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Thielemans R, Vanommeslaeghe F, Josipovic I, De Somer F, Devreese K, Boone M, Van Biesen W, Eloot S. The optimized anticoagulation strategy in prolonged hemodialysis. Clin Kidney J 2023; 16:2235-2242. [PMID: 37915936 PMCID: PMC10616481 DOI: 10.1093/ckj/sfad125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Indexed: 11/03/2023] Open
Abstract
Background During extended (nocturnal) hemodialysis (ENHD), the dose of low-molecular-weight heparin (LMWH) can be administered as a single injection or as a divided dose over different time points. Our hypothesis was that a single injection might be sufficient to maintain dialyzer fiber patency. In addition, we investigated whether the biochemical clotting parameter anti-Xa accurately predicts fiber blocking. Methods Our hypothesis was tested in 20 stable patients on ENHD in a random cross-over setting during two consecutive midweek sessions. The regular total dose of LMWH (i.e. enoxaparin, Clexane® 40-100 mg, Sanofi, Belgium) was either given (i) in a single injection at the dialysis start or (ii) divided over two injections, at the start and halfway the dialysis session. Blood samples were taken from the arterial blood line at different time points to determine plasma anti-Xa activity levels. Post-dialysis, the rinsed and dried hemodialyzers were scanned with a reference micro-computed tomography (µCT) scanning technique, and non-blocked fibers were counted in a central cross-section of the dialyzer outlet potting (ImageJ, NIH, USA). Results The percentage of open fibers in the dialyzers after a single injection of LMWH [91 (61-96)%] versus divided administration [94 (79-98)%] was not different. Time averaged anti-Xa activity levels were clinically not significantly different between both sessions. Anti-Xa activity levels correlated with the administered anticoagulation doses normalized for body weight, but not with the percentages open fibers in the dialyzers. Conclusion Our results indicate that there is no need to administer enoxaparin over two injections for ENHD up to 8 h. The usefulness of monitoring anti-Xa levels to predict fiber patency, assessed by µCT, can be questioned, but further clinical trials are needed.
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Affiliation(s)
- Raïsa Thielemans
- Nephrology Department, Ghent University Hospital, Ghent, Belgium
| | | | - Iván Josipovic
- Centre for X-ray Tomography (UGCT), Physics and Astronomy, Ghent University, Ghent, Belgium
| | - Filip De Somer
- Cardiac Surgery, Ghent University Hospital, Ghent, Belgium
| | - Katrien Devreese
- Laboratory Clinical Chemistry and Hematology, Ghent University Hospital, Ghent, Belgium
| | - Matthieu Boone
- Centre for X-ray Tomography (UGCT), Physics and Astronomy, Ghent University, Ghent, Belgium
| | - Wim Van Biesen
- Nephrology Department, Ghent University Hospital, Ghent, Belgium
| | - Sunny Eloot
- Nephrology Department, Ghent University Hospital, Ghent, Belgium
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Chiasakul T, Mullier F, Lecompte T, Nguyen P, Cuker A. Laboratory Monitoring of Heparin Anticoagulation in Hemodialysis: Rationale and Strategies. Semin Nephrol 2023; 43:151477. [PMID: 38290962 DOI: 10.1016/j.semnephrol.2023.151477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Unfractionated heparin (UFH) and low-molecular-weight heparins (LMWHs) are commonly used to prevent clotting of the hemodialysis extracorporeal circuit and optimize hemodialysis adequacy. There is no consensus on the optimal dosing for UFH and LMWHs during hemodialysis. In clinical practice, semiquantitative clotting scoring of the dialyzer and venous chamber may help to guide UFH and LMWH dose adjustment. Laboratory monitoring has not been shown to improve clinical outcomes and is therefore not routinely indicated in most hemodialysis patients. It might, however, be considered in select patients, such as those with extremes of body weight or history of repeated clotting or bleeding. Methods for laboratory monitoring include the activated partial thromboplastin time, activated clotting time, and antifactor Xa assays for UFH and antifactor Xa assay for LMWHs. Target ranges for anticoagulation in hemodialysis have been suggested but not clearly defined. When utilizing these tests, issues such as availability, standardization, interfering factors, and interpretation must be considered. In this narrative review, we discuss the rationale and methods of monitoring anticoagulation in hemodialysis.
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Affiliation(s)
- Thita Chiasakul
- Center of Excellence in Translational Hematology, Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
| | - François Mullier
- Namur Thrombosis and Hemostasis Center, Université Catholique de Louvain, Centre Hospitalier Universitaire UCL Namur, Hematology Laboratory, Yvoir, Belgium; Institut de Recherche Expérimentale et Clinique, Pôle Mont, Université Catholique de Louvain, Yvoir, Belgium
| | - Thomas Lecompte
- Pharmacy Department, University of Namur, Namur, Belgium; Université de Lorraine, Nancy, France
| | - Philippe Nguyen
- Hematology Laboratory, Reims University Hospital, Reims, France
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Belmouaz M, Goussard G, Joly F, Grand F, Sibille A, Ecotiere L, Desport E, Bauwens M, Thierry A, Bridoux F. Comparison of the injection of low-molecular weight heparin in the arterial vs. venous blood line for preventing extracorporeal circuit clotting during hemodialysis. Hemodial Int 2022; 26:314-322. [PMID: 35014175 DOI: 10.1111/hdi.13004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 12/01/2022]
Abstract
Low-molecular weight heparins (LMWH) are widely used for preventing clotting during hemodialysis (HD). Although injection in the venous blood line is recommended to avoid initial loss of LMWH through the dialyzer, LMWH is still frequently administered in the arterial blood line at the start of dialysis. This study aimed to compare the safety and efficacy of the same enoxaparin dose administered through the venous blood line or arterial blood line. We also evaluated antifactor Xa (aXa) activity according to the injection route and dialysis modalities: high-flux (HF) HD, medium cut-off (MCO) HD, and online hemodiafiltration (OL-HDF). Forty-three patients were studied over 18 consecutive dialysis sessions using a fixed enoxaparin dose (20 or 40 mg), first administered through the arterial blood line bolus and then through the venous blood line for another 18 sessions. Compared to arterial blood line administration, venous blood line bolus resulted in a significant increase in median post-dialysis aXa activity: 0.16 (0.1-0.6) IU/ml versus 0.31 (0.1-1.3) IU/ml, respectively, p = 0.006. After arterial blood line bolus of 40 mg enoxaparin, median post-dialysis aXa activity was significantly lower with OL-HDF compared to HF-HD: 0.14 (0.1-0.35) versus 0.32 (0.15-0.49), p = 0.02. A trend for lower clotting within lines and bubble trap using venous blood line bolus was observed. In conclusion, venous blood line enoxaparin injection is safe in OL-HDF patients. However, in HF-HD and MCO-HD, venous blood line injection of 40 mg enoxaparin may increase overdosing risk. Thus, aXa activity should be monitored in HF-HD and MCO-HD patients at risk of bleeding and/or on vitamin K antagonists and careful surveillance is required when administering a 40 mg enoxaparin dose through the venous blood line route.
