrology & Critical Care Nephrology Unit, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine
| | - Qi Zhang
- Division of Nephrology & Critical Care Nephrology Unit, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine
| | - Feng Zhuang
- Division of Nephrology & Critical Care Nephrology Unit, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine
| | - Feng Ding
- Division of Nephrology & Critical Care Nephrology Unit, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine
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15
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Xu Y, Yu G, Nie R, Wu Z. Microfluidic systems toward blood hemostasis monitoring and thrombosis diagnosis: From design principles to micro/nano fabrication technologies. VIEW 2022. [DOI: 10.1002/viw.20200183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Yi Xu
- Soft Intelligence Lab State Key Laboratory of Digital Manufacturing Equipment and Technology School of Mechanical Science and Engineering Huazhong University of Science and Technology Wuhan China
| | - Guang Yu
- Experimental Medicine Center Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Ruqiong Nie
- Department of Cardiology Sun Yat‐Sen Memorial Hospital Sun Yat‐Sen University Guangzhou China
| | - Zhigang Wu
- Soft Intelligence Lab State Key Laboratory of Digital Manufacturing Equipment and Technology School of Mechanical Science and Engineering Huazhong University of Science and Technology Wuhan China
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16
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Optimising the Nadroparin Dose for Thromboprophylaxis During Hemodialysis by Developing a Population Pharmacodynamic Model Using Anti-Xa Levels. Clin Pharmacokinet 2022; 61:1559-1569. [PMID: 36040615 PMCID: PMC9652168 DOI: 10.1007/s40262-022-01162-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The optimal nadroparin dose in patients undergoing hemodialysis is difficult to determine in clinical practice. Anti-Xa levels ≥ 0.4 IU/mL and < 2.0 IU/mL are suggested to prevent thrombus formation within the extracorporeal circuit whilst minimizing bleeding risk. We aimed to characterize the variability in the association between dose and anti-Xa levels, identify patient and dialysis characteristics that explained this variability, and optimize nadroparin dosing based on the identified characteristics. METHODS Anti-Xa samples were collected in patients who received intravenous nadroparin as thromboprophylaxis during routine dialysis sessions. A population pharmacodynamic model was developed using non-linear mixed-effects modelling. The percentage of patients ≥ 0.4 IU/mL (efficacy) and < 2.0 IU/mL (safety) was simulated for different doses, patient and dialysis characteristics. RESULTS Patients (n = 137) were predominantly receiving standard hemodialysis (84.7% vs. hemodiafiltration 15.3%) and had a mean bodyweight of 76.3 kg (± 16.9). Lean body mass (LBM), mode of dialysis, and dialyzer partially explained between-subject variability in anti-Xa levels. Patients on hemodiafiltration and those receiving hemodialysis with a high LBM (≥ 80 kg) had a low probability (< 29%) of anti-Xa levels ≥ 0.4 IU/mL during the entire dialysis session. All patients, except hemodialysis patients with a low LBM (< 50 kg), had a high probability (> 70%) of peak anti-Xa levels < 2.0 IU/mL. CONCLUSION Mainly patients receiving hemodiafiltration and those receiving hemodialysis with a high LBM can benefit from a higher nadroparin dose than currently used in clinical practice, while having anti-Xa levels < 2.0 IU/mL.
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17
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Chou TFA, Ma HH, Tsai SW, Chen CF, Wu PK, Chen WM. Dialysis patients have comparable results to patients who have received kidney transplant after total joint arthroplasty: a systematic review and meta-analysis. EFORT Open Rev 2021; 6:618-628. [PMID: 34532070 PMCID: PMC8419801 DOI: 10.1302/2058-5241.6.200116] [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] [Indexed: 11/05/2022] Open
Abstract
Patients with end-stage renal disease (ESRD) have inferior outcomes after hip and knee total joint arthroplasty (TJA), with higher risk for surgical site complications (SSC) and periprosthetic joint infection (PJI). We conducted a systematic review and meta-analysis regarding outcomes after hip and knee TJA in ESRD patients who have received dialysis or a kidney transplant (KT) using PubMed, MEDLINE, Cochrane Reviews, and Embase in order to: (1) determine the mortality and infection rate of TJA in patients receiving dialysis or KT and (2) to identify risk factors associated with the outcome. We included 22 studies and 9384 patients (dialysis, n = 8921, KT, n = 463). The overall mortality rate was 14.9% and was slightly higher in KT patients (dialysis vs. KT, 13.8% vs. 15.8%). The overall SSC rate was 3.4%, while dialysis and KT patients each had an incidence of 3.3% and 3.6%, respectively. For PJI, the overall rate was 3.9%, while the incidence for dialysis patients was 4.0% and for KT patients was 3.7%. Using multi-regression analysis, age, sex, the type of arthroplasty (knee or hip) performed, and the form of renal replacement therapy (dialysis or KT) were not significant risk factors. In patients on dialysis or who had received a KT, TJA is associated with a slight increase in mortality, SSC and PJI rates.
Cite this article: EFORT Open Rev 2021;6:618-628. DOI: 10.1302/2058-5241.6.200116
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Affiliation(s)
- Te-Feng Arthur Chou
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Hsuan-Hsiao Ma
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Shang-Wen Tsai
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Cheng-Fong Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Po-Kuei Wu
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Wei-Ming Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
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18
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Carle V, Wu Y, Mukherjee R, Kong XD, Rogg C, Laurent Q, Cecere E, Villequey C, Konakalla MS, Maric T, Lamers C, Díaz-Perlas C, Butler K, Goto J, Stegmayr B, Heinis C. Development of Selective FXIa Inhibitors Based on Cyclic Peptides and Their Application for Safe Anticoagulation. J Med Chem 2021; 64:6802-6813. [PMID: 33974422 DOI: 10.1021/acs.jmedchem.1c00056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Coagulation factor XI (FXI) has emerged as a promising target for the development of safer anticoagulation drugs that limit the risk of severe and life-threatening bleeding. Herein, we report the first cyclic peptide-based FXI inhibitor that selectively and potently inhibits activated FXI (FXIa) in human and animal blood. The cyclic peptide inhibitor (Ki = 2.8 ± 0.5 nM) achieved anticoagulation effects that are comparable to that of the gold standard heparin applied at a therapeutic dose (0.3-0.7 IU/mL in plasma) but with a substantially broader estimated therapeutic range. We extended the plasma half-life of the peptide via PEGylation and demonstrated effective FXIa inhibition over extended periods in vivo. We validated the anticoagulant effects of the PEGylated inhibitor in an ex vivo hemodialysis model with human blood. Our work shows that FXI can be selectively targeted with peptides and provides a promising candidate for the development of a safe anticoagulation therapy.
