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Purpose <p>Anticoagulation is essential in hemodialysis (HD) to maintain circuit patency and reduce thromboembolic risk. Common options include unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), regional citrate anticoagulation (RCA), and direct oral anticoagulants (DOACs). This review synthesizes current evidence on these agents in HD, emphasizing efficacy, safety, cost, administration, and remaining knowledge gaps.</p> Methods <p>We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidance and predefined inclusion and exclusion criteria. Interventions included DOACs, LMWH, UFH, RCA, nafamostat, and heparin-free strategies. Typical comparators were VKAs, saline flush protocols, or other anticoagulant classes. Eligible studies reported at least one outcome of interest: circuit patency, bleeding events, cost effectiveness, or identified gaps in the literature.</p> Results <p>DOACs particularly apixaban and rivaroxaban demonstrated efficacy comparable to VKAs for thromboembolic prevention. UFH and LMWH showed similar effectiveness in maintaining circuit patency, and RCA and nafamostat provided alternatives for patients at high bleeding risk. Safety profiles generally favored DOACs and RCA, with lower rates of major bleeding than warfarin and UFH/LMWH. Practical considerations indicated that UFH was often the most cost-effective option, whereas DOACs offered the convenience of oral administration at higher drug costs. Important evidence gaps persist, including limited long term comparative studies and few placebo-controlled trials.</p> Conclusion <p>Anticoagulant selection in HD should balance efficacy, safety, cost, administration, and monitoring, tailored to patient risk profiles and institutional resources. Future research should prioritize head-to-head comparisons, long term outcomes, cost effectiveness, and the effects of anticoagulation strategies on dialysis adequacy to support more precise clinical decision making.</p>

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Anticoagulation approaches in hemodialysis: a systematic review of efficacy, safety, and literature gap

  • 期刊论文

  • 发表日期：

    2026年2月1日

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  • Areej I. Alhazmi

摘要

Purpose

Anticoagulation is essential in hemodialysis (HD) to maintain circuit patency and reduce thromboembolic risk. Common options include unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), regional citrate anticoagulation (RCA), and direct oral anticoagulants (DOACs). This review synthesizes current evidence on these agents in HD, emphasizing efficacy, safety, cost, administration, and remaining knowledge gaps.

Methods

We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidance and predefined inclusion and exclusion criteria. Interventions included DOACs, LMWH, UFH, RCA, nafamostat, and heparin-free strategies. Typical comparators were VKAs, saline flush protocols, or other anticoagulant classes. Eligible studies reported at least one outcome of interest: circuit patency, bleeding events, cost effectiveness, or identified gaps in the literature.

Results

DOACs particularly apixaban and rivaroxaban demonstrated efficacy comparable to VKAs for thromboembolic prevention. UFH and LMWH showed similar effectiveness in maintaining circuit patency, and RCA and nafamostat provided alternatives for patients at high bleeding risk. Safety profiles generally favored DOACs and RCA, with lower rates of major bleeding than warfarin and UFH/LMWH. Practical considerations indicated that UFH was often the most cost-effective option, whereas DOACs offered the convenience of oral administration at higher drug costs. Important evidence gaps persist, including limited long term comparative studies and few placebo-controlled trials.

Conclusion

Anticoagulant selection in HD should balance efficacy, safety, cost, administration, and monitoring, tailored to patient risk profiles and institutional resources. Future research should prioritize head-to-head comparisons, long term outcomes, cost effectiveness, and the effects of anticoagulation strategies on dialysis adequacy to support more precise clinical decision making.