Thrombogenesis and anticoagulation in patients undergoing chronic hemodialysis

ABSTRACT:The coagulation cascade is complex but well studied. Dialysis membranes and lines are inherently pro-coagulant and activate both the intrinsic and extrinsic pathways of coagulation, as well as platelets and other circulating cellular elements. To provide safe and effective dialysis, appropriate anticoagulant measures must be applied. Haemodialysis, including anticoagulation, is prescribed by dialysis doctors but delivered by dialysis nurses. The main agents used in clinical practice for anticoagulation during haemodialysis are unfractionated heparin (UF heparin) and low-molecularweight heparin (LMWH). LMWH has a number of potential advantages, apart from cost. One of the most serious complications of the use of any form of heparin is heparin-induced thrombocytopaenia (HIT) Type II, which occurs more commonly with UF heparin than LMWH. HIT Type II risks severe morbidity and mortality and is challenging to treat successfully in both the acute and chronic phase. In HIT Type II anticoagulation must be delivered without heparin. A wide array of newer anticoagulants are becoming progressively available, each with unique advantages and disadvantages. In maintenance haemodialysis patients with an increased risk of bleeding, a 'no heparin' dialysis may be undertaken, or regional anticoagulation considered. Because this aspect of dialysis is so important to the safe and effective delivery of haemodialysis therapy, dialysis clinicians need to review and update their knowledge of dialysis anticoagulation on a regular basis.

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“…There is no reversal agent. Clinically, significant accumulation should be tested by anti‐Xa estimation before any invasive procedure 38 …”

Section: Danaparoid (Orgaron)mentioning

confidence: 99%

Review: Anticoagulation for haemodialysis

Suranyi

Chow

2010

Nephrology

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“…1,4,6 Heparin has a half-life of 90 minutes, which can be increased up to 3 hours in patients with renal insufficiency. 1,4,6,20 Heparin is inexpensive and easy to monitor, and its effects can be reversed with protamine. Studies 21,22 have indicated that the incidence of bleeding is greater with heparin administration than with other types of anticoagulation.…”

Section: Heparinmentioning

confidence: 99%

“…In addition, the patient's hemodynamic status may become unstable because of the loss of blood, and increased fluid administration may be needed. 4,6,8 Another important consideration when the CRRT circuit is changed more often than usual because of clotting is the potential for central catheter-associated bloodstream infections. This potential increases every time the CRRT blood tubing is disconnected from the catheter, because the dialysis catheters are central blood catheters.…”

mentioning

confidence: 99%

“…The potential for disruption of blood flow or puncture of the graft or fistula with the needle exists each time the patient is moved or turned. 6,12,13 These situations are usually no problem during a typical hemodialysis treatment, but in CRRT, the extremity must be immobilized much longer than in typical hemodialysis because CRRT can last several days. 12 Only a few studies indicate that fistulas or grafts are the access of choice in CRRT, although these access sites were considered safe in 1 study.…”

mentioning

confidence: 99%

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Continuous Renal Replacement Therapy and Anticoagulation:

Dirkes

Wonnacott

2016

Critical Care Nurse

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Continuous renal replacement therapy is currently used as a standard treatment for acute kidney injury in the intensive care unit, particularly for patients with unstable hemodynamic status. Because this therapy is continuous, for days or weeks, and the extracorporeal blood circuit is large, the circuit is prone to clotting. Several methods of keeping the extracorporeal circuit patent are available, including heparin infusion, flushes with physiological saline, use of thrombin inhibitors, and citrate. This article reviews methods for continuous renal replacement therapy, anticoagulation, efficacy, and implications for bedside critical care. (Critical Care Nurse. 2016;36[2]:34-42)

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“…UFH is given as a bolus dose before the start of IHD, and is also given as a maintenance dose during treatment. LMWH is usually given as a single bolus dose only before the start of IHD …”

Section: Introductionmentioning

confidence: 99%