Can patients with End-Stage Renal Disease (ESRD) on Hemodialysis (HD) be treated with a heparin drip?

From the Guidelines

Yes, patients with End-Stage Renal Disease (ESRD) on Hemodialysis (HD) can be treated with a heparin drip when clinically indicated. Heparin is commonly used during hemodialysis sessions to prevent clotting in the extracorporeal circuit, typically administered as a bolus of 1,000-5,000 units followed by a continuous infusion of 500-1,500 units per hour during the dialysis session 1. For systemic anticoagulation outside of dialysis, ESRD patients may receive continuous heparin infusions with standard dosing protocols, typically starting with a bolus of 80 units/kg followed by 18 units/kg/hour, with dose adjustments based on activated partial thromboplastin time (aPTT) monitoring.

Key Considerations

• ESRD patients may have altered pharmacokinetics of heparin due to uremia-associated platelet dysfunction and may require careful monitoring for bleeding complications 1.
• These patients often have multiple comorbidities and take medications that may increase bleeding risk.
• Regular monitoring of aPTT (target range typically 1.5-2.5 times control), platelet count, and clinical assessment for bleeding is essential during heparin therapy in this population.
• The use of heparin in ESRD patients on HD is supported by guidelines, including the KDIGO Clinical Practice Guideline for Acute Kidney Injury, which recommends using anticoagulation during RRT in AKI if a patient does not have an increased bleeding risk or impaired coagulation and is not already receiving systemic anticoagulation 1.

Recent Guidelines

• The American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia, provide guidance on the use of non-heparin anticoagulants in patients with HIT who require renal replacement therapy 1.
• However, the most recent and highest quality study on this topic is from 2018, which provides evidence on the use of argatroban, danaparoid, fondaparinux, bivalirudin, and rivaroxaban in patients with subacute HIT A, subacute HIT B, or remote HIT who require renal replacement therapy 1.

Clinical Implications

• The decision to use heparin in ESRD patients on HD should be individualized and based on a careful assessment of the patient's risk of bleeding and thrombosis.
• Close monitoring of aPTT, platelet count, and clinical assessment for bleeding is essential to minimize the risk of complications.
• The use of heparin in ESRD patients on HD can be effective in preventing clotting in the extracorporeal circuit and reducing the risk of thromboembolic events, but requires careful management to minimize the risk of bleeding complications.

From the Research

Anticoagulation Therapy for ESRD Patients on Hemodialysis

• Patients with End-Stage Renal Disease (ESRD) on Hemodialysis (HD) can be treated with a heparin drip, as heparin is a commonly used anticoagulant in HD to prevent clot formation within the extracorporeal circuit 2, 3, 4, 5, 6.
• The use of low-dose low molecular weight heparin in hemodialysis has been investigated, and it was found to be safe and effective as compared with unfractionated heparin 5.
• The optimal dosage of heparin in hemodialysis patients can be evaluated using thromboelastograph, and low-dose heparin is effective and safe as an anticoagulant in hemodialysis 6.
• Regional citrate anticoagulation may be an alternative approach for patients at high risk of bleeding who require hemodialysis, and it may lower the risk of minor bleeding compared to unfractionated heparin 2, 4.
• The effects of different anticoagulant strategies, including heparin and non-heparin drugs, on extracorporeal circuit thrombosis and bleeding risks are uncertain due to limited data and low certainty evidence 4.

Heparin Dosing and Monitoring

• The circulating heparin levels in patients with ESRD undergoing maintenance hemodialysis can vary widely, and the presence of detectable levels of heparin in predialysis plasma samples suggests that residual heparin may circulate in these patients for a longer period of time 3.
• The initial bolus dose and repeated maintenance dose of unfractionated heparin can be adjusted based on the patient's response to anticoagulation therapy, and thromboelastograph can be used to monitor the blood coagulation function and adjust the heparin dose accordingly 6.
• The activated partial thromboplastin time (APTT) and anti-Xa levels can be monitored to assess the anticoagulant effect of heparin, and the dose can be adjusted to achieve the desired level of anticoagulation 2, 5, 6.