From the Guidelines
Argatroban is the recommended anticoagulant for dialysis patients with heparin-induced thrombocytopenia, as it can be used for circuit anticoagulation and is administered as a bolus followed by a continuous infusion. When considering anticoagulation for dialysis patients, the decision should be based on the patient's potential risks and benefits from anticoagulation 1. For patients without an increased bleeding risk or impaired coagulation, unfractionated or low-molecular-weight heparin is recommended for intermittent renal replacement therapy (RRT), while regional citrate anticoagulation is suggested for continuous RRT (CRRT) 1. However, for patients with heparin-induced thrombocytopenia, alternative agents such as argatroban, bivalirudin, or citrate are necessary 1.
- Key considerations for anticoagulant choice in dialysis patients include:
- Bleeding risk
- Impaired coagulation
- Heparin-induced thrombocytopenia
- Type of RRT (intermittent or continuous)
- Argatroban can be administered as a bolus (100 mg/kg for continuous RRT or 250 mg/kg for intermittent haemodialysis) followed by a continuous infusion according to its conventional regimen 1.
- Danaparoid accumulates in renal failure and its use for continuous RRT is delicate, with very high doses proposed in this context of risk of bleeding 1.
- The choice of anticoagulant may be influenced by drug factors (availability and cost), patient factors (liver function), and experience of the clinician 1.
From the FDA Drug Label
2.9 Extracorporeal Dialysis The FDA drug label does not answer the question.
From the Research
Anticoagulants for Dialysis Patients
- The use of anticoagulants in dialysis patients is crucial to prevent thrombosis and ensure the effectiveness of dialysis treatment 2, 3, 4.
- Heparin is commonly used as an anticoagulant in dialysis patients, but it can cause heparin-induced thrombocytopenia (HIT), a potentially life-threatening condition 3, 4, 5.
- Alternative anticoagulants, such as argatroban, a direct thrombin inhibitor, have been shown to be effective in patients with HIT 2, 4.
- Argatroban has been found to provide effective anticoagulation in patients with HIT during renal replacement therapy, with minimal clearance by high-flux membranes during hemodialysis and continuous venovenous hemofiltration (CVVH) 2.
- Other alternative anticoagulants, such as danaparoid and lepirudin, have also been used in dialysis patients with HIT, but they have limitations, including prolonged half-lives in patients with renal failure and high cost 5.
- Unfractionated heparin (UFH) is still widely used as an anticoagulant in maintenance hemodialysis, despite its risks, including bleeding and HIT, due to its relatively low cost and availability 6.
Recommended Anticoagulant for Dialysis Patients
- Argatroban is recommended as an alternative anticoagulant for dialysis patients with HIT, due to its effectiveness and minimal clearance by dialysis membranes 2, 4.
- The choice of anticoagulant for dialysis patients should be individualized, taking into account the patient's risk of bleeding, thrombosis, and other factors, such as renal function and cost 3, 5, 6.