Anticoagulation in hd dr. nadia mohsen

2. Hemostaticchangesin dialysispatient

3. ANTICOAGULATION REQUIRED
DURING IHD/CRRT TO PREVENT
CLOTTING IN THE
EXTRACORPOREAL SERVICE.

4. CLOTTINGOF THE
EXTRACORPOREAL
CIRCUIT
leads to
➢ blood loss
➢ reduced solute clearance and ultrafiteration due to reduction in dialyser surface
area.
Hence it is important to prevent clotting and assess the adequacy of anticoagulation.

5. What does induce clotting??
The hemodialysis circuit represents a large extracorporeal
surface area and the simple passage of blood through the
circuit could potentially lead to the deposition and activation of
plasma coagulation proteins thus initiating clotting.

6. to minimizeclottingin the
extracorporealcircuit
Dialyser priming
Heparin administration
Vascular access
a. Ensuring adequate blood flow.
b. Correct needle position
c. preventing repeated machine alarm situation

8. EUROPEAN BEST PRACTICE
GUIDELINES FOR
ANTICOAGULATION IN
HEMODIALYSIS
significant risk of bleeding
We recommend that systemic anticoagulation should be avoided or kept
to a minimum. This may be achieved by using a high blood flow rate and
regular flushing of the extracorporealcircuit with saline every 15-30 minutes or
regional citrate infusion. Low-dose unfractionated heparin may be used with
caution in patients with intermediate risk of bleeding. (1C)
Anticoagulation without added risk of bleeding:
We recommend that patients without increased bleeding risk should be given
unfractionated heparin or LMWH during HD to reduce the risk of clotting of
the extracorporealsystem. (1A)
NephrolDial Transplant 2002; 17: Supplement7 S1-S111

9. STANDARD
ANTICOAGULATION
Sodium heparin (UFH)
LMWH

10. • Heparin enhance the anticoagulant
activity of antithrombin III which
inactivates thrombin and factor Xa and
to lesser extent IXa , XIa and XIIa.
• raises the blood clotting time,
monitoring with APTT
• Highly negatively charged and binds
non-specifically to endothelium,
platelets, circulating proteins,
macrophages and plastic surfaces.
• The effect of heparin is immediate and
has a short half-life (30 minutes to 2
hours after discontinuation).
• Protaminesulfate as antidote.
Guidelines for Anticoagulation of Extracorporeal

11. HEPARIN ADMINISTRATION
TECHNIQUES (UFH)
1. STANDARD HEPARINISATION (routine
anticoagulation) (full dose heparinisation)
2. Tight heparinization (reduced, minimum)
3. Heparin free dialysis

12. STANDARDHEPARINISATION
(routineanticoagulation)
• Those patients who do not have increased risk of hemorrhage or co
morbidities like CNS bleed, GI haemorrhage, uremic pericarditis and are
not currently taking oral anticoagulants
Delivery techniques
Intermittent boluses:
• Initial bolus followed by repeated intermittent maintenance boluses
• Initial bolus followed by bolus on demand
• Single dose
continuous infusions
Initial bolus followed by continuous infusions

14. • Termination of heparin infusion
a. AV fistula-One hour before end of dialysis
b. Venous catheters- at the end of dialysis
• Reversal of over heparinisation: Injection protamine 1 mg for every 100
units heparin
• Target clotting times during dialysis
• Routine heparinisation: the clotting time at 1½ -2 times the baseline
clotting time.
• Tight heparinisation: the clotting time at 1¼ times the baseline clotting
time.

15. POTENTIALCOMPLICATIONSOF
USE OF HEPARIN
Heparin use may be associated with complications like
• heparin induced thrombocytopenia (HIT)
• drug drug interaction
• bleeding events
The long-term use of heparin has been associated with serious
side effects such as:
hair loss (alopecia)
Hyperkalemia due to Heparin induced suppression of aldosterone
synthesis
osteoporosis
Hyperlipidaemia (↑TG & Cholesterol,↓ HDL).
pruritis and rashes( anaphylactoid reaction ( first use yndrome)
The risk of
bleedng is
Related to the
level of APTT
not to the
heparin dose

16. Drugdruginteraction

17. LOW MOLECULAR WEIGHT
HEPARIN (LMWH)

19. Anticoagulation in patients with HIT type 2
We suggest that patients with HIT type 2 or HITTS should
not be prescribed unfractionated heparin or low molecular
weight heparin (LMWH) (2B).

