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Randomized Controlled Trial
. 2015 Jun 15;10(6):e0128634.
doi: 10.1371/journal.pone.0128634. eCollection 2015.

Where and When To Inject Low Molecular Weight Heparin in Hemodiafiltration? A Cross Over Randomised Trial

Annemieke Dhondt  1 , Ruben Pauwels  1 , Katrien Devreese  2 , Sunny Eloot  1 , Griet Glorieux  1 , Raymond Vanholder  1
Affiliations
Randomized Controlled Trial

Where and When To Inject Low Molecular Weight Heparin in Hemodiafiltration? A Cross Over Randomised Trial

Annemieke Dhondt et al. PLoS One. .

Abstract

Background and objective: Low molecular weight heparins (LMWHs) are small enough to pass large pore dialysis membranes. Removal of LMWH if injected before the start of the session is possible during high-flux dialysis and hemodiafiltration. The aim of this study was to determine the optimal mode (place and time) of tinzaparin administration during postdilution hemodiafiltration.

Study design, setting, patients: In 13 chronic hemodiafiltration patients, 3 approaches of injection were compared in a randomised cross over trial: i) before the start of the session at the inlet blood line filled with rinsing solution (IN0), ii) 5 min after the start at the inlet line filled with blood (IN5) and iii) before the start of the session at the outlet blood line (OUT0). Anti-Xa activity, thrombin generation, visual clotting score and reduction ratios of urea and beta2microglobulin were measured.

Results: Anti-Xa activity was lower with IN0 compared with IN5 and OUT0, and also more thrombin generation was observed with IN0. No differences were observed in visual clotting scores and no clinically relevant differences were observed in solute reduction ratio. An anti-Xa of 0.3 IU/mL was discriminative for thrombin generation. Anti-Xa levels below 0.3 IU/mL at the end of the session were associated with worse clotting scores and lower reduction ratio of urea and beta2microglobulin.

Conclusions: Injection of tinzaparin at the inlet line before the start of postdilution hemodiafiltration is associated with loss of anticoagulant activity and can therefore not be recommended. Additionally, we found that an anti-Xa above 0.3 IU/mL at the end of the session is associated with less clotting and higher dialysis adequacy.

Trial registration: Clinicaltrials.gov NCT00756145.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Study flow chart: generation of allocation sequence, enrollment and assignment was done by AD.
Fig 2
Fig 2. Endogenous thrombin potential (ETP) in relation to anti-Xa activity.
Fig 3
Fig 3. Delta transmembrane pressure (TMP) in relation to hemoconcentration (BVS), anti-Xa-activity and endogenous thrombin potential (ETP).
Delta TMP is inversely correlated with hemoconcentration (p<0.0001, Spearman r = -0.68), no significant correlation between delta TMP and anti-Xa level or ETP at 240 min.
Fig 4
Fig 4. Reduction ratio of urea and beta2microglobulin in relation to anti-Xa activity and ETP.
Reduction ratio (RR) of urea (unfilled triangles) and beta2microglobulin (BETA2M) (filled triangles) in sessions with anti-Xa activity above or equal vs. below 0.3 IU/mL and detectable (ETP > 0) vs undetectable ETP (ETP = 0) at 240 min. Comparison between groups: * p<0.001.
See this image and copyright information in PMC

References

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