Hemodialysis: Chapter 7, Anticoagulation For Hemodialysis Procedure - Dr.Gawad

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1. Mohammed Abdel Gawad MD/PhD Neph, ESENeph
Nephrology Unit, School of Medicine, NewGiza University
Nephrology Consultant, Alexandria
Founder of NephroTube.com
Chair of AFRAN Web/Media Committee
ISN Education SoMe Team Member
Chapter 7
Anticoagulation For
Hemodialysis Procedure
You can get this book free from www.NephroTube.com

2. Watch the video recording of this lecture
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3. Visit
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to get more Nephrology lectures
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4. Pharmacology, 5
th
edition. Lippincott Williams & Wilkins. Chapter 20, IV. 2012
Image reference: Bombeli T, Spahn DR. Br J Anaesth. 2004 Aug;93(2):275-87

5. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

6. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

7. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

8. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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Unfractionated
heparin
Antithrombin
Factor Xa
Thrombin

9. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

10. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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•Administer the initial bolus heparin dose to the patient through the venous part
of the access.
•Flush the venous access with saline after heparin administration, then wait for 3-
5 minutes.
•It is not preferred to administer heparin through the arterial line.

11. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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•Administer the initial bolus heparin dose to the patient through the venous part
of the access.
•Flush the venous access with saline after heparin administration, then wait for 3-
5 minutes.
•It is not preferred to administer heparin through the arterial line.

12. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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13. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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•Administer the initial bolus heparin dose to the patient through the venous part
of the access.
•Flush the venous access with saline after heparin administration, then wait for 3-
5 minutes.
•It is not preferred to administer heparin through the arterial line.

14. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

15. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

16. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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In clinical practice, UFH is typically prescribed without monitoring coagulation
test, and the effectiveness of UFH anticoagulation is assessed by inspecting the
dialyzer and drip chambers for any signs of clotting

17. UFH antidote
•Reversal of the UFH effect can be done by using protamine sulfate.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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18. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

19. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

20. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Low molecular
weight heparin
Antithrombin
Factor Xa

21. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

22. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
LMWH has a longer half-life than UFH, which allows for anticoagulation with a
single bolus dose administered at the start of dialysis

23. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

24. Monitoring LMWH efficacy
•The effectiveness of LMWH is typically determined by measuring anti-
Xa activity, which is not commonly available .
•In practice, as in the case of UFH, the efficacy of LMWH anticoagulation
effect is assessed by inspecting the dialyzer and drip chambers for any
signs of clotting
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25. LMWH antidote
•No antidote is available for LMWH.
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26. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

27. UFH versus LMWH
•LMWH has a longer half-life, more rapid onset of action, higher
bioavailability, and more predictable effects than UFH.
•Some complications are less frequent with LMWH than with UFH.
•Regarding bleeding and extracorporeal clotting risks, available
evidence showed no significant differences between UFH and LMWH.
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As LMWH is very expensive and has generally not been
found to be superior to UFH, so UFH is widely used.

28. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

29. Heparin dose for hemodialysis anticoagulation in
patients on oral anticoagulants or antiplatelets
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Patients
taking
coumarin
INR of less than 2.5Need anticoagulation during dialysis
Metallic heart valves
with INR values
greater than 3.0
Do not require heparin
Aspirin and other antiplatelet
medications
•Need to receive standard heparin dosages.
•However, it is necessary to decrease or withhold
heparin doses in individuals with
thrombocytopenia (platelets < 50,000 × 106/L).
New oral anticoagulants •No precise data is available, and caution is
recommended while using them.

30. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

31. Complications of heparinization
•Bleeding
•Heparin-induced thrombocytopenia (HIT)
•Lipid disorders: Hypertriglyceridemia & Low HDL (less with LMWH use).
•Osteoporosis (less with LMWH use).
•Hyperkalemia: heparin-induced suppression of aldosterone synthesis (less
with LMWH use).
•Pruritus.
•Alopecia.
•Anaphylactoid reactions (First use syndrome).
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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32. Complications of heparinization
•Bleeding
•Heparin-induced thrombocytopenia (HIT)
•Lipid disorders: Hypertriglyceridemia & Low HDL (less with LMWH use).
•Osteoporosis (less with LMWH use).
•Hyperkalemia: heparin-induced suppression of aldosterone synthesis (less
with LMWH use).
•Pruritus.
•Alopecia.
•Anaphylactoid reactions (First use syndrome).
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If there is post-dialysis therapy needle puncture site prolonged
bleeding (>20 minutes), consider the following before deciding to
stop heparin use:
Re-evaluate the dose of heparin.
Evaluate vascular access for the possibility of outflow stenosis.
Evaluate the needle insertion technique.
Check if the patient is on oral anticoagulants.

33. Complications of heparinization
•Bleeding
•Heparin-induced thrombocytopenia (HIT)
•Lipid disorders: Hypertriglyceridemia & Low HDL (less with LMWH use).
•Osteoporosis (less with LMWH use).
•Hyperkalemia: heparin-induced suppression of aldosterone synthesis (less
with LMWH use).
•Pruritus.
•Alopecia.
•Anaphylactoid reactions (First use syndrome).
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HIT is less with LMWH. However, LMWH
must not be used in HIT as a substitution
for UFH because of cross-reactive
antibodies that will induce HIT.

34. Complications of heparinization
•Bleeding
•Heparin-induced thrombocytopenia (HIT)
•Lipid disorders: Hypertriglyceridemia & Low HDL (less with LMWH use).
•Osteoporosis (less with LMWH use).
•Hyperkalemia: heparin-induced suppression of aldosterone synthesis (less
with LMWH use).
•Pruritus.
•Alopecia.
•Anaphylactoid reactions (First use syndrome).
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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HIT type I HIT type II
Mild, transient, and self-limited,
occurs within the first two days of UFH exposure
Clinically significant condition
Nonimmune platelet aggregation Antibodies to platelet factor 4 (PF4) complexed to
UFH, referred to as "HIT antibodies" or
"PF4/heparin antibodies
No change in dialysis-related anticoagulationAnticoagulation using a non-heparin strategy and a
non-heparin catheter lock
HIT is less with LMWH. However, LMWH
must not be used in HIT as a substitution
for UFH because of cross-reactive
antibodies that will induce HIT.

35. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

36. Signs of clotting
•Very dark blood in the circuit.
•Visible clots in drip chambers and may be in venous line.
•Dialyzer clotting is associated with one or more of the following:
•Streaking in dialyzer.
•Visible clots in the arterial side header of the dialyzer.
•Increase arterial pressure and decrease venous pressure.
•Clotting distal to the venous chamber is associated with increased venous and
arterial pressure monitored by the machine.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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37. Signs of clotting
•Very dark blood in the circuit.
•Visible clots in drip chambers and may be in venous line.
•Dialyzer clotting is associated with one or more of the following:
•Streaking in dialyzer.
•Visible clots in the arterial side header of the dialyzer.
•Increase arterial pressure and decrease venous pressure.
•Clotting distal to the venous chamber is associated with increased venous and
arterial pressure monitored by the machine.
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Kidney Int Rep. 2020 Dec 31;6(2):351-356.

38. Signs of clotting
•Very dark blood in the circuit.
•Visible clots in drip chambers and may be in venous line.
•Dialyzer clotting is associated with one or more of the following:
•Streaking in dialyzer.
•Visible clots in the arterial side header of the dialyzer.
•Increase arterial pressure and decrease venous pressure.
•Clotting distal to the venous chamber is associated with increased venous and
arterial pressure monitored by the machine.
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Hemodial Int. 2020 Jan;24(1):61-70

