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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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2
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Santos A, Vega A, Davenport A. How to Ensure Patency of the Extracorporeal Circuit in Hemodialysis: Global Perspectives. Semin Nephrol 2023; 43:151476. [PMID: 38272778 DOI: 10.1016/j.semnephrol.2023.151476] [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: 01/27/2024]
Abstract
An adequate knowledge of anticoagulants used to prevent clotting in the extracorporeal circuit is crucial to provide optimal hemodialysis. Drugs can potentially prevent extracorporeal circuit clotting, but administration, half-life, and potential side effects differ. However, there is a lack of concise recommendations to guide anticoagulation and to avoid side effects. Because of the development of newer anticoagulant agents, direct thrombin inhibitors, and heparinoids, some of the side effects related to heparin may be overcome, but a deeper knowledge of these newer drugs is necessary. Moreover, types of heparin used, routes of administration, and health care economics vary around the world. We performed an extensive review of the literature, and the present article focuses on available anticoagulant drugs, exploring doses, side effects, particular use in hemodialysis, mechanism of action, pharmacokinetic properties, and use in special situations. Classical anticoagulants are still the standard of anticoagulation, but many questions remain unanswered; for example, is there real superiority of one treatment over another in terms of efficacy, safety, and health care economics? Anticoagulant protocols for hemodialysis need to be standardized and further studies performed to answer all of these questions.
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Affiliation(s)
- Alba Santos
- Nephrology Department, Hospital Universitario del Vinalopó, Elche, Spain.
| | - Almudena Vega
- Nephrology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Andrew Davenport
- Department of Renal Medicine, Division of Medicine, University College London, London, UK
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3
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Anticoagulation in patients with acute kidney injury undergoing kidney replacement therapy. Pediatr Nephrol 2022; 37:2303-2330. [PMID: 34668064 DOI: 10.1007/s00467-021-05020-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/13/2020] [Accepted: 02/18/2021] [Indexed: 10/20/2022]
Abstract
Kidney replacement therapy (KRT) is used to provide supportive therapy for critically ill patients with severe acute kidney injury and various other non-renal indications. Modalities of KRT include continuous KRT (CKRT), intermittent hemodialysis (HD), and sustained low efficiency daily dialysis (SLED). However, circuit clotting is a major complication that has been investigated extensively. Extracorporeal circuit clotting can cause reduction in solute clearances and can cause blood loss, leading to an upsurge in treatment costs and a rise in workload intensity. In this educational review, we discuss the pathophysiology of the clotting cascade within an extracorporeal circuit and the use of various types of anticoagulant methods in various pediatric KRT modalities.
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Canaud B, Davenport A. Prescription of online hemodiafiltration (ol-HDF). Semin Dial 2022; 35:413-419. [PMID: 35297521 DOI: 10.1111/sdi.13070] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/05/2022] [Indexed: 12/28/2022]
Abstract
HDF prescription should be able to satisfy the delivery of an optimal dialytic convective dose. Several factors are implicated in this endeavor. High blood flow rate is crucial to warranty processing an adequate blood volume and to ensure the highest shear rate per fiber needed to cleanse and prevent membrane fouling. A highly permeable dialyzer is needed with a surface area aligned to blood flow and performance needs. Anticoagulation requires specific adaptation in case of low molecular weight heparin use. By default, HDF prescription modality should ideally start by postdilution mode with a stepwise increment of convective dose by probing patient tolerance and efficacy. Alternative substitution modality should be considered if dialytic convective dose could not be achieved in the usual time frame. Convective dose prescription relies either on a manual mode (pressure control or volume control) or on automated mode (ultrafiltration control) depending on the technical options of the HDF machines. Dialysate flow rate is regulated by the HDF machine but should preferably keep constant dialysis fluid flowing the dialyzer with a Qb:Qd ratio of 1.4. Treatment time should not be reduced with HDF prescription. Treatment time should fit with patient tolerance (hemodynamic, osmotic, and solute shifts) and overall solute removal efficiency. Electrolytic prescription does not require specific adjustments as compared with conventional dialysis, but the patient needs to be monitored regularly and dialysate electrolyte adjusted to lab tests. A stepwise approach for implementing ol-HDF is preferable depending on the initial condition of the patient. Three particular cases may be considered: late-stage chronic kidney disease patient transitioning to renal replacement therapy, stable dialysis patient switching to HDF, and unstable or fragile patient or specific treatment schedule. Optimal dosing of HDF and personalized care to ensure treatment adequacy is the main goal for renal replacement therapy to improve patient outcomes. That should be ensured with HDF treatment.
