Dialysis Without Anticoagulation(Heparin Free Dialysis)
Mahmoud Eid
KUC Alexandria Egypt
Indications For Dialysis without anticoagulationbull Pericarditisbull Recent surgery with bleeding complications or risk especially Vascular and
cardiac surgery (AVF Catheter Insertion)
bull Eye surgery (retinal and cataract)
bull Renal transplant ()
bull Brain surgery
bull Coagulopathy
bull Thrombocytopenia
bull Intracerebral hemorrhage (Hgic stroke is the most common indication in USA)
bull Ischemic stroke Active bleeding
bull acutely ill patients
bull Patientrsquos at increased risk of bleeding (oral anticoagulation systemic anticoagulation)
bull Tips
bull The clinician must identify the true indications of heparin free dialysis as itrsquos use may be associated with some serious adverse effects
bull Risk vs Benefit
bull Eg in patients with persistent HTN
bull If there is no clear indication please consider (restricted heparin regimens other anticoagulants)
bull Patient Safety Comes first not money
Techniques
bull Regional Citrate anticoagulation (Ca)
bull Regional Heparin Anticoagulation (Protamine)
bull Intermittent Saline Flush (ISF)
bull Continuous Saline flush (CSF) predilution
bull Heparin CoatedGrafted Dialyzer Membranes
bull Citrasate acid concentrate for bicarbonate-based dialysis that uses citric acid
Technical or operator-induced factors (resulting in clotting) bull Dialyzer Priming Retained air in dialyzer (due to inadequate priming or poor priming technique)
bull Rapid blood pump speed while primingbull Not giving enough time (no rush)bull Empty priming bagsbull Air in the infusion or heparin linebull Tip return the dialyzer to the upright position after the ECC is filled with the patient bloodbull Proper wetting of the fibers
bull Vascular Access Inadequate blood flow due to needlecatheter positioning or clotting
bull Excessive access recirculation due to needletourniquet position reversal of catheter blood lines
bull Frequent interruption of blood flow due to inadequate delivery or machine alarm situations
bull High level of Blood in the venous air chamber (must leave 13 empty)
Tip (you must be able to see the stream of the blood in the chamber to avoid stasis)
bull Excessive ultrafiltration (rate gt net)
Signs of clotting in the extracorporeal circuit
bull Extremely dark blood
bull Shadows or black streaks in the dialyzer
bull Foaming with subsequent clot formation in drip chambers and venous trap
bull Rapid filling of transducer monitors with blood
bull Teetering (suction) blood in the postdialyzer venous line segment that is unable to continue into the venous chamber but falls back into the line segment)
bull Presence of clots at the arterial-side header of the dialyzer
bull Rapid rise of TMP
bull Unexplained increase in the venous pressure
Scoring The Circuit(sagedal2013)
Venous Chamber
Normal 1
fibrinous 2
Clot formation 3
Clotted System 4
Dialyzer
Normal 1
few blood stripes (affecting less than 5 of the surface fibres)
2
many blood stripes (more than 5 of the surface fibres)
3
coagulated filter 4
Also in case of AVF Hemostasis lt10 minutes =1 10-30 minutes=2 gt 30 minutes=3
Prescription General) bull Prime the circuit properly
bull Heparin rinse (This step is optional Avoid if heparin-associated thrombocytopenia is present) Rinse extracorporeal circuit with saline containing 3000 units of heparinL
bull allow the heparin-containing priming fluid to drain by filling the extracorporeal circuit with either the patients blood or unheparinizedsaline at the outset of dialysis
bull High blood flow rate Set the blood flow rate to 350-400 mL per minute if tolerated (FROM THE START) If a high blood flow rate is contraindicated due to the risk of disequilibrium consider using a small-surface-area dialyzer andor slowing the dialysate flow rate or shortening the treatment sessions
ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985
bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)
bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot
formation
bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear
bull The extra volume should be calculated and added to the UF
bull Online machines with programmed bolus (5008)
bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION
Continuous Saline Infusion
bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)
Heparin coated membranes
bull Hemophan user will prime the dialyzer with 12-20000 units of heparin circulated for 30 minutes before dialysis coated with (Mujais et al 1996)
bull AN69 ST dialyzers the user primes the dialyzer with 10000 units heparin 2L saline
bull Should be avoided in HIT due to mild heparinemia (Gueacutery et al 2014)
bull Plysulphone membrane some authors noted that there was some heparin adsorption (Kodras 2008Sagedal 2011 no difference between polysulphone and AN69 when both coated with heparin)
bull Heparin grafted membrane Evodial (Gambro) better success in Heparin Free Dialysis with (CSI amp ISF) Lavill et al 2014
bull Different membrane materials and circuit design There is no solid evidence to suggest that any one type of membrane material is better for heparin-free dialysis Although heparin coatings and LMWH coatings are being tried
Bicarbonate dialysis solution with low-concentration citrate (Citrasate)
bull A small amount of citric acid is used instead of acetic acid as the acidifying agent citrate by complexing with calcium has been suggested to inhibit blood coagulation and platelet activation locally at the dialyzer membrane surface resulting in improved dialyzer clearance and increased dialyzer reusability (Ahmad et al 2005)
Other technical points
bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)
bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)
bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )
bull
D5W vs Saline
bull No data Most done with NS a new clinical trial underway ldquoEffect of Sodium Concentration of Priming and Rinsing Fluids on Weight GainrdquohttpclinicaltrialsgovshowNCT01168947
bull According to you experience Stick to NS
Patient on Oral Anticoaguation
bull First assess the need for oral anticoagulation
bull Therapeutic vs Prophylactic
bull INR regular follow up
bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005
Aspirin
bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975
bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977
bull small number + in vitro
bull according to risk of bleeding gastric SE vs benefits
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
Indications For Dialysis without anticoagulationbull Pericarditisbull Recent surgery with bleeding complications or risk especially Vascular and
cardiac surgery (AVF Catheter Insertion)
bull Eye surgery (retinal and cataract)
bull Renal transplant ()
bull Brain surgery
bull Coagulopathy
bull Thrombocytopenia
bull Intracerebral hemorrhage (Hgic stroke is the most common indication in USA)
bull Ischemic stroke Active bleeding
bull acutely ill patients
bull Patientrsquos at increased risk of bleeding (oral anticoagulation systemic anticoagulation)
bull Tips
