From the Guidelines
Anticoagulation for dialysis patients should prioritize regional citrate anticoagulation or unfractionated heparin as the standard approach, with careful consideration of the patient's bleeding risk, comorbidities, and dialysis modality. The choice of anticoagulant is crucial in preventing thrombosis of the dialysis circuit while minimizing the risk of bleeding complications. According to the most recent and highest quality study, regional citrate anticoagulation is recommended for patients at high bleeding risk, as it chelates calcium in the dialysis circuit while maintaining normal coagulation in the patient 1.
Anticoagulation Strategies
- Unfractionated heparin: initial bolus of 1,000-2,000 units followed by continuous infusion of 500-1,500 units per hour during hemodialysis sessions, with dose adjustment based on activated clotting time (ACT) measurements, targeting 150-220 seconds.
- Regional citrate anticoagulation: recommended for patients at high bleeding risk, with careful monitoring of calcium levels and adjustment of citrate dose as needed.
- Low molecular weight heparins: such as enoxaparin (0.5-1 mg/kg as a single pre-dialysis dose), offer predictable dosing and reduced monitoring requirements.
- Heparin-free dialysis: with regular saline flushes every 15-30 minutes, can be used for patients with active bleeding or very high bleeding risk, though this may reduce dialysis efficiency.
Long-term Anticoagulation
- Warfarin with INR monitoring (target 2-3) remains common for long-term anticoagulation in dialysis patients with conditions like atrial fibrillation.
- Direct oral anticoagulants are generally avoided due to limited data and concerns about accumulation, especially in patients with severe or end-stage chronic kidney disease 1.
Individualized Approach
Anticoagulation strategies must be individualized based on the patient's bleeding risk, comorbidities, and dialysis modality, with regular reassessment of the regimen's effectiveness and safety. The patient's renal function, particularly creatinine clearance, should be carefully monitored, as it affects the clearance of anticoagulants and the risk of bleeding complications 1.
From the FDA Drug Label
A dose of 25 to 30 units/kg followed by an infusion rate of 1,500 to 2,000 units/hour is suggested based on pharmacodynamic data if specific manufacturers' recommendations are not available. For patients undergoing extracorporeal dialysis, a recommended anticoagulation strategy is an initial dose of 25 to 30 units/kg of heparin, followed by an infusion rate of 1,500 to 2,000 units/hour 2.
- The dose may vary based on the equipment manufacturer's recommendations.
- It is essential to follow the manufacturer's operating directions carefully.
From the Research
Anticoagulation Strategies for Dialysis
Anticoagulation is crucial for patients undergoing dialysis to prevent clotting in the extracorporeal circuit. Several anticoagulation strategies are recommended, including:
- Unfractionated heparin (UFH) 3
- Low-molecular-weight heparins (LMWHs) 4, 5
- Direct thrombin inhibitors, such as argatroban 6, 7
- Heparinoids 4
- Regional anticoagulants, such as prostanoids and nafamostat mesilate 4
- Citrate infusions or citrate-based dialyzate 4, 3
Patient-Specific Considerations
The choice of anticoagulant depends on various patient-specific factors, including:
- Presence of heparin-induced thrombocytopenia (HIT) 6, 7
- Risk of bleeding 4, 5
- Renal replacement therapy modality (e.g., hemodialysis, continuous venovenous hemofiltration) 6, 7
- Use of oral anticoagulants, such as phenprocoumon 5
Alternative Anticoagulation Options
For patients with contraindications to UFH or LMWHs, alternative anticoagulation options are available, including: