The heparins: all a nephrologist should know

Hetzel, Gerd R.; Sucker, Christoph

doi:10.1093/ndt/gfi004

Cited by 41 publications

(41 citation statements)

References 60 publications

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“…It is probable that thrombocytopenia in this context was associated more with severity of disease (sepsis and multiple organ dysfunction syndrome) than to an autoimmune effect induced by enoxaparin (heparin-induced thrombocytopenia), because it occurred earlier than 4 days and was not accompanied by thromboembolic events. 6,41 Filter survival did not differ between the two methods. Reeves et al 30 compared dalteparin with UFH in patients submitted to continuous venovenous hemodiafiltration, reporting a filter life span of 46.8 versus 51.7 hours for dalteparin and UFH, respectively, which is very similar to what was found in this study.…”

Section: Enoxaparin Vs Unfractioned Heparin In Cvvhd 325mentioning

confidence: 76%

“…24 Reported advantages of LMWH over other anticoagulants are easier administration (intermittent doses) due to their low affinity to plasma proteins, endothelial cells, and macrophages, larger bioavailability and a more predictable therapeutic effect not requiring laboratory monitoring of their antithrombotic activity. 6,11,15 Moreover, in the critically ill patient who often presents thrombocytopenia, 20 LMWH interfere less on platelet factor-4 (PF-4) that induces heparinassociated thrombocytopenia, thus reducing the incidence of this complication, a frequent finding with UFH. [25][26][27] However, available evidence supports the potential for enoxaparin accumulation and increased risk of bleeding in severe renal insufficiency (creatinine clearance of 30 mL/min or less), in the obese and in elderly patients, and careful monitoring is now recommended for LMWH anticoagulation through target levels of anti-factor Xa activity.…”

Section: Discussionmentioning

confidence: 99%

“…The UFH group worked as a control group as UFH also interferes on factor Xa in the coagulation cascade, although to a lesser extent. 6,15 The urea equilibration coefficient (UEC): [(ultrafiltrate urea/arterial urea) × 100] was measured every 24 hours; when this index is lower than 0.6 indicating a severe reduction in the depuration of small molecules, it is a good predictor of filter clotting.…”

Section: Laboratory Testsmentioning

confidence: 99%

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Enoxaparin versus unfractioned heparin as anticoagulant for continuous venovenous hemodialysis: a randomized open-label trial

et al. 2010

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Aim: In this study we aimed to compare the efficacy and safety of enoxaparin with unfractioned heparin (UFH) as anticoagulant for continuous venovenous hemodialysis (CVVHD). Methods: An open-label randomized controlled trial was carried out in an intensive care unit (ICU) where 40 patients with acute renal failure (ARF) who needed continuous renal replacement therapy were randomized to receive UFH (n = 21) or enoxaparin (n = 19). Coagulation parameters were evaluated, and antithrombotic activity of UFH was measured by activated partial thromboplastin time (aPTT) and for enoxaparin by anti-factor Xa activity. Primary outcomes were thrombosis of the extracorporeal circuit and bleeding, classified as major or minor. Results: Minor bleeding episodes were observed only in patients anticoagulated with enoxaparin (26 vs. 0%, p = 0.018). Comparing patients with or without bleeding after 24 hours of therapy, the level of anticoagulation tended to be higher (anti-factor Xa: 1.62 vs. 1.13 IU/mL, p = 0.09) and the platelet count to be lower [107 ± 53 vs. 229 ± 84 (×10 3 /μL), p = 0.09] in patients who bled, but without statistical difference. Filter life span of enoxaparin and UFH groups was similar (43 ± 15 vs. 52 ± 18 hr, p = 0.10), as well as the proportion of circuit clotting. Conclusion: Weightunadjusted enoxaparin in patients with ARF in CVVHD was associated with an increased rate of bleeding, a finding that addresses the need to adjust drug dose and to monitor anti-factor Xa activity during dialysis. No benefit to prolong dialysis circuit survival was found with enoxaparin. In patients who do not present contraindication for systemic anticoagulation, UFH remains an effective and low-cost option.

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Section: Enoxaparin Vs Unfractioned Heparin In Cvvhd 325mentioning

confidence: 76%

Section: Discussionmentioning

confidence: 99%

Section: Laboratory Testsmentioning

confidence: 99%

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Enoxaparin versus unfractioned heparin as anticoagulant for continuous venovenous hemodialysis: a randomized open-label trial

et al. 2010

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“…On the other hand, excessive anticoagulation carries the risk of haemorrhagic events, which portend an associated mortality and morbidity. Unfractionated heparin (UFH) has been the traditional drug of choice for anticoagulation in patients on HD (for dialysis- and non-dialysis-related indications, including treatment of thrombo-embolic disease and acute coronary artery syndromes) due to concerns regarding the safety of low-molecular-weight heparins (LMWH), which are not adequately dialysed out during short dialysis sessions [1] and carry the danger of accumulation [2,3,4] and a risk of anaphylaxis [5, 6]. Whether or not LMWH are as safe as UFH in subjects with stage 4–5 chronic kidney disease (CKD) has been the subject of much debate with two recent meta-analyses (from the same authors) highlighting the uncertainty [7, 8].…”