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Affiliation(s)
- Mohamed Belmouaz
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Guillaume Goussard
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Florent Joly
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Francois Grand
- Laboratory of Hematology, Poitiers University Hospital, Poitiers, France
| | - Audrey Sibille
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Laure Ecotiere
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Estelle Desport
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Marc Bauwens
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Antoine Thierry
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Frank Bridoux
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
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Optimising the Nadroparin Dose for Thromboprophylaxis During Hemodialysis by Developing a Population Pharmacodynamic Model Using Anti-Xa Levels. Clin Pharmacokinet 2022; 61:1559-1569. [PMID: 36040615 PMCID: PMC9652168 DOI: 10.1007/s40262-022-01162-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The optimal nadroparin dose in patients undergoing hemodialysis is difficult to determine in clinical practice. Anti-Xa levels ≥ 0.4 IU/mL and < 2.0 IU/mL are suggested to prevent thrombus formation within the extracorporeal circuit whilst minimizing bleeding risk. We aimed to characterize the variability in the association between dose and anti-Xa levels, identify patient and dialysis characteristics that explained this variability, and optimize nadroparin dosing based on the identified characteristics. METHODS Anti-Xa samples were collected in patients who received intravenous nadroparin as thromboprophylaxis during routine dialysis sessions. A population pharmacodynamic model was developed using non-linear mixed-effects modelling. The percentage of patients ≥ 0.4 IU/mL (efficacy) and < 2.0 IU/mL (safety) was simulated for different doses, patient and dialysis characteristics. RESULTS Patients (n = 137) were predominantly receiving standard hemodialysis (84.7% vs. hemodiafiltration 15.3%) and had a mean bodyweight of 76.3 kg (± 16.9). Lean body mass (LBM), mode of dialysis, and dialyzer partially explained between-subject variability in anti-Xa levels. Patients on hemodiafiltration and those receiving hemodialysis with a high LBM (≥ 80 kg) had a low probability (< 29%) of anti-Xa levels ≥ 0.4 IU/mL during the entire dialysis session. All patients, except hemodialysis patients with a low LBM (< 50 kg), had a high probability (> 70%) of peak anti-Xa levels < 2.0 IU/mL. CONCLUSION Mainly patients receiving hemodiafiltration and those receiving hemodialysis with a high LBM can benefit from a higher nadroparin dose than currently used in clinical practice, while having anti-Xa levels < 2.0 IU/mL.
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Santos A, Macías N, Vega A, Abad S, Linares T, Aragoncillo I, Cruzado L, Pascual C, Goicoechea M, López-Gómez JM. Expanded hemodialysis: Is anticoagulation of the dialysis circuit different from online hemodiafiltration and high-flux hemodialysis? Ther Apher Dial 2021; 26:147-153. [PMID: 33890717 DOI: 10.1111/1744-9987.13652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/13/2021] [Accepted: 04/17/2021] [Indexed: 11/28/2022]
Abstract
Expanded hemodialysis (HDx) has a high capacity for removing medium and medium-large molecules; however, there are no specific recommendations during HDx for anticoagulation of the dialysis circuit. We aimed to evaluate the differences in the efficacy of anticoagulation procedures using the venous port and 40 mg enoxaparin in HDx compared to high-flux hemodialysis (HF-HD) and postdilution online hemodiafiltration (HDF). We compared anticoagulant activity in 11 patients in HDx, HF-HD, and HDF under similar dialysis conditions. In the 33 dialysis sessions, 40 mg enoxaparin was administered through the venous port, and pre- and postdialysis antifactor Xa activity (aXa) and activated partial thromboplastin time (APTT), postdialysis clotting time of the vascular access, visual clotting score of the dialyzer, and any complications with the extracorporeal circuit or bleeding were registered. APTT postdialysis in HDx was not significantly different from that in HF-HD and HDF. Postdialysis aXa in HDx was not significantly different from that in HF-HD and HDF. We found no significant differences in visual clotting score of the dialyzer. Enoxaparin administered through the venous port was sufficient for anticoagulation within the extracorporeal circuit in HDx, HF-HD, and HDF. There were no differences in postdialysis aXa or APTT, most likely because when low molecular-weight heparin is applied through venous port, lesser enoxaparin concentration reaches the dialyzer. Thus, we conclude that the dose of enoxaparin administered through the venous port should not be adjusted according to dialysis technique.
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Affiliation(s)
- Alba Santos
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Nicolás Macías
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Almudena Vega
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Soraya Abad
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Tania Linares
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Inés Aragoncillo
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Leonidas Cruzado
- Department of Nephrology, Hospital Universitario de Elche, Elche, Spain
| | - Cristina Pascual
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marian Goicoechea
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Santos A, Macías N, Vega A, Abad S, Linares T, Aragoncillo I, Cruzado L, Pascual C, Goicoechea M, López-Gómez JM. Efficacy of enoxaparin in preventing coagulation during high-flux haemodialysis, expanded haemodialysis and haemodiafiltration. Clin Kidney J 2020; 14:1120-1125. [PMID: 33841857 PMCID: PMC8023216 DOI: 10.1093/ckj/sfaa057] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/18/2020] [Indexed: 12/16/2022] Open
Abstract
Background Low-molecular-weight heparins (LMWHs) are easily dialysable with high-flow membranes; however, it is not clear whether the LMWH dose should be adjusted according to the membrane type and dialysis technique. This study aimed to evaluate the influence of the dialyser on anticoagulation of the extracorporeal dialysis circuit. Methods Thirteen patients received the same dose of LMWH through the arterial port via three dialysis techniques: high-flux haemodialysis (HF-HD), online haemodiafiltration (HDF) and expanded haemodialysis (HDx). All dialysis was performed under similar conditions: duration, 4 h; blood flow, 400 mL/min; and dialysate flow, 500 mL/min. Antifactor Xa (aXa) activity and activated partial thromboplastin time (APTT) were measured before and after the dialysis. Clotting time of the vascular access site after haemodialysis, visual clotting score of the dialyser and any complications with the extracorporeal circuit or bleeding were registered. Results Post-dialysis aXa activity in HF-HD (0.26 ± 0.02 U/mL) was significantly different from that in HDF (0.21 ± 0.02 U/mL, P = 0.024), and there was a trend in HDx (0.22 ± 0.01 U/mL, P = 0.05). APTT post-dialysis in HF-HD (30.5 ± 0.7 s) was significantly different from that in HDx (28.2 ± 0.64 s, P = 0.009) and HDF (28.8 ± 0.73 s, P = 0.009). Conclusions AXa activity in HDF was significantly lower than that in HF-HD, possibly because of more losses of LMWH through the dialyser. Given the higher anticoagulant loss in HDF and probably in HDx than in HF-HD, the enoxaparin dose administered may be adjusted according to the dialysis technique.
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Affiliation(s)
- Alba Santos
- Nephrology Department, Hospital Universitario del Vinalopó, Elche, Spain
| | - Nicolás Macías
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Almudena Vega
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Soraya Abad
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Tania Linares
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Inés Aragoncillo
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Leonidas Cruzado
- Nephrology Department, Hospital Universitario de Elche, Elche, Spain
| | - Cristina Pascual
- Hematology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marian Goicoechea
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Tao M, Zheng D, Liang X, Ye M, Liu Y, Li Y, Shen H, He Q. Evaluation of the anticoagulant effect of low-molecular-weight heparins based on the anti-Xa level during haemodialysis. Nephrology (Carlton) 2020; 25:723-729. [PMID: 31999031 DOI: 10.1111/nep.13697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 01/14/2020] [Accepted: 01/19/2020] [Indexed: 11/29/2022]
Abstract
AIM Evaluate the relationship between anti-Xa activity and anticoagulant effect, and ascertain whether accumulation of low-molecular-weight heparins (LMWH) occurs during haemodialysis. METHODS There was an observational, single-centre study among participants who received the LMWH dalteparin, enoxaparin or nadroparin. A standard haemodialysis session lasted 4 hours. All included participants had anti-Xa activity measures at 0.5 and 4 hours. Extracorporeal circuit (ECC) clotting was evaluated by visual inspection of the haemodialyser and bubble trap after each haemodialysis session. The same person was tested at three consecutive haemodialysis sessions. RESULTS Overall, 90 participants were enrolled and 259 haemodialysis sessions assessed. There was no significant difference in the mean anti-Xa activity at 0.5 and 4 hours for three consecutive sessions, so LMWH accumulation did not occur. There were 69 (26.6%) sessions in which, ECC clotting was visible. Compared with the group where circuit clotting did not occur, the LMWH dose and anti-Xa activity in the group where circuit clotting occurred were significantly lower. At 0.5 hour, anti-Xa <0.88 IU/mL had significantly higher odds of ECC clotting than that at ≥0.88 IU/mL. At 4 hours, anti-Xa <0.35 IU/mL had significantly higher odds of ECC clotting than that at ≥0.35 IU/mL. CONCLUSION We found that over three haemodialysis sessions, no significant accumulation of LMWH was evident in subjects receiving a LMWH dose of between 2000 and 5000 IU for regular. Anti-Xa activity measurement can be used to adjust the dosage of LMWH and predict the anticoagulant effect during haemodialysis.
