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Kaur J, Arsene C, Yadav SK, Ogundipe O, Malik A, Sule AA, Krishnamoorthy G. Risk Factors in Hospitalized Patients for Heparin-Induced Thrombocytopenia by Real World Database: A New Role for Primary Hypercoagulable States. J Hematol 2021; 10:171-177. [PMID: 34527113 PMCID: PMC8425805 DOI: 10.14740/jh876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 07/06/2021] [Indexed: 11/11/2022] Open
Abstract
Background The aims of the study were to identify predictors of heparin-induced thrombocytopenia (HIT) in hospitalized adults, and to find additional factors associated with higher odds of HIT in primary hypercoagulable states. Methods A retrospective matched case-control study using discharge data from National Inpatient Sample database (2012 - 2014) was conducted. In primary outcome analysis, hospitalized patients with and without HIT were included as cases and controls, both matched for age and gender. In secondary outcome analysis, hospitalized patients with primary hypercoagulable states with and without HIT were included as cases and controls, both matched for age and gender. The statistical analyses were performed using Statistical Package for Social Sciences version 25. Results There are several predictors of HIT in hospitalized patients, such as obesity, malignancy, diabetes, renal failure, major surgery, congestive heart failure, and autoimmune diseases. In patients with primary hypercoagulable states, the presence of renal failure (odds ratio (OR) 2.955, 95% confidence interval (CI) 1.994 - 4.380), major surgery (OR 1.735, 95% CI 1.275 - 2.361), congestive heart failure (OR 4.497, 95% CI 2.466 - 8.202), or autoimmune diseases (OR 1.712, 95% CI 1.120 - 2.618) further increases the odds of HIT. Conclusions In hospitalized patients with primary hypercoagulable states, especially in association with renal failure, major surgery, congestive heart failure, or autoimmune diseases, unfractionated heparin should be used with caution.
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Affiliation(s)
- Jasmeet Kaur
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Camelia Arsene
- Department of Medical Education, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Sumeet Kumar Yadav
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Olusola Ogundipe
- Department of Infectious Diseases, William Beaumont Hospital, Royal Oak, MI, USA
| | - Ambreen Malik
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Anupam Ashutosh Sule
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Geetha Krishnamoorthy
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
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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: 24] [Impact Index Per Article: 6.0] [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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Prechel M, Hudec S, Lowden E, Escalante V, Emanuele N, Emanuele M, Walenga JM. Profiling Heparin-Induced Thrombocytopenia (HIT) Antibodies in Hospitalized Patients With and Without Diabetes. Clin Appl Thromb Hemost 2018; 24:294S-300S. [PMID: 30419766 PMCID: PMC6714824 DOI: 10.1177/1076029618808915] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Heparin (H) anticoagulation in populations characterized by elevated platelet factor 4
(PF4) frequently elicits PF4/H antibodies, presenting a risk of heparin-induced
thrombocytopenia. Recent studies have shown that anti-PF4/H enzyme-linked immunosorbent
assays (ELISAs) detect antibodies in individuals never exposed to heparin. Platelet factor
4/H cross-reactive antibodies may result from PF4-mediated defense responses to injury or
infection. This study questioned whether patients with diabetes are more likely to develop
the endogenous cross-reactive antibodies. A comparison of healthy volunteers versus
hospitalized patients with or without diabetes showed no significant differences in the
prevalence of PF4/H ELISA-positive results. However, the group of patients who had both
diabetes and an infectious condition had higher median antibody titer compared to other
patients with or without diabetes regardless of reason for hospitalization. Higher PF4/H
titers were also associated with patients with diabetes who were not on any medical
therapy. In the future, determining whether PF4/H cross-reactive antibodies sensitize
patients to respond adversely to heparin anticoagulation or predispose patients to other
complications may be relevant to diabetes care.
