The anticoagulant activity of enoxaparin sodium during on‐line hemodiafiltration and conventional hemodialysis

Sombolos, Kostas; Fragia, Theodora K.; Gionanlis, Lazaros; Veneti, Panagiota; Bamichas, Gerasimos; Fragidis, S.; Georgoulis, Ioannis; Natse, Taïsir

doi:10.1111/j.1542-4758.2009.00336.x

Cited by 21 publications

(18 citation statements)

References 17 publications

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“…Post and mid‐dilution fluid replacement is also known to generate hemoconcentration in the filter, with increased risk of clotting . A decreased anti‐Xa activity reflecting a decrease in anticoagulant activity of enoxaparin was demonstrated in on‐line postdilution hemodiafiltration compared with HD .…”

Section: Resultsmentioning

confidence: 99%

Anticoagulation in Chronic Hemodialysis: Progress Toward an Optimal Approach

Kessler¹,

Moureau

Nguyên

2015

Seminars in Dialysis

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Appropriate anticoagulation for hemodialysis (HD) requires a subtle balance between under-and over-heparinization to prevent extracorporeal circuit (ECC) clotting and bleeding, respectively. We discuss five key issues relating to anticoagulation therapy for chronic HD in adults following a review of relevant literature published since 2002: (i) options for standardization of anticoagulation in HD settings. The major nephrology societies have issued low evidence level recommendations on this subject. Interventional studies have generally investigated novel lowmolecular weight heparins and provided data on safety of dosing regimens that cannot readily be extrapolated to clinical practice; (ii) identification of clinical and biological parameters to aid individualization of anticoagulation treatment. We find that use of clinical and biological monitoring of anticoagulation during HD sessions is currently not clearly defined in routine clinical practice; (iii) role of ECC elements (dialysis membrane and blood lines), dialysis modalities, and blood flow in clotting development; (iv) options to reduce or suppress systemic heparinization during HD sessions. Alternative strategies have been investigated, especially when the routine mode of anticoagulation was not suitable in patients at high risk of bleeding or was contraindicated; (v) optimization of anticoagulation therapy for the individual patient. We conclude by proposing a standardized approach to deliver anticoagulation treatment for HD based on an individualized prescription prepared according to the patient's profile and needs.Maintaining full patency in the extracorporeal circuit (ECC) during hemodialysis (HD) sessions is a prerequisite for optimal HD quality (1-4). A complex disturbance of the coagulation system is commonly encountered in patients at the terminal stage of chronic kidney disease (CKD), leading to considerable morbidity and mortality (5). Although HD reduces the bleeding risk by the removal of uremic toxins, interaction between blood and artificial surfaces contributes to activate coagulation pathways. This nonphysiological environment leads to clotting on these foreign surfaces which reduces HD efficiency, shortens circuit lifetime, and increases patient blood loss, nursing workload, disposable consumption, and thus the cost of treatment (3,4).Appropriate anticoagulation requires a subtle balance between under-and over-heparinization to prevent ECC clotting and bleeding, respectively. HD patients are prone to prolonged bleeding episodes from dialysis fistula, as well as gastrointestinal and intracranial hemorrhage (5). Conversely, they may develop a prothrombotic status or comorbid conditions requiring oral anticoagulants or antiplatelet agents (1,5). Of interest, the dialysis population represents the only group of patients to receive heparin three times per week, with a potential longterm cumulative effect associated with an increased risk of osteoporosis, aldosterone suppression and hyperkalemia, and a deterioration of lipid profile...

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Section: Resultsmentioning

confidence: 99%

Anticoagulation in Chronic Hemodialysis: Progress Toward an Optimal Approach

Kessler¹,

Moureau

Nguyên

2015

Seminars in Dialysis

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“…Hence, it is very likely that when using LMWHs with shorter chains such as enoxaparin and nadroparin, removal will likewise occur or even be more pronounced. The removal of enoxaparin during hemodiafiltration has previously been demonstrated, however without assessing the impact of the administration site [27]. …”

Section: Discussionmentioning

confidence: 99%

Where and When To Inject Low Molecular Weight Heparin in Hemodiafiltration? A Cross Over Randomised Trial

et al. 2015

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Background and ObjectiveLow molecular weight heparins (LMWHs) are small enough to pass large pore dialysis membranes. Removal of LMWH if injected before the start of the session is possible during high-flux dialysis and hemodiafiltration. The aim of this study was to determine the optimal mode (place and time) of tinzaparin administration during postdilution hemodiafiltration.Study Design, Setting, PatientsIn 13 chronic hemodiafiltration patients, 3 approaches of injection were compared in a randomised cross over trial: i) before the start of the session at the inlet blood line filled with rinsing solution (IN0), ii) 5 min after the start at the inlet line filled with blood (IN5) and iii) before the start of the session at the outlet blood line (OUT0). Anti-Xa activity, thrombin generation, visual clotting score and reduction ratios of urea and beta2microglobulin were measured.ResultsAnti-Xa activity was lower with IN0 compared with IN5 and OUT0, and also more thrombin generation was observed with IN0. No differences were observed in visual clotting scores and no clinically relevant differences were observed in solute reduction ratio. An anti-Xa of 0.3 IU/mL was discriminative for thrombin generation. Anti-Xa levels below 0.3 IU/mL at the end of the session were associated with worse clotting scores and lower reduction ratio of urea and beta2microglobulin.ConclusionsInjection of tinzaparin at the inlet line before the start of postdilution hemodiafiltration is associated with loss of anticoagulant activity and can therefore not be recommended. Additionally, we found that an anti-Xa above 0.3 IU/mL at the end of the session is associated with less clotting and higher dialysis adequacy.Trial RegistrationClinicaltrials.gov NCT00756145

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“…Because a high FF induces considerable haemoconcentration [ 33 ] and clotting within the dialyser, adequate anticoagulation with either unfractionated heparin or low molecular weight heparin (LMWH) is mandatory. Although these agents, which belong to the MMW class (2–20 kDa), are for the main part protein bound, large convective volumes in ol-HDF may alter their pharmacokinetics [ 34 , 35 ]. In THDFS, the unfractionated heparin dose was ∼10% higher in the HDF group when compared with HD patients [ 14 ].…”

Section: Optimization Of Convection Volume In Clinical Practicementioning

confidence: 99%

Optimization of the convection volume in online post-dilution haemodiafiltration: practical and technical issues

Chapdelaine

Zuijdewijn

Mostovaya

et al. 2015

Clinical Kidney Journal

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In post-dilution online haemodiafiltration (ol-HDF), a relationship has been demonstrated between the magnitude of the convection volume and survival. However, to achieve high convection volumes (>22 L per session) detailed notion of its determining factors is highly desirable. This manuscript summarizes practical problems and pitfalls that were encountered during the quest for high convection volumes. Specifically, it addresses issues such as type of vascular access, needles, blood flow rate, recirculation, filtration fraction, anticoagulation and dialysers. Finally, five of the main HDF systems in Europe are briefly described as far as HDF prescription and optimization of the convection volume is concerned.

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The anticoagulant activity of enoxaparin sodium during on‐line hemodiafiltration and conventional hemodialysis

Cited by 21 publications

References 17 publications

Anticoagulation in Chronic Hemodialysis: Progress Toward an Optimal Approach

Anticoagulation in Chronic Hemodialysis: Progress Toward an Optimal Approach

Where and When To Inject Low Molecular Weight Heparin in Hemodiafiltration? A Cross Over Randomised Trial

Optimization of the convection volume in online post-dilution haemodiafiltration: practical and technical issues

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