bull The clinician must identify the true indications of heparin free dialysis as itrsquos use may be associated with some serious adverse effects
bull Risk vs Benefit
bull Eg in patients with persistent HTN
bull If there is no clear indication please consider (restricted heparin regimens other anticoagulants)
bull Patient Safety Comes first not money
Techniques
bull Regional Citrate anticoagulation (Ca)
bull Regional Heparin Anticoagulation (Protamine)
bull Intermittent Saline Flush (ISF)
bull Continuous Saline flush (CSF) predilution
bull Heparin CoatedGrafted Dialyzer Membranes
bull Citrasate acid concentrate for bicarbonate-based dialysis that uses citric acid
Technical or operator-induced factors (resulting in clotting) bull Dialyzer Priming Retained air in dialyzer (due to inadequate priming or poor priming technique)
bull Rapid blood pump speed while primingbull Not giving enough time (no rush)bull Empty priming bagsbull Air in the infusion or heparin linebull Tip return the dialyzer to the upright position after the ECC is filled with the patient bloodbull Proper wetting of the fibers
bull Vascular Access Inadequate blood flow due to needlecatheter positioning or clotting
bull Excessive access recirculation due to needletourniquet position reversal of catheter blood lines
bull Frequent interruption of blood flow due to inadequate delivery or machine alarm situations
bull High level of Blood in the venous air chamber (must leave 13 empty)
Tip (you must be able to see the stream of the blood in the chamber to avoid stasis)
bull Excessive ultrafiltration (rate gt net)
Signs of clotting in the extracorporeal circuit
bull Extremely dark blood
bull Shadows or black streaks in the dialyzer
bull Foaming with subsequent clot formation in drip chambers and venous trap
bull Rapid filling of transducer monitors with blood
bull Teetering (suction) blood in the postdialyzer venous line segment that is unable to continue into the venous chamber but falls back into the line segment)
bull Presence of clots at the arterial-side header of the dialyzer
bull Rapid rise of TMP
bull Unexplained increase in the venous pressure
Scoring The Circuit(sagedal2013)
Venous Chamber
Normal 1
fibrinous 2
Clot formation 3
Clotted System 4
Dialyzer
Normal 1
few blood stripes (affecting less than 5 of the surface fibres)
2
many blood stripes (more than 5 of the surface fibres)
3
coagulated filter 4
Also in case of AVF Hemostasis lt10 minutes =1 10-30 minutes=2 gt 30 minutes=3
Prescription General) bull Prime the circuit properly
bull Heparin rinse (This step is optional Avoid if heparin-associated thrombocytopenia is present) Rinse extracorporeal circuit with saline containing 3000 units of heparinL
bull allow the heparin-containing priming fluid to drain by filling the extracorporeal circuit with either the patients blood or unheparinizedsaline at the outset of dialysis
bull High blood flow rate Set the blood flow rate to 350-400 mL per minute if tolerated (FROM THE START) If a high blood flow rate is contraindicated due to the risk of disequilibrium consider using a small-surface-area dialyzer andor slowing the dialysate flow rate or shortening the treatment sessions
ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985
bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)
bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot
formation
bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear
bull The extra volume should be calculated and added to the UF
bull Online machines with programmed bolus (5008)
bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION
Continuous Saline Infusion
bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)
Heparin coated membranes
bull Hemophan user will prime the dialyzer with 12-20000 units of heparin circulated for 30 minutes before dialysis coated with (Mujais et al 1996)
bull AN69 ST dialyzers the user primes the dialyzer with 10000 units heparin 2L saline
bull Should be avoided in HIT due to mild heparinemia (Gueacutery et al 2014)
bull Plysulphone membrane some authors noted that there was some heparin adsorption (Kodras 2008Sagedal 2011 no difference between polysulphone and AN69 when both coated with heparin)
bull Heparin grafted membrane Evodial (Gambro) better success in Heparin Free Dialysis with (CSI amp ISF) Lavill et al 2014
bull Different membrane materials and circuit design There is no solid evidence to suggest that any one type of membrane material is better for heparin-free dialysis Although heparin coatings and LMWH coatings are being tried
Bicarbonate dialysis solution with low-concentration citrate (Citrasate)
bull A small amount of citric acid is used instead of acetic acid as the acidifying agent citrate by complexing with calcium has been suggested to inhibit blood coagulation and platelet activation locally at the dialyzer membrane surface resulting in improved dialyzer clearance and increased dialyzer reusability (Ahmad et al 2005)
Other technical points
bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)
bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)
bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )
bull
D5W vs Saline
bull No data Most done with NS a new clinical trial underway ldquoEffect of Sodium Concentration of Priming and Rinsing Fluids on Weight GainrdquohttpclinicaltrialsgovshowNCT01168947
bull According to you experience Stick to NS
Patient on Oral Anticoaguation
bull First assess the need for oral anticoagulation
bull Therapeutic vs Prophylactic
bull INR regular follow up
bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005
Aspirin
bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975
bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977
bull small number + in vitro
bull according to risk of bleeding gastric SE vs benefits
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
bull Tips
bull The clinician must identify the true indications of heparin free dialysis as itrsquos use may be associated with some serious adverse effects
bull Risk vs Benefit
bull Eg in patients with persistent HTN
bull If there is no clear indication please consider (restricted heparin regimens other anticoagulants)
bull Patient Safety Comes first not money
Techniques
bull Regional Citrate anticoagulation (Ca)
bull Regional Heparin Anticoagulation (Protamine)
bull Intermittent Saline Flush (ISF)
bull Continuous Saline flush (CSF) predilution
bull Heparin CoatedGrafted Dialyzer Membranes
bull Citrasate acid concentrate for bicarbonate-based dialysis that uses citric acid
Technical or operator-induced factors (resulting in clotting) bull Dialyzer Priming Retained air in dialyzer (due to inadequate priming or poor priming technique)
bull Rapid blood pump speed while primingbull Not giving enough time (no rush)bull Empty priming bagsbull Air in the infusion or heparin linebull Tip return the dialyzer to the upright position after the ECC is filled with the patient bloodbull Proper wetting of the fibers
bull Vascular Access Inadequate blood flow due to needlecatheter positioning or clotting