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Affiliation(s)
- Mei Tao
- Bengbu Medical College, Bengbu, P.R. China.,Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China
| | - Danna Zheng
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China
| | - Xudong Liang
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China
| | - Meiyu Ye
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China
| | - Yueming Liu
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China
| | - Yiwen Li
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China.,People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, P.R. China
| | - Huajuan Shen
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China
| | - Qiang He
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China.,People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, P.R. China
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Huang SHS, Qi K, Louzada M, Lindsay RM, Rehman F, Ke H, Muirhead N. Using dalteparin in quotidian and nocturnal hemodialysis patients: A prospective study. Hemodial Int 2019; 24:195-201. [PMID: 31804773 DOI: 10.1111/hdi.12805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/18/2019] [Accepted: 11/19/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Low-molecular weight heparin, such as dalteparin, is an alternative anticoagulation method in conventional hemodialysis (HD). However, there are limited studies on its use in quotidian and nocturnal HD. We assessed the optimal dose, treatment efficacy, and patient safety of dalteparin in quotidian and nocturnal HD populations. METHODS This study included 10 quotidian (7 in-center and 3 home) and 8 nocturnal home HD patients. Dalteparin was initiated and titrated based on clotting score in these patients. Trough anti-Xa levels were measured. The dalteparin dose, the dialyzer and HD circuit clotting scores, and bleeding episodes were recorded at 4 weeks. Patients who continued dalteparin were followed to 12 months. FINDINGS For the 10 quotidian HD patients, the median dalteparin dose was 1875 units [1250, 2500] after 4 weeks. For nocturnal HD patients, five of the eight patients switched back to heparin due to high clotting scores while on dalteparin within 4 weeks. However, three patients continued on dalteparin at 4 weeks. After 12 months, one maintained on 5000 units and the other two maintained on 7500 units of dalteparin. All the clotting scores at month 12 were ≤2. One patient died due to an unrelated cause. For all patients who continued on dalteparin, only 9% of the HD treatments had circuit clotting score >2 after reaching stable dose. All trough anti-Xa levels were <0.1 IU/mL. There were no episodes of bleeding. Fistula compression times were not increased. DISCUSSION This small pilot study suggests that dalteparin can be used effectively and relatively safety in quotidian HD. However, its use in nocturnal HD was only successful in a small proportion of patients. Alternative methods, including second dalteparin bolus after 4 hours of HD treatment, should be assessed for efficacy and practicality.
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Affiliation(s)
- Shih-Han S Huang
- Department of Medicine, Division of Nephrology, Western University, London, Ontario, Canada.,Department of Medical Biophysics, Western University, London, Ontario, Canada.,Department of Paediatrics and Pathology and Laboratory Medicine, Western University, London, Ontario, Canada.,Kidney Clinical Research Unit, Lawson Research Institute, London, Ontario, Canada
| | - Karen Qi
- Department of Pharmacy, Western University, London, Ontario, Canada
| | - Martha Louzada
- Department of Medicine, Division of Hematology, Western University, London, Ontario, Canada
| | - Robert M Lindsay
- Department of Medicine, Division of Nephrology, Western University, London, Ontario, Canada.,Department of Medical Biophysics, Western University, London, Ontario, Canada.,Kidney Clinical Research Unit, Lawson Research Institute, London, Ontario, Canada
| | - Faisal Rehman
- Department of Medicine, Division of Nephrology, Western University, London, Ontario, Canada.,Kidney Clinical Research Unit, Lawson Research Institute, London, Ontario, Canada
| | - Hanna Ke
- Kidney Clinical Research Unit, Lawson Research Institute, London, Ontario, Canada
| | - Norman Muirhead
- Department of Medicine, Division of Nephrology, Western University, London, Ontario, Canada
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10
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Lutkin M, Stronach L, Yadav P, Hothi DK. Dalteparin anticoagulation in paediatric home haemodialysis. Pediatr Nephrol 2018; 33:2337-2341. [PMID: 30173320 DOI: 10.1007/s00467-018-4032-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 07/04/2018] [Accepted: 07/20/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study was to investigate whether dalteparin is a safe and effective anticoagulant for paediatric home haemodialysis (HD) and to assess the determinants of dosing. METHODS Data were collected for all children (< 18 years) undergoing home HD from 2011 to 2017 at one large paediatric nephrology centre in the UK. All children had anticoagulation with dalteparin sodium according to a standardised protocol. Dalteparin safety was assessed by monitoring for accumulation, adequate clearance of dalteparin and adverse events. Dalteparin efficacy was assessed through monitoring for clot formation in dialysis circuits. Potential determinants of dalteparin dosing were assessed. RESULTS Eighteen children were included, their median age at start was 12 years, and 50% were male. Eighty-three percent of children had four home HD sessions each week, with a median total dialysis hours of 20 h/week. Thirty-three percent of children had nocturnal home HD. Median dalteparin dose at 12-month follow-up was 40 IU/kg (range 8-142 IU/kg). Factors associated with higher dalteparin dosing requirements included a younger age of the child (p < 0.01), a lower blood flow rate (p < 0.01) and the use of a central venous line for dialysis access (p = 0.038). No children had evidence of bioaccumulation of dalteparin or inadequate clearance. No significant bleeding or adverse events were reported. CONCLUSIONS Dalteparin is a safe and effective anticoagulant when used for paediatric home HD. In this study, there was no evidence of bioaccumulation or significant adverse events. Further research is required to directly compare dalteparin with unfractionated heparin (UFH) and evaluate anticoagulant choice for paediatric home HD.
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Affiliation(s)
- Miranda Lutkin
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Lynsey Stronach
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Pallavi Yadav
- Department of Paediatric Nephrology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Daljit K Hothi
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
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Sagedal S, Sandvik L, Klingenberg O, Sandset PM. β-Thromboglobulin may not reflect platelet activation during haemodialysis with the HeprAN membrane. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 77:679-684. [PMID: 29117741 DOI: 10.1080/00365513.2017.1397288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND When blood passes through the extracorporeal circuit during haemodialysis (HD) undesirable effects including platelet degranulation and coagulation activation take place. β-thromboglobulin (β-TG) is a sensitive marker of platelet activation. The aim of this study was to investigate platelet degranulation and coagulation activation during HD with the heparin-coated dialysis membrane HeprAN. METHODS Four HD sessions were evaluated in each of 12 chronic HD patients. None of the patients used oral warfarin, other anticoagulants or antiplatelet drugs. In the first session the HeprAN membrane or a conventional polyflux membrane was used in a randomized manner and thereafter alternately in a cross-over design, and 50% of the conventional dalteparin dose was given at start of HD. Prothrombin fragment 1 + 2 (PF1 + 2), β-TG and anti-factor Xa activity were measured repeatedly. RESULTS No dialysis sessions were terminated early due to clotting of the extracorporeal system. Activation of intravascular coagulation as assessed by change in PF1 + 2 during 4 hours of HD was the same with the two membranes. β-TG concentration decreased significantly during 4 hours of HD with the HeprAN membrane but remained stable with the polyflux membrane. CONCLUSION There were no differences in clotting scores or coagulation activation with the two membranes. The decrease in β-TG during HD with the HeprAN membrane suggests β-TG to be an inferior marker of platelet degranulation when using a heparin-coated dialysis membrane. A possible mechanism for the decline in β-TG concentration may be adherence of this heparin-binding protein to the heparin-coated dialysis membrane.
