title: Intermittent saline flushes during haemodialysis do not alleviate coagulation and clot formation in stable patients receiving reduced doses of dalteparin.
abstract: 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 >or=18 years of age and haemoglobin >or=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 beta-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 beta-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.
authors.affiliation: Department of Medicine, Rikshospitalet University Hospital, N-0027 Oslo, Norway. solbjorg.sagedal@rikshospitalet.no
authors.forename: Solbjørg
authors.initials: S
authors.lastname: Sagedal
authors.forename: Anders
authors.initials: A
authors.lastname: Hartmann
authors.forename: Kåre
authors.initials: K
authors.lastname: Osnes
authors.forename: Stine
authors.initials: S
authors.lastname: Bjørnsen
authors.forename: Josephine
authors.initials: J
authors.lastname: Torremocha
authors.forename: Per
authors.initials: P
authors.lastname: Fauchald
authors.forename: Johan
authors.initials: J
authors.lastname: Kofstad
authors.forename: Frank
authors.initials: F
authors.lastname: Brosstad
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage*; D001777:Blood Coagulation / Q000187:drug effects*; D017985:Dalteparin / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000379:methods; D012965:Sodium Chloride / Q000008:administration & dosage / Q000494:pharmacology*
chemical_list: D000925:Anticoagulants; D012965:Sodium Chloride; D017985:Dalteparin