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Affiliation(s)
- Margaret Prechel
- Health Sciences Division, Cardiovascular Research Institute, Loyola University Chicago, Maywood, IL, USA
| | - Susan Hudec
- Endocrinology Division, Department of Medicine, Loyola University Health System, Maywood, IL, USA
| | - Elizabeth Lowden
- Endocrinology Division, Department of Medicine, Loyola University Health System, Maywood, IL, USA
| | - Vicki Escalante
- Health Sciences Division, Cardiovascular Research Institute, Loyola University Chicago, Maywood, IL, USA
| | - Nicholas Emanuele
- Endocrinology Division, Department of Medicine, Loyola University Health System, Maywood, IL, USA
| | - Maryann Emanuele
- Endocrinology Division, Department of Medicine, Loyola University Health System, Maywood, IL, USA
| | - Jeanine M Walenga
- Health Sciences Division, Cardiovascular Research Institute, Loyola University Chicago, Maywood, IL, USA
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Significant association of anti-platelet factor 4/heparin antibody with cardiovascular disease in hemodialysis patients: a longitudinal 7-year study. Int Urol Nephrol 2018; 50:2289-2297. [PMID: 30324576 DOI: 10.1007/s11255-018-2002-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 10/04/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Hemodialysis patients have a high incidence of anti-platelet factor 4/heparin antibody (PF4-H Ab) and are at a high risk of cardiovascular disease. This study determines the association between PF4-H Ab and cardiovascular events including coronary artery disease (CAD), ischemic stroke (IS), and native arteriovenous fistula thrombosis (AVFT), in a longitudinal 7-year follow-up. PATIENTS AND METHODS 84 hemodialysis patients were enrolled. Data collection included chart reviews and assessments of laboratory records. PF4-H Ab was evaluated by ELISA and a titer ≥ 0.4 was defined to have PF4-H Ab. RESULTS 30 patients were PF4-H Ab positive, 30 patients had CAD, 29 patients had IS, and 43 patients had AVFT. In Cox proportional hazard regression analysis, PF4-H Ab (HR 2.72, p = 0.01) was a significant risk factor for CAD. Age (HR 1.06, p = 0.003), PF4-H Ab (HR 4.53, p < 0.001), 7-year averaged serum phosphate levels (HR 0.53, p = 0.012), and 7-year averaged blood platelet count (HR 1.01, p = 0.029) were risk factors for IS. Age (HR 1.03, p = 0.047), PF4-H Ab (HR 3.57, p < 0.001), and 7-year averaged serum triglyceride levels (HR 1.01, p = 0.005) were risk factors for AVFT. In PF4-H Ab-positive groups, thrombocytopenia was not associated with CAD, IS, and AVFT by Fisher's test analysis. CONCLUSION This study reveals that PF4-H Ab is a risk factor for developing CAD, IS, and AVFT among hemodialysis patients.
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Maharaj S, Chang S, Seegobin K, Morales J, Aysola A, Rana F, Shaikh M. Temporality of heparin-induced antibodies: a retrospective study in outpatients undergoing hemodialysis on unfractionated heparin. Exp Hematol Oncol 2018; 7:23. [PMID: 30221035 PMCID: PMC6137914 DOI: 10.1186/s40164-018-0115-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 09/06/2018] [Indexed: 01/27/2023] Open
Abstract
Background Heparin-induced antibodies (HIA) are responsible for causing heparin-induced thrombocytopenia and thrombosis. Research has shown that the temporality of heparin-induced antibodies does not follow the classic immunologic response. The immunobiology of HIA generation remains unclear with varying in vitro and in vivo data. Outpatients undergoing hemodialysis (HD) are exposed to heparin chronically. The HIA immune response can therefore be investigated in vivo in this population. Methods We examined the time between the start of HD using unfractionated heparin and HIA levels in 212 outpatients during a 6-year period. Antibodies were detected on enzyme-linked immunosorbent assay. HIA levels were analyzed to determine significance of the trend over time. HIA subgroups were also analyzed for correlation with subsequent thrombotic events and platelet count during follow up. Results Overall, the HIA response in HD was found to peak early with waning antibody response despite continued exposure to heparin. The peak prevalence of a strong immune response (optical density > 1.000) was early and short lived, while weaker immune response (optical density 0.400–1.000) persisted for the first 6 months then declined. The mean follow-up time per patient was 2.3 ± 1.4 years. Despite circulating HIA, including high titers, no patients developed HIT in this sample. There was no association between HIA and thrombocytopenia. There was increased incidence of thrombosis in patients with strong HIA compared to other groups, but this did not achieve statistical significance. Conclusions The data suggest a significant temporal pattern of HIA in outpatients undergoing HD using unfractionated heparin. Positive HIA was not found to be significantly associated with thrombocytopenia or thrombosis risk in these patients. However, while not achieving statistical significance, subsequent thrombotic events occurred most frequently in the strong positive HIA group (optical density > 1.000). Further research into HIA and risk of thrombosis in this population is needed.