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Affiliation(s)
- Solbjørg Sagedal
- a Department of Nephrology , Oslo University Hospital Ullevål , Oslo , Norway
| | - Leiv Sandvik
- b Oslo Centre for Biostatistics and Epidemiology, Research Support Services , Oslo University Hospital , Oslo , Norway
| | - Olav Klingenberg
- c Department of Medical Biochemistry , Oslo University Hospital , Oslo , Norway.,d Institute of Clinical Medicine , University of Oslo , Oslo , Norway
| | - Per Morten Sandset
- d Institute of Clinical Medicine , University of Oslo , Oslo , Norway.,e Department of Haematology , Oslo University Hospital and Research Institute of Internal Medicine, Oslo University Hospital , Oslo , Norway
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Malyszko J, Koc-Zorawska E, Kozminski P, Malyszko JS. Vascular adhesion protein-1 in hemodialysis and hemodiafiltration patients: effect of single hemodialysis session on its level in regard to type of anticoagulant. Int Urol Nephrol 2017; 49:875-879. [PMID: 28044236 PMCID: PMC5403847 DOI: 10.1007/s11255-016-1497-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 12/27/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE Traditional anticoagulants used in intermittent hemodialysis (HD) are unfractionated heparin (UFH) and increasingly low molecular weight heparins (LMWHs). Repeated and prolonged exposure to UFH and/or LMWHs may further disturb hemostasis in uremic patients. Vascular adhesion protein-1 (VAP-1) is secreted by vascular smooth muscle cells, adipocytes and endothelial cells with functional monoamine oxidase activity and is elevated in atherosclerosis, diabetes mellitus and obesity. The aim of this study was to assess the effects of UFH and LMWHs on VAP-1 concentration in HD patients. The effects on single HD session on VAP-1 were also evaluated as well as VAP-1 levels in regard to type of renal replacement therapy. METHODS We studied 82 hemodialyzed patients (mean age 63 years, dialysis vintage 59 months) and 17 patients treated by means of hemodiafiltration (HDF) (mean age 59 years, HD vintage 84 months, HDF 7 months). Patients were anticoagulated with enoxaparin (n = 46), dalteparin (n = 10), nadroparin (n = 6) or UFH (n = 20) during their HD sessions. VAP-1 was assessed using kits from BioVendor, Modrice, Czech Republic. RESULTS Patients on HDF had significantly lower VAP-1 when compared with HD patients. We found that VAP-1 concentration in patients dialyzed by using LMWH or UFH was similar. There was no effect on HD session on VAP-1 concentration. Diabetic patients had higher serum VAP-1 than non-diabetic. CONCLUSIONS HDF is associated with lower VAP-1 levels indicating less pronounced endothelial cell injury than hemodialysis. Type of heparin seems to have no effect on VAP-1 levels in hemodialyzed patients. However, the cross-sectional but not prospective design is a limitation of this study.
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Affiliation(s)
- Jolanta Malyszko
- 2nd Department of Nephrology and Hypertension with Dialysis Unit, Medical University, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland.
| | - Ewa Koc-Zorawska
- 2nd Department of Nephrology and Hypertension with Dialysis Unit, Medical University, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | | | - Jacek S Malyszko
- 1st Department Nephrology and Transplantology with Dialysis Unit, Medical University, Białystok, Poland
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13
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Dhondt A, Pauwels R, Devreese K, Eloot S, Glorieux G, Vanholder R. Where and When To Inject Low Molecular Weight Heparin in Hemodiafiltration? A Cross Over Randomised Trial. PLoS One 2015; 10:e0128634. [PMID: 26076014 PMCID: PMC4468116 DOI: 10.1371/journal.pone.0128634] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/27/2015] [Indexed: 11/25/2022] Open
Abstract
Background and Objective Low 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, Patients In 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. Results Anti-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. Conclusions Injection 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 Registration Clinicaltrials.gov NCT00756145
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Affiliation(s)
- Annemieke Dhondt
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
- * E-mail:
| | - Ruben Pauwels
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Katrien Devreese
- Coagulation Laboratory, Department of Clinical Chemistry, Microbiology and Immunology, Ghent University Hospital, Ghent, Belgium
| | - Sunny Eloot
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Griet Glorieux
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
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14
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Abstract
In the setting of end-stage kidney disease, the incidence and risk for thrombotic events are increased and use of anticoagulants is common. The incidence of bleeding, however, is also a frequent issue and creates additional challenges in the management of anticoagulation therapy. Patients with end-stage renal disease are typically excluded from large clinical trials exploring the use of anticoagulants, which limits our knowledge of optimal management approaches. Furthermore, varying degrees of renal failure in addition to conditions that alter the pharmacokinetics of various anticoagulants or pharmacodynamic response may warrant alternative approaches to dosing. This review will explore systemic chronic anticoagulation therapy in the setting of chronic kidney disease where hemodialysis is required. Agents discussed include vitamin K antagonists, low-molecular-weight heparins, fondaparinux, oral factor Xa antagonists, and direct thrombin inhibitors. Clinical challenges, approaches to dosing regimens, and tools for measuring responses and reversal will be explored.
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Affiliation(s)
- William E Dager
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California.,Departments of Medicine and Pharmaceutical Services, Davis Medical Center, University of California Davis School of Medicine, Sacramento, California.,Department of Pharmacy, Touro Vallejo School of Pharmacy, Vallejo, California
| | - Laura V Tsu
- Department of Pharmacy Practice, Midwestern College of Pharmacy, Glendale, Arizona
| | - Tiffany K Pon
- Department of Clinical Pharmacy, School of Pharmacy, University of California San Francisco, San Francisco, California
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15
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Pon TK, Dager WE, Roberts AJ, White RH. Subcutaneous Enoxaparin for Therapeutic Anticoagulation in Hemodialysis Patients. Thromb Res 2014; 133:1023-8. [DOI: 10.1016/j.thromres.2014.03.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 03/05/2014] [Accepted: 03/18/2014] [Indexed: 10/25/2022]
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16
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Krummel T, Scheidt E, Borni-Duval C, Bazin D, Lefebvre F, Nguyen P, Hannedouche T. Haemodialysis in patients treated with oral anticoagulant: should we heparinize? Nephrol Dial Transplant 2014; 29:906-13. [DOI: 10.1093/ndt/gft522] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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17
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Mahieu E, Claes K, Jacquemin M, Evenepoel P, Op De Beek K, Bogaert AM, Kuypers D, Verhamme P, Meijers B. Anticoagulation With Fondaparinux for Hemodiafiltration in Patients With Heparin-Induced Thrombocytopenia: Dose-Finding Study and Safety Evaluation. Artif Organs 2013; 37:482-7. [DOI: 10.1111/aor.12002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
| | - Kathleen Claes
- Department of Nephrology; University Hospitals Leuven; Leuven; Belgium
| | - Marc Jacquemin
- Center for Molecular and Vascular Biology; University of Leuven; Leuven; Belgium
| | - Pieter Evenepoel
- Department of Nephrology; University Hospitals Leuven; Leuven; Belgium
| | - Karel Op De Beek
- Department of Nephrology; University Hospitals Leuven; Leuven; Belgium
| | - Anne-Marie Bogaert
- Department of Nephrology; Algemeen Ziekenhuis Zusters van Barmhartigheid; Ronse
| | - Dirk Kuypers
- Department of Nephrology; University Hospitals Leuven; Leuven; Belgium
| | - Peter Verhamme
- Center for Molecular and Vascular Biology; University of Leuven; Leuven; Belgium
| | - Björn Meijers
- Department of Nephrology; University Hospitals Leuven; Leuven; Belgium
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Nigten J, de Groot KA, Grootendorst DC, Koolen SL, Herruer MH, Schut NH. Pharmacokinetics of Dalteparin during Haemodialysis. ACTA ACUST UNITED AC 2013; 124:179-83. [DOI: 10.1159/000356384] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 10/16/2013] [Indexed: 11/19/2022]
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19
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Sridharan S, Berdeprado J, Sivalingam M, Farrington K. Dalteparin Dosing in High-Flux Haemodialysis and Haemodiafiltration. ACTA ACUST UNITED AC 2012; 122:53-7. [DOI: 10.1159/000348830] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 01/15/2013] [Indexed: 11/19/2022]
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20
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Sagedal S, Witczak BJ, Osnes K, Hartmann A, Os I, Eikvar L, Klingenberg O, Brosstad F. A Heparin-Coated Dialysis Filter (AN69 ST) Does Not Reduce Clotting during Hemodialysis when Compared to a Conventional Polysulfone Filter (F×8). Blood Purif 2011; 32:151-5. [DOI: 10.1159/000325227] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 02/08/2011] [Indexed: 11/19/2022]
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21
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Garcés EO, Victorino JA, Thomé FS, Röhsig LM, Dornelles E, Louzada M, Stifft J, de Holanda F, Veronese FV. Enoxaparin versus unfractioned heparin as anticoagulant for continuous venovenous hemodialysis: a randomized open-label trial. Ren Fail 2010; 32:320-7. [PMID: 20370447 DOI: 10.3109/08860221003606281] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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 (x10(3)/microL), 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 Weight-unadjusted 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.