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Affiliation(s)
- Vanessa Carle
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Yuteng Wu
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Rakesh Mukherjee
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Xu-Dong Kong
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Chloé Rogg
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Quentin Laurent
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Enza Cecere
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Camille Villequey
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Madhuree S Konakalla
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Tamara Maric
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Christina Lamers
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Cristina Díaz-Perlas
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Kaycie Butler
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Junko Goto
- Department of Public Health and Clinical Medicine, University of Umeå, SE-901 87 Umeå, Sweden
| | - Bernd Stegmayr
- Department of Public Health and Clinical Medicine, University of Umeå, SE-901 87 Umeå, Sweden
| | - Christian Heinis
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
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19
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François K, De Clerck D, Tonnelier A, Cambier ML, Orlando C, Jochmans K, Cools W, Wissing KM. Dialyzer Performance During Hemodialysis Without Systemic Anticoagulation Using a Heparin-Grafted Dialyzer Combined With a Citrate-Enriched Dialysate: Results of the Randomized Crossover Noninferiority EvoCit Study. Am J Kidney Dis 2021; 79:79-87.e1. [PMID: 33940113 DOI: 10.1053/j.ajkd.2021.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 04/06/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE The EvoCit study was designed to evaluate performance of a heparin-grafted dialyzer during hemodialysis with and without systemic anticoagulation. STUDY DESIGN Randomized, crossover, noninferiority trial. Noninferiority was defined as a difference of≤10% for the primary outcome. SETTING & PARTICIPANTS Single hemodialysis center; 26 prevalent patients treated with 617 hemodialysis sessions. INTERVENTIONS Hemodialysis using a heparin-grafted dialyzer combined with a 1.0mmol/L citrate-enriched dialysate ("EvoCit") without systemic anticoagulation compared with hemodialysis performed with a heparin-grafted dialyzer with systemic heparin ("EvoHep"). Patients were randomly allocated to a first period of 4 weeks and crossed over to the alternative strategy for a second period of 4 weeks. OUTCOMES The primary end point was the difference in Kt/Vurea between EvoCit and EvoHep. Secondary end points were urea reduction ratio, middle molecule removal, treatment time, thrombin generation, and reduction in dialyzer blood compartment volume. RESULTS The estimated difference in Kt/Vurea between EvoCit and EvoHep was-0.03 (95% CI, -0.06 to-0.007), establishing noninferiority with mean Kt/Vurea of 1.47±0.05 (SE) for EvoCit and 1.50±0.05 for EvoHep. Noninferiority was also established for reduction ratios of urea and β2-microglobulin. Premature discontinuation of dialysis was required for 4.2% of sessions among 6 patients during EvoCit and no sessions during EvoHep. Effective treatment time was 236±5 minutes for EvoCit and 238±1 minutes for EvoHep. Thrombin generation was increased and there was greater reduction in dialyzer blood compartment volume after treatments with EvoCit compared with EvoHep. LIMITATIONS The effects of avoiding systemic anticoagulation on clinical outcomes were not evaluated. CONCLUSIONS EvoCit is noninferior to EvoHep with respect to solute clearance but results in a greater number of shortened treatments, more membrane clotting, and greater thrombin generation TRIAL REGISTRATION: Registered at ClinicalTrials.gov with study number NCT03887468.
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Affiliation(s)
- Karlien François
- Division of Nephrology and Hypertension, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | - Dieter De Clerck
- Division of Nephrology and Hypertension, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Annelies Tonnelier
- Division of Nephrology and Hypertension, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Marie-Laure Cambier
- Division of Nephrology and Hypertension, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Christelle Orlando
- Department of Hematology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Kristin Jochmans
- Department of Hematology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Wilfried Cools
- Interfaculty Center Data processing & Statistics, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Karl Martin Wissing
- Division of Nephrology and Hypertension, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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20
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Santos A, Macías N, Vega A, Abad S, Linares T, Aragoncillo I, Cruzado L, Pascual C, Goicoechea M, López-Gómez JM. Expanded hemodialysis: Is anticoagulation of the dialysis circuit different from online hemodiafiltration and high-flux hemodialysis? Ther Apher Dial 2021; 26:147-153. [PMID: 33890717 DOI: 10.1111/1744-9987.13652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/13/2021] [Accepted: 04/17/2021] [Indexed: 11/28/2022]
Abstract
Expanded hemodialysis (HDx) has a high capacity for removing medium and medium-large molecules; however, there are no specific recommendations during HDx for anticoagulation of the dialysis circuit. We aimed to evaluate the differences in the efficacy of anticoagulation procedures using the venous port and 40 mg enoxaparin in HDx compared to high-flux hemodialysis (HF-HD) and postdilution online hemodiafiltration (HDF). We compared anticoagulant activity in 11 patients in HDx, HF-HD, and HDF under similar dialysis conditions. In the 33 dialysis sessions, 40 mg enoxaparin was administered through the venous port, and pre- and postdialysis antifactor Xa activity (aXa) and activated partial thromboplastin time (APTT), postdialysis clotting time of the vascular access, visual clotting score of the dialyzer, and any complications with the extracorporeal circuit or bleeding were registered. APTT postdialysis in HDx was not significantly different from that in HF-HD and HDF. Postdialysis aXa in HDx was not significantly different from that in HF-HD and HDF. We found no significant differences in visual clotting score of the dialyzer. Enoxaparin administered through the venous port was sufficient for anticoagulation within the extracorporeal circuit in HDx, HF-HD, and HDF. There were no differences in postdialysis aXa or APTT, most likely because when low molecular-weight heparin is applied through venous port, lesser enoxaparin concentration reaches the dialyzer. Thus, we conclude that the dose of enoxaparin administered through the venous port should not be adjusted according to dialysis technique.
