title: Use and safety of heparin-free maintenance hemodialysis in the USA.
abstract: BACKGROUND
  Although heparin is used to anticoagulate the extracorporeal circuit for most patients on maintenance hemodialysis (HD), some patients undergo heparin-free HD. We describe the determinants of heparin-free HD and its association with adverse outcomes using data from a national dialysis provider merged with Medicare claims.
  
  
  METHODS
  We identified patients aged ≥67 years with no recent history of warfarin use who initiated maintenance HD from 2007 to 2008. We applied the Cox regression to a propensity score-matched cohort to estimate the hazards of all-cause mortality, bleeding (gastrointestinal hemorrhage, hemorrhagic stroke, other hemorrhage), atherothrombosis (ischemic stroke, myocardial infarction) and venous thromboembolism (VTE) (deep vein thrombosis, pulmonary embolism).
  
  
  RESULTS
  Among 12 468 patients, 836 (6.7%) were dialyzed heparin-free. In multivariable-adjusted analyses, a history of gastrointestinal bleeding, hemorrhagic stroke and lower hemoglobin and platelet counts were associated with higher odds of heparin-free HD. Heparin-free HD use also varied as much as 4-fold by facility region. We found no significant association of heparin-free HD with all-cause mortality [hazard ratio (HR) 1.08; 95% confidence interval (CI): 0.94-1.26], bleeding (HR 1.15; 95% CI: 0.83-1.60), atherothrombosis (HR 1.09, 95% CI: 0.90-1.31) or VTE (HR 1.23, 95% CI: 0.93-1.64) compared with HD with heparin.
  
  
  CONCLUSIONS
  Patient markers of increased risk of bleeding and facility region associated with heparin-free HD use. Despite the potential benefits of avoiding heparin use, heparin-free HD was not significantly associated with decreased hazards of death, bleeding or thrombosis, suggesting that it may be no safer than HD with heparin.
authors.affiliation: Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA. jishen@stanford.edu
authors.forename: Jenny I
authors.initials: JI
authors.lastname: Shen
authors.forename: Aya A
authors.initials: AA
authors.lastname: Mitani
authors.forename: Tara I
authors.initials: TI
authors.lastname: Chang
authors.forename: Wolfgang C
authors.initials: WC
authors.lastname: Winkelmayer
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects*; D015331:Cohort Studies; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced; D006495:Heparin, Low-Molecular-Weight / Q000009:adverse effects*; D006801:Humans; D020300:Intracranial Hemorrhages / Q000139:chemically induced; D008297:Male; D009203:Myocardial Infarction / Q000139:chemically induced; D011379:Prognosis; D011655:Pulmonary Embolism / Q000139:chemically induced; D006435:Renal Dialysis / Q000009:adverse effects*; D051436:Renal Insufficiency, Chronic / Q000150:complications* / Q000628:therapy; D012307:Risk Factors; D020521:Stroke / Q000139:chemically induced; D014481:United States; D020246:Venous Thrombosis / Q000139:chemically induced
chemical_list: D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight
keywords: anti-coagulation; gastrointestinal bleeding; hemodialysis; heparin; heparin-free
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