Anticoagulation Protocols in Chronic Hemodialysis

Monitoring and Adjustments

The American Society of Nephrology recommends monitoring the anticoagulant effect using activated partial thromboplastin time (aPTT), with a target of 1.5 to 2.5 times the normal value 1
The National Kidney Foundation suggests that unfractionated heparin is the anticoagulant of choice in patients with severe renal insufficiency (creatinine clearance <30 mL/min) 2
The National Kidney Foundation also notes that unfractionated heparin does not require dose adjustment for renal function, as its metabolism is primarily hepatic 2

The American College of Chest Physicians recommends avoiding heparin in patients with heparin-induced thrombocytopenia (HIT) 3
Alternative anticoagulants for hemodialysis in patients with HIT include argatroban, danaparoid, and citrate 4

Argatroban can be used as an alternative anticoagulant, with a bolus dose of 100 μg/kg for continuous hemodialysis or 250 μg/kg for intermittent hemodialysis, followed by continuous infusion 4
Danaparoid can be used as an alternative anticoagulant, with a bolus dose of 3750 U (2500 U if weight <55 kg) before the first two sessions and 3000 U (2000 U if weight <55 kg) thereafter 4
Citrate can be used as an alternative anticoagulant for equipment that supports this technique 4

The American Society of Anesthesiologists recommends using argatroban as an alternative anticoagulant in patients with heparin-induced thrombocytopenia, with a bolus dose of 250 μg/kg for intermittent hemodialysis or 100 μg/kg for continuous hemodialysis, followed by a continuous infusion adjusted to clinical response, with optimal dosing as low as 5 mg bolus with 0.15 mg/kg/hour infusion based on aPTT monitoring, as supported by evidence from Anaesthesia 5, 6
Danaparoid can be used as an alternative anticoagulant in patients with heparin-induced thrombocytopenia, with a bolus dose of 3,750 units before the first two sessions and 3,000 units for subsequent sessions, although argatroban is preferable in patients with renal failure due to its shorter half-life 5, 6