Section: Introductionmentioning

confidence: 99%

Comparison of Tinzaparin™ and Unfractionated Heparin as Anticoagulation on Haemodialysis: Equal Safety, Efficacy and Economical Parity

et al. 2008

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Background: The European Best Practice Guidelines on anticoagulation in chronic haemodialysis recommend the use of low-molecular-weight heparins (LMWH) over unfractionated heparin (UFH), based on previous small-scale studies and a meta-analysis which demonstrated equal efficacy of anticoagulation without an increase in hemorrhagic events. Method: We performed a prospective single-centre study where all stable patients on chronic in-hospital haemodialysis were converted from UFH to Tinzaparin™. Patients were monitored for 2 months before and 2 months after the switch. Access failures due to thrombosis, clotted circuits and hemorrhagic events were recorded. Results: 1,489 and 1,823 dialysis sessions took place on UFH and LMWH, respectively, in 108 patients (65 male). The total number of clotted circuits tended to decrease after the switch to LMWH (34 vs. 13) but was not statistically significant. There were four minor non-access-related episodes of haemorrhage while on treatment with UFH and none with Tinzaparin, and the length of bleeding time post needle removal was shorter with Tinzaparin than UFH. The cost-analysis demonstrated parity of Tinzaparin with UFH; using a median of 10,000 U of UFH versus 2,500 U of LMWH, each therapy cost GBP 10,783 (EUR 15,942; USD 20,446) per annum. Conclusion: Our findings suggest comparable safety and efficacy of Tinzaparin, parity of cost in comparison with UFH.

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“…UFH bears the risk to induce heparin-induced thrombocytopenia type II (HIT II); thus the peripheral platelet counts has to be monitored carefully [34] during the treatment. In case of developing HIT II the treatment has to be stopped or switched to the Cellsorba system which allows ACD-A as anticoagulation medium whole blood is re-infused to the patient through a contralateral vein ( fig.…”

Section: Anticoagulationmentioning

confidence: 99%

Selective Granulocyte and Monocyte Apheresis as a Non-Pharmacological Option for Patients with Inflammatory Bowel Disease

Leitner¹,

Worel²,

Vogelsang

2012

Transfus Med Hemother

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Ulcerative colitis and Crohn’s disease are the two most prevalent inflammatory bowel diseases. In both cases, the medically refractory and steroid-dependent type presents a therapeutic challenge. To help resolve this problem, a mainly Japanese team developed a new therapeutic option. There are two systems, both of which are able to selectively remove the main mediators of the disease, namely the activated pro-inflammatory cytokine-producing granulocytes and monocytes/macrophages, from the patient’s blood circulation (GMA = granulocyte monocyte apheresis). One of the two systems is the Adacolumn® (Immunoresearch Laboratories, Takasaki, Japan) consisting of the ADA-monitor and a single-use column, which contains approximately 35,000 cellulose acetate beads. The exact mode of action is not yet sufficiently understood, but however, a modulation of the immune system takes place. As a result, less pro-inflammatory cytokines are released. Furthermore, the production of anti-inflammatory interleukin-1 receptor antagonist is increased, and the apoptosis of granulocytes boosted. The decreased LECAM-1-expression on leukocytes impedes the leukotaxis to the inflamed tissue, and CD10-negative immature granulocytes appear in the peripheral blood. Another effect to be mentioned is the removal of the peripheral dendritic cells and the leachate of regulatory T cells (T-regs). The second system is the Cellsorba® FX Filter (Asahi Medical, Tokyo, Japan). The range of efficiency, the indication, and the procedure are very similar to the Adacolumn. Solely the additional removal of lymphocytes can possibly limit the implemetation since lymphopenia can increase the risk of autoimmune disease. Both systems provide a low-risk therapy with few adverse reactions. ASFA recommendations for GMA in inflammatory bowel disease are 2B due to the fact that not enough randomized double-blind studies are available to proof the efficacy of this treatment.

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The heparins: all a nephrologist should know

Cited by 41 publications

References 60 publications

Enoxaparin versus unfractioned heparin as anticoagulant for continuous venovenous hemodialysis: a randomized open-label trial

Enoxaparin versus unfractioned heparin as anticoagulant for continuous venovenous hemodialysis: a randomized open-label trial

Comparison of Tinzaparin™ and Unfractionated Heparin as Anticoagulation on Haemodialysis: Equal Safety, Efficacy and Economical Parity

Selective Granulocyte and Monocyte Apheresis as a Non-Pharmacological Option for Patients with Inflammatory Bowel Disease

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