1. blood clot in the dialyzer . It is usual but you can prevent by (1) increased heparin dosage (2) check your dialyzer KUF data (high KUF easily induce hemocentration and induce blood clot) 3. check your dialyzer manufacture ( for example BS series( toray) induce more blood clot compared with TS seriseries (3) use other anti-blood clot methods such saline flushing , low molecule weight ehparin or regional citrate or other new regimens)

Nephrol Dial Transplant (2005) 20: 1789–1790

doi:10.1093/ndt/gfi016

Advance Access publication 26 July 2005

Melagatran anticoagulation during haemodialysis—‘Primum

non nocere’

Michael J. Flanigan

University of Iowa Hospitals, Iowa City, USA

check your UF data --- you can use slow uf ( for exampe 4 kgw--- 1kg/hour ,instead of 2 kg in the inital first hour , then tapered).

Patient related such as the hematological factors (high hb, high platelets), hypovolemia, under dosing with anticoagulants, low QBs especially if coupled with machine start-stop often associated with an under-performing vascular access. An improperly primed dialysis circuit can also contribute.

If it is happening for lots of patients and it is a new problem, see what has changed - dialyser, machines, staff, priming protocol, anticoagulant etc. Also spend a it more time clearing air from the dialyser. If it is just one patient, are they having a lot of blood side alarms (stationary blood)? If not, check coagulation. Any new meds? Try increasing heparin?

Check appropriateness of your UFR by a blood volume monitor or measure haematocrit at the HD start and end. High increase would mean the blood gets to dense and will have higher tendency to clotting. Check also for presence of any air bubbles in the arterial head - they may block blood pasage through some fibres. Temporary turning of the dialyzer with the venous outflow up may help to get rid of the air bubbles in the blood path.

Franta Lopot, General University Hospital, Prague

Are you using anticoagualation during treatment sessions? If you are using Heparin what is the dose you use for Bolus at the initiation of treatment and what is the rate of your continuous infusion? In our unit we use 15-20 units per Kg Body weight for bolus and 5-10 units per kg per hour infusion of Heparin.

We've used low molecular weight heparin (tinzaparin) since the price dropped dramatically because our hospital made it the standard prophylaxis for VTE. Normally we start with the smallest pre-filled syringe 2500 units and increase to 3500 or 4500 units if necessary. For HIT we try Citrasate first and add fondaparinux if needed.