Nephrology Dialysis Transplantation, Vol 12, Issue 11 2355-2364, Copyright © 1997 by Oxford University Press
P Ambuhl, R Wuthrich, W Korte, L Schmid and R Krapf
Background: Thrombotic complications are common in
patients with endstage renal disease and contribute substantially to the
morbidity and mortality in this population. The aim of the present study
was to: I) determine the prevalence and the extent of hypercoagulability in
patients undergoing dialysis treatment by measuring parameters that
directly reflect thrombin concentrations, ii) assess changes in coagulation
status during haemodialysis (HD); iii) quantify the relative impact of
heparin, dialysis and their combined effects on coagulation status and iv)
detect factors that modify coagulation haemostasis in dialysis patients.
Method: A total of 39 patients (HD: n=29, CAPD: n=10)
was analysed for procoagulatory and fibrinolytic activity determined by
measurements of partial thromboplastin time, prothrombin fragments F1+2,
thrombin-antithrombin complexes and D-dimer concentrations. HD patients
were investigated prior to and during dialysis. A subgroup of patients was
infused heparin alone without dialysis or was dialysed without heparin
administration. Furthermore, subgroup and correlation analyses were
performed for the type of dialysis (HD vs CAPD), dialyzer and shunt, Kt/V,
underlying disease and treatment with recombinant erythropoietin (rhEPO).
Results: Baseline levels of all
parameters-procoagulatory and fibrinolytic- were substantially elevated in
all patients, but to a higher degree among those on CAPD. Moreover,
haemodialysis treatment increased procoagulatory markers even further,
suggesting stimulated coagulation and/or insufficient anticoagulation
during dialysis. However, after 3 h of dialysis thrombin concentrations,
determined by quantification of prothrombin fragments, were inversely
correlated with Kt/V. Selective heparin infusion diminished procoagulatory
activity only slightly and incompletely, whereas HD without heparin
resulted in excess thrombin accumulation. Finally, subgroup analyses
revealed more pronounced thrombin formation among patients treated with
polysulfon dialyzers, whereas erythropoietin dosage was positively related
with lower procoagulatory activity. Conclusion: A
majority of patients on dialysis are in a hypercoagulable state, which is
further aggravated by the haemodialysis procedure itself and may not be
sufficiently controlled with current anticoagulation regimens. Intensified
heparin treatment and the use of rhEPO are likely to improve coagulation
haemostasis, whereas the type of dialyzer should be considered as a
relevant procoagulatory factor. Key words: Blood
coagulation; erythropoietin; haemodialysis; heparin; prothrombin fragments;
thrombin-antithrombin complex
ORIGINAL ARTICLES
Plasma hypercoagulability in haemodialysis patient: impact of dialysis and anticoagulation
Department of Internal Medicine, and Division of Hematology and Laboratory Medicine, Kantonsspital, St Gallen, Switzerland; Institute of Physiology, University of Zurich, Zurich, Switzerland; Corresponding author at: Abteilung fur Nephrologie, Universitatsspital, Ramistrasse 100, CH-8091 Zurich, Switzerland
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