Activated Clotting Time Is Not a Sensitive Parameter to Monitor Anticoagulation with Low Molecular Weight Heparin in Hemodialysis

Greiber, S.; Weber, Ulrich; Galle, Jan; Brämer, Paul; Schollmeyer, P.

doi:10.1159/000190134

Cited by 17 publications

(8 citation statements)

References 8 publications

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“…However, in these studies the LMWHs were given intravenously and only enoxaparin or dalteparin were studied. In contrast, three other studies (Greiber et al, 1997;Henry et al, 2001;Linkins et al, 2002) showed little or no effect of LMWH on the ACT. In a study of UFH, enoxaparin or fondaparinux and its effects upon the ACT and the APTT in healthy volunteers, enoxaparin produced significantly less prolongation of both the ACT and the APTT than UFH, whereas fondaparinux had no effect on either of these tests and from which it was concluded that the ACT and APTT cannot be used to monitor enoxaparin or fondaparinux (Linkins et al, 2002).…”

Section: Monitoring Of Lmwhsmentioning

confidence: 74%

Point‐of‐care testing in haemostasis

Perry

Fitzmaurice

Kitchen³

et al. 2010

Br J Haematol

125

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SummaryPoint-of-care testing (POCT) in haematology has seen a significant increase in both the spectrum of tests available and the number of tests performed annually. POCT is frequently undertaken with the belief that this will reduce the turnaround time for results and so improve patient care. The most obvious example of POCT in haemostasis is the out-ofhospital monitoring of the International Normalized Ratio in patients receiving a vitamin K antagonist, such as warfarin. Other areas include the use of the Activated Clotting Time to monitor anticoagulation for patients on cardio-pulmonary bypass, platelet function testing to identify patients with apparent aspirin or clopidogrel resistance and thrombelastography to guide blood product replacement during cardiac and hepatic surgery. In contrast to laboratory testing, POCT is frequently undertaken by untrained or semi-trained individuals and in many cases is not subject to the same strict quality control programmes that exist in the central laboratory. Although external quality assessment programmes do exist for some POCT assays these are still relatively few. The use of POCT in haematology, particularly in the field of haemostasis, is likely to expand and it is important that systems are in place to ensure that the generated results are accurate and precise.Keywords: point-of-care testing, haemostasis, quality assurance, near patient testing.Point-of-care testing (POCT) is defined as a diagnostic test at or near the site of the patient with the rationale that such testing will result in the rapid generation of results and improve patient care. POCT is frequently undertaken by nonlaboratory personnel both within and outwith the hospital setting and the last 10 years has seen a significant increase in its use, particularly in the field of haemostasis. The importance of POCT is highlighted by a recent publication from the This review summarizes POCT in relation to haemostasis, and complements a previously published guideline by the British Committee for Standards in Haematology on POCT in Haematology (Briggs et al, 2008).

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Section: Monitoring Of Lmwhsmentioning

confidence: 74%

Point‐of‐care testing in haemostasis

Perry

Fitzmaurice

Kitchen³

et al. 2010

Br J Haematol

125

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“…Monitoring of anticoagulation with LMWH is possible with activated clotting time, representing a simple test system with widespread availability in dialysis centers, but repeated correlations with exact anti-Xa activity should be done during long-term use or in situations of increased bleeding risk [19,20]. In this investigation, single bolus anticoagulation lead to median peak levels of anti-Xa activity of 0.81 IU/ml, which was not associated with any bleeding complication.…”

Section: Discussionmentioning

confidence: 84%

Safety and Efficacy of Single Bolus Anticoagulation with Enoxaparin for Chronic Hemodialysis. Results of an Open-Label Post-Certification Study

