Inpatient hemodialysis without anticoagulation in adults

Background. Anticoagulation use during hemodialysis (HD) is standard practice but issues related to an increased risk of hemorrhage associated with inpatients make this a concern. Methods. An anticoagulation-free protocol in which (i) the dialysis circuit is aggressively primed with normal saline (NS) in an attempt to flush it of all air, (ii) blood flow during the HD treatment is maximized to up to 400 mL/min, (iii) the dialysis circuit is flushed every 15 min with 100 mL of NS, and (iv) the use of bloodlines that lack a blood-air interface was developed and used for all adult inpatient HD treatments at Rush University Medical Center. The purpose of this study was to evaluate the rate of HD circuit clotting using this approach and to determine if factors such as access type, blood flow, arterial and venous bloodline pressures, the need for reversing the arterial and venous access lines for low blood flow or high venous or arterial bloodline pressures, or the amount of net ultrafiltration were associated with HD circuit clotting. Patients were excluded from analysis if they were on a heparin drip, clopidogrel, warfarin or direct thrombin inhibitors. We reviewed 400 HD treatments in 400 adult patients from 12/12 to 10/13. Results. The HD access in these patients consisted of catheters in 45%, native AV fistulas in 40% and grafts in 15% of the patients. The average blood flow in the treatments was 378 +/- 46 mL/min. In 5% of the treatments, the arterial and venous bloodlines were reversed. Only 4 of the 400 (1%) of the treatments clotted the dialysis circuit. Factors associated with clotting were lower achieved blood flows (225 +/- 50 mL/min versus 379 +/- 44 mL/min), higher arterial bloodline pressures (-198 +/- 24 mmHg versus -151 +/- 45 mmHg) and reversal of arterial and venous access lines. Conclusion. Our anticoagulation-free protocol allows inpatient HD to be performed in adults across all access types and with essentially no circuit clotting.