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Efficacy and safety of low molecular weight heparin compared to unfractionated heparin for chronic outpatient hemodialysis in end stage renal disease: systematic review and meta-analysis.

Palamaner Subash Shantha G, Kumar AA, Sethi M, Khanna RC, Pancholy SB - PeerJ (2015)

Bottom Line: Random effects model was used for meta-analysis.LMWH is as safe and effective as UFH.Considering the poor quality of studies included for the review, larger well conducted RCTs are required before conclusions can be drawn.

View Article: PubMed Central - HTML - PubMed

Affiliation: The Wright Center for Graduate Medical Education , Scranton, PA , USA ; The Johns Hopkins University, Bloomberg School of Public Health , Baltimore, MD , USA.

ABSTRACT
Background. Low molecular weight heparin (LMWH) is an effective anti-coagulant for thrombotic events. However, due to its predominant renal clearance, there are concerns that it might be associated with increased bleeding in patients with renal disease. Objectives. We systematically evaluated the efficacy and safety of LMWH compared to unfractionated heparin (UH) in end stage renal disease (ESRD) patients. Search Methods. Pubmed, Embase and cochrane central were searched for eligible citations. Selection Criteria. Randomized controlled trials, comparing LMWH and UH, involving adult (age > 18 years), ESRD patients receiving outpatient, chronic, intermittent hemodialysis were included. Data Collection and Analysis. Two independent reviewers performed independent data abstraction. I2 statistic was used to assess heterogeneity. Random effects model was used for meta-analysis. Results. Nineteen studies were included for systematic review and 4 were included for meta-analysis. There were no significant differences between LMWH and UFH for extracorporeal circuit thrombosis [risk ratio: 1 (95% CI [0.62-1.62])] and bleeding complications [risk ratio: 1.16 (95% CI [0.62-2.15])]. Conclusions. LMWH is as safe and effective as UFH. Considering the poor quality of studies included for the review, larger well conducted RCTs are required before conclusions can be drawn.

No MeSH data available.


Related in: MedlinePlus

Forest plots: bleeding complications.Forest plots comparing LMWH Vs UH for bleeding complications.
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fig-3: Forest plots: bleeding complications.Forest plots comparing LMWH Vs UH for bleeding complications.

Mentions: Of the secondary outcomes, deep vein thrombosis and pulmonary embolism were not reported by any of the included studies. Two studies (Lord et al., 2002; Saltissi et al., 1999) had addressed vascular compression times. The vascular compression times for LMWH (Tinzaparin) (9.5 ± 3.0 min) compared to UH (9.5 min ± 1.8 min) were similar in the study by Lord et al. (2002). In Saltissi et al. (1999), vascular compression time for LMWH (enoxaparin) (388 ± 164 s) was similar to that for UH (331 ± 135 s). In total there were 5 studies that had addressed one or more of the lipid profile components. The study by Mahmood et al. (2010) had reported acute changes in triglyceride levels during dialysis with LMWH (Tinzaparin) compared with UH. However, Saltissi et al. (1999), reported lipid changes at 12 weeks and observed that there were no differences in the lipid changes from baseline when LMWH (enoxaparin) was compared to UH for LDL, HDL, total cholesterol, VLDL and triglycerides. However, Schrader et al. (1988) reported that UF group had significantly higher triglyceride and VLDL cholesterol levels compared to UH group (Fragmin) (P < 0.05) at the end of 12 months but the groups were similar with LDL and HDL levels. Gritters et al. (2006) observed that there were no differences between the LMWH group and the UH group with regards to LDL levels measured at 1 week after study initiation. Elisaf et al. (1997) showed that total cholesterol, triglycerides, LDL cholesterol and total cholesterol/HDL ratio significantly decreased after LMWH (Tinzaparin) switch from UH at 3 months, 6 months and 12 months but HDL cholesterol did not significantly change during this period. Four studies had reported bleeding complications (Borm et al., 1986; Schrader et al., 1988; Saltissi et al., 1999; Lord et al., 2002). The number of events/patient in each group were respectively 2/10, 3/32, 12/36, and 19/35 for the LMWH group and 1/10, 8/32, 6/36 and 16/35 for the UFH group. The risk ratio for bleeding in the LMWH group for Borm et al., 1986; Schrader et al., 1988; Saltissi et al., 1999; Lord et al., 2002 compared to UFH were respectively 2.00 (0.21–18.69), 0.38 (0.11–1.29), 2.00 (0.84–4.75) and 1.19 (0.74–1.90) (Table 4). The pooled risk ratio from meta-analysis of these 4 studies was 1.16 (0.62–2.15) (Fig. 3).


