NDT Advance Access originally published online on October 18, 2005
Nephrology Dialysis Transplantation 2006 21(2):444-449; doi:10.1093/ndt/gfi203
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© The Author [2005]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Original Articles: Dialysis and Transplantation
Intermittent saline flushes during haemodialysis do not alleviate coagulation and clot formation in stable patients receiving reduced doses of dalteparin
1 Department of Internal Medicine, 2 Laboratory for Renal Physiology, 3 Institute of Biostatistics, 4 Research Institute for Internal Medicine, 5 Dialysis Unit and 6 Department of Clinical Biochemistry, Rikshospitalet University Hospital, Oslo, Norway
Correspondence and offprint requests to: Solbjørg Sagedal, MD, Department of Medicine, Rikshospitalet University Hospital, N-0027 Oslo, Norway. Email: solbjorg.sagedal{at}rikshospitalet.no
Background. Heparin-free haemodialysis (HD) with intermittent saline flushes (ISF) in patients with bleeding risk is widely used. The aim of this study was to investigate if ISF reduce coagulation and clotting in stable patients receiving reduced doses of dalteparin.
Methods. Inclusion criteria were stable chronic HD patients 
18 years of age and haemoglobin 11 g/dl. Exclusion criteria were use of warfarin and acetylsalicylic acid. Six HD sessions were evaluated per patient. Dalteparin was given as one bolus dose at start of HD (50% of the conventional dose). In HD number 1, 3 and 5, 100 ml saline solution was flushed through the filter each 30 min. In HD 2, 4 and 6, no ISF were given. Potential clotting in the bubble trap was visually observed each hour and graded on a 4-point scale: 1 = normal, 2 = fibrinous ring, 3 = clot formation and 4 = coagulated system. The dialyser was visually inspected at the end of each session: 1 = normal, 2 = a few blood stripes (affecting less than 5% of the surface fibres), 3 = many blood stripes (more than 5% of the fibres) and 4 = coagulated filter. The coagulation marker PF1+2, the platelet activation marker ß-TG and anti-FXa activity were repeatedly measured during HD.
Results. Six men and two women were included. In four cases (four different patients), HD was stopped due to a coagulated system, all cases on days with ISF performed. Multiple linear regression analyses with repeated measurements showed that ISF adjusted for dalteparin dose/kg significantly increased mean clot in the bubble trap, estimate (B) = 0.717, P = 0.0001 and also showed that ISF increased PF1+2, B = 0.16, P = 0.001 when adjusted for anti-FXa activity and hours of dialysis, whereas ß-TG was only borderline increased, B = 0.09, P = 0.055.
Conclusions. ISF during HD does not alleviate visible clotting or intravascular coagulation activity in stable patients receiving reduced doses of dalteparin and polysulphone dialysers. Whether this applies to unstable patients with increased bleeding risk not receiving any anticoagulation remains to be shown.
Keywords: anticoagulation; clotting; dalteparin; haemodialysis; prothrombin fragment 1+2; saline flushes
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