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Affiliation(s)
- Alba Santos
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Nicolás Macías
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Almudena Vega
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Soraya Abad
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Tania Linares
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Inés Aragoncillo
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Leonidas Cruzado
- Department of Nephrology, Hospital Universitario de Elche, Elche, Spain
| | - Cristina Pascual
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marian Goicoechea
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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21
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Khoo BZE, Lim RS, See YP, Yeo SC. Dialysis circuit clotting in critically ill patients with COVID-19 infection. BMC Nephrol 2021; 22:141. [PMID: 33879086 PMCID: PMC8056790 DOI: 10.1186/s12882-021-02357-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/12/2021] [Indexed: 12/22/2022] Open
Abstract
Background Coronavirus Disease 2019 (COVID-19) infection has been associated with a hypercoagulable state with increased reports of thrombotic events. Acute kidney injury requiring dialysis is common in critically ill patients and circuit clotting compromises efficacy of treatment. This study aims to analyze the circuit life and circuit clotting during continuous kidney replacement therapy (CKRT) and intermittent hemodialysis in patients with and without COVID-19. Methods This is a single-center, retrospective cohort study in critically ill patients undergoing CKRT or intermittent hemodialysis between 1 February 2020 to 22 May 2020. Patients in the intensive care unit (ICU) with COVID-19 infection and contemporary controls who tested negative were included. Co-primary outcomes were functional circuit life for patients on CKRT and all circuit clotting events for patients on CKRT and/or intermittent hemodialysis. Results Seventy CKRT circuits and 32 intermittent hemodialysis sessions for 12 COVID-19 cases and 22 CKRT circuits and 18 intermittent hemodialysis sessions for 15 controls were analyzed. CKRT circuit clotting was more common in the COVID-19 group compared to the control group (64% vs 36%, p = 0.02), despite higher anticoagulation use in the COVID-19 group (41% vs 14%, p = 0.02). Functional CKRT circuit life was similar in COVID-19 patients and controls (median 11 vs 12 h, p = 0.69). On Cox regression analysis, circuit clotting was similar with hazard ratio (HR) 1.90 [95% confidence interval (CI): 0.89–4.04]; however, clotting was increased in COVID-19 patients after adjustment for anticoagulation use (HR: 3.31 [95% CI 1.49–7.33]). In patients with COVID-19, CKRT circuits with anticoagulation had a longer circuit life compared to CKRT circuits without anticoagulation (median 22 versus 7 h respectively, p < 0.001). Circuit clotting was similar in both groups undergoing intermittent hemodialysis. Conclusion Dialysis clotting amongst COVID-19 patients is increased despite more anticoagulation use and the hazard for clotting is greater especially after adjusting for anticoagulation use. Circuit life was suboptimal in COVID-19 patients on circuits without anticoagulation and therefore routine use of anticoagulation amongst COVID-19 patients should be considered whenever possible. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02357-3.
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Affiliation(s)
- Benjamin Zhi En Khoo
- Department of Renal Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
| | - Regina Shaoying Lim
- Department of Renal Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yong Pey See
- Department of Renal Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - See Cheng Yeo
- Department of Renal Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
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Luo L, Fan M, Chen Q, Cheng J. A simplified protocol for individualized regional citrate anticoagulation for hemodialysis: A single-center, randomized clinical study. Medicine (Baltimore) 2021; 100:e24639. [PMID: 33663073 PMCID: PMC7909225 DOI: 10.1097/md.0000000000024639] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 01/15/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION The lack of individualized treatment protocols and complicated procedures are important factors limiting the use of regional citrate anticoagulation (RCA) technology in hemodialysis. This study aims to validate the safety and efficacy of a simplified individualized RCA protocol for hemodialysis. MATERIALS AND METHODS From June 2019 to August 2019, 45 patients with active bleeding or bleeding tendency undergoing maintenance hemodialysis in the Nephrology Department of the First Affiliated Hospital of Nanchang University were randomly divided into a modified conventional RCA protocol group with a low-flux dialyzer, a simplified individualized RCA protocol group with a high-flux dialyzer, and a simplified individualized RCA protocol group with a low-flux dialyzer. RESULTS A total of 45 patients were included in this study. The mean age of the patients was 57.38 ± 19.05 years, and 78% were men. Forty-three patients completed 4 hours of hemodialysis, and the median total clotting scores in the 3 groups were 11, 12, and 12. Compared with the modified conventional RCA protocol group with a low-flux dialyzer, the 2 simplified individualized RCA protocol groups had better clotting scores for the dialyzer, arterial bubble trap, and single-pool urea clearance index (spKt/VBUN) and lower costs. Moreover, these parameters did not differ between the 2 simplified individualized RCA protocol groups. No electrolyte or acid-base imbalances or citrate poisoning was observed in any of the 3 groups. Adverse events did not differ significantly among the 3 groups. CONCLUSIONS The simplified individualized RCA protocol is safe, effective, and easy to implement. Therefore, this protocol can be promoted for clinical practice. TRIAL REGISTRATION This study was registered in the Chinese Clinical Study Registry under registration number ChiCTR1900023801.
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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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McIntyre D, Coyer F, Bonner A. Identifying nurse sensitive indicators specific to haemodialysis nursing: A Delphi approach. Collegian 2020. [DOI: 10.1016/j.colegn.2019.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Plasma levels of enoxaparin oligosaccharides, antifactor-Xa and thrombin generation in patients undergoing haemodialysis. Blood Coagul Fibrinolysis 2020; 31:152-159. [PMID: 31990754 DOI: 10.1097/mbc.0000000000000892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
: Low molecular weight heparins are used during haemodialysis for thromboprophylaxis of the dialysis circuit, with plasma antifactor-Xa (anti-Xa) activity used as a surrogate measure for effective anticoagulation. However, this pharmacokinetic parameter does not always correlate with pharmacodynamic effects in patients. The aim of this study was to investigate the relationship between actual plasma levels of the low molecular weight heparins enoxaparin, anti-Xa activity, and global coagulation measurement of thrombin generation during haemodialysis. Blood was analysed from 16 adult patients with end-stage kidney disease at 0, 2, 4 h, and at completion of 31 dialysis sessions where single fixed doses of 20 (n = 3), 40 (n = 16), 60 (n = 6), or 80 (n = 6) mg of enoxaparin (equating to 0.23-1.07 mg/kg) were used as thromboprophylaxis. Plasma enoxaparin oligosaccharides [degree of polymerization (dp)6-dp16] were measured by high-performance size exclusion chromatography, anti-Xa activity by colourimetric assay, and thrombin generation by calibrated automated thrombogram. Plasma enoxaparin fragments were undetectable at the beginning of each dialysis, peaked at 2 h to levels that correlated with dose (r = 0.68, P < 0.001) then remained relatively stable. In contrast, therapeutic anti-Xa levels achieved at 2 h in 18 cases (58%) quickly dropped to only six cases (19%) at the end of dialysis, by which time thrombin generation had also recovered in 81% of patients. Statistical modelling revealed a threshold value of anti-Xa at 0.53 IU/ml that supressed thrombin generation to 15.28% of baseline (P < 0.001). Despite loss of anticoagulant activity in the majority of patients, plasma levels of enoxaparin oligosaccharides remained detectable and relatively unchanged throughout dialysis.