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Affiliation(s)
- Bernard Canaud
- School of Medicine, Montpellier University, Montpellier, France.,Global Medical Office, FMC Deutschland, Bad Homburg, Germany
| | - Andrew Davenport
- University College London Department of Renal Medicine, Royal Free Hospital, University College, London, UK
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5
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Belmouaz M, Goussard G, Joly F, Grand F, Sibille A, Ecotiere L, Desport E, Bauwens M, Thierry A, Bridoux F. Comparison of the injection of low-molecular weight heparin in the arterial vs. venous blood line for preventing extracorporeal circuit clotting during hemodialysis. Hemodial Int 2022; 26:314-322. [PMID: 35014175 DOI: 10.1111/hdi.13004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 12/01/2022]
Abstract
Low-molecular weight heparins (LMWH) are widely used for preventing clotting during hemodialysis (HD). Although injection in the venous blood line is recommended to avoid initial loss of LMWH through the dialyzer, LMWH is still frequently administered in the arterial blood line at the start of dialysis. This study aimed to compare the safety and efficacy of the same enoxaparin dose administered through the venous blood line or arterial blood line. We also evaluated antifactor Xa (aXa) activity according to the injection route and dialysis modalities: high-flux (HF) HD, medium cut-off (MCO) HD, and online hemodiafiltration (OL-HDF). Forty-three patients were studied over 18 consecutive dialysis sessions using a fixed enoxaparin dose (20 or 40 mg), first administered through the arterial blood line bolus and then through the venous blood line for another 18 sessions. Compared to arterial blood line administration, venous blood line bolus resulted in a significant increase in median post-dialysis aXa activity: 0.16 (0.1-0.6) IU/ml versus 0.31 (0.1-1.3) IU/ml, respectively, p = 0.006. After arterial blood line bolus of 40 mg enoxaparin, median post-dialysis aXa activity was significantly lower with OL-HDF compared to HF-HD: 0.14 (0.1-0.35) versus 0.32 (0.15-0.49), p = 0.02. A trend for lower clotting within lines and bubble trap using venous blood line bolus was observed. In conclusion, venous blood line enoxaparin injection is safe in OL-HDF patients. However, in HF-HD and MCO-HD, venous blood line injection of 40 mg enoxaparin may increase overdosing risk. Thus, aXa activity should be monitored in HF-HD and MCO-HD patients at risk of bleeding and/or on vitamin K antagonists and careful surveillance is required when administering a 40 mg enoxaparin dose through the venous blood line route.
