• Haemodialysis anticoagulation and adequacy. Nephrology 2005 Oct;10(S4):S78-80.



• Haemodialysis anticoagulation and adequacy. Westmead NSW (Australia): CARI - Caring for Australasians with Renal Impairment; 2005 Jul. 7 p. [7 references]

This is the current release of the guideline.

End-stage kidney disease (ESKD)

Assessment of Therapeutic Effectiveness
Management
Treatment

Family Practice
Internal Medicine
Nephrology
Nursing

Nurses
Physicians

To review the available evidence for the effects of different intradialytic heparin regimens on hemodialysis adequacy

Patients with end-stage kidney disease (ESKD) on prolonged hemodialysis

Management/Monitoring

Monitoring for:

• Hemodialysis adequacy
• Heparin-induced thrombocytopenia
• Thrombosis
• Hemorrhage

Treatment

Hemodialysis anticoagulation

• Standard unfractionated heparin
• Low molecular weight heparins

• Urea clearance (Kt/V)
• Urea reduction ratio
• Heparin-induced thrombocytopenia
• Thrombosis
• Hemorrhage

Searches of Electronic Databases

Databases searched: Medical Subject Headings (MeSH) terms and text words for dialysis were combined with MeSH terms and text words for adequacy and anticoagulation and then combined with the Cochrane highly sensitive search strategy for randomised controlled trials. The search was carried out in Medline (1966 – July Week 2 2004). The Cochrane Renal Group Trials Register was also searched for trials not indexed in Medline.

Date of searches: 27 July 2004.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence

Level I: Evidence obtained from a systematic review of all relevant randomized controlled trials (RCTs)

Level II: Evidence obtained from at least one properly designed RCT

Level III: Evidence obtained from well-designed pseudo-randomized controlled trials (alternate allocation or some other method); comparative studies with concurrent controls and allocation not randomized, cohort studies, case-control studies, interrupted time series with a control group; comparative studies with historical control, two or more single arm studies, interrupted time series without a parallel control group

Level IV: Evidence obtained from case series, either post-test or pretest/post-test

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Not stated

Expert Consensus

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Comparison with Guidelines from Other Groups
Peer Review

Recommendations of Others. Recommendations regarding hemodialysis anticoagulation and adequacy from the following groups were discussed: Kidney Disease Outcomes Quality Initiative, British Renal Association, Canadian Society of Nephrology, European Best Practice Guidelines, and International Guidelines.

Definitions for the levels of evidence (I–IV) can be found at the end of the "Major Recommendations" field.

Guidelines

1. No clear differences in haemodialysis adequacy results have been demonstrated using standard unfractionated heparin and low molecular weight heparins. (Level II evidence, limited data)
2. No differences in dialysis adequacy results are achieved using different low molecular weight heparins. (Level II evidence, limited data)
3. There is no clear difference in the risk of thrombosis or haemorrhage with low molecular weight heparins compared with standard heparins, although the results of individual studies have been quite variable. (Level I evidence)

Suggestions for Clinical Care

(Suggestions are based on Level III and IV sources)

• Low molecular weight heparins (LMWHs) have been suggested to have a number of other potential benefits with regard to bleeding risk, anticoagulant efficacy, risk of heparin-induced-thrombocytopaenia and lipid profile. These benefits remain unproven in patients on dialysis, with inconclusive and sometimes conflicting data available from randomized controlled trials (RCTs).
• LMWHs are simpler and more convenient to use given their once-only bolus method of administration; this may be an important consideration for some centres and some groups of patients. (Opinion)
• This convenience is balanced by the substantially higher cost of these agents compared with unfractionated heparin. Until more data directly comparing the two becomes available, individual units should make a decision based on whether the extra cost can be justified by the issues of convenience. (Opinion)
• LMWHs have a limited duration of action, so a single bolus injection may not provide adequate anticoagulation for long dialysis sessions (e.g., overnight dialysis).

Definitions:

Levels of Evidence

Level I: Evidence obtained from a systematic review of all relevant randomized controlled trials (RCTs)

Level II: Evidence obtained from at least one properly designed RCT

Level III: Evidence obtained from well-designed pseudo-randomized controlled trials (alternate allocation or some other method); comparative studies with concurrent controls and allocation not randomized, cohort studies, case-control studies, interrupted time series with a control group; comparative studies with historical control, two or more single arm studies, interrupted time series without a parallel control group

Level IV: Evidence obtained from case series, either post-test or pretest/post-test

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• Appropriate use of anticoagulants in patients with end-stage kidney disease (ESKD) on hemodialysis
• Low molecular weight heparins are simpler and more convenient to use given their once-only bolus method of administration; this may be an important consideration for some centres and some groups of patients

Substantially higher cost of low molecular weight heparins compared with unfractionated heparin

Implementation and Audit

Consideration should be given to ongoing measurement of adequacy (either locally or by database e.g., the Australia and New Zealand Dialysis and Transplant Registry [ANZDATA]) in those patients changed over to low-molecular weight heparin (LMWH).

Living with Illness

Effectiveness

• Haemodialysis anticoagulation and adequacy. Nephrology 2005 Oct;10(S4):S78-80.



• Haemodialysis anticoagulation and adequacy. Westmead NSW (Australia): CARI - Caring for Australasians with Renal Impairment; 2005 Jul. 7 p. [7 references]

Not applicable: The guideline was not adapted from another source.

2005 Oct

Caring for Australasians with Renal Impairment - Disease Specific Society

Industry-sponsored funding administered through Kidney Health Australia

Not stated

Authors: David Harris, Convenor (Westmead, New South Wales); Merlin Thomas (Prahran, Victoria); David Johnson (Woolloongabba, Queensland); Kathy Nicholls (Parkville, Victoria); Adrian Gillin (Camperdown, New South Wales)

All guideline writers are required to fill out a declaration of conflict of interest.

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI Institute on April 22, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.