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Affiliation(s)
- Satish Maharaj
- 1Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Florida College of Medicine-Jacksonville, UF Health Jacksonville, 653 W 8th St, Jacksonville, FL 32209 USA
| | - Simone Chang
- 2University of Miami Health System, Miami, FL USA
| | - Karan Seegobin
- 1Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Florida College of Medicine-Jacksonville, UF Health Jacksonville, 653 W 8th St, Jacksonville, FL 32209 USA
| | - James Morales
- 1Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Florida College of Medicine-Jacksonville, UF Health Jacksonville, 653 W 8th St, Jacksonville, FL 32209 USA
| | - Agnes Aysola
- 1Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Florida College of Medicine-Jacksonville, UF Health Jacksonville, 653 W 8th St, Jacksonville, FL 32209 USA
| | - Fauzia Rana
- 1Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Florida College of Medicine-Jacksonville, UF Health Jacksonville, 653 W 8th St, Jacksonville, FL 32209 USA
| | - Marwan Shaikh
- 1Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Florida College of Medicine-Jacksonville, UF Health Jacksonville, 653 W 8th St, Jacksonville, FL 32209 USA
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Chen YH, Lin KC, Tsai YF, Yu LK, Huang LH, Chen CA. Anti-platelet factor 4/heparin antibody is associated with progression of peripheral arterial disease in hemodialysis patients. Int Urol Nephrol 2015. [PMID: 26198856 DOI: 10.1007/s11255-015-1056-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Heparin therapy may induce anti-platelet factor 4/heparin antibody (PF4-H Ab). Hemodialysis patients receive scheduled heparin and are at a risk of developing PF4-H Ab. Hemodialysis patients are also at a high risk of peripheral arterial disease (PAD). This study examines whether chronic PF4-H Ab exposure contributes to the progression of PAD measured by ankle brachial index (ABI) in hemodialysis patients. MATERIALS AND METHODS A total of 71 hemodialysis patients were enrolled, and the association between clinical, biochemical parameters and ABI after 3 years was studied. PF4-H Ab was evaluated by ELISA, and patients with titer ≥ 0.4 were taken as having PF4-H Ab. RESULTS Mean ABI was 1.04 ± 0.18 at baseline and 1.01 ± 0.17 after 3 years. Mean ΔABI (change in ABI after 3 years) was -0.04 ± 0.13. PF4-H Ab was positive in 26 patients. PF4-H Ab was not related to hemodialysis duration, DM history, smoking and age. Platelet count showed no correlation with PF4-H Ab. However, there was significance in ΔABI between PF4-H Ab-positive and PF4-H Ab-negative patients (p = 0.002). ΔABI was negatively correlated with PF4-H Ab and 3-year averaged serum Ca × P only (β = -0.378, p = 0.001; β = -0.263, p = 0.018, respectively). However, in PF4-H Ab-positive patients, the extent of ΔABI did not correlate with PF4-H Ab titers (r = -0.021, p = 0.921). CONCLUSIONS PF4-H Ab positivity, along with high levels of serum Ca × P, played a potential role in the progression of PAD over time.
