Successful use of a bivalirudin treatment protocol to prevent extracorporeal thrombosis in ambulatory hemodialysis patients with heparin-induced thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is an uncommon problem in hemodialysis (HD) patients. There have been a few reports on the use of lepirudin, argatroban, or danaparoid in the management of extracorporeal thrombosis (ECT) during dialysis in these patients, because heparin is contraindicated. Here, we report the first long-term use of bivalirudin to prevent ECT. Our study was conducted at Fahd Bin Jassim Kidney Center in Doha, Qatar. All patients diagnosed with HIT were included. A bivalirudin treatment protocol was developed with the initial dosage and dosage adjustments based on the value of activated partial thromboplastin time (aPTT), the risk of bleeding, and the recurrence of ECT. Eight patients were positive for HIT AB. Among them, three were excluded: two due to the use of warfarin for atrial fibrillation and one due to a negative repeat HIT AB test with no ECT. Five patients who were positive for HIT AB and experienced recurrent ECT events during dialysis were included. These patients were monitored while on bivalirudin protocol for a mean of 4.6 ± 2 months, during which they received a mean number of HD treatments of 66 ± 24. There were no bleeding events or adverse reactions related to bivalirudin during the study. Here, we report the first long-term successful use of a bivalirudin protocol to prevent ECT in ambulatory HD patients with HIT. This protocol allowed for a simple dosing initiation with easy adjustment based on weight, aPTT, and recurrence of ECT events. The protocol provided excellent safety.

Erythropoietin-stimulating agents in the management of anemia of end-stage renal disease patients on regular hemodialysis: a prospective randomized comparative study from Qatar.

Despite extensive use, to the best of our knowledge, no trial has simultaneously compared the three currently used erythropoietin-stimulating agents (ESAs) in a prospective manner in the treatment of anemia of end-stage renal disease patients. All hemodialysis patients in Qatar who were treated with short-acting epoetin alfa or beta have been screened. Eligible patients had been prospectively randomized, either to continue on the previous regimen of epoetin or to receive darbepoetin alfa or continuous erythropoietin receptor activator (CERA) for a total period of 40 weeks. All groups were assessed at the end of the study for safety and efficacy parameters. A total of 327 eligible patients were randomized. Mean hemoglobin concentration remained constant within the recommended target range (11-12 g/dL) throughout the study in the three studied groups. The percentage of patients who reached the target range was constantly above 50% in the second half of the study among CERA group patients who also had significantly lower mean number of dose adjustments as compared with the other two groups (P = 0.001). Similarly, the number of discontinuations of ESA among epoetin, darbepoetin, and CERA groups was 17, 19, and 9, respectively (P = 0.042). The frequencies of adverse events were similar in all groups. This study has specifically compared the effect of ESA type on the variability of serum hemoglobin levels in hemodialysis patients. Furthermore, it confirmed the efficacy and safety of once monthly CERA for maintaining tight hemoglobin control within recommended target ranges.