{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T04:55:20Z","timestamp":1787028920744,"version":"build-2736575974"},"reference-count":24,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2024,8,4]],"date-time":"2024-08-04T00:00:00Z","timestamp":1722729600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"RBWH and RBWH Foundation 2019 Research Project","award":["EC00172"],"award-info":[{"award-number":["EC00172"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medical Sciences"],"abstract":"<jats:p>Background: There has been growing interest in exploring combined interventions to achieve a more effective heparin-free treatment approach. Aim: to evaluate combination of interventions compared to standard practice (intermittent flushes) to prevent clotting and consequently reduce premature interruptions of hemodialysis. Methods: This open-label randomized controlled trial recruited chronic hemodialysis patients with contra-indication to systemic heparinization. Participants were randomized into one of five groups to receive different strategies of heparin-free hemodialysis treatment for up to three sessions. Primary endpoint: the successful completion of hemodialysis without clotting. Secondary outcomes: the clotting of the air traps assessed by a semi-quantitative scale, online KT\/V, and safety of the interventions. Results: Forty participants were recruited and randomized between May and December 2020. Participants showed similar baseline biochemistry results and coagulation profiles. The highest success rates were observed in group 3 (heparin-coated dialyzers combined with intermittent flushes) (100%) and group 5 (hemodiafiltration with online predilution combined with heparin-coated dialyzers), with 91% vs. the control (intermittent flushes) (64%). Group 2 (heparin-coated dialyzers alone) had the poorest success rate, with 38% of the sessions being prematurely terminated due to clotting. KT\/V and clotting scores were similar between groups. No adverse events related to the trial interventions were observed. Conclusions: The proposed combination of interventions may have had additive effects, leading to less frequent clotting and the premature termination of an HD\/HDF session. Our study supports the feasibility of conducting a larger randomized controlled trial focusing on the efficacy of combined interventions for heparin-free HD in patients with a high risk of bleeding.<\/jats:p>","DOI":"10.3390\/medsci12030038","type":"journal-article","created":{"date-parts":[[2024,8,5]],"date-time":"2024-08-05T11:28:54Z","timestamp":1722857334000},"page":"38","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Hemodialysis without Systemic Anticoagulation: A Randomized Controlled Trial to Evaluate Five Strategies in Patients at a High Risk of Bleeding"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3520-3225","authenticated-orcid":false,"given":"Pedro H. Franca","family":"Gois","sequence":"first","affiliation":[{"name":"Kidney Health Service, Royal Brisbane and Women\u2019s Hospital, Herston, QLD 4029, Australia"},{"name":"Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia"},{"name":"Nephrology Department, John Hunter Hospital, New Lambton Heights, NSW 2305, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6830-0582","authenticated-orcid":false,"given":"David","family":"McIntyre","sequence":"additional","affiliation":[{"name":"Nephrology Department, Townsville University Hospital, Douglas, QLD 4814, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6024-7684","authenticated-orcid":false,"given":"Sharad","family":"Ratanjee","sequence":"additional","affiliation":[{"name":"Kidney Health Service, Royal Brisbane and Women\u2019s Hospital, Herston, QLD 4029, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anita","family":"Pelecanos","sequence":"additional","affiliation":[{"name":"Statistics Unit, QIMR Berghofer Medical Research Institute, Herston, QLD 4006, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carla","family":"Scuderi","sequence":"additional","affiliation":[{"name":"Kidney Health Service, Royal Brisbane and Women\u2019s Hospital, Herston, QLD 4029, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chungun L.","family":"Janoschka","sequence":"additional","affiliation":[{"name":"Kidney Health Service, Royal Brisbane and Women\u2019s Hospital, Herston, QLD 4029, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kara","family":"Summers","sequence":"additional","affiliation":[{"name":"Kidney Health Service, Royal Brisbane and Women\u2019s Hospital, Herston, QLD 4029, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haibing","family":"Wu","sequence":"additional","affiliation":[{"name":"Kidney Health Service, Royal Brisbane and Women\u2019s Hospital, Herston, QLD 4029, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Belinda","family":"Elford","sequence":"additional","affiliation":[{"name":"Kidney Health Service, Royal Brisbane and Women\u2019s Hospital, Herston, QLD 4029, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1215-1773","authenticated-orcid":false,"given":"Dwarakanathan","family":"Ranganathan","sequence":"additional","affiliation":[{"name":"Kidney Health Service, Royal Brisbane and Women\u2019s Hospital, Herston, QLD 4029, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4342-5300","authenticated-orcid":false,"given":"Helen G.","family":"Healy","sequence":"additional","affiliation":[{"name":"Kidney Health Service, Royal Brisbane and Women\u2019s Hospital, Herston, QLD 4029, Australia"},{"name":"Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia"},{"name":"Conjoint Kidney Research Laboratory, Chemical Pathology\u2014Pathology Queensland, Herston, QLD 4006, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,8,4]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"474","DOI":"10.1111\/sdi.12380","article-title":"Anticoagulation in Chronic Hemodialysis: Progress Toward an Optimal Approach","volume":"28","author":"Kessler","year":"2015","journal-title":"Semin. Dial."