An evaluation of four modes of low-dose anticoagulation during intermittent haemodialysis

Skagerlind, Malin S. E.; Stegmayr, Bernd G

doi:10.1007/s00228-017-2389-x

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An evaluation of four modes of low-dose anticoagulation during intermittent haemodialysis

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Author(s): Malin S. E. Skagerlind ¹ ^, ² ^, , Bernd G. Stegmayr ¹

Publication date (Electronic): 2 December 2017

Journal: European Journal of Clinical Pharmacology

Publisher: Springer Berlin Heidelberg

Keywords: Haemodialysis, Haemorrhage, Priming, Anticoagulation

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Abstract

Introduction

Intensive care participants that need dialysis frequently suffer from increased risk of bleeding. Standard intermittent haemodialysis (SHD) includes anticoagulation to avoid clotting of the dialysis system. The aim of this study was to clarify which of four different low-dose anticoagulant modes was preferable in reducing the exposure to i.v. unfractionated heparin (heparin) and maintaining patency of the dialysis circuit.

Methods

Twenty-three patients on SHD were included to perform haemodialysis with four modes of low-dose anticoagulation. For comparative analyses, patients served as their own control. Haemodialysis with a single bolus of tinzaparin at the start was compared to haemodialysis initiated without i.v. heparin but priming with (1) heparin in saline (H), (2) heparin and albumin in saline (HA), (3) heparin and albumin in combination with a citrate-containing dialysate (HAC), (4) saline and usinga heparin-coated filters (Evodial®). The priming fluid was discarded before dialysis started. Blood samples were collected at 0, 30 and 180 min during haemodialysis. Smaller bolus doses of heparin (500 Units/dose) were allowed during the modes to avoid interruption by clotting.

Findings

The mean activated partial thromboplastin (APTT) time as well as the doses of anticoagulation administered was highest with SHD and least with HAC and Evodial®. Mode H versus SHD had the highest rate of prematurely interrupted dialyses (33%, p = 0.008). The urea reduction rate was less with Evodial® vs. SHD ( p < 0.01). One hypersensitivity reaction occurred with Evodial®. Changes in blood cell concentrations and triglycerides differed between the modes.

Discussion

If intermittent haemodialysis is necessary in patients at risk of bleeding, anticoagulation using HAC and Evodial® appeared most preferable with least administration of heparin, lowest APTT increase and lowest risk for prematurely clotted dialyzers in contrast to the least plausible H mode.

Electronic supplementary material

The online version of this article (10.1007/s00228-017-2389-x) contains supplementary material, which is available to authorized users.

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Most cited references 23

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Results of the HepZero study comparing heparin-grafted membrane and standard care show that heparin-grafted dialyzer is safe and easy to use for heparin-free dialysis.

Maurice Laville, Marc Dorval, Joan Fort Ros … (2014)

Heparin is used to prevent clotting during hemodialysis, but heparin-free hemodialysis is sometimes needed to decrease the risk of bleeding. The HepZero study is a randomized, multicenter international controlled open-label trial comparing no-heparin hemodialysis strategies designed to assess non-inferiority of a heparin grafted dialyzer (NCT01318486). A total of 251 maintenance hemodialysis patients at increased risk of hemorrhage were randomly allocated for up to three heparin-free hemodialysis sessions using a heparin-grafted dialyzer or the center standard-of-care consisting of regular saline flushes or pre-dilution. The first heparin-free hemodialysis session was considered successful when there was neither complete occlusion of air traps or dialyzer, nor additional saline flushes, changes of dialyzer or bloodlines, or premature termination. The current standard-of-care resulted in high failure rates (50%). The success rate in the heparin-grafted membrane arm was significantly higher than in the control group (68.5% versus 50.4%), which was consistent for both standard-of-care modalities. The absolute difference between the heparin-grafted membrane and the controls was 18.2%, with a lower bound of the 90% confidence interval equal to plus 7.9%. The hypothesis of the non-inferiority at the minus 15% level was accepted, although superiority at the plus 15% level was not reached. Thus, use of a heparin-grafted membrane is a safe, helpful, and easy-to-use method for heparin-free hemodialysis in patients at increased risk of hemorrhage.

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Author and article information

Contributors

Malin S. E. Skagerlind:

ORCID: http://orcid.org/0000-0002-3052-6455

+46907850000 , malin.skagerlind@umu.se

Journal

Journal ID (nlm-ta): Eur J Clin Pharmacol

Journal ID (iso-abbrev): Eur. J. Clin. Pharmacol

Title: European Journal of Clinical Pharmacology

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 0031-6970

ISSN (Electronic): 1432-1041

Publication date (Electronic): 2 December 2017

Publication date PMC-release: 2 December 2017

Publication date (Print): 2018

Volume: 74

Issue: 3

Pages: 267-274

Affiliations

[1 ]ISNI 0000 0001 1034 3451, GRID grid.12650.30, Department of Public Health and Clinical Medicine, , University of Umea, ; Umea, Sweden

[2 ]ISNI 0000 0004 0623 991X, GRID grid.412215.1, Department of Nephrology, Centre of Medicine, , University Hospital of Umea, ; 90185 Umea, Sweden

Author information

Malin S. E. Skagerlind http://orcid.org/0000-0002-3052-6455

Article

Publisher ID: 2389

DOI: 10.1007/s00228-017-2389-x

PMC ID: 5808085

PubMed ID: 29198062

SO-VID: 988ae2d4-a57f-4373-8f55-d293a9b97be0

License:

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.