bull Excessive access recirculation due to needletourniquet position reversal of catheter blood lines
bull Frequent interruption of blood flow due to inadequate delivery or machine alarm situations
bull High level of Blood in the venous air chamber (must leave 13 empty)
Tip (you must be able to see the stream of the blood in the chamber to avoid stasis)
bull Excessive ultrafiltration (rate gt net)
Signs of clotting in the extracorporeal circuit
bull Extremely dark blood
bull Shadows or black streaks in the dialyzer
bull Foaming with subsequent clot formation in drip chambers and venous trap
bull Rapid filling of transducer monitors with blood
bull Teetering (suction) blood in the postdialyzer venous line segment that is unable to continue into the venous chamber but falls back into the line segment)
bull Presence of clots at the arterial-side header of the dialyzer
bull Rapid rise of TMP
bull Unexplained increase in the venous pressure
Scoring The Circuit(sagedal2013)
Venous Chamber
Normal 1
fibrinous 2
Clot formation 3
Clotted System 4
Dialyzer
Normal 1
few blood stripes (affecting less than 5 of the surface fibres)
2
many blood stripes (more than 5 of the surface fibres)
3
coagulated filter 4
Also in case of AVF Hemostasis lt10 minutes =1 10-30 minutes=2 gt 30 minutes=3
Prescription General) bull Prime the circuit properly
bull Heparin rinse (This step is optional Avoid if heparin-associated thrombocytopenia is present) Rinse extracorporeal circuit with saline containing 3000 units of heparinL
bull allow the heparin-containing priming fluid to drain by filling the extracorporeal circuit with either the patients blood or unheparinizedsaline at the outset of dialysis
bull High blood flow rate Set the blood flow rate to 350-400 mL per minute if tolerated (FROM THE START) If a high blood flow rate is contraindicated due to the risk of disequilibrium consider using a small-surface-area dialyzer andor slowing the dialysate flow rate or shortening the treatment sessions
ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985
bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)
bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot
formation
bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear
bull The extra volume should be calculated and added to the UF
bull Online machines with programmed bolus (5008)
bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION
Continuous Saline Infusion
bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)
Heparin coated membranes
bull Hemophan user will prime the dialyzer with 12-20000 units of heparin circulated for 30 minutes before dialysis coated with (Mujais et al 1996)
bull AN69 ST dialyzers the user primes the dialyzer with 10000 units heparin 2L saline
bull Should be avoided in HIT due to mild heparinemia (Gueacutery et al 2014)
bull Plysulphone membrane some authors noted that there was some heparin adsorption (Kodras 2008Sagedal 2011 no difference between polysulphone and AN69 when both coated with heparin)
bull Heparin grafted membrane Evodial (Gambro) better success in Heparin Free Dialysis with (CSI amp ISF) Lavill et al 2014
bull Different membrane materials and circuit design There is no solid evidence to suggest that any one type of membrane material is better for heparin-free dialysis Although heparin coatings and LMWH coatings are being tried
Bicarbonate dialysis solution with low-concentration citrate (Citrasate)
bull A small amount of citric acid is used instead of acetic acid as the acidifying agent citrate by complexing with calcium has been suggested to inhibit blood coagulation and platelet activation locally at the dialyzer membrane surface resulting in improved dialyzer clearance and increased dialyzer reusability (Ahmad et al 2005)
Other technical points
bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)
bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)
bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )
bull
D5W vs Saline
bull No data Most done with NS a new clinical trial underway ldquoEffect of Sodium Concentration of Priming and Rinsing Fluids on Weight GainrdquohttpclinicaltrialsgovshowNCT01168947
bull According to you experience Stick to NS
Patient on Oral Anticoaguation
bull First assess the need for oral anticoagulation
bull Therapeutic vs Prophylactic
bull INR regular follow up
bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005
Aspirin
bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975
bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977
bull small number + in vitro
bull according to risk of bleeding gastric SE vs benefits
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
Techniques
bull Regional Citrate anticoagulation (Ca)
bull Regional Heparin Anticoagulation (Protamine)
bull Intermittent Saline Flush (ISF)
bull Continuous Saline flush (CSF) predilution
bull Heparin CoatedGrafted Dialyzer Membranes
bull Citrasate acid concentrate for bicarbonate-based dialysis that uses citric acid
Technical or operator-induced factors (resulting in clotting) bull Dialyzer Priming Retained air in dialyzer (due to inadequate priming or poor priming technique)
bull Rapid blood pump speed while primingbull Not giving enough time (no rush)bull Empty priming bagsbull Air in the infusion or heparin linebull Tip return the dialyzer to the upright position after the ECC is filled with the patient bloodbull Proper wetting of the fibers
bull Vascular Access Inadequate blood flow due to needlecatheter positioning or clotting
bull Excessive access recirculation due to needletourniquet position reversal of catheter blood lines
bull Frequent interruption of blood flow due to inadequate delivery or machine alarm situations
bull High level of Blood in the venous air chamber (must leave 13 empty)
Tip (you must be able to see the stream of the blood in the chamber to avoid stasis)
bull Excessive ultrafiltration (rate gt net)
Signs of clotting in the extracorporeal circuit
bull Extremely dark blood
bull Shadows or black streaks in the dialyzer
bull Foaming with subsequent clot formation in drip chambers and venous trap
bull Rapid filling of transducer monitors with blood
bull Teetering (suction) blood in the postdialyzer venous line segment that is unable to continue into the venous chamber but falls back into the line segment)
bull Presence of clots at the arterial-side header of the dialyzer
bull Rapid rise of TMP
bull Unexplained increase in the venous pressure
Scoring The Circuit(sagedal2013)
Venous Chamber
Normal 1
fibrinous 2
Clot formation 3
Clotted System 4
Dialyzer
Normal 1
few blood stripes (affecting less than 5 of the surface fibres)
2
many blood stripes (more than 5 of the surface fibres)
3
coagulated filter 4
Also in case of AVF Hemostasis lt10 minutes =1 10-30 minutes=2 gt 30 minutes=3
Prescription General) bull Prime the circuit properly
bull Heparin rinse (This step is optional Avoid if heparin-associated thrombocytopenia is present) Rinse extracorporeal circuit with saline containing 3000 units of heparinL
bull allow the heparin-containing priming fluid to drain by filling the extracorporeal circuit with either the patients blood or unheparinizedsaline at the outset of dialysis
