Monitoring of Enoxaparin during Hemodialysis Covered by Regional Citrate Anticoagulation in Acute Kidney Injury: A Prospective Cohort Study

Abstract

Background: Current guidelines recommend the monitoring of anti-factor Xa (anti-Xa) levels to avoid an accumulation of low-molecular-weight heparins in patients with acute kidney injury, but there is no evidence on how to proceed with such monitoring during continuous renal replacement therapy. Against this background, we investigated the potential accumulation of enoxaparin administered subcutaneously for venous thromboembolism prophylaxis in critically ill patients during continuous renal replacement therapy covered by regional citrate anticoagulation. Methods: Anti-Xa levels were measured at baseline (≤12 h before renal replacement therapy) and on three consecutive days (A to C) when enoxaparin had reached trough levels. Supplementary testing included modified assays of rotational thromboelastometry known to be highly sensitive for low-molecular-weight heparins. Results: The 16 men and 13 women included were adults comparable in age, body mass index, thromboembolism risk assessment, and clinical severity of the disease. Throughout the four examinations, the median trough levels of anti-Xa remained below the detection limit of the test (<0.1 IU mL−1), with interquartile ranges of <0.1 to 0.14 IU mL−1 at baseline and <0.1 to 0.16 IU mL−1 on days A/B/C. All rotational thromboelastometry parameters of clot initiation and clot formation dynamics did not significantly change from baseline to day C. Conclusions: Neither anti-Xa levels nor modified assays of rotational thromboelastometry revealed any accumulation of enoxaparin administered for thromboprophylaxis during continuous renal replacement therapy covered by regional citrate anticoagulation. Although generally recommended in patients with acute kidney injury, monitoring of anti-Xa levels should be questioned in this defined setting.

Association between longer duration of citrate accumulation and 90-day mortality of acute-on-chronic liver failure

“…However, no significant differences in 90-day mortality risk were found in ACLF patients with or without LDCA. As RCA brings no alteration of pro- and anti-coagulation function and ACLF patients have re-balanced but fragile coagulation function [ 1 , 5 ], our new results would support the use of RCA with caution in ACLF patients. Adequate training, experienced operation, and well-developed safety protocols would further expand indications of RCA [ 6 ].…”

Update on the Pharmacological Actions of Enoxaparin in Nonsurgical Patients

“…Enoxaparin has many fields of application, in particular for the prevention of venous thromboembolism (VTE) in surgical or in medical patients and for the treatment of VTE (i.e., deep-vein thrombosis and/or pulmonary embolism) [ 5 , 6 , 7 ]. Yet, it has also been used in the antithrombotic treatment of acute coronary syndrome (administered with antiplatelet drugs), including in patients managed medically or with subsequent percutaneous coronary intervention (PCI) or for prevention of thrombosis during hemodialysis [ 8 , 9 , 10 , 11 ].…”