Prospective Study of Routine Heparin Avoidance Hemodialysis in a Tertiary Acute Care Inpatient Practice

Sami Safadi, Robert C Albright Jr, John J Dillon, Amy W Williams, Fares Alahdab, Julie K Brown, Amanda L Severson, Walter K Kremers, Mary Ann Ryan, Marie C Hogan, Sami Safadi, Robert C Albright Jr, John J Dillon, Amy W Williams, Fares Alahdab, Julie K Brown, Amanda L Severson, Walter K Kremers, Mary Ann Ryan, Marie C Hogan

Abstract

Introduction: Extracorporeal circuit (EC) anticoagulation with heparin is a key advance in hemodialysis (HD), but anticoagulation is problematic in inpatients at risk of bleeding. We prospectively evaluated a heparin-avoidance HD protocol, clotting of the EC circuit (CEC), impact on dialysis efficiency, and associated risk factors in our acute care inpatients who required HD (January 17, 2014 to May 31, 2015).

Methods: HD sessions without routine EC heparin were performed using airless dialysis tubing. Patients received systemic anticoagulation therapy and/or antiplatelets for non-HD indications. We observed patients for indications of CEC (interrupted HD session, circuit loss, or inability to return blood). The primary outcome was CEC. Logistic regression with generalized estimating equations assessed associations between CEC and other variables.

Results: HD sessions (n = 1200) were performed in 338 patients (204 with end-stage renal disease; 134 with acute kidney injury); a median session was 211 minutes (interquartile range [IQR]: 183-240 minutes); delivered dialysis dose measured by Kt/V was 1.4 (IQR: 1.2 Kt/V 1.7). Heparin in the EC was prescribed in only 4.5% of sessions; EC clotting rate was 5.2%. Determinants for CEC were temporary catheters (odds ratio [OR]: 2.8; P < 0.01), transfusions (OR: 2.4; P = 0.04), therapeutic systemic anticoagulation (OR: 0.2; P < 0.01), and antiplatelets (OR: 0.4; P < 0.01). CEC was associated with a lower delivered Kt/V (difference: 0.39; P < 0.01). Most CEC events during transfusions (71%) occurred with administration of blood products through the HD circuit.

Discussion: We successfully adopted heparin avoidance using airless HD tubing as our standard inpatient protocol. This protocol is feasible and safe in acute care inpatient HD. CEC rates were low and were associated with temporary HD catheters and transfusions. Antiplatelet agents and systemic anticoagulation were protective.ClinicalTrials.gov Identifier:NCT02086682.

Keywords: acute kidney injury; anticoagulation; extracorporeal circulation; hemodialysis; no heparin.

Figures

Figure 1
Figure 1
Study design and enrollment of subjects. No patients were lost to follow-up. HD, hemodialysis.
Figure 2
Figure 2
Comparison of (a) conventional hemodialysis (Readyset) bloodlines and (b) airless (Streamline) bloodlines. (c) Arterial side of the Streamline blood lines and (d) the venous side of the Streamline bloodlines.
Figure 3
Figure 3
Clotting of the extracorporeal circuit (EC) is associated with a higher total score on the visual scale. The black bar is the median; the box width is the interquartile range.
Figure 4
Figure 4
Kaplan-Meier survival analysis showing high short-term mortality in the cohort.
Table S1
Table S1
Visual assessment grading of extracorporeal circuit clotting.

