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Kidney Week

Abstract: SA-PO1029

Anticoagulation for People Receiving Long-Term Hemodialysis: A Cochrane Review and Meta-Analysis

Session Information

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis


  • Palmer, Suetonia, University of Otago, Christchurch, New Zealand
  • Natale, Patrizia, Diaverum, Lund, Sweden
  • Ruospo, Marinella, Diaverum, Lund, Sweden
  • Strippoli, Giovanni F.M., Diaverum, Lund, Sweden

Hemodialysis requires safe and effective anticoagulation to prevent clot formation during the procedure. Low molecular weight heparins (LMWH) may provide more predictable anticoagulant effects and be simpler to administer than unfractionated heparin (UFH) but may increase risks of bleeding. This Cochrane review evaluates the benefits and harms of anticoagulation strategies for long-term hemodialysis.


We searched the Cochrane Kidney and Transplant Register of Studies for randomized controlled trials evaluating anticoagulant agents administered for hemodialysis treatment in adults with end-stage kidney disease (ESKD). Two authors independently screened citations for eligibility, extracted data, and assessed risk of bias using the Cochrane tool. Evidence certainty was evaluated using GRADE.


Eighty-seven studies (3548 participants) were eligible. Median trial duration was 0.75 months (range 1 week to 24 months). Median trial age was 58.2 years (range 10.93 to 74 years). Methodological risks of bias were high or incomplete for most studies. Forty-three studies (2066 participants) compared LMWH with UFH. The certainty of the evidence was very low or low for all outcomes. Two of 43 studies reported the outcome for extracorporeal dialysis circuit thrombosis, with one study reporting one or more events. LMWH had very uncertain effects on dialysis circuit thrombosis compared to UFH (very low certainty evidence). Four studies reported zero major bleeding events (very low certainty evidence). No study reported time to achieve dialysis vascular access hemostasis. LMWH had uncertain effects on all-cause mortality (relative risk [RR] 2.41, 95% CI 0.62, 9.33; low certainty evidence). A single study reported the effect of LMWH on dialysis adequacy, measured as KT/V, such that meta-analysis could not be performed. Treatment effects of other anticoagulants were very uncertain.


Evidence for different forms of anticoagulation for hemodialysis is of very low certainty due to methodological limitations in existing trials and paucity of trial data. This review suggests the need for a head-to-head trial of LMWH versus UFH that is sufficiently powered to assess critical clinical outcomes such as bleeding, dialysis adequacy, mortality or cardiovascular events, or complications related to dialysis vascular access.