Klingel

Schwarting

Lotz

et al. 2004

Kidney Blood Press Res

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Background: Low-molecular-weight heparin (LMWH) is supposed to be advantageous compared to unfractionated heparin for chronic hemodialysis (HD) with respect to lipid and bone metabolism, polymorphonuclear cell stimulation, induction of antibody-mediated thrombocytopenia, and aldosterone suppression. Due to longer biological half-life, LMWH offers the possibility of single bolus administration. Methods: To assess safety and efficacy of single bolus anticoagulation with enoxaparin for chronic HD, 781 stable HD patients from 79 German dialysis centers (mean age 62 years; 31% ESRD due to diabetes mellitus) were monitored by clinical and laboratory parameters for 32 weeks. Additionally, in a single dialysis center, 22 chronic HD patients were investigated by molecular markers of coagulation during chronic HD under conditions of single bolus or continuous anticoagulation regimens. Anti-Xa activity and the thrombin- antithrombin-III complex (TAT) were determined before the enoxaparin bolus, after 15 min, 2 h, and at the end of HD in venous and arterial blood lines. Results: Chronic HD was performed in 24,117 HD treatments with enoxaparin at a median dose of 70.1 IU/kg (5,000 IU median total dose) for single bolus anticoagulation. In 83.0% of HD treatments, enoxaparin was given as single bolus. In 98.3% of patients no adverse event was reported. No drug-related severe adverse event occurred. Significant clotting problems were observed in only 0.3% of HD treatments with single bolus anticoagulation. As assessed in 257 HD treatments, essentially identical anti-Xa levels were detected at the end of HD with single bolus (50 IU/kg) or continuous (mean total dose 43 IU/kg) anticoagulation regimens. Bolus anticoagulation resulted in higher TAT generation at the end of HD. However, this was not associated with increased macroscopic clot formation. Conclusion: Single bolus anticoagulation with enoxaparin was safe and effective for chronic HD. For a duration of 4 h HD, a median dose of 70 IU/kg can be recommended for regular use, which is in accordance with the manufacturer’s instructions for use of enoxaparin recommending a range of 50–100 IU/kg.

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“…(2) In renal failure, dosing has to be reduced. (3) If monitoring is performed, anti‐factor Xa activity needs to be measured, while aPTT and ACT are not reliable 30,31 . Recently, a modified Xa‐ACT has been demonstrated to measure reliably the anticoagulant effect of LMWH preparations within a point‐of‐care setup 31 .…”

Section: Standard Anticoagulation In Hemodialysismentioning

confidence: 99%

Essentials of anticoagulation in hemodialysis

Fischer

2007

Hemodialysis International

140

135

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Numerous acquired hemostatic abnormalities have been identified in renal insufficiency. Hemodialysis procedures add to these disturbances as they repetitively imply turbulent blood flow, high shear stress, and contact of blood to artificial surfaces. This nonphysiological environment leads to activation of platelets, leukocytes, and the coagulation cascade, resulting in fouling of the membrane and ultimately in clotting of fibers and the whole hemodialyzer. Anticoagulation in hemodialysis is targeted to prevent this activation of coagulation during the procedure. Most agents inhibit the plasmatic coagulation cascade. Still commonly used is unfractionated heparin, followed by low-molecular-weight heparin preparations with distinct advantages. Immune-mediated heparin-induced thrombocytopenia constitutes a potentially life-threatening complication of heparin therapy requiring immediate switch to nonheparin alternative anticoagulants. Danaparoid, lepirudin, and argatroban are currently being used for alternative anticoagulation, all of which possess both advantages and limitations. In the past, empirical strategies reducing or avoiding heparin were applied for patients at bleeding risk, whereas nowadays regional citrate anticoagulation is increasingly used to prevent bleeding by allowing procedures without any systemic anticoagulation. Avoidance of clotting within the whole hemodialyzer circuit is not granted. Specific knowledge of the mechanisms of coagulation, the targets of the anticoagulants in use, and their respective characteristics constitutes the basis for individualized anticoagulation aimed at achieving full patency of the circuit throughout the procedure. Patency of the circuit is an important prerequisite for optimal hemodialysis quality.

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Activated Clotting Time Is Not a Sensitive Parameter to Monitor Anticoagulation with Low Molecular Weight Heparin in Hemodialysis

Cited by 17 publications

References 8 publications

Point‐of‐care testing in haemostasis

Point‐of‐care testing in haemostasis

Safety and Efficacy of Single Bolus Anticoagulation with Enoxaparin for Chronic Hemodialysis. Results of an Open-Label Post-Certification Study

Essentials of anticoagulation in hemodialysis

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