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26
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Fazendeiro Matos J, Pinto B, Felix C, Carvalho H, Ponce P, Peralta R. Does subjective assessment of dialyzer appearance reflect dialyzer performance in online hemodiafiltration? Hemodial Int 2019; 24:61-70. [PMID: 31633275 PMCID: PMC7027516 DOI: 10.1111/hdi.12788] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 08/28/2019] [Accepted: 08/30/2019] [Indexed: 11/29/2022]
Abstract
Introduction: In post‐dilution online hemodiafiltration, a very thin balance subsists in preventing coagulation of the extracorporeal circuit (ECC) during treatment and bleeding in the patient, concerning dialyzer status and anticoagulation dose. The aim of this study was to assess whether there are clinical outcome differences between the visual aspect of the dialyzer's status in terms of clotted fibers at end of dialysis treatments, single‐pool urea kinetic modeling (spKt/V) and substitution volume (SubsVol). Methods: It is a multicenter, descriptive‐correlational study, involving 2829 patients during April 2016. Previous training was given to the Nursing staff to evaluate and classify both the dialyzer's and the venous chamber's appearance of the ECC venous line. Registration was performed at bedside immediately after the patient disconnection. Findings and discussion: Mean age was 68.96 years (SD = 13.75), 60.8% were men. The average hematocrit was 33.91% (SD = 3.45%). The average dry weight was 68.53 kg (SD = 13.27 kg). Mean unfractioned heparin (UFH) dose was 58.13 IU/kg. Only 32.4% of the patients had a clean dialyzer at the end of treatment. 19.4% of patients finished the treatment with more than 10% of clotted fibers. Patients with no residual blood (clean, 32.4%) presented a higher UFH dose (66.32 IU/kg) compared to overall average dose. UFH dose had a significant effect on dialyzer status. There were significant differences in average of spKt/V and SubsVol between the category clean and the other categories of dialyzer's status. Evaluating the dialyzer status represents an excellent opportunity to help the physicians to establish an ideal heparin dose. Only the category clean is significant to achieve the target. The nursing staff, by classifying the ECC appearance at patient's bedside and recording it in a centralized database, can be a major contributor to achieve an individualized and optimal UFH dose and subsequently better patient outcomes.
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Affiliation(s)
| | - Bruno Pinto
- NephroCare Portugal, Fresenius Medical Care Portugal, Porto, Portugal
| | - Carla Felix
- NephroCare Portugal, Fresenius Medical Care Portugal, Porto, Portugal
| | - Helena Carvalho
- Instituto Universitário de Lisboa (ISCTE-IUL), Centro de Investigação e Estudos de Sociologia (CIES-IUL), Lisbon, Portugal
| | - Pedro Ponce
- NephroCare Portugal, Fresenius Medical Care Portugal, Lisbon, Portugal
| | - Ricardo Peralta
- NephroCare Portugal, Fresenius Medical Care Portugal, Porto, Portugal
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27
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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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28
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Danaparoid use for haemodialysis in a morbidly obese patient with heparin-induced thrombocytopenia - Need for a higher than recommended weight-based dosing. Thromb Res 2019; 180:70-73. [PMID: 31229923 DOI: 10.1016/j.thromres.2019.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/08/2019] [Accepted: 06/14/2019] [Indexed: 11/20/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Heparin is widely used to prevent clotting of the extracorporeal circuit during haemodialysis (HD). Heparin-induced thrombocytopenia (HIT) is a potentially devastating immune mediated adverse drug reaction caused by the emergence of antibodies that activate platelets in the presence of heparin, leading to a pro-thrombotic state. Danaparoid is an alternative anticoagulant used in patients on HD with HIT but its dosing recommendations in obese patients on HD are relatively scarce. CASE SUMMARY We report a case of a 48-year-old morbidly obese patient who received weight-based dosing of danaparoid for HD with monitoring of anti-Xa activity. However, despite the patient's anti-Xa level being within the therapeutic range at various time points, the circuit lines kept clotting during HD. WHAT IS NEW AND CONCLUSION The report provides evidence that the manufacturer's recommendations on dosing danaparoid based on body weight may lead to sub-optimal therapeutic benefit and highlight the need for higher than recommended weight-based dosing in obese individuals on dialysis.
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29
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Douglass ME, Goudie MJ, Pant J, Singha P, Hopkins S, Devine R, Schmiedt CW, Handa H. Catalyzed Nitric Oxide Release Via Cu Nanoparticles Leads to an Increase in Antimicrobial Effects and Hemocompatibility for Short Term Extracorporeal Circulation. ACS APPLIED BIO MATERIALS 2019; 2:2539-2548. [PMID: 33718805 DOI: 10.1021/acsabm.9b00237] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Devices used for extracorporeal circulation are met with two major medical concerns: thrombosis and infection. A device that allows for anticoagulant-free circulation while reducing risk of infection has yet to be developed. We report the use of a copper nanoparticle (Cu NP) catalyst for the release of nitric oxide (NO) from the endogenous donor S-nitrosoglutathione (GSNO) in a coating applied to commercial Tygon S3™ E-3603 poly(vinyl chloride) tubing in order to reduce adhered bacterial viability and the occurrence thrombosis for the first time in an animal model. Cu GSNO coated material demonstrated a nitric oxide (NO) release flux ranging from an initial flux of 6.3 ± 0.9 ×10-10 mol cm-2 min-1 to 7.1 ± 0.4 ×10-10 mol cm-2 min-1 after 4 h of release, while GSNO loops without Cu NPs only ranged from an initial flux of 1.1 ± 0.2 ×10-10 mol cm-2 min-1 to 2.3 ± 0.2 ×10-10 mol cm-2 min-1 after 4 h of release, indicating that the addition of Cu NPs can increase NO flux up to five times in the same 4 h period. Additionally, a 3-log reduction in S. aureus and 1-log reduction in P. aeruginosa was observed in viable bacterial adhesion over a 24 h period compared to control loops. A Cell Counting Kit-8 (CCK-8) assay was used to validate no overall cytotoxicity towards 3T3 mouse fibroblasts. Finally, extracorporeal circuits were coated and exposed to 4 h of blood flow under an in vivo rabbit model. The Cu GSNO combination was successful in maintaining 89.3% of baseline platelet counts, while the control loops were able to maintain 67.6% of the baseline. These results suggest that the combination of Cu NPs with GSNO increases hemocompatibility and antimicrobial properties of ECC loops without any cytotoxic effects towards mammalian cells.
