Unfractionated Heparin Drip in ESRD Patients Pending Surgery
Yes, unfractionated heparin (UFH) drip is the preferred anticoagulation option for patients with End-Stage Renal Disease (ESRD) pending surgery due to its renal-independent clearance and reversibility. 1
Rationale for UFH in ESRD Patients
- UFH is eliminated through both renal and hepatic pathways, making it safer than low molecular weight heparins (LMWH) in ESRD patients 2
- LMWH has significant accumulation in patients with impaired renal function (CrCl <30 mL/min), increasing bleeding risk 2
- For patients requiring anticoagulation during renal replacement therapy, UFH is specifically recommended by KDOQI guidelines 1
Perioperative Anticoagulation Management
Pre-operative Considerations
- UFH's short half-life (60-90 minutes) allows for better control of anticoagulation status during the perioperative period
- UFH can be discontinued 4-6 hours before surgery with minimal residual anticoagulant effect
- Monitor aPTT to ensure adequate anticoagulation while minimizing bleeding risk
- Target aPTT: 35-45 seconds (1.5-2.0 times control) 3
- This range optimizes the balance between filter coagulation and patient hemorrhage
Dosing Considerations
- Initial bolus: 60-80 units/kg IV
- Maintenance: 12-15 units/kg/hour continuous infusion
- Adjust based on aPTT measured 6 hours after initiation and then daily
- For ESRD patients, consider starting at lower doses (10-12 units/kg/hour) due to potential accumulation 4
Monitoring Parameters
- Check aPTT every 6 hours until stable, then daily
- Monitor for signs of bleeding (petechiae, hematuria, gastrointestinal bleeding)
- Check platelet count daily to monitor for heparin-induced thrombocytopenia (HIT)
Special Considerations for ESRD Patients
- ESRD patients have both increased thrombotic and bleeding risks
- UFH is preferred over LMWH in severe renal failure per the American College of Chest Physicians guidelines 1, 4
- Fixed-dose subcutaneous UFH (approximately 220-245 units/kg every 12 hours) can be an alternative if IV access is limited 4
Potential Complications and Management
Bleeding Risk
- Major bleeding risk increases significantly when aPTT exceeds 45-55 seconds 3
- If bleeding occurs, discontinue heparin immediately
- Protamine sulfate (1 mg per 100 units of heparin given in the previous 2-3 hours) can reverse anticoagulation
Heparin-Induced Thrombocytopenia (HIT)
- If HIT develops, all heparin must be stopped
- Switch to direct thrombin inhibitors (argatroban) or Factor Xa inhibitors (fondaparinux) 1
- For patients with HIT without severe liver failure, argatroban is preferred 1
Post-Surgical Considerations
- Resume UFH 12-24 hours after surgery if hemostasis is adequate
- Consider prophylactic dosing initially (5,000 units subcutaneously every 8-12 hours) before resuming therapeutic dosing
- For high bleeding risk procedures, delay resumption of therapeutic anticoagulation for 48-72 hours 1
UFH provides the safest anticoagulation option for ESRD patients pending surgery due to its predictable pharmacokinetics, non-renal clearance, and reversibility with protamine sulfate if urgent surgery becomes necessary.