Safadi Sami, Albright Robert C, Dillon John J, Williams Amy W, Alahdab Fares, Brown Julie K, Severson Amanda L, Kremers Walter K, Ryan Mary Ann, Hogan Marie C
Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Division of Preventive, Occupational, and Aerospace Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Kidney Int Rep. 2017 Mar 16;2(4):695-704. doi: 10.1016/j.ekir.2017.03.003. eCollection 2017 Jul.
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).
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.
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; < 0.01), transfusions (OR: 2.4; = 0.04), therapeutic systemic anticoagulation (OR: 0.2; < 0.01), and antiplatelets (OR: 0.4; < 0.01). CEC was associated with a lower delivered Kt/V (difference: 0.39; < 0.01). Most CEC events during transfusions (71%) occurred with administration of blood products through the HD circuit.
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.NCT02086682.
使用肝素进行体外循环（EC）抗凝是血液透析（HD）的一项关键进展，但对于有出血风险的住院患者而言，抗凝存在问题。我们前瞻性评估了一项避免使用肝素的HD方案、EC回路凝血（CEC）情况、对透析效率的影响以及在2014年1月17日至2015年5月31日期间需要HD的急性护理住院患者中的相关危险因素。
使用无空气透析管路进行不常规使用EC肝素的HD治疗。患者因非HD适应症接受全身抗凝治疗和/或抗血小板治疗。我们观察患者是否出现CEC迹象（HD治疗中断、回路堵塞或回血失败）。主要结局是CEC。采用广义估计方程的逻辑回归评估CEC与其他变量之间的关联。
338例患者共进行了1200次HD治疗（204例终末期肾病患者；134例急性肾损伤患者）；中位治疗时长为211分钟（四分位间距[IQR]：183 - 240分钟）；通过Kt/V测量的透析剂量为1.4（IQR：1.2 Kt/V至1.7）。仅4.5%的治疗中使用了EC肝素；EC凝血率为5.2%。CEC的决定因素包括临时导管（比值比[OR]：2.8；P < 0.01）、输血（OR：2.4；P = 0.04）、治疗性全身抗凝（OR：0.2；P < 0.01）和抗血小板治疗（OR：0.4；P < 0.01）。CEC与较低的透析剂量Kt/V相关（差异：0.39；P < 0.01）。输血期间的大多数CEC事件（71%）发生在通过HD回路输注血液制品时。
我们成功采用了以无空气HD管路避免使用肝素作为标准住院方案。该方案在急性护理住院患者HD中可行且安全。CEC发生率较低，且与临时HD导管和输血有关。抗血小板药物和全身抗凝具有保护作用。NCT02086682。
