Arterial Versus Venous Port Site Administration of Nadroparin for Preventing Thrombosis of Extracorporeal Blood Circuits in Patients Receiving Hemodiafiltration Treatment

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.

Comparison of the injection of low‐molecular weight heparin in the arterial vs. venous blood line for preventing extracorporeal circuit clotting during hemodialysis

“…Thus, we hypothesized that the efficacy of LMWH administered into the arterial blood line for preventing extracorporeal circuit clotting may be potentially reinforced by the additional local anticoagulant effect of citric acid‐based dialysate 23,24 . In line with our study, a significant improvement in visual clotting scores for dialyzers and tubing lines in OL‐HDF, after the switch of single dose LMWH bolus from the arterial blood line to the venous blood line route, has been recently reported 25 . These results indicate loss of LMWH when administered into the arterial blood line route, allowing for a significant LMWH dose reduction with the venous blood line route of injection.…”

“…23,24 In line with our study, a significant improvement in visual clotting scores for dialyzers and tubing lines in OL-HDF, after the switch of single dose LMWH bolus from the arterial blood line to the venous blood line route, has been recently reported. 25 These results indicate loss of LMWH when administered into the arterial blood line route, allowing for a significant LMWH dose reduction with the venous blood line route of injection.…”

“…As there are no current international recommendations regarding the injection route, the arterial blood line route is still frequently used in France, as recommended historically by health regulatory authorities according to manufacturer's instructions. However, since the venous blood line route reduces LMWH loss in the dialysis circuit, 12,25 it may impact health-related costs. Thus, updated recommendations for LMWH injections during dialysis by medical agencies and health regulatory authorities may appear desirable.…”

Prescription of online hemodiafiltration (ol‐HDF)

“…When a fractionated heparin (low molecular weight heparin) is used as a single bolus dose at initiation, injection of the compound should be performed either directly into the venous needle or in the venous blood line, or delayed if injected into the arterial blood line, for preserving an optimal antithrombotic efficiency. It has been clearly shown that immediate injection of the LMWH into the arterial blood line is associated with 20 to 30% loss of the active compound, reduced antithrombotic capacity or higher dosing required to maintain the same efficacy 27,28 …”

“…It has been clearly shown that immediate injection of the LMWH into the arterial blood line is associated with 20 to 30% loss of the active compound, reduced antithrombotic capacity or higher dosing required to maintain the same efficacy. 27,28 3.1.4 | HDF prescription modality HDF substitution mode (post-, pre-, or mixed-dilution) relies on few principles: First, post-dilution mode is by default the first line option. It provides the highest efficacy per liter of substituted volume, cost-effectiveness considering reduced water, and electrolytic consumption.…”