Dalteparin Dosing in High-Flux Haemodialysis and Haemodiafiltration

Abstract

Background: Low-molecular-weight heparins are being increasingly used as an alternative to unfractionated heparin for anticoagulation of the haemodialysis (HD) circuit. Data on dalteparin use in high-flux HD and haemodiafiltration (HDF) are limited. We examined the safety and efficacy of dalteparin in this setting to enable recommendations on the optimal dose range. Methods: This prospective study was conducted in a single dialysis unit. Subjects who had been receiving dalteparin for at least 10 HD sessions were studied. Anti-Xa activity was measured for all subjects at the start of the HD session, at 60 min into HD and at the end of dialysis. Results: 55 subjects were studied. None had detectable anti-Xa activity at the start of the session. Using adequacy criteria based on target anti-Xa activity >0.4 IU/ml at 1 h and <0.4 IU/ml at the end of dialysis, 39 (71%) patients had adequate anticoagulation, 12 (22%) patients were under-anticoagulated and 4 (7%) were over-anticoagulated. The mean dose in the adequately anticoagulated group was 60.7 ± 11.7 IU/kg, in the under-anticoagulated group 39.3 ± 9.6 IU/kg and in the over-anticoagulated group 70.1 ± 14.6 IU/kg. The optimal dose of dalteparin appears to be 60 ± 10 IU/kg, which facilitates the achievement of the target anti-Xa activity in the range of 0.4-0.75 IU/ml at 1 h and <0.4 IU/ml at the session end. Conclusion: Dalteparin is a safe and effective anticoagulant for patients on high-flux HD and HDF. The optimal dose appears to be 60 ± 10 IU/kg. The desirable target range of anti-Xa activity is 0.4-0.75 at 1 h and <0.4 IU/ml at the session end.

Practical Value of Anti-Xa Activity in the Evaluation of Extracorporeal Circuit Anticoagulation during Haemodialysis: Results of a Cross-Sectional Single-Centre Study

“…As LMWHs are administered with the sole purpose to prevent coagulation of the ECC, anti-Xa activity levels should be undetectable or at least below the target range after dialysis to prevent increased haemorrhagic risks for patients. Also anti-Xa target values at the end of the dialysis session have been previously reported, for example, an anti-Xa activity <0.4 IU/mL by Sridharan et al [7] .…”

“…With the development of automated assays to directly measure the factor Xa-inhibiting effect of LMWHs, a tool for monitoring LMWH therapy during dialysis is readily available [10] . However, guidelines on how to use the anti-Xa activity for this purpose are lacking and no consensus has been reached on the target range or on the optimal time point for measurement of the anti-Xa activity during dialysis [7,11] . The summary of product characteristics (SMPC) of the LMWH Dalteparin advises an anti-Xa target range of 0.5-1.0 IU/mL during dialysis [12] .…”

Niedermolekulare Heparine bei Niereninsuffizienz – Was ist bei der Anwendung zu beachten?

“…1). Dabei sollte beachtet werden, dass sich bei einigen LMWH niedrigere als die zugelassenen Dosierungen als ausreichend wirksam erwiesen haben [15,16,17,18]. Bei einer Dialysedauer von mehr als 4 Stunden kann eine zusätzliche Dosis im Verlauf der Dialyse oder eine kontinuierliche Gabe notwendig sein.…”

“…Dabei können die in Tabelle 1 Tab. 1 Empfehlungen zur Dosierung von niedermolekularen Heparinen bei Patienten mit Niereninsuffizienz (angelehnt an Empfehlungen in den deutschen Fachinformationen und publizierten Studien [15,16,17,18,22,23]); Angaben zum mittleren Molekulargewicht (mMW) nach Gray et al [24].…”

Using dalteparin in quotidian and nocturnal hemodialysis patients: A prospective study

“…By contrast, LMWH carries a lower risk of heparin‐induced osteoporosis and thrombocytopenia, has reduced bleeding risks, and is given by bolus injection rather than infusion . Most of the published studies on LMWH use in this setting are single center, and/or crossover studies from UFH to dalteparin or tinzaparin . Guidelines have recommended using LMWH over UFH as the anticoagulant of choice for conventional HD…”