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Affiliation(s)
- Erwin Otero Garcés
- Graduate Program in Medical Sciences: Nephrology, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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22
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Wijnhoven TJ, van de Westerlo EM, Smits NC, Lensen JF, Rops AL, van der Vlag J, Berden JH, van den Heuvel LP, van Kuppevelt TH. Characterization of anticoagulant heparinoids by immunoprofiling. Glycoconj J 2007; 25:177-85. [PMID: 17909966 PMCID: PMC2234449 DOI: 10.1007/s10719-007-9070-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Revised: 08/20/2007] [Accepted: 08/28/2007] [Indexed: 11/29/2022]
Abstract
Heparinoids are used in the clinic as anticoagulants. A specific pentasaccharide in heparinoids activates antithrombin III, resulting in inactivation of factor Xa and–when additional saccharides are present–inactivation of factor IIa. Structural and functional analysis of the heterogeneous heparinoids generally requires advanced equipment, is time consuming, and needs (extensive) sample preparation. In this study, a novel and fast method for the characterization of heparinoids is introduced based on reactivity with nine unique anti-heparin antibodies. Eight heparinoids were biochemically analyzed by electrophoresis and their reactivity with domain-specific anti-heparin antibodies was established by ELISA. Each heparinoid displayed a distinct immunoprofile matching its structural characteristics. The immunoprofile could also be linked to biological characteristics, such as the anti-Xa/anti-IIa ratio, which was reflected by reactivity of the heparinoids with antibodies HS4C3 (indicative for 3-O-sulfates) and HS4E4 (indicative for domains allowing anti-factor IIa activity). In addition, the immunoprofile could be indicative for heparinoid-induced side-effects, such as heparin-induced thrombocytopenia, as illustrated by reactivity with antibody NS4F5, which defines a very high sulfated domain. In conclusion, immunoprofiling provides a novel, fast, and simple methodology for the characterization of heparinoids, and allows high-throughput screening of (new) heparinoids for defined structural and biological characteristics.
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Affiliation(s)
- Tessa J. Wijnhoven
- Department of Matrix Biochemistry, Nijmegen Centre for Molecular Life Sciences, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- Department of Pediatric Nephrology, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Els M. van de Westerlo
- Department of Matrix Biochemistry, Nijmegen Centre for Molecular Life Sciences, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Nicole C. Smits
- Department of Matrix Biochemistry, Nijmegen Centre for Molecular Life Sciences, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Joost F. Lensen
- Department of Matrix Biochemistry, Nijmegen Centre for Molecular Life Sciences, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Angelique L. Rops
- Nephrology Research Laboratory, Division of Nephrology, Nijmegen Centre for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Johan van der Vlag
- Nephrology Research Laboratory, Division of Nephrology, Nijmegen Centre for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Jo H. Berden
- Nephrology Research Laboratory, Division of Nephrology, Nijmegen Centre for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Lambert P. van den Heuvel
- Department of Pediatric Nephrology, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Toin H. van Kuppevelt
- Department of Matrix Biochemistry, Nijmegen Centre for Molecular Life Sciences, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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Li LJ, Zhang YM, Liu XL, Du WB, Huang JR, Yang Q, Xu XW, Chen YM. Artificial liver support system in China: a review over the last 30 years. Ther Apher Dial 2006; 10:160-7. [PMID: 16684218 DOI: 10.1111/j.1744-9987.2006.00358.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Severe viral hepatitis with high mortality is the most common cause of liver failure in China. Treatment of severe viral hepatitis by hemoperfusion was initially adopted in the late 1970s and early 1980s. Following 10 years of development in China, a plasma exchange (PE)-centered artificial liver support system (ALSS), principally dependent on PE technology was developed. Based on the condition and symptoms of each patient, PE was given alone, or combined with hemodialysis, hemofiltration, hemodiafiltration, hemoperfusion, or plasma perfusion. In the late 1990s, training courses for ALSS were developed, and ALSS began to be carried out across China. Guidelines for artificial liver therapy were formulated and published by the Artificial Liver and Liver Failure Group of the Chinese Society of Infection. In recent years, new methods have been attempted, including small pore-size plasma separators, a molecular adsorbent-based recirculating system (MARS), and a continuous albumin purification system (CAPS). According to a retrospective analysis published in 2004, ALSS therapy significantly (P < 0.001) improved the survival rate of patients with severe hepatitis compared with patients who received only medicines (43.4%, 157/362 vs. 15.4%, 55/358 in chronic patients and 78.9%, 30/38 vs. 11.9%, 5/42 in acute and subacute patients). Furthermore, ALSS has also proved valuable as a bridge to liver transplantation in the treatment of patients with end-stage severe hepatitis in China. More recently, ALSS has been used in the treatment of drug-induced liver failure, acute fatty liver during pregnancy, and other difficult-to-treat disorders in China.
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Affiliation(s)
- Lan Juan Li
- Key Laboratory of Infectious Diseases, Ministry of Public Health, Department of Infectious Disease, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
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Schinzel H, Berghoff K, Beuermann I, Sauer O, von Mach MA, Weilemann LS. Anticoagulation with low-molecular-weight heparin (dalteparin) in plasmapheresis therapy: initial experience. Transfusion 2006; 46:624-9. [PMID: 16584439 DOI: 10.1111/j.1537-2995.2006.00755.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND In contrast to other extracorporeal treatments no established regime exists for anticoagulation with low-molecular-weight heparin (LMWH) in plasmapheresis therapy. A study was conducted to investigate whether LMWH (dalteparin-Na) is suitable as an effective anticoagulant in plasmapheresis therapy. STUDY DESIGN AND METHODS Eleven patients with autoimmune neurological diseases and the necessity for a plasmapheresis therapy were enrolled. A capillary membrane filter was used. A total of 2000 mL of human plasma was isovolumetrically exchanged per plasmapheresis cycle. The anticoagulation was accomplished with a single bolus of LMWH (dalteparin) of 80 to 90 IU per kg of body weight. The system was visually monitored. Anti-factor (F)Xa activity, thrombin-antithrombin III complex (TAT), and prothrombin fragment 1+2 (F 1+2) were determined at regular intervals. Samples were taken from the collected plasma pool to determine the loss of LMWH during the plasmapheresis procedure. RESULTS All plasmapheresis cycles with LMWH were successful without complications. Approximately 40 percent of the initially administered LMWH bolus was lost by the large porous filter during the plasmapheresis. The anti-FXa values were determined to be 0.5 IU per mL during the entire plasmapheresis. TAT values were elevated (TAT median, 14.3 microg/L). F 1+2 values measured before the filter cartridge remained within the normal range for the entire plasmapheresis cycle (<1.2 nmol/L) and were increasingly elevated after the filter. CONCLUSION Our initial experiences with LMWH for anticoagulation in plasmapheresis indicate that a body weight adjusted dose of LMWH (dalteparin) is suitable for anticoagulation in plasmapheresis therapy. No complications were observed. The data are encouraging. Further investigations will show if and how the present anticoagulation regime could be further optimized.