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Affiliation(s)
- Mohamed Belmouaz
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Guillaume Goussard
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Florent Joly
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Francois Grand
- Laboratory of Hematology, Poitiers University Hospital, Poitiers, France
| | - Audrey Sibille
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Laure Ecotiere
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Estelle Desport
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Marc Bauwens
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Antoine Thierry
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Frank Bridoux
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
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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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7
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Hebibi H, Attaf D, Cornillac L, Achiche J, El Boundri F, Francais P, Chazot C, Canaud B. Arterial Versus Venous Port Site Administration of Nadroparin for Preventing Thrombosis of Extracorporeal Blood Circuits in Patients Receiving Hemodiafiltration Treatment. Kidney Int Rep 2020; 6:351-356. [PMID: 33615060 PMCID: PMC7879117 DOI: 10.1016/j.ekir.2020.11.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/10/2020] [Accepted: 11/17/2020] [Indexed: 11/02/2022] Open
Abstract
Introduction Administration of low-molecular-weight heparins (LMWHs) is necessary for preventing extracorporeal circuit thrombosis during hemodialysis. A substantial amount of LMWH is removed with online hemodiafiltration (OL-HDF) when administered through the inlet site of the extracorporeal circuit. Consequently, administration of LMWH at the outlet site appears to be more efficient. In this study we aimed to compare the effects of nadroparin calcium (NAD) administered through the outlet versus the inlet port site in postdilution OL-HDF and assess the NAD dose reduction. Methods Forty-nine hemodialysis patients were included in 3 consecutive 6-week studies as follows: phase I, inlet port line; phase II, outlet port line; and phase III, outlet port line with reduced dose. We evaluated clotting in the hemodialyzer and venous bubble trap, the dialysis dose (K t/V), and substitution volume. Results Thirty four percent, 63%, and 66% were categorized as "white" during phases I, II, and III, respectively. During phases I, II, and III, 75%, 93%, and 95% of the venous bubble traps were "clean," and 9%, 0.6%, and 0.4% of the dialyzers clotted, respectively. Average NAD dose was 0.43 ml during phase I and 0.3 ml during phase II. During phase III, the LMWH dose was reduced by 33% to 50% in 15 patients. In phase III, Kt/V improved from 1.64 to 1.75 and substitution volume increased from 20.18 to 21.96 L. Conclusions When using OL-HDF, a single administration of NAD at the outlet port line allows for a significant dose reduction and was associated with improved dialysis performance.
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Affiliation(s)
- Hedia Hebibi
- NephroCare Île-de-France, Villejuif, France.,NephroCare Île-de-France, Bièvres, France
| | - David Attaf
- Fresenius Medical Care, Ile de France, France
| | | | | | | | | | | | - Bernard Canaud
- Global Medical Office, Fresenius Medical Care Deutschland, Bad Homburg, German.,Montpellier University, Montpellier, France
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8
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Claudel SE, Miles LA, Murea M. Anticoagulation in hemodialysis: A narrative review. Semin Dial 2020; 34:103-115. [PMID: 33135208 DOI: 10.1111/sdi.12932] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/28/2020] [Accepted: 10/11/2020] [Indexed: 12/18/2022]
Abstract
Systemic anticoagulation in maintenance hemodialysis (HD) has historically been considered necessary to maintain the extracorporeal circuit (ECC) and preserve dialysis efficiency. Unfractionated heparin (UFH) is the most commonly used anticoagulant due to low cost and staff familiarity. Despite widespread use, there is little standardization of heparin dosing protocols in the United States. Although the complication rates with UFH are low for the general population, certain contraindications have led to exploration in alternative anticoagulants in patients with end-stage kidney disease (ESKD). Here we review the current evidence regarding heparin dosing protocols, complications associated with heparin use, and discuss alternatives to UFH including anticoagulant-free routine HD.