bull High blood flow rate Set the blood flow rate to 350-400 mL per minute if tolerated (FROM THE START) If a high blood flow rate is contraindicated due to the risk of disequilibrium consider using a small-surface-area dialyzer andor slowing the dialysate flow rate or shortening the treatment sessions
ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985
bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)
bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot
formation
bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear
bull The extra volume should be calculated and added to the UF
bull Online machines with programmed bolus (5008)
bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION
Continuous Saline Infusion
bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)
Heparin coated membranes
bull Hemophan user will prime the dialyzer with 12-20000 units of heparin circulated for 30 minutes before dialysis coated with (Mujais et al 1996)
bull AN69 ST dialyzers the user primes the dialyzer with 10000 units heparin 2L saline
bull Should be avoided in HIT due to mild heparinemia (Gueacutery et al 2014)
bull Plysulphone membrane some authors noted that there was some heparin adsorption (Kodras 2008Sagedal 2011 no difference between polysulphone and AN69 when both coated with heparin)
bull Heparin grafted membrane Evodial (Gambro) better success in Heparin Free Dialysis with (CSI amp ISF) Lavill et al 2014
bull Different membrane materials and circuit design There is no solid evidence to suggest that any one type of membrane material is better for heparin-free dialysis Although heparin coatings and LMWH coatings are being tried
Bicarbonate dialysis solution with low-concentration citrate (Citrasate)
bull A small amount of citric acid is used instead of acetic acid as the acidifying agent citrate by complexing with calcium has been suggested to inhibit blood coagulation and platelet activation locally at the dialyzer membrane surface resulting in improved dialyzer clearance and increased dialyzer reusability (Ahmad et al 2005)
Other technical points
bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)
bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)
bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )
bull
D5W vs Saline
bull No data Most done with NS a new clinical trial underway ldquoEffect of Sodium Concentration of Priming and Rinsing Fluids on Weight GainrdquohttpclinicaltrialsgovshowNCT01168947
bull According to you experience Stick to NS
Patient on Oral Anticoaguation
bull First assess the need for oral anticoagulation
bull Therapeutic vs Prophylactic
bull INR regular follow up
bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005
Aspirin
bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975
bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977
bull small number + in vitro
bull according to risk of bleeding gastric SE vs benefits
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
Technical or operator-induced factors (resulting in clotting) bull Dialyzer Priming Retained air in dialyzer (due to inadequate priming or poor priming technique)
bull Rapid blood pump speed while primingbull Not giving enough time (no rush)bull Empty priming bagsbull Air in the infusion or heparin linebull Tip return the dialyzer to the upright position after the ECC is filled with the patient bloodbull Proper wetting of the fibers
bull Vascular Access Inadequate blood flow due to needlecatheter positioning or clotting
bull Excessive access recirculation due to needletourniquet position reversal of catheter blood lines
bull Frequent interruption of blood flow due to inadequate delivery or machine alarm situations
bull High level of Blood in the venous air chamber (must leave 13 empty)
Tip (you must be able to see the stream of the blood in the chamber to avoid stasis)
bull Excessive ultrafiltration (rate gt net)
Signs of clotting in the extracorporeal circuit
bull Extremely dark blood
bull Shadows or black streaks in the dialyzer
bull Foaming with subsequent clot formation in drip chambers and venous trap
bull Rapid filling of transducer monitors with blood
bull Teetering (suction) blood in the postdialyzer venous line segment that is unable to continue into the venous chamber but falls back into the line segment)
bull Presence of clots at the arterial-side header of the dialyzer
bull Rapid rise of TMP
bull Unexplained increase in the venous pressure
Scoring The Circuit(sagedal2013)
Venous Chamber
Normal 1
fibrinous 2
Clot formation 3
Clotted System 4
Dialyzer
Normal 1
few blood stripes (affecting less than 5 of the surface fibres)
2
many blood stripes (more than 5 of the surface fibres)
3
coagulated filter 4
Also in case of AVF Hemostasis lt10 minutes =1 10-30 minutes=2 gt 30 minutes=3
Prescription General) bull Prime the circuit properly
bull Heparin rinse (This step is optional Avoid if heparin-associated thrombocytopenia is present) Rinse extracorporeal circuit with saline containing 3000 units of heparinL
bull allow the heparin-containing priming fluid to drain by filling the extracorporeal circuit with either the patients blood or unheparinizedsaline at the outset of dialysis
bull High blood flow rate Set the blood flow rate to 350-400 mL per minute if tolerated (FROM THE START) If a high blood flow rate is contraindicated due to the risk of disequilibrium consider using a small-surface-area dialyzer andor slowing the dialysate flow rate or shortening the treatment sessions
ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985
bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)
bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot
formation
bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear
bull The extra volume should be calculated and added to the UF
bull Online machines with programmed bolus (5008)
bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION
Continuous Saline Infusion
bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)
Heparin coated membranes
bull Hemophan user will prime the dialyzer with 12-20000 units of heparin circulated for 30 minutes before dialysis coated with (Mujais et al 1996)
bull AN69 ST dialyzers the user primes the dialyzer with 10000 units heparin 2L saline
bull Should be avoided in HIT due to mild heparinemia (Gueacutery et al 2014)
bull Plysulphone membrane some authors noted that there was some heparin adsorption (Kodras 2008Sagedal 2011 no difference between polysulphone and AN69 when both coated with heparin)
bull Heparin grafted membrane Evodial (Gambro) better success in Heparin Free Dialysis with (CSI amp ISF) Lavill et al 2014
bull Different membrane materials and circuit design There is no solid evidence to suggest that any one type of membrane material is better for heparin-free dialysis Although heparin coatings and LMWH coatings are being tried
Bicarbonate dialysis solution with low-concentration citrate (Citrasate)