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Affiliation(s)
- Helmut Schinzel
- Medical Clinic and Policlinic II, Johannes Gutenberg University of Mainz, Germany.
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25
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Sagedal S, Hartmann A, Osnes K, Bjørnsen S, Torremocha J, Fauchald P, Kofstad J, Brosstad F. Intermittent saline flushes during haemodialysis do not alleviate coagulation and clot formation in stable patients receiving reduced doses of dalteparin. Nephrol Dial Transplant 2005; 21:444-9. [PMID: 16234293 DOI: 10.1093/ndt/gfi203] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Heparin-free haemodialysis (HD) with intermittent saline flushes (ISF) in patients with bleeding risk is widely used. The aim of this study was to investigate if ISF reduce coagulation and clotting in stable patients receiving reduced doses of dalteparin. METHODS Inclusion criteria were stable chronic HD patients >or=18 years of age and haemoglobin >or=11 g/dl. Exclusion criteria were use of warfarin and acetylsalicylic acid. Six HD sessions were evaluated per patient. Dalteparin was given as one bolus dose at start of HD (50% of the conventional dose). In HD number 1, 3 and 5, 100 ml saline solution was flushed through the filter each 30 min. In HD 2, 4 and 6, no ISF were given. Potential clotting in the bubble trap was visually observed each hour and graded on a 4-point scale: 1 = normal, 2 = fibrinous ring, 3 = clot formation and 4 = coagulated system. The dialyser was visually inspected at the end of each session: 1 = normal, 2 = a few blood stripes (affecting less than 5% of the surface fibres), 3 = many blood stripes (more than 5% of the fibres) and 4 = coagulated filter. The coagulation marker PF1+2, the platelet activation marker beta-TG and anti-FXa activity were repeatedly measured during HD. RESULTS Six men and two women were included. In four cases (four different patients), HD was stopped due to a coagulated system, all cases on days with ISF performed. Multiple linear regression analyses with repeated measurements showed that ISF adjusted for dalteparin dose/kg significantly increased mean clot in the bubble trap, estimate (B) = 0.717, P = 0.0001 and also showed that ISF increased PF1+2, B = 0.16, P = 0.001 when adjusted for anti-FXa activity and hours of dialysis, whereas beta-TG was only borderline increased, B = 0.09, P = 0.055. CONCLUSIONS ISF during HD does not alleviate visible clotting or intravascular coagulation activity in stable patients receiving reduced doses of dalteparin and polysulphone dialysers. Whether this applies to unstable patients with increased bleeding risk not receiving any anticoagulation remains to be shown.
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Affiliation(s)
- Solbjørg Sagedal
- Department of Medicine, Rikshospitalet University Hospital, N-0027 Oslo, Norway.
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Ziai F, Benesch T, Kodras K, Neumann I, Dimopoulos-Xicki L, Haas M. The effect of oral anticoagulation on clotting during hemodialysis. Kidney Int 2005; 68:862-6. [PMID: 16014067 DOI: 10.1111/j.1523-1755.2005.00468.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Between 5% and 10% of hemodialysis patients are treated with oral anticoagulants. It is currently unknown whether additional anticoagulation with heparin or low-molecular-weight heparin (LMWH) is needed to prevent clotting during hemodialysis. METHODS In this prospective, randomized, cross-over study 10 patients treated with oral anticoagulants (phenprocoumon) received either no additional anticoagulation or low dose dalteparin (bolus of 40 IU/kg body weight) before dialysis. Efficacy of hemodialysis was measured by normalized weekly Kt/V and urea reduction rate (URR). Thrombus formation was evaluated by measurement of D-dimer and inspection of air traps and dialyser. RESULTS The median international normalized ratio (INR) did not differ between both observation periods (phenprocoumon 2.2(2 to 3) vs. dalteparin 2.1(2 to 2.9). The anti-Xa level in dalteparin patients was 0.33 (0.27 to 0.38) IU/mL after 2 hours and 0.16 (0.03 to 0.23) IU/mL after 4 hours of hemodialysis. The median increase of D-dimer was significantly higher in patients without additional dalteparin therapy during hemodialysis (DeltaD-dimer 0.23 microg/mL vs. 0.03 mug/mL) (P= 0.0004). Complete thrombosis of the dialyser membrane occurred in one patient in the phenprocoumon group but in none with combined treatment. The extent of thrombosis in the arterial and venous air trap and dialyser was significantly less in patients with additional dalteparin therapy (P= 0.0014, P= 0.0002, and P= 0.0005, respectively). Weekly Kt/V and URR was similar in both groups. CONCLUSION Standard oral anticoagulation with an INR between 2 and 3 is insufficient to prevent clotting during hemodialysis. Additional low dose anticoagulation with a LMWH or heparin is necessary to facilitate treatment.
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Affiliation(s)
- Farzad Ziai
- Department of Internal Medicine III, Division of Nephrology and Dialysis, University Hospital Vienna, Vienna, Austria
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27
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Affiliation(s)
- Gerd R Hetzel
- Department of Nephrology, University Medical Center, Moorenstrasse 5, D-40225 Düsseldorf, Germany.
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Lipoprotein lipase in hemodialysis patients: indications that low molecular weight heparin depletes functional stores, despite low plasma levels of the enzyme. BMC Nephrol 2004; 5:17. [PMID: 15527497 PMCID: PMC534103 DOI: 10.1186/1471-2369-5-17] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2004] [Accepted: 11/03/2004] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lipoprotein lipase (LPL) has a central role in the catabolism of triglyceride-rich lipoproteins. The enzyme is anchored to the vascular endothelium through interaction with heparan sulphate proteoglycans and is displaced from this interaction by heparin. When heparin is infused, there is a peak of LPL activity accompanied by a reduction in triglycerides (TG) during the first hour, followed by a decrease in LPL activity to a stable plateau during the remaining session while TG increase towards and beyond baseline. This suggests that tissue stores of LPL become depleted. It has been argued that low molecular weight (LMW) heparins cause less disturbance of the LPL system than conventional heparin does. METHODS We have followed LPL activity and TG during a dialysis-session with a LMW heparin (dalteparin) using the same patients and regime as in a previous study with conventional heparin, i.e. a primed infusion. RESULTS The shape of the curve for LPL activity resembled that during the earlier dialyses with conventional heparin, but the values were lower during dialysis with dalteparin. The area under the curve for LPL activity during the peak period (0-180 minutes) was only 27% and for the plateau period (180-240 minutes) it was only 36% of that observed with conventional heparin (p < 0.01). These remarkably low plasma LPL activities prompted us to re-analyze LPL activity and to measure LPL mass in frozen samples from our earlier studies. There was excellent correlation between the new and old values which rules out the possibility of assay variations as a confounding factor. TG increased from 2.14 mmol/L before, to 2.59 mmol/L after the dialysis (p < 0.01). From 30 minutes on, the TG values were significantly higher after dalteparin compared to conventional heparin (p < 0.05). CONCLUSION These results indicate that LMW heparins disturb the LPL system as much or more than conventional heparin does.