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Affiliation(s)
- Megan E Douglass
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Marcus J Goudie
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Jitendra Pant
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Priyadarshini Singha
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Sean Hopkins
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Ryan Devine
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Chad W Schmiedt
- Department of Small Animal Medicine and Surgery, University of Georgia, Athens, GA, USA
| | - Hitesh Handa
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
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30
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Voigt M, Gebert M, Haug U, Hulko M, Storr M, Boschetti-de-Fierro A, Beck W, Krause B. Retention of beneficial molecules and coagulation factors during haemodialysis and haemodiafiltration. Sci Rep 2019; 9:6370. [PMID: 31015539 PMCID: PMC6478905 DOI: 10.1038/s41598-019-42783-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/08/2019] [Indexed: 01/08/2023] Open
Abstract
Middle molecules (MMs) are associated with the pathology of uraemia, and are not effectively removed by standard extracorporeal treatments. Increased convection used in haemodiafiltration (HDF) can enhance the removal of MMs; however, high-volume HDF is not available to all patients. The new medium cut-off (MCO) membrane has been developed to allow increased removal of MMs using standard haemodialysis (HD). Improved removal of MMs has been shown with the MCO membrane compared with standard high-flux dialysers, but it is not known whether the increased pore size affects the retention of commonly used medications or that of coagulation factors in dialysis patients. Using an in vitro model, the retention of erythropoietin, heparin, insulin, vancomycin and several coagulation factors (Factors II, VII and X, protein C and antithrombin III) was investigated with the MCO membrane dialyser, compared with high-flux dialysers with polysulfone (in HDF) or polyethersulfone membranes (in HD and HDF). The retention of all molecules investigated was comparable between the MCO membrane and the high-flux dialysers. Results from the in vitro studies suggest that switching from a high-flux dialyser to the MCO membrane should not require changes to the medication dosing or anti-coagulation protocols of dialysis patients.
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Affiliation(s)
- Manuel Voigt
- Baxter International Inc., Research & Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany
| | - Michael Gebert
- Baxter International Inc., Research & Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany
| | - Ulrike Haug
- Baxter International Inc., Research & Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany
| | - Michael Hulko
- Baxter International Inc., Research & Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany
| | - Markus Storr
- Baxter International Inc., Research & Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany
| | | | - Werner Beck
- Baxter International Inc., Research & Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany
| | - Bernd Krause
- Baxter International Inc., Research & Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany
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Samaha E, Schwameis M, Schranz S, Watschinger B, Buchmüller A, Jilma B. Acetylsalicylic acid decreases clotting in combination with enoxaparin during haemodialysis in vitro. Nephrol Dial Transplant 2019; 34:509-515. [PMID: 30053218 DOI: 10.1093/ndt/gfy229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/16/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Anticoagulation is a cornerstone in haemodialysis (HD) therapy to avoid clotting of blood when it comes into contact with the dialysis membrane. Although heparins are usually administered as anticoagulants, they are not always sufficient to maintain adequate HD. We investigated the additional effect of acetylsalicylic acid compared with standard anticoagulation on maintaining adequate flow properties during HD in vitro. METHODS We collected blood from 42 healthy volunteers, between 18 and 60 years of age, into bags filled with 1, 1.5 or 2 mg enoxaparin, with (treatment group) or without (control group) 100 mg of aspirin. Blood was evaluated before, during and at the end of each experiment to determine coagulation parameters, whole blood aggregation and thromboelastogram measurements. Transmembrane pressure was recorded as indirect estimate of dialysis patency. The primary endpoint was time to filter clotting. RESULTS Addition of acetylsalicylic acid significantly prolonged the time to circuit clotting from 120 (105-150) min to >180 min (120-180) min (P = 0.047) and allowed lowering the enoxaparin concentration from 2 mg per circuit to 1 mg without an increase in clotting. Furthermore, it reduced the transmembrane pressure from 46 to 4 mmHg (P < 0.001) after 4 h of dialysis. Acetylsalicylic acid better preserved the platelet count (128 versus 116 × 10E9/L, P = 0.01) and improved platelet aggregation at the end of the dialysis procedure. CONCLUSION Adding acetylsalicylic acid to HD circuits lowered the transmembrane pressure, better preserved platelet function and prolonged the time to circuit clotting, which in sum increases haemodialyser performance and may facilitate a more effective HD.
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Affiliation(s)
- Eslam Samaha
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine II, Division of Pulmonology, Medical University of Vienna, Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Sabine Schranz
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Bruno Watschinger
- Department of Internal Medicine III, Division of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Anja Buchmüller
- Bayer Healthcare AG, Nordrhein-Westfalen, Wuppertal, Germany
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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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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Soroka S, Agharazii M, Donnelly S, Roy L, Muirhead N, Cournoyer S, MacKinnon M, Pannu N, Barrett B, Madore F, Tennankore K, Wilson JA, Hilton F, Sherman N, Wolter K, Orazem J, Feugère G. An Adjustable Dalteparin Sodium Dose Regimen for the Prevention of Clotting in the Extracorporeal Circuit in Hemodialysis: A Clinical Trial of Safety and Efficacy (the PARROT Study). Can J Kidney Health Dis 2018; 5:2054358118809104. [PMID: 30542622 PMCID: PMC6236648 DOI: 10.1177/2054358118809104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 09/14/2018] [Indexed: 01/03/2023] Open
Abstract
Background: Dalteparin sodium, a low-molecular-weight heparin, is indicated for
prevention of clotting in the extracorporeal circuit during hemodialysis
(HD). Product labeling recommends a fixed single-bolus dose of 5000
international units (IU) for HD sessions lasting up to 4 hours, but
adjustable dosing may be beneficial in clinical practice. Objective: The aim of the PARROT study was to investigate the safety and efficacy of an
adjustable dose of dalteparin in patients with end-stage renal disease
requiring 3 to 4 HD sessions per week. Design: A 7-week, open-label, multicenter study with a single treatment arm,
conducted between October 2013 and March 2016. Setting: Ten sites in Canada. Patients: A total of 152 patients with end-stage renal disease requiring 3 to 4 HD
sessions per week. Measurements: The primary outcome was the proportion of HD sessions completed without
premature termination due to inadequate anticoagulation. Methods: All participants initially received a dose of 5000 IU dalteparin, which could
be adjusted at subsequent HD sessions when clinically indicated, by
increment or decrement of 500 or 1000 IU, with no specified dose limits. Results: Patients were followed for 256 patient-months. Nearly all (99.9%; 95%
confidence interval [CI]: 99.7-100) evaluable HD sessions were completed
without premature clotting. Dose was adjusted for more than half (52.3%) of
participants, mostly owing to clotting or access compression time >10
minutes. Median dalteparin dose was 5000 IU (range: 500-13 000 IU). There
were no major bleeds, and minor bleeding was reported in 2.3% of all HD
sessions. There was no evidence of bioaccumulation. Limitations: This short-term study, with a single treatment arm, was designed to optimize
dalteparin dose using a flexible dosing schedule; it was not designed to
specifically evaluate dalteparin dose minimization, provide a direct
comparison of dalteparin versus unfractionated heparin, or provide
information on long-term safety for flexible dalteparin dosing. Patients
were excluded if they were at high risk of bleeding, including those on
anticoagulants and those on antiplatelet agents other than aspirin <100
mg/d. Conclusions: Overall, an adjustable dalteparin sodium dose regimen allowed safe completion
of HD, with clinical benefits over fixed dosing. Trial Registration: ClinicalTrials.gov NCT01879618, registered June 13,
2013.