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Affiliation(s)
- Sophie E Claudel
- Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Lauren A Miles
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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9
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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. Efficacy of enoxaparin in preventing coagulation during high-flux haemodialysis, expanded haemodialysis and haemodiafiltration. Clin Kidney J 2020; 14:1120-1125. [PMID: 33841857 PMCID: PMC8023216 DOI: 10.1093/ckj/sfaa057] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/18/2020] [Indexed: 12/16/2022] Open
Abstract
Background Low-molecular-weight heparins (LMWHs) are easily dialysable with high-flow membranes; however, it is not clear whether the LMWH dose should be adjusted according to the membrane type and dialysis technique. This study aimed to evaluate the influence of the dialyser on anticoagulation of the extracorporeal dialysis circuit. Methods Thirteen patients received the same dose of LMWH through the arterial port via three dialysis techniques: high-flux haemodialysis (HF-HD), online haemodiafiltration (HDF) and expanded haemodialysis (HDx). All dialysis was performed under similar conditions: duration, 4 h; blood flow, 400 mL/min; and dialysate flow, 500 mL/min. Antifactor Xa (aXa) activity and activated partial thromboplastin time (APTT) were measured before and after the dialysis. Clotting time of the vascular access site after haemodialysis, visual clotting score of the dialyser and any complications with the extracorporeal circuit or bleeding were registered. Results Post-dialysis aXa activity in HF-HD (0.26 ± 0.02 U/mL) was significantly different from that in HDF (0.21 ± 0.02 U/mL, P = 0.024), and there was a trend in HDx (0.22 ± 0.01 U/mL, P = 0.05). APTT post-dialysis in HF-HD (30.5 ± 0.7 s) was significantly different from that in HDx (28.2 ± 0.64 s, P = 0.009) and HDF (28.8 ± 0.73 s, P = 0.009). Conclusions AXa activity in HDF was significantly lower than that in HF-HD, possibly because of more losses of LMWH through the dialyser. Given the higher anticoagulant loss in HDF and probably in HDx than in HF-HD, the enoxaparin dose administered may be adjusted according to the dialysis technique.
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Affiliation(s)
- Alba Santos
- Nephrology Department, Hospital Universitario del Vinalopó, Elche, Spain
| | - Nicolás Macías
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Almudena Vega
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Soraya Abad
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Tania Linares
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Inés Aragoncillo
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Leonidas Cruzado
- Nephrology Department, Hospital Universitario de Elche, Elche, Spain
| | - Cristina Pascual
- Hematology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marian Goicoechea
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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10
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Tao M, Zheng D, Liang X, Ye M, Liu Y, Li Y, Shen H, He Q. Evaluation of the anticoagulant effect of low-molecular-weight heparins based on the anti-Xa level during haemodialysis. Nephrology (Carlton) 2020; 25:723-729. [PMID: 31999031 DOI: 10.1111/nep.13697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 01/14/2020] [Accepted: 01/19/2020] [Indexed: 11/29/2022]
Abstract
AIM Evaluate the relationship between anti-Xa activity and anticoagulant effect, and ascertain whether accumulation of low-molecular-weight heparins (LMWH) occurs during haemodialysis. METHODS There was an observational, single-centre study among participants who received the LMWH dalteparin, enoxaparin or nadroparin. A standard haemodialysis session lasted 4 hours. All included participants had anti-Xa activity measures at 0.5 and 4 hours. Extracorporeal circuit (ECC) clotting was evaluated by visual inspection of the haemodialyser and bubble trap after each haemodialysis session. The same person was tested at three consecutive haemodialysis sessions. RESULTS Overall, 90 participants were enrolled and 259 haemodialysis sessions assessed. There was no significant difference in the mean anti-Xa activity at 0.5 and 4 hours for three consecutive sessions, so LMWH accumulation did not occur. There were 69 (26.6%) sessions in which, ECC clotting was visible. Compared with the group where circuit clotting did not occur, the LMWH dose and anti-Xa activity in the group where circuit clotting occurred were significantly lower. At 0.5 hour, anti-Xa <0.88 IU/mL had significantly higher odds of ECC clotting than that at ≥0.88 IU/mL. At 4 hours, anti-Xa <0.35 IU/mL had significantly higher odds of ECC clotting than that at ≥0.35 IU/mL. CONCLUSION We found that over three haemodialysis sessions, no significant accumulation of LMWH was evident in subjects receiving a LMWH dose of between 2000 and 5000 IU for regular. Anti-Xa activity measurement can be used to adjust the dosage of LMWH and predict the anticoagulant effect during haemodialysis.
