Thromboprophylaxis to prevent clotting of extracorporeal circuit and permanent vascular access in patient with end stage renal disease on haemodialysis in the UK.

 

E Davies¹, J Williams¹, B Prasad¹,  M Kumwenda

¹ Wrexham Maelor Hospital, Glan Clwyd Hospital, Wales²

 

Background: There are several options of anticoagulation during haemodialysis and for permanent vascular access: unfractionated heparin, low molecular weight heparin and prostacyclin during dialysis, warfarin or antiplatelet agents for AV fistulae ,grafts and tunnelled catheters. Urokinase or alteplase can be used as antifibrinolytic agents for tunnelled catheters.

Objectives: To investgate the anticoagulation protocols for dialysis and vascular access  in different dialysis centers in the UK.

Methodology: Main dialysis centers were identified and telephone interviews were conducted by 2 doctors and 2 nurses in 2004.

Results: 72 dialysis centers were contacted, 62(86%) took part. 20 vascular access nurses and 42 sisters or dialysis nurses were interviewed.

1) Heparin use was as follows:

 

Loading dose       No of centers (%)             Maintainance dose        No of centers (%)

<5000                          54                                     1000                                 23

5000                            11                                1500 – 5000                            9.6

10000                            3                                    >5000                                  9.6

Variable doses/patient                                                                  Variable dose/patient                   

dependent                    32                               dependent                               57.8

 

2) Prophylactic agents used for permanent vascular access were: aspirin in 14%, warfarin in 18%, clopidogrel in 4.8% of centers, 63.8% of dialysis centers did not use any.

3) For tunnelled catheters the dose for heparin lock per catheter was <5000u in 9% and 5000u in 86% of centers, the dose varied between 1000 and 5000u in the other centers. Urokinase was used as antifibrinolytic agent for tunnelled catheters in 84% of centers, 14% did not use any antifibrinolytic agents at all.

4) Agents not in routine use were low molecular weight heparin, prostacyclin and alteplase.

Conclusion and relevance: There was a wide variation in anticoagulation to prevent clotting during haemodialysis and for permanent vascular access in the UK. There is a need to determine which anticoagulant protocol is most efficacious and the safest for patients with end stage renal disease on haemodialysis.