bull A small amount of citric acid is used instead of acetic acid as the acidifying agent citrate by complexing with calcium has been suggested to inhibit blood coagulation and platelet activation locally at the dialyzer membrane surface resulting in improved dialyzer clearance and increased dialyzer reusability (Ahmad et al 2005)
Other technical points
bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)
bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)
bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )
bull
D5W vs Saline
bull No data Most done with NS a new clinical trial underway ldquoEffect of Sodium Concentration of Priming and Rinsing Fluids on Weight GainrdquohttpclinicaltrialsgovshowNCT01168947
bull According to you experience Stick to NS
Patient on Oral Anticoaguation
bull First assess the need for oral anticoagulation
bull Therapeutic vs Prophylactic
bull INR regular follow up
bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005
Aspirin
bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975
bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977
bull small number + in vitro
bull according to risk of bleeding gastric SE vs benefits
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
Signs of clotting in the extracorporeal circuit
bull Extremely dark blood
bull Shadows or black streaks in the dialyzer
bull Foaming with subsequent clot formation in drip chambers and venous trap
bull Rapid filling of transducer monitors with blood
bull Teetering (suction) blood in the postdialyzer venous line segment that is unable to continue into the venous chamber but falls back into the line segment)
bull Presence of clots at the arterial-side header of the dialyzer
bull Rapid rise of TMP
bull Unexplained increase in the venous pressure
Scoring The Circuit(sagedal2013)
Venous Chamber
Normal 1
fibrinous 2
Clot formation 3
Clotted System 4
Dialyzer
Normal 1
few blood stripes (affecting less than 5 of the surface fibres)
2
many blood stripes (more than 5 of the surface fibres)
3
coagulated filter 4
Also in case of AVF Hemostasis lt10 minutes =1 10-30 minutes=2 gt 30 minutes=3
Prescription General) bull Prime the circuit properly
bull Heparin rinse (This step is optional Avoid if heparin-associated thrombocytopenia is present) Rinse extracorporeal circuit with saline containing 3000 units of heparinL
bull allow the heparin-containing priming fluid to drain by filling the extracorporeal circuit with either the patients blood or unheparinizedsaline at the outset of dialysis
bull High blood flow rate Set the blood flow rate to 350-400 mL per minute if tolerated (FROM THE START) If a high blood flow rate is contraindicated due to the risk of disequilibrium consider using a small-surface-area dialyzer andor slowing the dialysate flow rate or shortening the treatment sessions
ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985
bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)
bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot
formation
bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear
bull The extra volume should be calculated and added to the UF
bull Online machines with programmed bolus (5008)
bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION
Continuous Saline Infusion
bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)
Heparin coated membranes
bull Hemophan user will prime the dialyzer with 12-20000 units of heparin circulated for 30 minutes before dialysis coated with (Mujais et al 1996)
bull AN69 ST dialyzers the user primes the dialyzer with 10000 units heparin 2L saline
bull Should be avoided in HIT due to mild heparinemia (Gueacutery et al 2014)
bull Plysulphone membrane some authors noted that there was some heparin adsorption (Kodras 2008Sagedal 2011 no difference between polysulphone and AN69 when both coated with heparin)
bull Heparin grafted membrane Evodial (Gambro) better success in Heparin Free Dialysis with (CSI amp ISF) Lavill et al 2014
bull Different membrane materials and circuit design There is no solid evidence to suggest that any one type of membrane material is better for heparin-free dialysis Although heparin coatings and LMWH coatings are being tried
Bicarbonate dialysis solution with low-concentration citrate (Citrasate)
bull A small amount of citric acid is used instead of acetic acid as the acidifying agent citrate by complexing with calcium has been suggested to inhibit blood coagulation and platelet activation locally at the dialyzer membrane surface resulting in improved dialyzer clearance and increased dialyzer reusability (Ahmad et al 2005)
Other technical points
bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)
bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)
bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )
bull
D5W vs Saline
bull No data Most done with NS a new clinical trial underway ldquoEffect of Sodium Concentration of Priming and Rinsing Fluids on Weight GainrdquohttpclinicaltrialsgovshowNCT01168947
bull According to you experience Stick to NS
Patient on Oral Anticoaguation
bull First assess the need for oral anticoagulation
bull Therapeutic vs Prophylactic
bull INR regular follow up
bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005
Aspirin
bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975
bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977
bull small number + in vitro
bull according to risk of bleeding gastric SE vs benefits
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
Scoring The Circuit(sagedal2013)
Venous Chamber
Normal 1
fibrinous 2
Clot formation 3
Clotted System 4
Dialyzer
Normal 1
few blood stripes (affecting less than 5 of the surface fibres)
2
many blood stripes (more than 5 of the surface fibres)
3
coagulated filter 4
Also in case of AVF Hemostasis lt10 minutes =1 10-30 minutes=2 gt 30 minutes=3
Prescription General) bull Prime the circuit properly
bull Heparin rinse (This step is optional Avoid if heparin-associated thrombocytopenia is present) Rinse extracorporeal circuit with saline containing 3000 units of heparinL
bull allow the heparin-containing priming fluid to drain by filling the extracorporeal circuit with either the patients blood or unheparinizedsaline at the outset of dialysis
bull High blood flow rate Set the blood flow rate to 350-400 mL per minute if tolerated (FROM THE START) If a high blood flow rate is contraindicated due to the risk of disequilibrium consider using a small-surface-area dialyzer andor slowing the dialysate flow rate or shortening the treatment sessions
ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985
bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)
bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot
formation
bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear
bull The extra volume should be calculated and added to the UF
bull Online machines with programmed bolus (5008)
bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION
Continuous Saline Infusion
bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)
Heparin coated membranes
bull Hemophan user will prime the dialyzer with 12-20000 units of heparin circulated for 30 minutes before dialysis coated with (Mujais et al 1996)