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Affiliation(s)
- Mei Tao
- Bengbu Medical College, Bengbu, P.R. China.,Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China
| | - Danna Zheng
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China
| | - Xudong Liang
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China
| | - Meiyu Ye
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China
| | - Yueming Liu
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China
| | - Yiwen Li
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China.,People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, P.R. China
| | - Huajuan Shen
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China
| | - Qiang He
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China.,People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, P.R. China
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11
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Ashby D, Borman N, Burton J, Corbett R, Davenport A, Farrington K, Flowers K, Fotheringham J, Andrea Fox RN, Franklin G, Gardiner C, Martin Gerrish RN, Greenwood S, Hothi D, Khares A, Koufaki P, Levy J, Lindley E, Macdonald J, Mafrici B, Mooney A, Tattersall J, Tyerman K, Villar E, Wilkie M. Renal Association Clinical Practice Guideline on Haemodialysis. BMC Nephrol 2019; 20:379. [PMID: 31623578 PMCID: PMC6798406 DOI: 10.1186/s12882-019-1527-3] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 12/15/2022] Open
Abstract
This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: "what does good quality haemodialysis look like?"The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to - most of this is freely available online, at least in summary form.A few notes on the individual sections: 1. This section is about how much dialysis a patient should have. The effectiveness of dialysis varies between patients because of differences in body size and age etc., so different people need different amounts, and this section gives guidance on what defines "enough" dialysis and how to make sure each person is getting that. Quite a bit of this section is very technical, for example, the term "eKt/V" is often used: this is a calculation based on blood tests before and after dialysis, which measures the effectiveness of a single dialysis session in a particular patient. 2. This section deals with "non-standard" dialysis, which basically means anything other than 3 times per week. For example, a few people need 4 or more sessions per week to keep healthy, and some people are fine with only 2 sessions per week - this is usually people who are older, or those who have only just started dialysis. Special considerations for children and pregnant patients are also covered here. 3. This section deals with membranes (the type of "filter" used in the dialysis machine) and "HDF" (haemodiafiltration) which is a more complex kind of dialysis which some doctors think is better. Studies are still being done, but at the moment we think it's as good as but not better than regular dialysis. 4. This section deals with fluid removal during dialysis sessions: how to remove enough fluid without causing cramps and low blood pressure. Amongst other recommendations we advise close collaboration with patients over this. 5. This section deals with dialysate, which is the fluid used to "pull" toxins out of the blood (it is sometimes called the "bath"). The level of things like potassium in the dialysate is important, otherwise too much or too little may be removed. There is a section on dialysate buffer (bicarbonate) and also a section on phosphate, which occasionally needs to be added into the dialysate. 6. This section is about anticoagulation (blood thinning) which is needed to stop the circuit from clotting, but sometimes causes side effects. 7. This section is about certain safety aspects of dialysis, not seeking to replace well-established local protocols, but focussing on just a few where we thought some national-level guidance would be useful. 8. This section draws together a few aspects of dialysis which don't easily fit elsewhere, and which impact on how dialysis feels to patients, rather than the medical outcome, though of course these are linked. This is where home haemodialysis and exercise are covered. There is an appendix at the end which covers a few aspects in more detail, especially the mathematical ideas. Several aspects of dialysis are not included in this guideline since they are covered elsewhere, often because they are aspects which affect non-dialysis patients too. This includes: anaemia, calcium and bone health, high blood pressure, nutrition, infection control, vascular access, transplant planning, and when dialysis should be started.
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Affiliation(s)
- Damien Ashby
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England.
