Systemic Anticoagulation and Prevention of Hemodialysis Catheter Malfunction

Abstract

Although chronic anticoagulation is commonly prescribed to prevent thrombosis and malfunction of hemodialysis tunneled cuffed catheters (TCC), there are only limited data regarding its efficacy. The aim of this prospective study was to evaluate whether anticoagulation with adjusted-dose warfarin targeting an international normalized ratio (INR) of 1.5-2.0 is associated with improved catheter outcome in long-term patients at high risk of TCC malfunction. Among the 65 patients included in the study, 35 were considered at high risk (i.e., patients with a history of previous TCC thrombosis requiring catheter replacement and/or with TCC malfunction occurring within 2 weeks after catheter insertion in the absence of mechanical problems) and were prescribed warfarin, whereas 30 low-risk patients did not receive anticoagulation. During follow-up, TCC malfunction, defined as the need for inversion of catheter lines and/or recombinant tissue-type plasminogen activator infusion, was observed in 61.5% of patients. Among patients receiving warfarin, 19 (54.3%) achieved adequate anticoagulation (i.e., > 80% of follow-up INR values and INR value at the time of malfunction within target range). Anticoagulation was considered inadequate in 16 patients (45.7%). Malfunction-free catheter survival at 9 months was 47.1% in patients with adequate anticoagulation compared with 8.1% in patients with inadequate anticoagulation (p = 0.01). This difference remained statistically significant after adjustment for aspirin intake. These results suggest that achieving adequate anticoagulation with target INR 1.5-2.0 may prevent TCC malfunction and improve catheter outcome.

Warfarin use and the risks of stroke and bleeding in hemodialysis patients with atrial fibrillation: A systematic review and a meta-analysis

“…However, HD patients have a higher risk of clotting. Arterio-venous graft and tunneled central venous catheter render an increased risk of local or systemic thromboembolism in HD patients [24][25][26]. Although the balance of risks and benefits of warfarin perform favorable in mild to moderate CKD patients with AF [19], as lack of evidence from randomized controlled trials in these populations, current and previous observational studies on warfarin therapy failed to offer recommendations regarding warfarin management.…”

Major Bleeding in Hemodialysis Patients

“…Two studies evaluated low-intensity anticoagulation (target INR 1.4 to 1.9) for the prevention of HD access thrombosis (4,13). The one randomized, placebo-controlled trial was discontinued early because of a clinically important increase in major bleeding episodes in the patients who were randomly assigned to warfarin.…”

Low-Intensity Adjusted-Dose Warfarin for the Prevention of Hemodialysis Catheter Failure

“…Warfarin (1 mg daily) was ineffective in a randomized trial of 85 patients, although there was a decrease in thrombosis in the subgroup that achieved INR greater than 1.0 (12). An observational study in which 35 patients with previous catheter malfunction were anticoagulated to INR 1.5 to 2.0 and compared with 35 controls showed a trend toward lower rates of malfunction in the anticoagulated patients, particularly in those in whom anticoagulation targets were met (13). A prospective observational study of 62 patients showed fewer episodes of thrombosis with warfarin (INR 2.0 to 3.0) compared with no therapy (14).…”