Efficacy and safety of low molecular weight heparin compared to unfractionated heparin for chronic outpatient hemodialysis in end stage renal disease: systematic review and meta-analysis.

Palamaner Subash Shantha G, Kumar AA, Sethi M, Khanna RC, Pancholy SB - PeerJ (2015)

Forest plots: bleeding complications.Forest plots comparing LMWH Vs UH for bleeding complications.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4359121&req=5

fig-3: Forest plots: bleeding complications.Forest plots comparing LMWH Vs UH for bleeding complications.
Mentions: Of the secondary outcomes, deep vein thrombosis and pulmonary embolism were not reported by any of the included studies. Two studies (Lord et al., 2002; Saltissi et al., 1999) had addressed vascular compression times. The vascular compression times for LMWH (Tinzaparin) (9.5 ± 3.0 min) compared to UH (9.5 min ± 1.8 min) were similar in the study by Lord et al. (2002). In Saltissi et al. (1999), vascular compression time for LMWH (enoxaparin) (388 ± 164 s) was similar to that for UH (331 ± 135 s). In total there were 5 studies that had addressed one or more of the lipid profile components. The study by Mahmood et al. (2010) had reported acute changes in triglyceride levels during dialysis with LMWH (Tinzaparin) compared with UH. However, Saltissi et al. (1999), reported lipid changes at 12 weeks and observed that there were no differences in the lipid changes from baseline when LMWH (enoxaparin) was compared to UH for LDL, HDL, total cholesterol, VLDL and triglycerides. However, Schrader et al. (1988) reported that UF group had significantly higher triglyceride and VLDL cholesterol levels compared to UH group (Fragmin) (P < 0.05) at the end of 12 months but the groups were similar with LDL and HDL levels. Gritters et al. (2006) observed that there were no differences between the LMWH group and the UH group with regards to LDL levels measured at 1 week after study initiation. Elisaf et al. (1997) showed that total cholesterol, triglycerides, LDL cholesterol and total cholesterol/HDL ratio significantly decreased after LMWH (Tinzaparin) switch from UH at 3 months, 6 months and 12 months but HDL cholesterol did not significantly change during this period. Four studies had reported bleeding complications (Borm et al., 1986; Schrader et al., 1988; Saltissi et al., 1999; Lord et al., 2002). The number of events/patient in each group were respectively 2/10, 3/32, 12/36, and 19/35 for the LMWH group and 1/10, 8/32, 6/36 and 16/35 for the UFH group. The risk ratio for bleeding in the LMWH group for Borm et al., 1986; Schrader et al., 1988; Saltissi et al., 1999; Lord et al., 2002 compared to UFH were respectively 2.00 (0.21–18.69), 0.38 (0.11–1.29), 2.00 (0.84–4.75) and 1.19 (0.74–1.90) (Table 4). The pooled risk ratio from meta-analysis of these 4 studies was 1.16 (0.62–2.15) (Fig. 3).

Bottom Line: Random effects model was used for meta-analysis.LMWH is as safe and effective as UFH.Considering the poor quality of studies included for the review, larger well conducted RCTs are required before conclusions can be drawn.

View Article: PubMed Central - HTML - PubMed

Affiliation: The Wright Center for Graduate Medical Education , Scranton, PA , USA ; The Johns Hopkins University, Bloomberg School of Public Health , Baltimore, MD , USA.

ABSTRACT
Background. Low molecular weight heparin (LMWH) is an effective anti-coagulant for thrombotic events. However, due to its predominant renal clearance, there are concerns that it might be associated with increased bleeding in patients with renal disease. Objectives. We systematically evaluated the efficacy and safety of LMWH compared to unfractionated heparin (UH) in end stage renal disease (ESRD) patients. Search Methods. Pubmed, Embase and cochrane central were searched for eligible citations. Selection Criteria. Randomized controlled trials, comparing LMWH and UH, involving adult (age > 18 years), ESRD patients receiving outpatient, chronic, intermittent hemodialysis were included. Data Collection and Analysis. Two independent reviewers performed independent data abstraction. I2 statistic was used to assess heterogeneity. Random effects model was used for meta-analysis. Results. Nineteen studies were included for systematic review and 4 were included for meta-analysis. There were no significant differences between LMWH and UFH for extracorporeal circuit thrombosis [risk ratio: 1 (95% CI [0.62-1.62])] and bleeding complications [risk ratio: 1.16 (95% CI [0.62-2.15])]. Conclusions. LMWH is as safe and effective as UFH. Considering the poor quality of studies included for the review, larger well conducted RCTs are required before conclusions can be drawn.

No MeSH data available.


Related in: MedlinePlus