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Małyszko J, Małyszko JS, Hryszko T, Pawlak K, Myśliwiec M. Comparison of effects of different heparins on thrombin activatable fibrinolysis inhibitor in hemodialyzed patients. Am J Nephrol 2004; 24:624-9. [PMID: 15627717 DOI: 10.1159/000082862] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2004] [Accepted: 11/15/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND Thrombin activatable fibrinolysis inhibitor (TAFI) is a regulator of endogenous fibrinolysis. Heparin is used routinely during dialysis sessions to prevent clot formation in the extracorporeal circuit; therefore the aim of the study was to assess whether unfractionated heparin or low-molecular-weight heparins affect TAFI concentration and activity in hemodialyzed patients. METHODS Dalteparin (n = 16) or enoxaparin (n = 25) were administered before the second hemodialysis session in the week in a single dose, whereas unfractionated heparin (n = 18) was given first as a bolus, then in a pump. We also evaluated thrombin activity (thrombin-antithrombin complexes, prothrombin fragments 1 + 2), TAFI activator, thrombomodulin, a catalyzer of TAFI activation and a marker of endothelial cell injury, and the degree of plasmin generation (plasmin-antiplasmin complexes). RESULTS TAFI concentration, activity and markers of ongoing coagulation, i.e. prothrombin fragments 1 + 2 and thrombin-antithrombin complexes, were significantly higher in patients anticoagulated with unfractionated heparin when compared to both enoxaparin and dalteparin groups. Thrombin-antithrombin complexes, plasmin-antiplasmin complexes, prothrombin fragments 1 + 2, and thrombomodulin did not differ between patients anticoagulated with dalteparin and enoxaparin. CONCLUSIONS Our results suggest that low-molecular-weight heparins influence TAFI and other hemostatic parameters in hemodialyzed patients to a lesser degree than unfractionated heparin. Increased TAFI is possibly due to thrombin appearance during hemodialysis with unfractionated heparin.
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Affiliation(s)
- Jolanta Małyszko
- Department of Nephrology and Transplantology, Medical University, Białystok, Poland.
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Klingel R, Schwarting A, Lotz J, Eckert M, Hohmann V, Hafner G. Safety and Efficacy of Single Bolus Anticoagulation with Enoxaparin for Chronic Hemodialysis. Results of an Open-Label Post-Certification Study. Kidney Blood Press Res 2004; 27:211-7. [PMID: 15273423 DOI: 10.1159/000079866] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2004] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Low-molecular-weight heparin (LMWH) is supposed to be advantageous compared to unfractionated heparin for chronic hemodialysis (HD) with respect to lipid and bone metabolism, polymorphonuclear cell stimulation, induction of antibody-mediated thrombocytopenia, and aldosterone suppression. Due to longer biological half-life, LMWH offers the possibility of single bolus administration. METHODS To assess safety and efficacy of single bolus anticoagulation with enoxaparin for chronic HD, 781 stable HD patients from 79 German dialysis centers (mean age 62 years; 31% ESRD due to diabetes mellitus) were monitored by clinical and laboratory parameters for 32 weeks. Additionally, in a single dialysis center, 22 chronic HD patients were investigated by molecular markers of coagulation during chronic HD under conditions of single bolus or continuous anticoagulation regimens. Anti-Xa activity and the thrombin- antithrombin-III complex (TAT) were determined before the enoxaparin bolus, after 15 min, 2 h, and at the end of HD in venous and arterial blood lines. RESULTS Chronic HD was performed in 24,117 HD treatments with enoxaparin at a median dose of 70.1 IU/kg (5,000 IU median total dose) for single bolus anticoagulation. In 83.0% of HD treatments, enoxaparin was given as single bolus. In 98.3% of patients no adverse event was reported. No drug-related severe adverse event occurred. Significant clotting problems were observed in only 0.3% of HD treatments with single bolus anticoagulation. As assessed in 257 HD treatments, essentially identical anti-Xa levels were detected at the end of HD with single bolus (50 IU/kg) or continuous (mean total dose 43 IU/kg) anticoagulation regimens. Bolus anticoagulation resulted in higher TAT generation at the end of HD. However, this was not associated with increased macroscopic clot formation. CONCLUSION Single bolus anticoagulation with enoxaparin was safe and effective for chronic HD. For a duration of 4 h HD, a median dose of 70 IU/kg can be recommended for regular use, which is in accordance with the manufacturer's instructions for use of enoxaparin recommending a range of 50-100 IU/kg.
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Frank RD, Brandenburg VM, Lanzmich R, Floege J. Factor Xa-activated whole blood clotting time (Xa-ACT) for bedside monitoring of dalteparin anticoagulation during haemodialysis. Nephrol Dial Transplant 2004; 19:1552-8. [PMID: 15034159 DOI: 10.1093/ndt/gfh203] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Low molecular weight heparins (LMWH) like dalteparin are increasingly used for anticoagulation during haemodialysis (HD). The available laboratory tests for monitoring LMWH anticoagulation are time-consuming and expensive, and the suitability of the conventional activated clotting time (ACT) is controversial. A simple and cheap bedside test would be useful. METHODS We studied the factor Xa-activated whole blood clotting time (Xa-ACT) in vitro and in vivo in nine patients undergoing chronic HD with i.v. dalteparin bolus anticoagulation and compared it with the conventional ACT. Plasma anti-factor Xa (antiXa) activity was determined with a chromogenic assay. Thrombin-antithrombin complexes were measured to detect coagulation activation. RESULTS Xa-ACT and ACT were prolonged with rising dalteparin concentration. In vitro, both clotting times were strongly correlated with the antiXa levels (r = 0.94 and 0.89, respectively). Nevertheless, compared with the ACT, the Xa-ACT was considerably more sensitive to the LMWH in vitro (healthy blood: Xa-ACT 90 s/U vs ACT 26 s/U; uraemic blood: Xa-ACT 96 s/U vs ACT 31 s/U) as well as in vivo (Xa-ACT 81 s/U vs ACT 22 s/U) and reflected different intensities of anticoagulation. An initial dalteparin bolus of 80+/-11 U/kg body weight was able to prevent coagulation activation for up to 4 h of HD. CONCLUSION For monitoring LMWH anticoagulation the Xa-ACT was superior to the conventional ACT in vitro as well as in vivo during HD. The Xa-ACT can be useful as a LMWH bedside test. The ACT was not sensitive enough to serve as a LMWH monitoring tool.
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Affiliation(s)
- Rolf Dario Frank
- Department of Nephrology and Clinical Immunlogy, University Hospital Aachen, D-52057 Aachen, Germany.
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Klingel R, Schaefer M, Schwarting A, Himmelsbach F, Altes U, Uhlenbusch-Körwer I, Hafner G. Comparative analysis of procoagulatory activity of haemodialysis, haemofiltration and haemodiafiltration with a polysulfone membrane (APS) and with different modes of enoxaparin anticoagulation. Nephrol Dial Transplant 2004; 19:164-70. [PMID: 14671052 DOI: 10.1093/ndt/gfg459] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Treatment modalities of renal replacement therapy differ in their diffusive and convective mass transfer characteristics. It was the goal of this study to clarify whether an increase in convective mass transfer as performed with haemofiltration (HF) and haemodiafiltration (HDF) in comparison with high-flux haemodialysis (HD) is associated with an alteration in procoagulatory activity or with complement activation. METHODS Ten stable chronic HD patients were monitored during 120 treatments in a randomized cross over design. A high-flux polysulfone dialyser (APS 900) was used for high-flux HD, pre-dilution HF and pre-dilution HDF. Constant flow of on-line substitution fluid for HF and HDF was 200 ml/min. The low molecular weight heparin (LMWH) enoxaparin was used for anticoagulation (i) as single bolus (50 IU/kg body weight, median 3700 IU) and (ii) as bolus of 1200 IU followed by a median continuous dose of 400 IU/h. Blood samples were collected before the LMWH bolus, after 10 min, 60 min, 120 min and at the end of treatment in venous and arterial blood lines to determine antiXa activity, thrombin-antithrombin-III complex (TAT), D-dimer and C5a generation. RESULTS Net ultrafiltration did not significantly differ between HD, HF and HDF but total ultrafiltration in HF and HDF far exceeded total ultrafiltration in HD. With conditions of single bolus, or bolus and continuous anticoagulation with enoxaparin, after comparable treatment times (median duration 4.25 h), TAT and D-dimer generation at identical anti-Xa levels revealed significantly higher coagulation activity during HF and HDF, compared with high-flux HD as assessed by comparative area under the curve (AUC) analysis. Plasma concentration of C5a in venous bloodlines did not significantly differ during HD, HF and HDF. CONCLUSION A higher convective mass transfer during HF and HDF, in comparison with high-flux HD caused by a greater total ultrafiltration volume was associated with increased procoagulatory activity in the extracorporeal circuit. Molecular markers assessing the activation of coagulation are appropriate to adjust the anticoagulation regime to high UF volumes in order to minimize bleeding risk and optimize patency of the extracorporeal circuit.
