From the Guidelines
Heparin anticoagulation should be resumed immediately after hemodialysis if the patient requires ongoing anticoagulation therapy, with the exact timing individualized based on the patient's bleeding risk and the type of dialysis access. When considering the resumption of heparin after hemodialysis, it's crucial to weigh the risks of thrombosis against the risks of bleeding, particularly at the dialysis access site [ 1 ]. For patients on chronic hemodialysis who receive heparin during their sessions, no additional heparin is typically needed after dialysis as the anticoagulant effect naturally diminishes. However, for patients who require therapeutic anticoagulation for conditions like atrial fibrillation, deep vein thrombosis, or pulmonary embolism, intravenous unfractionated heparin can be restarted without a bolus dose once hemostasis at the dialysis access site is achieved, usually within 1-4 hours after catheter removal. Some key considerations include:
- The patient's individual bleeding risk, which may necessitate longer delays in resuming anticoagulation
- The type of dialysis access, as patients with temporary dialysis catheters may require different protocols than those with arteriovenous fistulas or grafts
- The use of low molecular weight heparin (such as enoxaparin), which can typically be administered 4-6 hours after dialysis completion [ 1 ]. Given the most recent guidelines on perioperative management of antithrombotic therapy [ 1 ], the approach to resuming heparin after hemodialysis should prioritize minimizing bleeding risks while preventing thrombotic complications, with a focus on individualizing care based on patient-specific factors.
From the Research
Resuming Heparin Anticoagulation after Hemodialysis
- The provided studies do not directly address when to resume heparin (unfractionated heparin) anticoagulation after hemodialysis (HD) 2, 3, 4, 5, 6.
- However, it can be inferred that the decision to resume heparin anticoagulation should be based on individual patient factors, such as bleeding risk and history of heparin-induced thrombocytopenia 4, 5.
- Laboratory monitoring of heparin anticoagulation in hemodialysis may be considered in select patients, such as those with extremes of body weight or history of repeated clotting or bleeding 6.
- The use of alternate anticoagulant agents, including direct thrombin inhibitors and anti-Xa agents, may be preferable in patients with a history of heparin-induced thrombocytopenia or other contraindications to heparin use 5.
Considerations for Heparin Anticoagulation in Hemodialysis
- The optimal dosing for unfractionated heparin (UFH) and low-molecular-weight heparins (LMWHs) during hemodialysis is not well established 6.
- Semiquantitative clotting scoring of the dialyzer and venous chamber may help guide UFH and LMWH dose adjustment 6.
- Methods for laboratory monitoring of anticoagulation in hemodialysis include the activated partial thromboplastin time, activated clotting time, and antifactor Xa assays for UFH and antifactor Xa assay for LMWHs 6.