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Affiliation(s)
- Steven Soroka
- Division of Nephrology, Dalhousie University, Halifax, NS, Canada
| | - Mohsen Agharazii
- Endocrinology and Nephrology, CHU de Québec Research Center, L'Hôtel-Dieu de Québec, Université Laval, Québec City, QC, Canada
| | - Sandra Donnelly
- Division of Nephrology, William Osler Health System, Brampton Civic Hospital, Brampton, ON, Canada
| | - Louise Roy
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Norman Muirhead
- Department of Medicine, London Health Sciences Centre, Western University, London, ON, Canada
| | - Serge Cournoyer
- Nephrology, Hôpital Charles-LeMoyne, Greenfield Park, QC, Canada
| | | | - Neesh Pannu
- Nephrology, University of Alberta, Edmonton, AB, Canada
| | - Brendan Barrett
- Division of Nephrology, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - François Madore
- Faculté de Médecine, Hôpital du Sacré-Cœur de Montréal, Montréal, QC, Canada
| | | | - Jo-Anne Wilson
- Division of Nephrology, Dalhousie University, Halifax, NS, Canada
| | - Fiona Hilton
- Pfizer Essential Health, Pfizer Inc, Groton, CT, USA.,Pfizer Essential Health, Pfizer Inc, New York, NY, USA
| | - Nancy Sherman
- Pfizer Essential Health, Pfizer Inc, New York, NY, USA
| | - Kevin Wolter
- Pfizer Essential Health, Pfizer Inc, New York, NY, USA
| | - John Orazem
- Pfizer Essential Health, Pfizer Inc, New York, NY, USA
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35
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Piccoli GB, Nielsen L, Gendrot L, Fois A, Cataldo E, Cabiddu G. Prescribing Hemodialysis or Hemodiafiltration: When One Size Does Not Fit All the Proposal of a Personalized Approach Based on Comorbidity and Nutritional Status. J Clin Med 2018; 7:E331. [PMID: 30297628 PMCID: PMC6210736 DOI: 10.3390/jcm7100331] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 12/14/2022] Open
Abstract
There is no simple way to prescribe hemodialysis. Changes in the dialysis population, improvements in dialysis techniques, and different attitudes towards the initiation of dialysis have influenced treatment goals and, consequently, dialysis prescription. However, in clinical practice prescription of dialysis still often follows a "one size fits all" rule, and there is no agreed distinction between treatment goals for the younger, lower-risk population, and for older, high comorbidity patients. In the younger dialysis population, efficiency is our main goal, as assessed by the demonstrated close relationship between depuration (tested by kinetic adequacy) and survival. In the ageing dialysis population, tolerance is probably a better objective: "good dialysis" should allow the patient to attain a stable metabolic balance with minimal dialysis-related morbidity. We would like therefore to open the discussion on a personalized approach to dialysis prescription, focused on efficiency in younger patients and on tolerance in older ones, based on life expectancy, comorbidity, residual kidney function, and nutritional status, with particular attention placed on elderly, high-comorbidity populations, such as the ones presently treated in most European centers. Prescription of dialysis includes reaching decisions on the following elements: dialysis modality (hemodialysis (HD) or hemodiafiltration (HDF)); type of membrane (permeability, surface); and the frequency and duration of sessions. Blood and dialysate flow, anticoagulation, and reinfusion (in HDF) are also briefly discussed. The approach described in this concept paper was developed considering the following items: nutritional markers and integrated scores (albumin, pre-albumin, cholesterol; body size, Body Mass Index (BMI), Malnutrition Inflammation Score (MIS), and Subjective Global Assessment (SGA)); life expectancy (age, comorbidity (Charlson Index), and dialysis vintage); kinetic goals (Kt/V, normalized protein catabolic rate (n-PCR), calcium phosphate, parathyroid hormone (PTH), beta-2 microglobulin); technical aspects including vascular access (fistula versus catheter, degree of functionality); residual kidney function and weight gain; and dialysis tolerance (intradialytic hypotension, post-dialysis fatigue, and subjective evaluation of the effect of dialysis on quality of life). In the era of personalized medicine, we hope the approach described in this concept paper, which requires validation but has the merit of providing innovation, may be a first step towards raising attention on this issue and will be of help in guiding dialysis choices that exploit the extraordinary potential of the present dialysis "menu".
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Affiliation(s)
- Giorgina Barbara Piccoli
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
- Dipartimento di Scienze Cliniche e Biologiche, University of Torino, Ospedale san Luigi, Regione Gonzole, 10100 Torino, Italy.
| | - Louise Nielsen
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Lurilyn Gendrot
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Antioco Fois
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Emanuela Cataldo
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
- Nefrologia, Università Aldo Moro, Piazza Umberto I, 70121 Bari, Italy.
| | - Gianfranca Cabiddu
- Nefrologia Ospedale Brotzu, Piazzale Alessandro Ricchi, 1, 09134 Cagliari, Italy.