39. Signs of clotting
•Very dark blood in the circuit.
•Visible clots in drip chambers and may be in venous line.
•Dialyzer clotting is associated with one or more of the following:
•Streaking in dialyzer.
•Visible clots in the arterial side header of the dialyzer.
•Increase arterial pressure and decrease venous pressure.
•Clotting distal to the venous chamber is associated with increased venous and
arterial pressure monitored by the machine.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

40. Signs of clotting
•Very dark blood in the circuit.
•Visible clots in drip chambers and may be in venous line.
•Dialyzer clotting is associated with one or more of the following:
•Streaking in dialyzer.
•Visible clots in the arterial side header of the dialyzer.
•Increase arterial pressure and decrease venous pressure.
•Clotting distal to the venous chamber is associated with increased venous and
arterial pressure monitored by the machine.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

41. Signs of clotting
•Very dark blood in the circuit.
•Visible clots in drip chambers and may be in venous line.
•Dialyzer clotting is associated with one or more of the following:
•Streaking in dialyzer.
•Visible clots in the arterial side header of the dialyzer.
•Increase arterial pressure and decrease venous pressure.
•Clotting distal to the venous chamber is associated with increased venous and arterial
pressure monitored by the machine.
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42. Suggested causes of clotting
•Incorrect heparin administration.
•Incorrect heparin dose.
•Slow blood flow.
•Excessive ultrafiltration.
•Vascular access problems.
•Kinking of blood lines.
•Air trapping inside the dialyzer.
•Multiple interruptions of dialysis sessions due to frequent alarms.
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43. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

44. Indications of heparin-free dialysis
•Bleeding disorder.
•Active bleeding.
•Intracerebral hemorrhage.
•Thrombocytopenia.
•Pericarditis.
•Recent surgery.
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45. Indications of heparin-free dialysis
•Bleeding disorder.
•Active bleeding.
•Intracerebral hemorrhage.
•Thrombocytopenia.
•Pericarditis.
•Recent surgery.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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46. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

47. I. Traditional method
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48. I. Traditional method
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II. Modified method
Citrate anticoagulation with
a calcium-containing
dialysate and without
calcium infusion has been
successfully employed.

49. Complications of RCA
•Calcium disorder
•Arrhythmia
•Hypernatremia
•Metabolic alkalosis
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50. RCA versus Heparin anticoagulation
•RCA is more expensive than heparin.
•RCA use is more complex than heparin use.
•RCA reduces bleeding risk as it anticoagulates only the extracorporeal
system.
•RCA has similar or better efficacy on circuit patency than heparin.
•RCA diminishes complement and neutrophil activation in the
extracorporeal circuit.
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51. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
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•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

52. Local citrate anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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The use of citrate as an acidifying agent in dialysate has the following advantages:
•Prevent dialyzer clotting.
•Increase in the dialysis delivered dose.
•Increase in solute transport.

53. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

54. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

55. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

56. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

57. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

58. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

59. Talk Outline: Chapter 7
Anticoagulation For Hemodialysis Procedure
•Heparin anticoagulation:
oUnfractionated heparin (UFH):
✓Mechanism of UFH anticoagulant action
✓Unfractionated heparin anticoagulation dosing protocols
✓Monitoring UFH efficacy & UFH antidote
oLow molecular weight heparin (LMWH):
✓Mechanism of action
✓Dose of LMWH for hemodialysis session anticoagulation
✓Monitoring LMWH efficacy & LMWH antidote
oUFH versus LMWH
oHeparin dose for hemodialysis anticoagulation in patients on oral
anticoagulants or antiplatelet agents
oComplications of heparinization
oClotting despite anticoagulation
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
•Heparin-free dialysis
•Regional citrate anticoagulation (RCA)
•Local citrate anticoagulation
•Heparinoids (Danaparoid and Fondaparinux)
•Direct thrombin inhibitors
•Other anticoagulants

60. Other anticoagulants
•Prostacyclin (PGI2) and its synthetic derivative Epoprostenol
•Nafamostat mesylate
•Heparin-coated dialyzers
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
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61. Thank You