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Affiliation(s)
- Yen-Hsun Chen
- Division of Cardiology, Tainan Sinlau Hospital, Tainan, Taiwan, Republic of China
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Elevated heparin-induced antibodies are more common in diabetic patients with vascular disease. THROMBOSIS 2014; 2014:649652. [PMID: 24672719 PMCID: PMC3941208 DOI: 10.1155/2014/649652] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 12/30/2013] [Indexed: 11/24/2022]
Abstract
Background. Hypercoagulable disorders can lead to deep vein thrombosis (DVT), arterial thrombosis or embolization, and early or recurrent bypass graft failure. The purpose of this study was to identify whether diabetes increased the likelihood of heparin-induced platelet factor 4 antibodies in at risk vascular patients.
Methods. We reviewed clinical data on 300 consecutive patients. A hypercoagulable workup was performed if patients presented with (1) early bypass/graft thrombosis (<30 days), (2) multiple bypass/graft thrombosis, and (3) a history of DVT, pulmonary embolus (PE), or native vessel thrombosis. Relevant clinical variables were analyzed and compared between patients with diabetes (DM) and without diabetes (nDM).
Results. 85 patients (47 women; age 53 ± 16 years, range 16–82 years) had one of the defined conditions and underwent a hypercoagulable evaluation. Screening was done in 4.7% of patients with early bypass graft thrombosis, 60% of patients were screened because of multiple bypass or graft thrombosis, and 35.3% had a previous history of DVT, PE, or native vessel thrombosis. Of the 43 patients with DM and 42 nDM evaluated, 59 patients (69%) had an abnormal hypercoagulable profile. An elevated heparin antibody level was present in 30% of DM and 12% of nDM patients (chi-squared test P < 0.04). Additionally, DM was associated with a higher likelihood of arterial complications while nDM was associated with a higher rate of venous adverse events (chi-squared test P < 0.003).
Conclusions. Diabetes is associated with a higher likelihood of developing heparin-induced antibodies and an increased combined incidence of arterial complications that include early or multiple bypass/graft thrombosis. This finding may influence the choice of anticoagulation in diabetic patients at risk with vascular disease.
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Palmer SC, Navaneethan SD, Craig JC, Johnson DW, Perkovic V, Nigwekar SU, Hegbrant J, Strippoli GFM. HMG CoA reductase inhibitors (statins) for dialysis patients. Cochrane Database Syst Rev 2013; 2013:CD004289. [PMID: 24022428 PMCID: PMC10754478 DOI: 10.1002/14651858.cd004289.pub5] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND People with advanced kidney disease treated with dialysis experience mortality rates from cardiovascular disease that are substantially higher than for the general population. Studies that have assessed the benefits of statins (HMG CoA reductase inhibitors) report conflicting conclusions for people on dialysis and existing meta-analyses have not had sufficient power to determine whether the effects of statins vary with severity of kidney disease. Recently, additional data for the effects of statins in dialysis patients have become available. This is an update of a review first published in 2004 and last updated in 2009. OBJECTIVES To assess the benefits and harms of statin use in adults who require dialysis (haemodialysis or peritoneal dialysis). SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 29 February 2012 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of statins with placebo, no treatment, standard care or other statins on mortality, cardiovascular events and treatment-related toxicity in adults treated with dialysis were sought for inclusion. DATA COLLECTION AND ANALYSIS Two or more authors independently extracted data and assessed study risk of bias. Treatment effects were summarised using a random-effects model and subgroup analyses were conducted to explore sources of heterogeneity. Treatment effects were expressed as mean difference (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI). MAIN RESULTS The risk of bias was high in many of the included studies. Random sequence generation and allocation concealment was reported in three (12%) and four studies (16%), respectively. Participants and personnel were blinded in 13 studies (52%), and outcome assessors were blinded in five studies (20%). Complete outcome reporting occurred in nine studies (36%). Adverse events were only reported in nine studies (36%); 11 studies (44%) reported