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36
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Gameiro J, Jorge S, Lopes JA. Haemodialysis-related-heparin-induced thrombocytopenia: Case series and literature review. Nefrologia 2018; 38:551-557. [PMID: 29871769 DOI: 10.1016/j.nefro.2018.02.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 02/12/2018] [Accepted: 02/27/2018] [Indexed: 01/18/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a serious and life-threatening complication that occurs in five per cent of patients exposed to heparin. It should be considered in patients with a platelet count <100×109cells/l or a >50% decrease from baseline count in association with heparin therapy. Thromboembolic complications develop in 50% of patients. Bleeding is rare as the platelet count nadir typically does not drop below 20×109cells/l. Up to 12% of dialysis patients develop HIT, named haemodialysis-related-heparin-induced thrombocytopenia (HD-HIT), as they are a risk group with continuous exposure to heparin. The definition of HD-HIT is less strict, in the range of a platelet count decrease of 30% and below 150×109cells/l due to the intermittent use of heparin. Heparin cessation and alternative anticoagulation are the key interventions in patients with HIT. In dialysis patients, citrate anticoagulation, heparin-free dialysis or peritoneal dialysis are options that must be considered. The authors describe the presentation, diagnosis, treatment and outcomes of five cases of HD-HIT, and emphasize the importance of an accurate diagnosis and early intervention in order to reduce the mortality risk, which can be as high as 20 per cent.
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Affiliation(s)
- Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal.
| | - Sofia Jorge
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
| | - José António Lopes
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
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37
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Schmitz M, Joannidis M, Czock D, John S, Jörres A, Klein SJ, Oppert M, Schwenger V, Kielstein J, Zarbock A, Kindgen-Milles D, Willam C. [Regional citrate anticoagulation in renal replacement therapy in the intensive care station : Recommendations from the renal section of the DGIIN, ÖGIAIN and DIVI]. Med Klin Intensivmed Notfmed 2018; 113:377-383. [PMID: 29737362 DOI: 10.1007/s00063-018-0445-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/03/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) in continuous renal replacement therapy can effectively anticoagulate dialysis circuits without having adverse effects on systemic heparin application. In particular, in continuous renal replacement therapy RCA is well established and represents a safe procedure with longer filter lifetimes and fewer bleeding complications. OBJECTIVES To provide guidance on the indications, advantages and disadvantages, and use of RCA, current recommendations from the renal section of the DGIIN (Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin), ÖGIAIN (Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin) and DIVI (Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin) are stated. MATERIALS AND METHODS The recommendations in this paper are based on the current KDIGO (Kidney Disease: Improving Global Outcomes) guidelines, other published guidelines and protocols as well as the expert knowledge and clinical experience of the authors. RESULTS The use of commercially available machines with coupled pumps and integrated safety features, effective personal training and standardized protocols for clinical usage (SOP) is particularly important for the safe clinical use of RCA in renal replacement therapy. Contrary to previous recommendations, even liver failure or shock with lactic acidosis may no longer be an absolute contra-indication for RCA. However, these particular patients have to be carefully monitored for signs of citrate accumulation.
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Affiliation(s)
- M Schmitz
- Klinik für Nephrologie und Allgemeine Innere Medizin, Städtisches Klinikum Solingen, Gotenstraße 1, 42653, Solingen, Deutschland.
| | - M Joannidis
- Gemeinsame Einrichtung internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - D Czock
- Medizinische Klinik, Abteilung Klinische Pharmakologie und Pharmakoepidemiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Deutschland
| | - S John
- Abteilung Internistische Intensivmedizin, Medizinische Klinik 8, Paracelsus Medizinische Privatuniversität (PMU) Nürnberg, Universität Erlangen-Nürnberg, Klinikum Nürnberg-Süd, Nürnberg, Deutschland
| | - A Jörres
- Medizinische Klinik I für Nephrologie, Transplantationsmedizin und internistische Intensivmedizin, Klinikum der Universität Witten/Herdecke, Köln-Merheim, Deutschland
| | - S J Klein
- Gemeinsame Einrichtung internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - M Oppert
- Klinik für Notfall- und internistische Intensivmedizin, Klinikum Ernst von Bergmann, Potsdam, Deutschland
| | - V Schwenger
- Klinik für Nieren‑, Hochdruck- und Autoimmunerkrankungen, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Deutschland
| | - J Kielstein
- Medizinische Klinik V, Nephrologie, Rheumatologie, Blutreinigungsverfahren, Städtisches Klinikum Braunschweig, Braunschweig, Deutschland
| | - A Zarbock
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - D Kindgen-Milles
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Moorenstr. 5, 40225, Düsseldorf, Deutschland
| | - C Willam
- Medizinische Klinik 4, Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland
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38
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Parker K, Mitra S, Thachil J. Is anticoagulating haemodialysis patients with non-valvular atrial fibrillation too risky? Br J Haematol 2018; 181:725-736. [PMID: 29468649 DOI: 10.1111/bjh.15144] [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] [Indexed: 12/25/2022]
Abstract
There is an increasing understanding of the risks from atrial fibrillation (AF) in the current era. In patients with end-stage renal disease (ESRD) on dialysis, the prevalence of AF is significantly higher compared to the general population and those with earlier stages of CKD. Although anticoagulation of these patients may seem appropriate, there is a lack of conclusive evidence that it provides the same protection from thromboembolic complications as it does in patients not on dialysis. In addition, the increased risk of bleeding in patients requiring dialysis makes the use of anticoagulants less favourable. This article aims to discuss the problem of AF in dialysis patients, summarise the current evidence around the use of oral anticoagulants for AF in ESRD and provide some practical suggestions on management of AF in the haemodialysis population.
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Affiliation(s)
- Kathrine Parker
- Department of Pharmacy, Manchester Royal Infirmary, Manchester, UK
| | - Sandip Mitra
- Department of Renal Medicine, Manchester Institute of Nephrology and Transplantation, Manchester, UK
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
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39
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Dialysis Procedures Alter Metabolic Conditions. Nutrients 2017; 9:nu9060548. [PMID: 28554992 PMCID: PMC5490527 DOI: 10.3390/nu9060548] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 04/25/2017] [Accepted: 05/23/2017] [Indexed: 12/15/2022] Open
Abstract
A progressive chronic kidney disease results in retention of various substances that more or less contribute to dysfunction of various metabolic systems. The accumulated substances are denominated uremic toxins. Although many toxins remain undetected, numerous newly defined toxins participate in the disturbance of food breakdown. In addition, toxic effects may downregulate other pathways, resulting in a reduced ability of free fatty acid breakdown by lipoprotein lipase (LPL) and hepatic lipase (HL). Dialysis may even worsen metabolic functions. For LPL and HL, the use of heparin and low molecular weight heparin as anticoagulation during hemodialysis (HD) initiate a loss of these enzymes from their binding sites and degradation, causing a temporary dysregulation in triglyceride breakdown. This lack of function will cause retention of the triglyceride containing lipids for at least 8 h. In parallel, the breakdown into free fatty acids is limited, as is the energy supply by them. This is repeated thrice a week for a normal HD patient. In addition, dialysis will cause a loss of amino acids and disturb glucose metabolism depending on the dialysates used. The addition of glucose in the dialysate may support oxidation of carbohydrate and the retention of Amadori products and subsequent tissue alterations. To avoid these effects, it seems necessary to further study the effects of anticoagulation in HD, the extent of use of glucose in the dialysate, and the supplementation of amino acids.