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Guery, B., Alberti, C., Servais, A., Harrami, E., Bererhi, L., Zins, B., Touam, M., and Joly, D. (2014). Hemodialysis without systemic anticoagulation: A prospective randomized trial to evaluate 3 strategies in patients at risk of bleeding. PLoS ONE, 9.","DOI":"10.1371\/journal.pone.0097187"},{"key":"ref_3","first-page":"S61","article-title":"Caring for Australians with Renal I: The CARI guidelines. Dialysis adequacy (HD) guidelines","volume":"10","author":"Kerr","year":"2005","journal-title":"Nephrology"},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"European Best Practice Guidelines Expert Group on Hemodialysis, E.R.A. Section V (2002). Chronic intermittent haemodialysis and prevention of clotting in the extracorporal system. Nephrol. Dial. Transplant., 17, 63\u201371.","DOI":"10.1093\/ndt\/17.suppl_7.63"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"2097","DOI":"10.1093\/ndt\/gfg272","article-title":"Optimal anticoagulation strategy in haemodialysis with heparin-coated polyacrylonitrile membrane","volume":"18","author":"Lavaud","year":"2003","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1260","DOI":"10.1038\/ki.2014.225","article-title":"Results of the HepZero study comparing heparin-grafted membrane and standard care show that heparin-grafted dialyzer is safe and easy to use for heparin-free dialysis","volume":"86","author":"Laville","year":"2014","journal-title":"Kidney Int."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"c5","DOI":"10.1159\/000077589","article-title":"Hemodialysis using heparin-bound Hemophan in patients at risk of bleeding","volume":"97","author":"Lee","year":"2004","journal-title":"Nephron Clin. Pract."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"65","DOI":"10.2147\/IJNRD.S43252","article-title":"Intermittent saline flushes or continuous saline infusion: What works better when heparin-free dialysis is recommended?","volume":"6","author":"Zimbudzi","year":"2013","journal-title":"Int. J. Nephrol. Renov. Dis."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1901","DOI":"10.1093\/ckj\/sfaa228","article-title":"Strategies for asymmetrical triacetate dialyser heparin-free effective haemodialysis: The SAFE study","volume":"14","author":"Vandenbosch","year":"2021","journal-title":"Clin. Kidney J."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"707","DOI":"10.1093\/ndt\/gfw461","article-title":"A noninferiority trial comparing a heparin-grafted membrane plus citrate-containing dialysate versus regional citrate anticoagulation: Results of the CiTED study","volume":"32","author":"Meijers","year":"2017","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1053\/j.ajkd.2021.04.004","article-title":"Dialyzer Performance During Hemodialysis Without Systemic Anticoagulation Using a Heparin-Grafted Dialyzer Combined With a Citrate-Enriched Dialysate: Results of the Randomized Crossover Noninferiority EvoCit Study","volume":"79","author":"Francois","year":"2022","journal-title":"Am. J. Kidney Dis."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Francois, K., Wissing, K.M., Jacobs, R., Boone, D., Jacobs, K., and Tielemans, C. (2014). Avoidance of systemic anticoagulation during intermittent haemodialysis with heparin-grafted polyacrilonitrile membrane and citrate-enriched dialysate: A retrospective cohort study. BMC Nephrol., 15.","DOI":"10.1186\/1471-2369-15-104"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"426","DOI":"10.1111\/hdi.12774","article-title":"Hemodialysis without anticoagulation: Less clotting in conventional hemodialysis than in predilution hemodiafiltration","volume":"23","author":"Krummel","year":"2019","journal-title":"Hemodial. Int."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1111\/j.1525-1594.2006.00188.x","article-title":"Activation of coagulation during hemodialysis: Effect of blood lines alone and whole extracorporeal circuit","volume":"30","author":"Lucchi","year":"2006","journal-title":"Artif. Organs"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1093\/ndt\/gfg459","article-title":"Comparative analysis of procoagulatory activity of haemodialysis, haemofiltration and haemodiafiltration with a polysulfone membrane (APS) and with different modes of enoxaparin anticoagulation","volume":"19","author":"Klingel","year":"2004","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"642","DOI":"10.1053\/j.ajkd.2007.02.001","article-title":"Heparin-coated polyacrylonitrile membrane versus regional citrate anticoagulation: A prospective randomized study of 2 anticoagulation strategies in patients at risk of bleeding","volume":"49","author":"Evenepoel","year":"2007","journal-title":"Am. J. Kidney Dis."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"20","DOI":"10.1007\/s00134-011-2438-3","article-title":"Efficacy and safety of regional citrate anticoagulation in critically ill patients undergoing continuous renal replacement therapy","volume":"38","author":"Zhang","year":"2012","journal-title":"Intensive Care Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1186\/s40697-016-0113-x","article-title":"Regional citrate anticoagulation in hemodialysis: An observational study of safety, efficacy, and effect on calcium balance during routine care","volume":"3","author":"Singer","year":"2016","journal-title":"Can. J. Kidney Health Dis."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1161\/CIRCULATIONAHA.113.004768","article-title":"Sex difference in risk of second but not of first venous thrombosis: Paradox explained","volume":"129","author":"Roach","year":"2014","journal-title":"Circulation"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"552","DOI":"10.1093\/ckj\/sfu114","article-title":"Inpatient hemodialysis without anticoagulation in adults","volume":"7","author":"Sahota","year":"2014","journal-title":"Clin. Kidney J."},{"key":"ref_21","first-page":"329","article-title":"Hypotension in hemodialysis secondary to a reaction to synthetic membranes","volume":"38","author":"Blanco","year":"2018","journal-title":"Nefrologia"},{"key":"ref_22","first-page":"707","article-title":"Reaction to synthetic membranes in hemodialysis","volume":"36","year":"2016","journal-title":"Nefrologia"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"267","DOI":"10.1007\/s00228-017-2389-x","article-title":"An evaluation of four modes of low-dose anticoagulation during intermittent haemodialysis","volume":"74","author":"Skagerlind","year":"2018","journal-title":"Eur. J. Clin. Pharmacol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"396","DOI":"10.1111\/j.1525-139X.2005.00078.x","article-title":"Clinical waste generation from renal units: Implications and solutions","volume":"18","author":"Hoenich","year":"2005","journal-title":"Semin. 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