References

    1. Davenport A. What are the anticoagulation options for intermittent hemodialysis? Nat Rev Nephrol. 2011;7:499–508.
    1. Ludlow M.K. Heparin-free dialysis. ANNA J. 1989;16:295–298.
    1. Shen J.I., Winkelmayer W.C. Use and safety of unfractionated heparin for anticoagulation during maintenance hemodialysis. Am J Kidney Dis. 2012;60:473–486.
    1. Rottembourg J., Bouayed F., Durande J., El Shahat Y., Guimont M.C. No heparin for routine hemodialysis sessions in patients with high bleeding risk. Artif Organs. 1979;3 311–311.
    1. Schwab S.J., Onorato J.J., Sharar L.R. Hemodialysis without anticoagulation: one-year prospective trial in hospitalized patients at risk for bleeding. Am J Med. 1987;83:405–410.
    1. Sanders P.W., Taylor H., Curtis J.J. Hemodialysis without anticoagulation. Am J Kidney Dis. 1985;5:32–35.
    1. Casati S., Moia M., Graziani G. Hemodialysis without anticoagulants: efficiency and hemostatic aspects. Clin Nephrol. 1984;21:102–105.
    1. Caruana R.J., Raja R.M., Bush J.V. Heparin free dialysis: comparative data and results in high risk patients. Kidney Int. 1987;31:1351–1355.
    1. Keller F., Seemann J., Preuschof L. Risk factors of system clotting in heparin-free haemodialysis. Nephrol Dial Transplant. 1990;5:802–807.
    1. Cronin R.E., Reilly R.F. Unfractionated heparin for hemodialysis: still the best option. Semin Dial. 2010;23:510–515.
    1. Laville M., Dorval M., Fort Ros J. Results of the HepZero study comparing heparin-grafted membrane and standard care show that heparin-grafted dialyzer is safe and easy to use for heparin-free dialysis. Kidney Int. 2014;86:1260–1267.
    1. NxStage Medical: Streamline website. Available at: . Accessed April 5, 2017.
    1. Cooke JD, Moran J. Streamline airless system optimizes dialysis adequacy with reduced costs. Available at: . Accessed April 5, 2017.
    1. Hass S, Ahuja M. Improving adequacy, heparin anticoagulation and dialyzer efficiency with new bloodline technology. Available at: . Accessed April 5, 2017.
    1. Smith P. Streamline bloodlines improve Kt/V while lowering dialysate usage. Adv Chronic Kidney Dis. 2010;17:209.
    1. Holden R.M., Harman G.J., Wang M. Major bleeding in hemodialysis patients. Clin J Am Soc Nephrol. 2008;3:105–110.
    1. Quan H., Sundararajan V., Halfon P. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43:1130–1139.
    1. Fresenius Medical Care . Fresenius USA, Inc.; Concord, CA: 2015. 2008K Hemodialysis Machine Operator's Manual; pp. 104–111.
    1. Kuhlmann U., Goldau R., Samadi N. Accuracy and safety of online clearance monitoring based on conductivity variation. Nephrol Dial Transplant. 2001;16:1053–1058.
    1. McIntyre C.W., Lambie S.H., Taal M.W. Assessment of haemodialysis adequacy by ionic dialysance: intra-patient variability of delivered treatment. Nephrol Dial Transplant. 2003;18:559–562.
    1. Pinson C.W., Schuman E.S., Gross G.F. Surgery in long-term dialysis patients: experience with more than 300 cases. Am J Surg. 1986;151:567–571.
    1. US Renal Data System . National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; Bethesda, MD: 2014. 2014 Annual Data Report: Epidemiology of Kidney Disease in the United States. ESRD in the United States: An Overview of USRDS Annual Data Report Volume 2; pp. S79–S92.
    1. Shen J.I., Mitani A.A., Chang T.I. Use and safety of heparin-free maintenance hemodialysis in the USA. Nephrol Dial Transplant. 2013;28:1589–1602.
    1. McGill R.L., Blas A., Bialkin S. Clinical consequences of heparin-free hemodialysis. Hemodial Int. 2005;9:393–398.
    1. Sahota S., Rodby R. Inpatient hemodialysis without anticoagulation in adults. Clin Kidney J. 2014;7:552–556.
    1. Stamatiadis D., Helioti H., Mansour M. Hemodialysis for patients bleeding or at risk for bleeding, can be simple, safe and efficient. Clin Nephrol. 2004;62:29–34.
    1. Semret M, Ryan M, Albright R, et al. A quality audit analysis of hemodialysis circuit clotting in an inpatient dialysis unit. Available at: . Accessed January 24, 2017.

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