| | - Natalie Borman
- Wessex Kidney Centre, Portsmouth NHS Trust, Portsmouth, England
| | - James Burton
- University Hospitals of Leicester NHS Trust, Leicester, England
| | - Richard Corbett
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England
| | | | - Ken Farrington
- Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, England
| | - Katey Flowers
- Wessex Kidney Centre, Portsmouth NHS Trust, Portsmouth, England
| | | | - R N Andrea Fox
- School of Nursing and Midwifery, University of Sheffield, Sheffield, England
| | - Gail Franklin
- East & North Hertfordshire NHS Trust, Stevenage, England
| | | | | | - Sharlene Greenwood
- Renal and Exercise Rehabilitation, King's College Hospital, London, England
| | | | - Abdul Khares
- Haemodialysis Patient, c/o The Renal Association, Bristol, UK
| | - Pelagia Koufaki
- School of Health Sciences, Queen Margaret University, Edinburgh, Scotland
| | - Jeremy Levy
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England
| | - Elizabeth Lindley
- Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, England
| | - Jamie Macdonald
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
| | - Bruno Mafrici
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | | | - Kay Tyerman
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Enric Villar
- Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, England
| | - Martin Wilkie
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England
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Reporting of "dialysis adequacy" as an outcome in randomised trials conducted in adults on haemodialysis. PLoS One 2019; 14:e0207045. [PMID: 30721242 PMCID: PMC6363141 DOI: 10.1371/journal.pone.0207045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 12/04/2018] [Indexed: 12/16/2022] Open
Abstract
Background Clinical trials are most informative for evidence-based decision-making when they consistently measure and report outcomes of relevance to stakeholders, especially patients, clinicians, and policy makers. However, sometimes terminology used is interpreted differently by different stakeholders, which might lead to confusion during shared decision making. The construct dialysis adequacy is frequently used, suggesting it is an important outcome both for health care professionals as for patients. Objective To assess the scope and consistency of the construct dialysis adequacy as reported in randomised controlled trials in hemodialysis, and evaluate whether these align to the insights and understanding of this construct by patients. Methods To assess scope and consistency of dialysis adequacy by professionals, we performed a systematic review searching the Cochrane Central Register of Controlled Trials (CENTRAL) up to July 2017. We identified all randomised controlled trails (RCT) including patients on hemodialysis and reporting dialysis adequacy, adequacy or adequacy of dialysis and extracted and classified all reported outcomes. To explore interpretation and meaning of the construct of adequacy by patients, we conducted 11 semi-structured interviews with HD patients using thematic analysis. Belgian registration number B670201731001. Findings From the 31 included trials, we extracted and classified 98 outcome measures defined by the authors as adequacy of dialysis, of which 94 (95%) were biochemical, 3 (3%) non-biochemical surrogate and 2 (2%) patient-relevant. The three most commonly reported measures were all biochemical. None of the studies defined adequacy of dialysis as a patient relevant outcome such as survival or quality of life. Patients had a substantially different understanding of the construct dialysis adequacy than the biochemical interpretation reported in the literature. Being alive, time spent while being on dialysis, fatigue and friendliness of staff were the most prominent themes that patients linked to the construct of dialysis adequacy. Conclusion Adequacy of dialysis as reported in the literature refers to biochemical outcome measures, most of which are not related with patient relevant outcomes. For patients, adequate dialysis is a dialysis that enables them to spend as much quality time in their life as possible.
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Canaud B, Vienken J, Ash S, Ward RA. Hemodiafiltration to Address Unmet Medical Needs ESKD Patients. Clin J Am Soc Nephrol 2018; 13:1435-1443. [PMID: 29511057 PMCID: PMC6140578 DOI: 10.2215/cjn.12631117] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Hemodiafiltration combines diffusive and convective solute removal in a single therapy by ultrafiltering 20% or more of the blood volume processed using a high-flux hemodialyzer and maintaining fluid balance by infusing sterile nonpyrogenic replacement fluid directly into the patient's blood. In online hemodiafiltration, the large volumes of replacement fluid required are obtained by online filtration of standard dialysate through a series of bacteria- and endotoxin-retaining filters. Currently available systems for online hemodiafiltration are on the basis of conventional dialysis machines with added features to safely prepare and infuse replacement fluid and closely control fluid balance. Hemodiafiltration provides greater removal of higher molecular weight uremic retention solutes than conventional high-flux hemodialysis, and recently completed randomized, controlled clinical trials suggest better patient survival with online hemodiafiltration compared with standard high-flux hemodialysis when a high convection volume is delivered. Hemodiafiltration is also associated with improvements in other clinical outcomes, such as a reduction in intradialytic hypotension, and it is now used routinely to treat >100,000 patients, mainly in Europe and Japan.
