This document discusses techniques for performing dialysis without anticoagulation. It describes indications for heparin-free dialysis such as recent surgery or bleeding risks. Techniques mentioned include regional citrate anticoagulation, saline flushes, heparin-coated membranes, and citrasate dialysate. Signs of clotting and scoring systems are provided. Tips for priming, high blood flows, and alternatives to heparin locking are also outlined. The key recommendations are to prime properly, have no rushing, follow a written protocol, and focus on patient safety above all else.

1. Dialysis Without Anticoagulation
(Heparin Free Dialysis)
Mahmoud Eid
KUC, Alexandria Egypt

2. Indications For Dialysis without anticoagulation
• Pericarditis
• Recent surgery, with bleeding complications or risk, especially: Vascular and
cardiac surgery (AVF ???, Catheter Insertion)
• Eye surgery (retinal and cataract)
• Renal transplant (???)
• Brain surgery
• Coagulopathy
• Thrombocytopenia
• Intracerebral hemorrhage (Hgic stroke is the most common indication in USA)
• Ischemic stroke Active bleeding
• acutely ill patients
• Patient’s at increased risk of bleeding (oral anticoagulation; systemic
anticoagulation)

3. • Tips
• The clinician must identify the true indications of heparin free dialysis
as it’s use may be associated with some serious adverse effects
• Risk vs Benefit !!
• E.g. in patients with persistent HTN ??????
• If there is no clear indication please consider (restricted heparin
regimens, other anticoagulants)
• Patient Safety Comes first not money

4. Techniques
• Regional Citrate anticoagulation (Ca)
• Regional Heparin Anticoagulation (Protamine)
• Intermittent Saline Flush (ISF)
• Continuous Saline flush (CSF) ; predilution
• Heparin Coated/Grafted Dialyzer Membranes
• Citrasate; acid concentrate for bicarbonate-based dialysis that uses
citric acid

5. Technical or operator-induced factors (resulting in
clotting)
• Dialyzer Priming ; Retained air in dialyzer (due to inadequate priming or poor priming technique)
• Rapid blood pump speed while priming
• Not giving enough time (no rush)
• Empty priming bags
• Air in the infusion or heparin line
• Tip return the dialyzer to the upright position after the ECC is filled with the patient blood
• Proper wetting of the fibers
• Vascular Access Inadequate blood flow due to needle/catheter positioning or clotting.
• Excessive access recirculation due to needle/tourniquet position, reversal of catheter blood lines
• Frequent interruption of blood flow due to inadequate delivery or machine alarm situations
• High level of Blood in the venous air chamber (must leave 1/3 empty)
Tip (you must be able to see the stream of the blood in the chamber to avoid stasis)
• Excessive ultrafiltration (rate > net)

6. Signs of clotting in the extracorporeal circuit
• Extremely dark blood
• Shadows or black streaks in the dialyzer
• Foaming with subsequent clot formation in drip chambers and venous trap
• Rapid filling of transducer monitors with blood
• Teetering (suction) blood in the postdialyzer venous line segment that is
unable to continue into the venous chamber but falls back into the line
segment)
• Presence of clots at the arterial-side header of the dialyzer
• Rapid rise of TMP
• Unexplained increase in the venous pressure

7. Scoring The Circuit(sagedal;2013)
Venous Chamber
Normal 1
fibrinous 2
Clot formation 3
Clotted System 4
Dialyzer
Normal 1
few blood stripes (affecting less than 5% of the
2
surface fibres)
many blood stripes (more than 5% of the surface
fibres)
3
coagulated filter 4
Also in case of AVF
Hemostasis <10 minutes =1 10-30 minutes=2 > 30 minutes=3

8. Prescription General)
• Prime the circuit properly.
• Heparin rinse. (This step is optional. Avoid if heparin-associated
thrombocytopenia is present.) Rinse extracorporeal circuit with saline
containing 3,000 units of heparin/L,
• allow the heparin-containing priming fluid to drain by filling the
extracorporeal circuit with either the patient's blood or unheparinized
saline at the outset of dialysis.
• High blood flow rate. Set the blood flow rate to 350-400 mL per
minute if tolerated (FROM THE START). If a high blood flow rate is
contraindicated due to the risk of disequilibrium, consider using a
small-surface-area dialyzer and/or slowing the dialysate flow rate, or
shortening the treatment sessions.