bull AN69 ST dialyzers the user primes the dialyzer with 10000 units heparin 2L saline
bull Should be avoided in HIT due to mild heparinemia (Gueacutery et al 2014)
bull Plysulphone membrane some authors noted that there was some heparin adsorption (Kodras 2008Sagedal 2011 no difference between polysulphone and AN69 when both coated with heparin)
bull Heparin grafted membrane Evodial (Gambro) better success in Heparin Free Dialysis with (CSI amp ISF) Lavill et al 2014
bull Different membrane materials and circuit design There is no solid evidence to suggest that any one type of membrane material is better for heparin-free dialysis Although heparin coatings and LMWH coatings are being tried
Bicarbonate dialysis solution with low-concentration citrate (Citrasate)
bull A small amount of citric acid is used instead of acetic acid as the acidifying agent citrate by complexing with calcium has been suggested to inhibit blood coagulation and platelet activation locally at the dialyzer membrane surface resulting in improved dialyzer clearance and increased dialyzer reusability (Ahmad et al 2005)
Other technical points
bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)
bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)
bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )
bull
D5W vs Saline
bull No data Most done with NS a new clinical trial underway ldquoEffect of Sodium Concentration of Priming and Rinsing Fluids on Weight GainrdquohttpclinicaltrialsgovshowNCT01168947
bull According to you experience Stick to NS
Patient on Oral Anticoaguation
bull First assess the need for oral anticoagulation
bull Therapeutic vs Prophylactic
bull INR regular follow up
bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005
Aspirin
bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975
bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977
bull small number + in vitro
bull according to risk of bleeding gastric SE vs benefits
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
Prescription General) bull Prime the circuit properly
bull Heparin rinse (This step is optional Avoid if heparin-associated thrombocytopenia is present) Rinse extracorporeal circuit with saline containing 3000 units of heparinL
bull allow the heparin-containing priming fluid to drain by filling the extracorporeal circuit with either the patients blood or unheparinizedsaline at the outset of dialysis
bull High blood flow rate Set the blood flow rate to 350-400 mL per minute if tolerated (FROM THE START) If a high blood flow rate is contraindicated due to the risk of disequilibrium consider using a small-surface-area dialyzer andor slowing the dialysate flow rate or shortening the treatment sessions
ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985
bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)
bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot
formation
bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear
bull The extra volume should be calculated and added to the UF
bull Online machines with programmed bolus (5008)
bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION
Continuous Saline Infusion
bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)
Heparin coated membranes
bull Hemophan user will prime the dialyzer with 12-20000 units of heparin circulated for 30 minutes before dialysis coated with (Mujais et al 1996)
bull AN69 ST dialyzers the user primes the dialyzer with 10000 units heparin 2L saline
bull Should be avoided in HIT due to mild heparinemia (Gueacutery et al 2014)
bull Plysulphone membrane some authors noted that there was some heparin adsorption (Kodras 2008Sagedal 2011 no difference between polysulphone and AN69 when both coated with heparin)
bull Heparin grafted membrane Evodial (Gambro) better success in Heparin Free Dialysis with (CSI amp ISF) Lavill et al 2014
bull Different membrane materials and circuit design There is no solid evidence to suggest that any one type of membrane material is better for heparin-free dialysis Although heparin coatings and LMWH coatings are being tried
Bicarbonate dialysis solution with low-concentration citrate (Citrasate)
bull A small amount of citric acid is used instead of acetic acid as the acidifying agent citrate by complexing with calcium has been suggested to inhibit blood coagulation and platelet activation locally at the dialyzer membrane surface resulting in improved dialyzer clearance and increased dialyzer reusability (Ahmad et al 2005)
Other technical points
bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)
bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)
bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )
bull
D5W vs Saline
bull No data Most done with NS a new clinical trial underway ldquoEffect of Sodium Concentration of Priming and Rinsing Fluids on Weight GainrdquohttpclinicaltrialsgovshowNCT01168947
bull According to you experience Stick to NS
Patient on Oral Anticoaguation
bull First assess the need for oral anticoagulation
bull Therapeutic vs Prophylactic
bull INR regular follow up
bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005
Aspirin
bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975
bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977
bull small number + in vitro
bull according to risk of bleeding gastric SE vs benefits
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
ISF bull Anticoagulation-free HD utilizing NS flushes was reported by Sanders et al 1985
bull The utility of this step is controversial one recent study suggested that use of a saline rinse may actually promote clotting (perhaps via introduction of microbubbles into the circuit) (Sagedal et al 2006)
bull The purpose of the ISF is to bull allow inspection of a hollow-fiber dialyzer for evidence of clotting bull allow for timely discontinuation of treatment or changing of the dialyzerbull believed by some to reduce the propensity for dialyzer clotting or interfere with clot
formation
bull Procedure Rinse the dialyzer rapidly with 50-250 mL of saline while occluding the blood inlet line every 15-60 minutes until the dialyzer and the venous chamber are clear
bull The extra volume should be calculated and added to the UF
bull Online machines with programmed bolus (5008)
bull SHOULD NOT BE USED ROUTINELY WITH HEPARIN ANTICOAGULATION
Continuous Saline Infusion
bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)
Heparin coated membranes
bull Hemophan user will prime the dialyzer with 12-20000 units of heparin circulated for 30 minutes before dialysis coated with (Mujais et al 1996)
bull AN69 ST dialyzers the user primes the dialyzer with 10000 units heparin 2L saline
bull Should be avoided in HIT due to mild heparinemia (Gueacutery et al 2014)
bull Plysulphone membrane some authors noted that there was some heparin adsorption (Kodras 2008Sagedal 2011 no difference between polysulphone and AN69 when both coated with heparin)
bull Heparin grafted membrane Evodial (Gambro) better success in Heparin Free Dialysis with (CSI amp ISF) Lavill et al 2014