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40
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Delanaye P, Bouquegneau A, Dubois BE, Sprynger M, Mariat C, Krzesinski JM, Lancellotti P. Fibrillation auriculaire et anticoagulation chez le patient hémodialysé : une décision difficile. Nephrol Ther 2017; 13:59-66. [DOI: 10.1016/j.nephro.2016.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 09/17/2016] [Accepted: 09/18/2016] [Indexed: 10/20/2022]
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41
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Fajardo C, Sanchez CP, Cutler D, Sahney S, Sheth R. Inpatient citrate-based hemodialysis in pediatric patients. Pediatr Nephrol 2016; 31:1667-72. [PMID: 27167382 DOI: 10.1007/s00467-016-3403-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 04/20/2016] [Accepted: 04/21/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Citrate-based dialysate is an effective method of hemodialysis (HD) anticoagulation in adults. The objective of this study was to evaluate this therapy as an alternative to heparin anticoagulation in pediatric patients in the inpatient setting requiring HD. METHODS We performed a prospective, non-randomized study of citrate-based dialysate HD treatments (N = 119) over a 9-month period in 18 pediatric patients (age range 0-18 years) admitted to hospital. Primary outcome measures were thrombosis incidence rates that resulted in circuit loss, catheter loss or early dialysis termination. Secondary outcome measures were hypocalcemia incidence and heparin use. Data analysis was performed using descriptive and comparative statistics. RESULTS There was a thrombosis incidence rate of 2.5 % circuit loss, 2.5 % catheter loss and 5.9 % early dialysis termination due to the thrombosis risk. In 64 % of treatments a circuit clot developed but with no circuit loss, and mild asymptomatic hypocalcemia deveoped in 58 % of the monitored HD sessions . No patient required additional heparin during the citrate-based HD treatments, but 11.1 % were subsequently converted to heparin anticoagulation. CONCLUSIONS Our study showed a low percentage of thrombotic episodes resulting in catheter or circuit loss. Hypocalcemia was common but remained mild and asymptomatic. Citrate-based dialysate was well tolerated by our patients. We therefore conclude that citrate-based dialysate is a safe alternative to heparin-based hemodialysis anticoagulation.
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Affiliation(s)
- Cecile Fajardo
- Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, CA, 92354, USA
| | - Cheryl P Sanchez
- Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, CA, 92354, USA
| | - Drew Cutler
- Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, CA, 92354, USA
| | - Shobha Sahney
- Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, CA, 92354, USA
| | - Rita Sheth
- Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, CA, 92354, USA.
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42
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Jain A, Graveline A, Waterhouse A, Vernet A, Flaumenhaft R, Ingber DE. A shear gradient-activated microfluidic device for automated monitoring of whole blood haemostasis and platelet function. Nat Commun 2016; 7:10176. [PMID: 26733371 PMCID: PMC4729824 DOI: 10.1038/ncomms10176] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 11/11/2015] [Indexed: 12/15/2022] Open
Abstract
Accurate assessment of blood haemostasis is essential for the management of patients who use extracorporeal devices, receive anticoagulation therapy or experience coagulopathies. However, current monitoring devices do not measure effects of haemodynamic forces that contribute significantly to platelet function and thrombus formation. Here we describe a microfluidic device that mimics a network of stenosed arteriolar vessels, permitting evaluation of blood clotting within small sample volumes under pathophysiological flow. By applying a clotting time analysis based on a phenomenological mathematical model of thrombus formation, coagulation and platelet function can be accurately measured in vitro in patient blood samples. When the device is integrated into an extracorporeal circuit in pig endotoxemia or heparin therapy models, it produces real-time readouts of alterations in coagulation ex vivo that are more reliable than standard clotting assays. Thus, this disposable device may be useful for personalized diagnostics and for real-time surveillance of antithrombotic therapy in clinic. The current hemostasis assays are unable to predict thrombotic or bleeding risk in clinics. Here, Jain et al. present a novel microfluidic device mimicking stenosed arterioles that determines clotting times in vitro and in extracorporeal circuits, offering a simple and reliable monitoring of blood homeostasis and platelet function.
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Affiliation(s)
- Abhishek Jain
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts 02115, USA.,Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts 02115, USA.,Vascular Biology Program, Departments of Pathology and Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Amanda Graveline
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts 02115, USA
| | - Anna Waterhouse
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts 02115, USA
| | - Andyna Vernet
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts 02115, USA
| | - Robert Flaumenhaft
- Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Donald E Ingber
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts 02115, USA.,Vascular Biology Program, Departments of Pathology and Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA.,Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts 02138, USA
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43
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Jose MD, Longmuir H, Dodds B, Bereznicki L, Prasad R, Batt TJ, Strippoli GFM, Palmer SC. Anticoagulation for people receiving long-term haemodialysis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Matthew D Jose
- University of Tasmania; School of Medicine; Hobart Tasmania Australia 7000
| | - Henrietta Longmuir
- University of Tasmania; School of Medicine; Hobart Tasmania Australia 7000
| | - Benjamin Dodds
- University of Tasmania; School of Medicine; Hobart Tasmania Australia 7000
| | - Luke Bereznicki
- University of Tasmania; Division of Pharmacy, School of Medicine; Churchill Avenue Hobart Tasmania Australia 7000
| | - Ritam Prasad
- Royal Hobart Hospital; Department of Haematology/Pathology; 48 Liverpool Street Hobart TAS Australia 7000
| | - Tracey J Batt
- Royal Hobart Hospital; Department of Haematology/Pathology; 48 Liverpool Street Hobart TAS Australia 7000
| | - Giovanni FM Strippoli
- The Children's Hospital at Westmead; Cochrane Kidney and Transplant, Centre for Kidney Research; Westmead NSW Australia 2145
- University of Bari; Department of Emergency and Organ Transplantation; Bari Italy
- Diaverum; Medical Scientific Office; Lund Sweden
- Diaverum Academy; Bari Italy
| | - Suetonia C Palmer
- University of Otago Christchurch; Department of Medicine; 2 Riccarton Ave PO Box 4345 Christchurch New Zealand 8140
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