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Affiliation(s)
- Reinhard Klingel
- Apheresis Research Institute, Stadtwaldguertel 77, D-50935 Cologne, Germany.
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Nasstrom B, Stegmayr BG, Olivecrona G, Olivecrona T. Lower plasma levels of lipoprotein lipase after infusion of low molecular weight heparin than after administration of conventional heparin indicate more rapid catabolism of the enzyme. THE JOURNAL OF LABORATORY AND CLINICAL MEDICINE 2003; 142:90-9. [PMID: 12960955 DOI: 10.1016/s0022-2143(03)00059-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The functional pool of lipoprotein lipase (LPL) is anchored to heparan sulfate at the vascular endothelium. Injection of heparin releases the enzyme into the circulating blood. Animal experiments have shown that the enzyme is then extracted and degraded by the liver. Low molecular weight (LMW) heparin preparations are widely used in the clinic and are supposed to release less LPL. In this study, we infused a LMW heparin into healthy volunteers for 8 hours. The peak of LPL activity was only about 30% and the subsequent plateau of LPL activity only about 40% compared with those seen with conventional heparin. When a bolus of heparin was given after 4 hours' infusion of LMW or conventional heparin, only relatively small, and similar, amounts of LPL entered plasma. This suggests that the difference between LMW and conventional heparin lay in the ability to retain LPL in the circulating blood, not in the ability to release the lipase. Triglycerides (TGs) decreased when the heparin infusion was started, as expected from the high circulating LPL activities. After 1 to 2 hours, TG levels increased again, and after 8 hours they were about twice as high as before the heparin infusion. This indicates that the amount of LPL available for lipoprotein metabolism had become critically low in relation to TG transport rates. This study indicates that LMW heparin compared with conventional heparin causes as much or more depletion of LPL and subsequent impairment of TG clearing.
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Affiliation(s)
- Birgit Nasstrom
- Division of Nephrology, Department of Internal Medicine, Umeå University, Umeå, Sweden
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Beijering RJ, ten Cate H, Stevens P, Vanholder R, Van Dorp WT, van Olden RW, Wickstr??m B, Spr??gel P, ten Cate JW. Randomised Long-Term Comparison of Tinzaparin and Dalteparin in Haemodialysis. Clin Drug Investig 2003. [DOI: 10.2165/00044011-200323020-00002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Polkinghorne KR, McMahon LP, Becker GJ. Pharmacokinetic studies of dalteparin (Fragmin), enoxaparin (Clexane), and danaparoid sodium (Orgaran) in stable chronic hemodialysis patients. Am J Kidney Dis 2002; 40:990-5. [PMID: 12407644 DOI: 10.1053/ajkd.2002.36331] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Low molecular weight heparins (LMWHs) and danaparoid are an alternative to unfractionated heparin (UH) for anticoagulation during hemodialysis. Few data are available concerning their duration of action and whether drug accumulation occurs with continued use. We performed a prospective randomized study of the pharmacokinetics of dalteparin and enoxaparin plus danaparoid in 21 hemodialysis patients. METHODS Patients were randomly assigned to administration of enoxaparin, 40 mg; dalteparin, 2,500 U; or danaparoid, 34 U/kg, for 4 weeks. Antifactor Xa levels were measured at the end of weeks 1 and 4 immediately before the injection and at prescribed intervals up to 48 hours postinjection. RESULTS No bleeding or thrombotic episodes occurred during the study. Mean antifactor Xa activities 4 hours postinjection were 0.2 +/- 0.035 (SEM), 0.38 +/- 0.028, and 0.54 +/- 0.051 U/mL week 1 and 0.26 +/- 0.038, 0.40 +/- 0.055, and 0.64 +/- 0.050 U/mL week 4 for dalteparin, enoxaparin, and danaparoid, respectively. Both weeks 1 and 4, antifactor Xa activity 3 hours postdose was significantly greater for danaparoid sodium compared with enoxaparin and dalteparin. There were no significant differences between antifactor Xa activity week 4 versus week 1 for enoxaparin and dalteparin; however, danaparoid sodium levels during dialysis were significantly greater after 4 weeks of treatment (P = 0.0328, 1 hour; P = 0.003, 2 hours; P = 0.0128, 3 and 4 hours). CONCLUSION Dalteparin and enoxaparin provide adequate anticoagulation for hemodialysis using single bolus injections at relatively low doses. Danaparoid sodium at the current recommended dosage resulted in greater anticoagulation than enoxaparin or dalteparin and may have an
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Affiliation(s)
- Kevan R Polkinghorne
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia.
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Sagedal S, Hartmann A, Sundstrøm K, Bjørnsen S, Brosstad F. Anticoagulation intensity sufficient for haemodialysis does not prevent activation of coagulation and platelets. Nephrol Dial Transplant 2001; 16:987-93. [PMID: 11328905 DOI: 10.1093/ndt/16.5.987] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A single bolus of dalteparin at the start of haemodialysis (HD) may prevent clot formation, but subclinical activation of platelets and coagulation may still occur. Consequently, the relationship between clinical clotting events and activation markers of platelets and coagulation before and during HD is of interest. METHODS The effect of tapered doses of dalteparin during 84 HD sessions (4-4.5 h) was prospectively examined in 12 patients. Six of the patients were treated with warfarin. The initial dalteparin dose was reduced to 50% if no clotting was observed. Clinical clotting was evaluated by inspection of the air trap every hour and by inspection of the dialyser after each session. Anti-FXa activity was measured for assessment of dalteparin activity. Markers of activated plasma coagulation, (thrombin-antithrombin (TAT) and prothrombin fragment 1+2 (PF1+2)) and a marker of platelet activation (beta-thromboglobulin, beta-TG), were measured before the start of and after 3 and 4 h of dialysis. Ten pre-dialytic patients with chronic renal failure served as a control group. A total of 230 measurements of each parameter were performed. RESULTS An anti-FXa activity above 0.4 IU/ml at the end of HD inhibits overt clot formation for 4 h. This was obtained by an intravenous dalteparin dose of about 5000 IU. TAT and PF1+2 correlated to clinical clotting episodes (r=0.50 and 0.47, P<0.001). beta-TG was not significantly correlated to clinical clotting. All parameters increased during the sessions (TAT, PF1+2, beta-TG, P<0.001). When measurements during clinical clotting episodes were disregarded, all parameters were still markedly increased. Warfarin-treated patients had lower TAT and PF1+2. Dialysis patients had higher beta-TG values than pre-dialytic patients. CONCLUSION Despite clinically effective anticoagulation, obtained by dalteparin administration, platelets and coagulation are activated by HD, resulting in a potentially thrombophilic state. Warfarin treatment reduces clinical clot formation and subclinical activation of coagulation.
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Affiliation(s)
- S Sagedal
- Department of Internal Medicine, Research Institute for Internal Medicine, National Hospital, Oslo, Norway
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Affiliation(s)
- R Ouseph
- Department of Medicine, University of Louisville, Kentucky 40202, USA.
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