industry funding.We included 25 studies (8289 participants) in this latest update; 23 studies (24 comparisons, 8166 participants) compared statins with placebo or no treatment, and two studies (123 participants) compared statins directly with one or more other statins. Statins had little or no effect on major cardiovascular events (4 studies, 7084 participants: RR 0.95, 95% CI 0.88 to 1.03), all-cause mortality (13 studies, 4705 participants: RR 0.96, 95% CI 0.90 to 1.02), cardiovascular mortality (13 studies, 4627 participants: RR 0.94, 95% CI 0.84 to 1.06) and myocardial infarction (3 studies, 4047 participants: RR 0.87, 95% CI 0.71 to 1.07); and uncertain effects on stroke (2 studies, 4018 participants: RR 1.29, 95% CI 0.96 to 1.72).Risks of adverse events from statin therapy were uncertain; these included effects on elevated creatine kinase (5 studies, 3067 participants: RR 1.25, 95% CI 0.55 to 2.83) or liver function enzymes (4 studies, 3044 participants; RR 1.09, 95% CI 0.41 to 1.25), withdrawal due to adverse events (9 studies, 1832 participants: RR 1.04, 95% CI 0.87 to 1.25) or cancer (2 studies, 4012 participants: RR 0.90, 95% CI 0.72 to 1.11). Statins reduced total serum cholesterol (14 studies, 1803 participants; MD -44.86 mg/dL, 95% CI -55.19 to -34.53) and low-density lipoprotein cholesterol (12 studies, 1747 participants: MD -39.99 mg/dL, 95% CI -52.46 to -27.52) levels. Data comparing statin therapy directly with another statin were sparse. AUTHORS' CONCLUSIONS Statins have little or no beneficial effects on mortality or cardiovascular events and uncertain adverse effects in adults treated with dialysis despite clinically relevant reductions in serum cholesterol levels.
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Affiliation(s)
- Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Sankar D Navaneethan
- Glickman Urological and Kidney Institute, Cleveland ClinicDepartment of Nephrology and HypertensionClevelandOHUSA44195
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - David W Johnson
- Princess Alexandra HospitalDepartment of NephrologyIpswich RdWoolloongabbaQueenslandAustralia4102
| | - Vlado Perkovic
- The George Institute for Global HealthRenal and Metabolic DivisionCamperdownNSWAustralia
| | - Sagar U Nigwekar
- Harvard Medical SchoolBrigham and Women's Hospital, Massachusetts General Hospital, Scholars in Clinical Sciences ProgramBostonMAUSA
| | - Jorgen Hegbrant
- Diaverum Renal Services GroupMedical OfficePO Box 4167LundSwedenSE‐227 22
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
- University of BariDepartment of Emergency and Organ TransplantationBariItaly70100
- Mario Negri Sud ConsortiumDepartment of Clinical Pharmacology and EpidemiologySanta Maria ImbaroItaly
- DiaverumMedical‐Scientific OfficeLundSweden
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Shen JI, Winkelmayer WC. Use and safety of unfractionated heparin for anticoagulation during maintenance hemodialysis. Am J Kidney Dis 2012; 60:473-86. [PMID: 22560830 PMCID: PMC4088960 DOI: 10.1053/j.ajkd.2012.03.017] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Accepted: 03/30/2012] [Indexed: 01/27/2023]
Abstract
Anticoagulation is essential to hemodialysis, and unfractionated heparin (UFH) is the most commonly used anticoagulant in the United States. However, there is no universally accepted standard for its administration in long-term hemodialysis. Dosage schedules vary and include weight-based protocols and low-dose protocols for those at high risk of bleeding, as well as regional anticoagulation with heparin and heparin-coated dialyzers. Adjustments are based largely on clinical signs of under- and overanticoagulation. Risks of UFH use include bleeding, heparin-induced thrombocytopenia, hypertriglyceridemia, anaphylaxis, and possibly bone mineral disease, hyperkalemia, and catheter-associated sepsis. Alternative anticoagulants include low-molecular-weight heparin, direct thrombin inhibitors, heparinoids, and citrate. Anticoagulant-free hemodialysis and peritoneal dialysis also are potential substitutes. However, some of these alternative treatments are not as available as or are more costly than UFH, are dependent on country and health care system, and present dosing challenges. When properly monitored, UFH is a relatively safe and economical choice for anticoagulation in long-term hemodialysis for most patients.
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Affiliation(s)
- Jenny I Shen
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA 94305, USA.
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