Anticoagulation With Fondaparinux for Hemodiafiltration in Patients With Heparin‐Induced Thrombocytopenia: Dose‐Finding Study and Safety Evaluation

Mahieu, Elien; Claes, Kathleen; Jacquemin, Marc; Evenepoel, Pieter; Beek, Karel Op De; Bogaert, Anne-Marie; Kuypers, Dirk; Verhamme, Peter; Meijers, Björn

doi:10.1111/aor.12002

Cited by 22 publications

(15 citation statements)

References 17 publications

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“…The risk of heparin induced thrombocytopenia can be estimated using the 4T scoring system [171], and is usually confirmed by laboratory testing and detailed guidelines on diagnosis and treatment are published by the British Society of Haematology, but in suspected or confirmed cases, all heparins should be withdrawn [172]. The risk of thrombosis increases with the severity of thrombocytopaenia, and anticoagulation is usually started with either the direct thrombin inhibitor argatroban [173], or a natural (danaparoid) or synthetic (fondaparinux) heparinoid [174, 175]. Argatroban is reversible, given by continuous infusion, and requires careful laboratory monitoring with aPTTr.…”

Section: Rationale For Clinical Practice Guidelinesmentioning

confidence: 99%

Renal Association Clinical Practice Guideline on Haemodialysis

et al. 2019

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This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: “what does good quality haemodialysis look like?”The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to – most of this is freely available online, at least in summary form.A few notes on the individual sections: This section is about how much dialysis a patient should have. The effectiveness of dialysis varies between patients because of differences in body size and age etc., so different people need different amounts, and this section gives guidance on what defines “enough” dialysis and how to make sure each person is getting that. Quite a bit of this section is very technical, for example, the term “eKt/V” is often used: this is a calculation based on blood tests before and after dialysis, which measures the effectiveness of a single dialysis session in a particular patient.This section deals with “non-standard” dialysis, which basically means anything other than 3 times per week. For example, a few people need 4 or more sessions per week to keep healthy, and some people are fine with only 2 sessions per week – this is usually people who are older, or those who have only just started dialysis. Special considerations for children and pregnant patients are also covered here.This section deals with membranes (the type of “filter” used in the dialysis machine) and “HDF” (haemodiafiltration) which is a more complex kind of dialysis which some doctors think is better. Studies are still being done, but at the moment we think it’s as good as but not better than regular dialysis.This section deals with fluid removal during dialysis sessions: how to remove enough fluid without causing cramps and low blood pressure. Amongst other recommendations we advise close collaboration with patients over this.This section deals with dialysate, which is the fluid used to “pull” toxins out of the blood (it is sometimes called the “bath”). The level of things like potassium in the dialysate is important, otherwise too much or too little may be removed. There is a section on dialysate buffer (bicarbonate) and also a section on phosphate, which occasional...

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Section: Rationale For Clinical Practice Guidelinesmentioning

confidence: 99%

Renal Association Clinical Practice Guideline on Haemodialysis

et al. 2019

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“…Hemodialysis and other forms of renal replacement therapy have an important distinguishing feature from cardiac/ vascular surgery, namely that they are not a one-off exposure but rather a therapy that will require continuous or intermittent heparin exposure for a period of at least several days, if not weeks, months, or indefinitely. Thus, acute hemodialysis and other renal replacement therapy will generally require anticoagulation with a non-heparin anticoagulant (eg, argatroban, 51 danaparoid, 52 bivalirudin, 53 or fondaparinux [54][55][56] ), which at least in theory can be continued indefinitely. However, the expense and inconvenience of using an alternative non-heparin anticoagulant for intermittent hemodialysis 3 times per week on an indefinite basis has led some investigators [57][58][59] to resume UFH anticoagulation after HIT antibody seroreversion.…”

Section: Hemodialysismentioning

confidence: 99%

How I treat patients with a history of heparin-induced thrombocytopenia

Warkentin

Anderson

2016

Blood

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Heparin-induced thrombocytopenia (HIT) is a relatively common prothrombotic adverse drug reaction of unusual pathogenesis that features platelet-activating immunoglobulin G antibodies. The HIT immune response is remarkably transient, with heparin-dependent antibodies no longer detectable 40 to 100 days (median) after an episode of HIT, depending on the assay performed. Moreover, the minimum interval from an immunizing heparin exposure to the development of HIT is 5 days irrespective of the patient’s previous heparin exposure status or history of HIT. This means that short-term heparin reexposure can be safely performed if platelet-activating antibodies are no longer detectable at reexposure baseline and is recommended when heparin is the clear anticoagulant of choice, such as for cardiac or vascular surgery. The risk of recurrent HIT 1 to 2 weeks after heparin reexposure is ∼2% to 5% and is attributable to formation of delayed-onset (or autoimmune-like) HIT antibodies that activate platelets even in the absence of pharmacologic heparin. Some studies suggest that longer-term heparin reexposure (eg, for chronic hemodialysis) may also be reasonable. However, for other antithrombotic indications that involve patients with a history of HIT (eg, treatment of venous thromboembolism or acute coronary syndrome), preference should be given to non-heparin agents such as fondaparinux, danaparoid, argatroban, bivalirudin, or one of the new direct-acting oral anticoagulants as appropriate.

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“…5 Data in these patients and those with renal failure requiring renal replacement therapy (RRT) are limited to case reports and small case series. [7][8][9][10][11] Dosing recommendations, therefore, are largely based on expert opinion, and clinical practice is variable. 5,11 We report the use of fondaparinux for the prevention of VTE at our institution, a 939-bed academic medical center with approximately 140 intensive care unit (ICU) beds, in critically ill patients with moderate to severe renal impairment, including those receiving RRT.…”

Section: Introductionmentioning

confidence: 99%