bull Different membrane materials and circuit design There is no solid evidence to suggest that any one type of membrane material is better for heparin-free dialysis Although heparin coatings and LMWH coatings are being tried
Bicarbonate dialysis solution with low-concentration citrate (Citrasate)
bull A small amount of citric acid is used instead of acetic acid as the acidifying agent citrate by complexing with calcium has been suggested to inhibit blood coagulation and platelet activation locally at the dialyzer membrane surface resulting in improved dialyzer clearance and increased dialyzer reusability (Ahmad et al 2005)
Other technical points
bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)
bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)
bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )
bull
D5W vs Saline
bull No data Most done with NS a new clinical trial underway ldquoEffect of Sodium Concentration of Priming and Rinsing Fluids on Weight GainrdquohttpclinicaltrialsgovshowNCT01168947
bull According to you experience Stick to NS
Patient on Oral Anticoaguation
bull First assess the need for oral anticoagulation
bull Therapeutic vs Prophylactic
bull INR regular follow up
bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005
Aspirin
bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975
bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977
bull small number + in vitro
bull according to risk of bleeding gastric SE vs benefits
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
Continuous Saline Infusion
bull CSI can also be used as an alternative to coagulation during dialysis Utilizing this technique saline is administered to the ECC continuously throughout the dialysis session at a given rate 200 mLhour (Zimbudzi 2013)
Heparin coated membranes
bull Hemophan user will prime the dialyzer with 12-20000 units of heparin circulated for 30 minutes before dialysis coated with (Mujais et al 1996)
bull AN69 ST dialyzers the user primes the dialyzer with 10000 units heparin 2L saline
bull Should be avoided in HIT due to mild heparinemia (Gueacutery et al 2014)
bull Plysulphone membrane some authors noted that there was some heparin adsorption (Kodras 2008Sagedal 2011 no difference between polysulphone and AN69 when both coated with heparin)
bull Heparin grafted membrane Evodial (Gambro) better success in Heparin Free Dialysis with (CSI amp ISF) Lavill et al 2014
bull Different membrane materials and circuit design There is no solid evidence to suggest that any one type of membrane material is better for heparin-free dialysis Although heparin coatings and LMWH coatings are being tried
Bicarbonate dialysis solution with low-concentration citrate (Citrasate)
bull A small amount of citric acid is used instead of acetic acid as the acidifying agent citrate by complexing with calcium has been suggested to inhibit blood coagulation and platelet activation locally at the dialyzer membrane surface resulting in improved dialyzer clearance and increased dialyzer reusability (Ahmad et al 2005)
Other technical points
bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)
bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)
bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )
bull
D5W vs Saline
bull No data Most done with NS a new clinical trial underway ldquoEffect of Sodium Concentration of Priming and Rinsing Fluids on Weight GainrdquohttpclinicaltrialsgovshowNCT01168947
bull According to you experience Stick to NS
Patient on Oral Anticoaguation
bull First assess the need for oral anticoagulation
bull Therapeutic vs Prophylactic
bull INR regular follow up
bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005
Aspirin
bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975
bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977
bull small number + in vitro
bull according to risk of bleeding gastric SE vs benefits
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
Heparin coated membranes
bull Hemophan user will prime the dialyzer with 12-20000 units of heparin circulated for 30 minutes before dialysis coated with (Mujais et al 1996)
bull AN69 ST dialyzers the user primes the dialyzer with 10000 units heparin 2L saline
bull Should be avoided in HIT due to mild heparinemia (Gueacutery et al 2014)
bull Plysulphone membrane some authors noted that there was some heparin adsorption (Kodras 2008Sagedal 2011 no difference between polysulphone and AN69 when both coated with heparin)
bull Heparin grafted membrane Evodial (Gambro) better success in Heparin Free Dialysis with (CSI amp ISF) Lavill et al 2014
bull Different membrane materials and circuit design There is no solid evidence to suggest that any one type of membrane material is better for heparin-free dialysis Although heparin coatings and LMWH coatings are being tried
Bicarbonate dialysis solution with low-concentration citrate (Citrasate)
bull A small amount of citric acid is used instead of acetic acid as the acidifying agent citrate by complexing with calcium has been suggested to inhibit blood coagulation and platelet activation locally at the dialyzer membrane surface resulting in improved dialyzer clearance and increased dialyzer reusability (Ahmad et al 2005)
Other technical points
bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)
bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)
bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )
bull
D5W vs Saline
bull No data Most done with NS a new clinical trial underway ldquoEffect of Sodium Concentration of Priming and Rinsing Fluids on Weight GainrdquohttpclinicaltrialsgovshowNCT01168947
bull According to you experience Stick to NS
Patient on Oral Anticoaguation
bull First assess the need for oral anticoagulation
bull Therapeutic vs Prophylactic
bull INR regular follow up
bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005
Aspirin
bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975
bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977
bull small number + in vitro
bull according to risk of bleeding gastric SE vs benefits
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
bull Different membrane materials and circuit design There is no solid evidence to suggest that any one type of membrane material is better for heparin-free dialysis Although heparin coatings and LMWH coatings are being tried
Bicarbonate dialysis solution with low-concentration citrate (Citrasate)
bull A small amount of citric acid is used instead of acetic acid as the acidifying agent citrate by complexing with calcium has been suggested to inhibit blood coagulation and platelet activation locally at the dialyzer membrane surface resulting in improved dialyzer clearance and increased dialyzer reusability (Ahmad et al 2005)
Other technical points
bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)
bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)
bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )
bull
D5W vs Saline
bull No data Most done with NS a new clinical trial underway ldquoEffect of Sodium Concentration of Priming and Rinsing Fluids on Weight GainrdquohttpclinicaltrialsgovshowNCT01168947
