Heparin-Free Hemodialysis with Prophylactic Change of Dialyser and Blood Lines

Abstract

Heparinization during hemodialysis may cause severe bleeding complications in patients with high bleeding risk. Heparin-free hemodialyses (n = 208) were performed in 46 unselected patients with high bleeding risk after kidney transplantation (n = 25), after major surgery (n = 10), and with bleeding disorders (n = 11). Dialyser and blood lines were primed without heparin. In addition to the established measures (high blood flow, intermittent rinsing), system clotting was prevented by prophylactically changing the dialyser and blood lines in 107 of 208 dialyses (52 percent). Total system clotting with blood loss ranging from 100 to 250 ml occurred in six cases (3 percent). Mean hemodialysis time (+/- SD) was 4.1 hours (+/- 0.4), rising volume of the extracorporeal system 1.4 liters/hour (+/- 0.6), blood flow 244 ml/min (+/- 38), clotting time 12 min (+/- 4), and weight loss 2.5 kg (+/- 1.5). Mean hemodialysis creatinine clearance was 110 ml/min (+/- 34) and BUN clearance 138 ml/min (+/- 48). Heparin-free hemodialysis with prophylactic change of system is thus a safe and practical method of treatment for patients at high bleeding risk, but it is less effective, more expensive and the patient requires closer care.

Hemodialysis without Systemic Anticoagulation: A Prospective Randomized Trial to Evaluate 3 Strategies in Patients at Risk of Bleeding

“…Regional heparin/protamine [8], regional citrate/calcium [9]–[13] and prostacyclin [14], [15] are efficient but their use was limited by technical difficulties or clinical complications. Conversely, intermittent saline flushes (ISS) and constant saline infusion (CSI) of the circuit were described as simple and safe techniques to reduce clotting [7], [16], [17] and are widely used use in daily practice. Finally, the AN69ST membrane (polyacrylonitrile surface, modified by a polyethyleneimine layer) allows stable binding of unfractionated heparin [18].…”

Use and safety of heparin-free maintenance hemodialysis in the USA

“…Instead of using heparin, technicians intermittently flush the extracorporeal circuit with 100-200 mL of saline to prevent blood clots. Practitioners must weigh the decreased risk of bleeding against the increased risk of clotting in the circuit, which not only reduces dialysis efficiency, but also often requires a change of the circuit leading to extra blood loss for patients and increased time, labor and expense for providers [7][8][9][10][11].…”

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

“…5 Moreover, the level of evidence is low, as no randomized controlled study evaluating regular saline flushes has ever been reported. [6][7][8][9][10][11][12][13] No-heparin hemodialysis (NH-HD) treatment with predilution is another procedure used in some dialysis facilities. 14 However, fluid infusion is far from optimal because of the increased volume load that has to be removed during the current dialysis session, and an additional logistic burden for dialysis nurses owing to the need for closer one-to-one monitoring.…”