Enoxaparin versus unfractioned heparin as anticoagulant for continuous venovenous hemodialysis: a randomized open-label trial

Abstract

Aim: In this study we aimed to compare the efficacy and safety of enoxaparin with unfractioned heparin (UFH) as anticoagulant for continuous venovenous hemodialysis (CVVHD). Methods: An open-label randomized controlled trial was carried out in an intensive care unit (ICU) where 40 patients with acute renal failure (ARF) who needed continuous renal replacement therapy were randomized to receive UFH (n = 21) or enoxaparin (n = 19). Coagulation parameters were evaluated, and antithrombotic activity of UFH was measured by activated partial thromboplastin time (aPTT) and for enoxaparin by anti-factor Xa activity. Primary outcomes were thrombosis of the extracorporeal circuit and bleeding, classified as major or minor. Results: Minor bleeding episodes were observed only in patients anticoagulated with enoxaparin (26 vs. 0%, p = 0.018). Comparing patients with or without bleeding after 24 hours of therapy, the level of anticoagulation tended to be higher (anti-factor Xa: 1.62 vs. 1.13 IU/mL, p = 0.09) and the platelet count to be lower [107 ± 53 vs. 229 ± 84 (×10 3 /μL), p = 0.09] in patients who bled, but without statistical difference. Filter life span of enoxaparin and UFH groups was similar (43 ± 15 vs. 52 ± 18 hr, p = 0.10), as well as the proportion of circuit clotting. Conclusion: Weightunadjusted enoxaparin in patients with ARF in CVVHD was associated with an increased rate of bleeding, a finding that addresses the need to adjust drug dose and to monitor anti-factor Xa activity during dialysis. No benefit to prolong dialysis circuit survival was found with enoxaparin. In patients who do not present contraindication for systemic anticoagulation, UFH remains an effective and low-cost option.

Platelet Consumption and Filter Clotting Using Two Different Membrane Sizes during Continuous Venovenous Haemodiafiltration in the Intensive Care Unit

“…Despite its efficacy, postdilution CVVHDF can lead to significant haemoconcentration, potentially causing higher clotting frequency if compared with continuous venovenous haemodialysis (CVVHD) in predilution technique. Limited data suggest higher filter longevity in CVVHD compared to the median filter longevity documented in our study [27]. However, there is a lack of literature comparing the two different techniques with regard to frequency of clotting and filter related complications in ICU patient with ARF.…”

The Japanese clinical practice guideline for acute kidney injury 2016

“…The frequency of hemorrhagic complications with citrate and unfractionated heparin was found to be either equal, or significantly lower with citrate. Five more RCTs examined the use of LMWH as an anticoagulant in CRRT [ 290 – 294 ]; three of them [ 290 , 291 , 293 ] compared LMWH with unfractionated heparin, while two [ 292 , 294 ] compared LMWH with citrate. Only one of the five RCTs [ 292 ] examined the clinical outcomes; in this RCT, the mortality was significantly lower in the citrate group.…”

Continuous renal replacement therapy in elderly with acute kidney injury

“…In Garces et al [31], the efficacy and safety of LMWH were compared to unfractionated heparin during CRRT. No major bleeding occurred; however, minor bleeding episodes were observed in 26% of the patients on enoxaparin.…”

“…AKI increases the risk of LMWH accumulation because of its prolonged half-life, which is due to its renal clearance. LMWH accumulation might lead to excessive anticoagulation and an increased risk for bleeding [31].…”