From the FDA Drug Label
Use as an anticoagulant in blood transfusions, extracorporeal circulation, and dialysis procedures Prophylaxis and treatment of venous thrombosis and pulmonary embolism Prevention of postoperative deep venous thrombosis and pulmonary embolism in patients undergoing major abdominothoracic surgery or who, for other reasons, are at risk of developing thromboembolic disease
Heparin can be used in patients with Deep Vein Thrombosis (DVT) on dialysis.
- The dosage should be adjusted based on laboratory monitoring.
- It is essential to monitor for signs and symptoms of hemorrhage, thrombocytopenia, and heparin-induced thrombocytopenia and thrombosis (HITTS) 1.
From the Research
For patients with deep vein thrombosis (DVT) on dialysis, unfractionated heparin (UFH) is generally recommended as the first-line anticoagulant due to its non-renal clearance and ability to be monitored using activated partial thromboplastin time (aPTT). This recommendation is based on the most recent and highest quality evidence available, which prioritizes morbidity, mortality, and quality of life as the primary outcomes.
When using UFH, a typical regimen includes an initial bolus of 80 units/kg followed by continuous infusion at 18 units/kg/hour, adjusted to maintain aPTT at 1.5-2.5 times normal 2. Low molecular weight heparin (LMWH) with anti-Xa monitoring can also be considered, but dose reduction is required (typically 50% of normal dose) due to the risk of accumulation and bleeding complications in patients with severe renal impairment 3, 4. Warfarin can be used for long-term anticoagulation with a target INR of 2-3, initiated alongside parenteral anticoagulation and continued for at least 3 months.
Direct oral anticoagulants (DOACs) are generally avoided in dialysis patients due to their varying degrees of renal clearance and limited data in this population. The choice between agents should consider the patient's bleeding risk, dialysis schedule, and comorbidities. Regular monitoring of anticoagulation parameters and assessment for bleeding complications are essential in these high-risk patients. It is also important to note that LMWH may be associated with fewer episodes of bleeding and clotting compared to UFH, but the evidence is not strong enough to support its use as the first-line anticoagulant in patients with severe renal impairment 5, 6.
Key considerations in the management of DVT in dialysis patients include:
- Monitoring of anticoagulation parameters, such as aPTT and anti-Xa levels
- Assessment for bleeding complications, such as gastrointestinal bleeding and hemorrhagic stroke
- Adjustment of anticoagulant doses based on patient response and bleeding risk
- Consideration of patient comorbidities, such as hypertension and diabetes, which may affect anticoagulant choice and dosing.