anticoagulant

2. Type of anticoagulation
• The most commonly used anticoagulant in haemodialysis is
unfractionated heparin.
• LMWH (low molecular weight heparin) is also used in Western
Europe.
• There is other option of anticoagulation for haemodialysis as table
below:

3. Anticoagulation option for HD
Heparin (UFH)
Advantage
Safety, rapid dissipation of
anticoagulation effect, low cost
Disadvantage
Short half-life requiring continuous
infusion and/or repeated boluses, HIT
Low Molecular
Weight Heparin
(LMWH)
Single injection, monitoring not
required
Long half-life, risk of bleeding 10–15
hours after procedure, no reversal
antidote, HIT, cost, not approved for
this use in United States
Heparin-coated
dialyzer
No or reduced systemic
heparinization (UFH or LMWH)
Increased setup time, increased
dialyzer clotting, HIT, cost
Direct thrombin
inhibitors argatroban
Rapid acting, hepatic
metabolism, short elimination
half-life, alternative to heparin in
patient with HIT
Activated clotting time (ACT)
monitoring required, cost

4. Regional citrate
Advantage
Reduced risk of bleeding,
alternative to heparin in
patient with HIT
Disadvantage
Procedural complexity,
increased laboratory
monitoring, primarily an
inpatient procedure, cost
Citrate dialysate
alone, or with low-
dose heparin
Minimal systemic
anticoagulation, reduced risk of
bleeding, increased Kt/V,
alternative to heparin in
patient with HIT
Dialyzer clotting without
small dose of systemic
heparin, cost
Heparin free ± saline
boluses
Reduced risk of bleeding Dialyzer clotting with
increased materials cost

5. • Low molecular weight heparin (LMWH)
-is derived from Unfractionated Heparin (UFH) by digestion
or depolymerization of longer chains of heparin into shorter
chains by chemical or enzymatic means.
-LMWH is made from standard heparin but is associated
with a lower rate of HIT than standard heparin.
• -Example: Dalteparin ,Danaparoid, Enoxaparin, Tinzaparin,
Apixaban, Edoxaban, Fondaparinux, Rivaroxaban (xarelto)

6. • Regional citrate anticoagulation
-Citrate has been recommended as the first-line anticoagulant
for continuous renal replacement therapy (CRRT) in critically ill
patients.
-Compared with heparin, citrate anticoagulation is safer and
more efficacious. Citrate inhibits the coagulation cascade by
lowering the ionized calcium (iCa) concentration in the filter.

7. • Thrombin inhibitors
-Thrombin inhibitor are a class of medication that act
as anticoagulants (delaying blood clotting ) by directly
inhibiting the enzyme thrombin (factor IIa).
-Argatroban and hirudin are direct thrombin inhibitors that
have been used successfully to anticoagulate the dialysis
circuit

8. Preparation of anticoagulation therapy
• Dialysis use a variety of protocols for dosing of anticoagulation.
• In general, patients receive a bolus of 2,000-4,000 IU at the start of the
dialysis treatment.
• A continuous or hourly intermittent infusion often follows, which
provides more consistent levels of anticoagulation (and presumably
less risk of bleeding) than a single second bolus.
• The hourly rate can range from 500-2,000 IU/h or more, depending on
the dose of the initial bolus, and some centers avoid all heparin in the
final hour of dialysis to decrease the likelihood of bleeding at the needle
sites.
• Many dialysis units use weight-based dosing protocols, but interpatient
variability in heparin elimination makes these protocols only
marginally better at achieving consistent levels of anticoagulation than
fixed doses, except at the extremes of weight.

9. Loading Dose
25 IU/kg
Maintanence
•1,000 IU/h
•Stop 30-60 min before end of
treatment
Parameters for adjustment
Standard Protocols
•If excessive bleeding or clotting
occurs, adjust maintenance
infusion by 500 IU/h
2,000 IU
•None
-If excessive bleeding or clotting
occurs, adjust loading dose by
500 IU
-If clotting persists with loading
dose ≥4,500 IU, add second bolus
dose or start maintenance
infusion

10. 10 IU/kg •10 IU/kg/h
•Stop 30-60 min before end of
treatment
Low Dose Protocol
•If excessive bleeding occurs,
eliminate loading dose
•If bleeding persists or clotting
occurs, adjust maintenance
infusion by 500 IU/h
25 IU/kg •None •If excessive bleeding occurs,
decrease loading dose by 5 IU/kg
•If clotting occurs, add second
bolus dose (50% of first bolus) or
start maintenance infusion