Anticoagulation Strategies in Hemodialysis

Anticoagulation for Hemodialysis Circuit

The American Heart Association recommends using unfractionated heparin (UFH) as the anticoagulant of choice for the extracorporeal circuit in patients with end-stage renal disease (ESRD) on hemodialysis, with a target INR of 2.0-3.0 for systemic anticoagulation in atrial fibrillation 1
Regional citrate is an emerging alternative for circuit anticoagulation, especially in patients at high risk of bleeding, with a caloric contribution of 0.59 kcal/mmol that should be included in total energy intake calculations 2, 3

For patients with non-valvular atrial fibrillation and a CHA₂DS₂-VASc score ≥2 on hemodialysis, the American Heart Association recommends prescribing warfarin (INR 2.0-3.0) for oral anticoagulation, with an acceptable risk of bleeding 1, 5
Direct thrombin inhibitors (dabigatran) and factor Xa inhibitors (rivaroxaban) are not recommended in patients with atrial fibrillation and ESRD on hemodialysis due to a lack of clinical trial evidence on the balance of risks and benefits 1, 5

For patients with heparin-induced thrombocytopenia (HIT), argatroban is the preferred option, with a low incidence of new thrombosis (0%-4%) and major bleeding (0%-6%) 4
Argatroban has been used in doses between 0.7 and 1.7 μg/kg/min as anticoagulation for continuous renal replacement therapy 2

The International Journal of Oral Science recommends scheduling dental or surgical procedures the day after hemodialysis to minimize the effect of anticoagulants, with a half-life of approximately 4 hours for low-molecular-weight heparin and 1-2 hours for unfractionated heparin 6
Bleeding time should be measured, with bleeding times of 10-15 minutes associated with high risks of hemorrhage, and platelet transfusion should be considered if the platelet count is <50,000/mm³ 6