20. There are multiple forms of LMWH
e.g. Enoxaparin, Dalteparin,
Nadroparin, Reviparin Tinzaparin

21. • shorter chain length
consisting of ≤ 15
saccharide units.
The results in:
1. less non-specific binding &
less bleeding
2. longer half-life
• Binds anti-thrombin III and inhibits
factor Xa
In most cases the affinity of LMWH for
Xa versus thrombin is of the order of
3:1.
• The anticoagulant effect of LMWH
can be monitored by the anti-factor
Xa activity in plasma:

23. ANTICOAGULATION IN
PATIENTS WHO CARRY THE
RISK FOR BLEEDING

24. • Tight heparinization
(reduced, minimum) (CRRT,
IHD)
• Heparin free dialysis
(CRRT, IHD)
• Regional Anticoagulation
• Protamine reversal anticoagulation
• Regional citrate Anticoagulation (RCA)
(CRRT)
• Heparin coated membrane
• Prostacyclin regional anticoagulation
(antiplatelet agents)
• Citrasate dialysate
• Hiparinoids & anti thrombin agents (IHD,
CRRT with HIT )

25. EUROPEAN BEST PRACTICE
GUIDELINES FOR
ANTICOAGULATION IN
HEMODIALYSIS
significant risk of bleeding
We recommend that systemic anticoagulation should be avoided or kept
to a minimum. This may be achieved by using a high blood flow rate and
regular flushing of the extracorporealcircuit with saline every 15-30 minutes or
regional citrate infusion. Low-dose unfractionated heparin may be used with
caution in patients with intermediate risk of bleeding. (1C)
Anticoagulation without added risk of bleeding:
We recommend that patients without increased bleeding risk should be given
unfractionated heparin or LMWH during HD to reduce the risk of clotting of the
extracorporealsystem. (1A)
NephrolDial Transplant 2002; 17: Supplement7 S1-S111

26. Priming in some units with heparin (3000 IU/ L saline) (avoid in HIT)
Multiple flushes of 250 ml of saline every 30 min, in association with a
high blood flow rate
Periodic saline rinse allows inspection of dialyser for evidence of clotting
No Heparin Dialysis

27. Indication
a. Patient at slight risk of bleeding
b chronic & prolonged bleeding
c. Heparin free dialysis unsuccessful due to
frequent clotting
Delivery technique
constant infusion
Initial bolus dose : 750 IU
constant infusion rate : 600 IU/ hour, Monitor and
keep ACT at baseline +40% (170-190 seconds)
heparin infusion Continue till end of dialysis
Tight heparinisation
(Minimum dose heparin)
Intermittent boluses
bolus of 500 IU/60 minutes to
keep the ACT within target ??
Do not try
intermittent
boluses as it
will lead to
rising and
falling clotting
times XXX

28. Regional citrate Anticoagulation
(RCA)
• Continuous infusion of isosmotic trisodium citrate solution (102 mmol/L) into
the arterial side of the dialyzer.
• Citrate bind to plasma calcium fall in plasma calcium preventing
the coagulation cascade anticoagulation.
• Calcium disturbance (monitoring)
• Metabolic alkalosis (Metabolism of citrate to HCO3)
• Hypernatremia( Hypertonic sodium citrate solution)
• Contraindicated in patient can not metabolized citrate such as : liver failure

30. Others

31. • Constant infusion of heparin into the
dialyzer inlet line and the simultaneous,
constant infusion of protamine prior to the
blood returning to the patient.
• Rebound bleeding 2-4 hours after the
end of dialysis as the reticuloendothelial
system releases free heparin from the
protamine-heparin complex back into the
general circulation.
Regional anticoagulation
with Protamine reversal

33. HEPARIN-INDUCED
THROMBOCYTOPENIA (HIT)

34. Clinicalpresentation
In patients with HIT Type II all heparin products must be avoided, including:
1.Topical preparations, coated products as well as intravenous preparations.
2.Systemic anticoagulation
Dialysis patients may have:
‘no heparin’ dialysis / switched to P.D/ RCA or anticoagulation with non- heparins
agents: commonly used include Danaparoid, Fonadparinux Hirudin, and Argatroban.
Venous catheters must not be heparin locked, but can be locked with recombinant
tissue plasminogen activator or citrate ( trisodium citrate 46.7%).

35. Conclusion
• Anticoagulation in Hemodialysis is an area in
dialysis that in continuous development and
evolution.
• UFH vs LMWH depend on your local practice and
resources
• good understanding for the Management of high
risk for bleeding on dialysis is mandatory

36. Thankyou