9. ISF
• Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al ;1985
• The utility of this step is controversial; one recent study suggested that use of a
saline rinse may actually promote clotting (perhaps via introduction of
microbubbles into the circuit) (Sagedal et al., 2006).
• The purpose of the ISF is to
• allow inspection of a hollow-fiber dialyzer for evidence of clotting
• allow for timely discontinuation of treatment or changing of the dialyzer
• believed by some to reduce the propensity for dialyzer clotting or interfere with clot
formation.
• Procedure: Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the
blood inlet line every 15-60 minutes, until the dialyzer and the venous chamber
are clear.
• The extra volume should be calculated and added to the UF
• Online machines with programmed bolus (5008)
• SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION

10. Continuous Saline Infusion
• CSI can also be used as an alternative to coagulation during dialysis.
Utilizing this technique, saline is administered to the ECC continuously
throughout the dialysis session at a given rate, 200 mL/hour.
(Zimbudzi, 2013)

11. Heparin coated membranes
• Hemophan user will prime the dialyzer with 12-20,000 units of heparin
circulated for 30 minutes before dialysis coated with (Mujais et al 1996)
• AN69 ST dialyzers the user primes the dialyzer with 10,000 units heparin
/2L saline
• Should be avoided in HIT due to mild heparinemia (Guéry et al ; 2014)
• Plysulphone membrane; some authors noted that there was some heparin
adsorption (Kodras 2008,Sagedal 2011; no difference between
polysulphone and AN69 when both coated with heparin)
• Heparin grafted membrane Evodial (Gambro) better success in Heparin
Free Dialysis with (CSI & ISF) Lavill et al ;2014

12. • Different membrane materials and circuit design. There is no solid
evidence to suggest that any one type of membrane material is better
for heparin-free dialysis. Although heparin coatings and LMWH
coatings are being tried,

13. Bicarbonate dialysis solution with low-concentration
citrate (Citrasate)
• A small amount of citric acid is used instead of acetic acid as the
acidifying agent. citrate, by complexing with calcium, has been
suggested to inhibit blood coagulation and platelet activation locally
at the dialyzer membrane surface, resulting in improved dialyzer
clearance and increased dialyzer reusability (Ahmad et al., 2005).

14. Other technical points
• elimination of dead spaces in blood tubing and reducing the presence of
air/blood interfaces in dialysis lines may be the most promising approaches
to lower incidence of extracorporeal circuit clotting (Streamline tubing) .
• Blood product transfusion or lipid administration. Administration via the
inlet blood line has been reported to increase clotting risk during dialysis.
(can be administered after the dialyzer safely)
• Heparin free hemodialysis with prophylactic change of system is a safe and
practical method of treatment for patients at high bleeding risk, but it is
less effective, more expensive and the patient requires closer care
(Preuschof et al 1988 )
•

15. D5W vs Saline
• No data .. Most done with NS
a new clinical trial underway “Effect of Sodium Concentration of
Priming and Rinsing Fluids on Weight Gain”
http://clinicaltrials.gov/show/NCT01168947
• According to you experience
Stick to NS

16. Patient on Oral Anticoaguation
• First assess the need for oral anticoagulation
• Therapeutic vs Prophylactic
• INR regular follow up
• According to assessment of the circuit patient may need extra
anticoagulation using heparin or not
Read more
Krummel et al 2013, Ziai et al 2005

17. Aspirin ???
• Reduction of platelet/fibrin deposition in haemodialysers
by aspirin administration. Stewart et al 1975
• Effect of sulphinpyrazone and aspirin on platelet adhesion to activated
charcoal and dialysis membranes in vitro Winchester et al 1977
• small number + in vitro
• according to risk of bleeding/ gastric SE vs benefits

18. SLED
• SLED :
• Marshall et al 2001 & Berbec et al 2006 26% & 29% respectively;
clotting
• CRRT
• Nagarik ET AL 2010

19. Dialysis Dose Delivery ?
• Mcgill et all 2005 : no difference in the dialysis dose and increased
dialyzer treatment time is not necessary

20. Water for dialysis!!
• Some senior dialysis veterans(patients mostly) claim that excessive
ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al
1977

21. Catheter Locking
• McGill et al 2005 , Instillation of heparin solution in dialysis catheters
after HF-HD results in prolonged unintentional anticoagulation. The
duration and intensity of anticoagulation are sufficient to create
increased risk of hemorrhagic events. Heparin locking after HD should
be avoided in cases where adverse hemorrhagic events are likely.
• Avoid Heparin Locking in HIT
Heparin-induced thrombocytopenia due to heparin lock in a
hemodialysis patient: a case report. (Chan et al 2014)
*ACCP Guidelines (Suggest the use of regional citrate over the use of
heparin or LMWH in patients requiring catheter locking 2C)

22. Alternatives :
• Citrate (low and high concentration)
• Saline flushes and saline lock
• Beigi et al 2014; Flushing PermCath with normal saline 0.9% is as
effective as heparin in maintaining patency of the catheter, while it
may reduce the risks associated with heparin
• in the saline flush group, it was locked with saline solution 0.9%
• Hypertonic saline solution (10% saline catheters' retaining time and
average blood flow velocities remained the same Chen et al 2014)
• Low heparin concentration (100 u/ml-1000 u /ml)

23. Recommendations
• Good priming
• No Rushing
• Written protocol (indications, procedure)
• Think of the patient’s safety

24. THANK YOU