bull According to you experience Stick to NS
Patient on Oral Anticoaguation
bull First assess the need for oral anticoagulation
bull Therapeutic vs Prophylactic
bull INR regular follow up
bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005
Aspirin
bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975
bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977
bull small number + in vitro
bull according to risk of bleeding gastric SE vs benefits
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
Bicarbonate dialysis solution with low-concentration citrate (Citrasate)
bull A small amount of citric acid is used instead of acetic acid as the acidifying agent citrate by complexing with calcium has been suggested to inhibit blood coagulation and platelet activation locally at the dialyzer membrane surface resulting in improved dialyzer clearance and increased dialyzer reusability (Ahmad et al 2005)
Other technical points
bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)
bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)
bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )
bull
D5W vs Saline
bull No data Most done with NS a new clinical trial underway ldquoEffect of Sodium Concentration of Priming and Rinsing Fluids on Weight GainrdquohttpclinicaltrialsgovshowNCT01168947
bull According to you experience Stick to NS
Patient on Oral Anticoaguation
bull First assess the need for oral anticoagulation
bull Therapeutic vs Prophylactic
bull INR regular follow up
bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005
Aspirin
bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975
bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977
bull small number + in vitro
bull according to risk of bleeding gastric SE vs benefits
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
Other technical points
bull elimination of dead spaces in blood tubing and reducing the presence of airblood interfaces in dialysis lines may be the most promising approaches to lower incidence of extracorporeal circuit clotting (Streamline tubing)
bull Blood product transfusion or lipid administration Administration via the inlet blood line has been reported to increase clotting risk during dialysis (can be administered after the dialyzer safely)
bull Heparin free hemodialysis with prophylactic change of system is a safe and practical method of treatment for patients at high bleeding risk but it is less effective more expensive and the patient requires closer care (Preuschof et al 1988 )
bull
D5W vs Saline
bull No data Most done with NS a new clinical trial underway ldquoEffect of Sodium Concentration of Priming and Rinsing Fluids on Weight GainrdquohttpclinicaltrialsgovshowNCT01168947
bull According to you experience Stick to NS
Patient on Oral Anticoaguation
bull First assess the need for oral anticoagulation
bull Therapeutic vs Prophylactic
bull INR regular follow up
bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005
Aspirin
bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975
bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977
bull small number + in vitro
bull according to risk of bleeding gastric SE vs benefits
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
D5W vs Saline
bull No data Most done with NS a new clinical trial underway ldquoEffect of Sodium Concentration of Priming and Rinsing Fluids on Weight GainrdquohttpclinicaltrialsgovshowNCT01168947
bull According to you experience Stick to NS
Patient on Oral Anticoaguation
bull First assess the need for oral anticoagulation
bull Therapeutic vs Prophylactic
bull INR regular follow up
bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005
Aspirin
bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975
bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977
bull small number + in vitro
bull according to risk of bleeding gastric SE vs benefits
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
Patient on Oral Anticoaguation
bull First assess the need for oral anticoagulation
bull Therapeutic vs Prophylactic
bull INR regular follow up
bull According to assessment of the circuit patient may need extra anticoagulation using heparin or not Read more Krummel et al 2013 Ziai et al 2005
Aspirin
bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975
bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977
bull small number + in vitro
bull according to risk of bleeding gastric SE vs benefits
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
Aspirin
bull Reduction of plateletfibrin deposition in haemodialysersby aspirin administration Stewart et al 1975
bull Effect of sulphinpyrazone and aspirin on platelet adhesion to activated charcoal and dialysis membranes in vitro Winchester et al 1977
bull small number + in vitro
bull according to risk of bleeding gastric SE vs benefits
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
SLED
bull SLED
bull Marshall et al 2001 amp Berbec et al 2006 26 amp 29 respectively clotting
bull CRRT
bull Nagarik ET AL 2010
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
Dialysis Dose Delivery
bull Mcgill et all 2005 no difference in the dialysis dose and increased dialyzer treatment time is not necessary
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
Water for dialysis
bull Some senior dialysis veterans(patients mostly) claim that excessive ECC clotting could be related to the quality of dialysis water
Clotting in dialyzers due to low pH of dialysis fluid Schwarzbeck et al 1977
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
Catheter Locking
bull McGill et al 2005 Instillation of heparin solution in dialysis catheters after HF-HD results in prolonged unintentional anticoagulation The duration and intensity of anticoagulation are sufficient to create increased risk of hemorrhagic events Heparin locking after HD should be avoided in cases where adverse hemorrhagic events are likely
bull Avoid Heparin Locking in HIT Heparin-induced thrombocytopenia due to heparin lock in a hemodialysis patient a case report (Chan et al 2014)
ACCP Guidelines (Suggest the use of regional citrate over the use of heparin or LMWH in patients requiring catheter locking 2C)
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
Alternatives
bull Citrate (low and high concentration)
bull Saline flushes and saline lock
bull Beigi et al 2014 Flushing PermCath with normal saline 09 is as effective as heparin in maintaining patency of the catheter while it may reduce the risks associated with heparinbull in the saline flush group it was locked with saline solution 09
bull Hypertonic saline solution (10 saline catheters retaining time and average blood flow velocities remained the same Chen et al 2014)
bull Low heparin concentration (100 uml-1000 u ml)
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
Recommendations
bull Good priming
bull No Rushing
bull Written protocol (indications procedure)
bull Think of the patientrsquos safety
THANK YOU
THANK YOU
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