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Affiliation(s)
- Bernard Canaud
- Center of Excellence Medical, Fresenius Medical Care, Bad Homburg, Germany
- University of Montpellier, Research and Training Unit Medicine, Montpellier, France
| | | | - Stephen Ash
- Indiana University Health Arnett Hospital, Lafayette, Indiana
- HemoCleanse Technologies, LLC, Lafayette, Indiana
- Ash Access Technology, Inc., Lafayette, Indiana; and
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14
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Lindberg M. EVIDENCE-BASED RENAL CARE: DOES IT MATTER? J Ren Care 2018; 44:63-64. [PMID: 29722205 DOI: 10.1111/jorc.12244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Magnus Lindberg
- Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, SE 801 76, Gävle, Sweden.,Department of Public Health and Caring Sciences, Uppsala University, Box 564 SE 751 22, Uppsala, Sweden
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15
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Ekdahl KN, Soveri I, Hilborn J, Fellström B, Nilsson B. Cardiovascular disease in haemodialysis: role of the intravascular innate immune system. Nat Rev Nephrol 2017; 13:285-296. [PMID: 28239169 DOI: 10.1038/nrneph.2017.17] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Haemodialysis is a life-saving renal replacement modality for end-stage renal disease, but this therapy also represents a major challenge to the intravascular innate immune system, which is comprised of the complement, contact and coagulation systems. Chronic inflammation is strongly associated with cardiovascular disease (CVD) in patients on haemodialysis. Biomaterial-induced contact activation of proteins within the plasma cascade systems occurs during haemodialysis and initially leads to local generation of inflammatory mediators on the biomaterial surface. The inflammation is spread by soluble activation products and mediators that are generated during haemodialysis and transported in the extracorporeal circuit back into the patient together with activated leukocytes and platelets. The combined effect is activation of the endothelium of the cardiovascular system, which loses its anti-thrombotic and anti-inflammatory properties, leading to atherogenesis and arteriosclerosis. This concept suggests that maximum suppression of the intravascular innate immune system is needed to minimize the risk of CVD in patients on haemodialysis. A potential approach to achieve this goal is to treat patients with broad-specificity systemic drugs that target more than one of the intravascular cascade systems. Alternatively, 'stealth' biomaterials that cause minimal cascade system activation could be used in haemodialysis circuits.
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Affiliation(s)
- Kristina N Ekdahl
- Department of Immunology, Genetics and Pathology (IGP), Rudbeck Laboratory C5:3, Uppsala University, SE-751 85 Uppsala, Sweden.,Linnæus Center of Biomaterials Chemistry, Linnæus University, SE-391 82 Kalmar, Sweden
| | - Inga Soveri
- Department of Medical Sciences, Uppsala University, SE-75185 Uppsala, Sweden
| | - Jöns Hilborn
- Department of Chemistry, Ångström Laboratory, Uppsala University, SE-751 21, Sweden
| | - Bengt Fellström
- Department of Medical Sciences, Uppsala University, SE-75185 Uppsala, Sweden
| | - Bo Nilsson
- Department of Immunology, Genetics and Pathology (IGP), Rudbeck Laboratory C5:3, Uppsala University, SE-751 85 Uppsala, Sweden
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16
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Salvadè I, Del Giorno R, Gaetano D, Gabutti L. Assessing the contact-activation of coagulation during hemodialysis with three different polysulfone filters: A prospective randomized cross-over trial. Hemodial Int 2016; 21:375-384. [DOI: 10.1111/hdi.12509] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Igor Salvadè
- Division of Nephrology; Ospedale la Carità, Via Ospedale 1; 6600 Locarno Switzerland
| | - Rosaria Del Giorno
- Department of Internal Medicine, Nephrology and Dialysis Unit; Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale (EOC); Bellinzona Switzerland
| | - Donato Gaetano
- Division of Nephrology; Ospedale la Carità, Via Ospedale 1; 6600 Locarno Switzerland
| | - Luca Gabutti
- Department of Internal Medicine, Nephrology and Dialysis Unit; Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale (EOC); Bellinzona Switzerland
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