Please help - Alternatives to (pork) heparin

[aharris2]

I am sure this has been written about before, but please help.

A young man started dialysis today and suddenly became aware that he was about to be given pork heparin. He objected on religious grounds and asked if there was an alternative. The charge nurse said no and gave him horror stories about clotting off and basically coerced him into using it.

I know there are alternatives, not alternative heparins (are there?) but alternative approaches to preventing "clotting off". Haven't I read here about allergies and sensitivities to heparins and what was done instead?

I gave the young man the address for IHD. Hopefully he will join us. Even if he doesn't, I would like to print out your replies and give them to him (hopefully before his next session) so that he can work from a position of strength and make informed decisions.

Thanks in advance everyone!

Alene

[willieandwinnie]

Alene, when my husband was doing dialysis he was allergic to pork heparin and the clinic order another kind. I am looking through our stuff to see if I can find it. I think that is just horrible that the center is doing that to him. I will post when I locate the information. 

I knew I had it. It's beef. and there is also a synthetic heparin. He really needs to speak up. Hope this information helps. I'm sure others when chime in on this. 

[okarol]

In general, practicing Muslims avoid eating pork or drinking alcohol, and are proscribed from taking medicines that contain alcohol or pig byproducts unless they are life-saving drugs and no substitute is available. Porcine heparin, for example, contains gelatin from pork products, and is the only heparin universally used.

"That was thought to cause a potential problem for Jewish, Muslim, and Seventh-day Adventist patients at this institution," says Doha Hamza, the coordinator of Muslim volunteers at the spiritual care service department at Stanford (CA) University Medical Center. "We investigated the issue with an imam and a Muslim doctor who concurred that the use of porcine heparin is lawful because of the chemical modification the product undergoes and the urgent need involved. Also the amount is so small, it doesn't fit the definition of consumption." Similar solutions might be found for insulin products derived from pork and porcine heart valves.

this is from: http://globalrph.mediwire.com/main/Default.aspx?P=Content&ArticleID=158977 Cultural Competence: Caring for your Muslim patients
Source: Medical Economics - By: Dorothy L. Pennachio - Originally published: May 6, 2005

[boxman55]

I get no heparin I take warfarin each day to keep my blood thin and they run me on a citrasate bath when I am hooked up. I am allergic to hep...Boxman

[glitter]

My Mom doesnt eat pork either, recently when she was in the hospital (she has COPD) they were giving her heparin- I realized it had pork in it also- which she considers unclean- I regret to say I did not tell her- I didn't want her to panic- and they had told us she was dying (she isnt and is doing well) the nurse also told me there was no subsitute. I didn't know what to do- Thanks for your reply Box- are there any other alternatives?

[qwerty]

For our patients that cant or wont use heparin we pre-treat the dialyzer with 3000u during recirculation and ensure to dump all the prime before we hook them up. This way they are recieving NO heparin. Only the dialyzer fibers are being prepared to help prevent clotting. We then give normal saline bolus 50-100ml every 30min when we do vitals to assist in keeping the dialyzer clear. This generally works for us without issue. Hope this helps.

[monrein]

http://www.medscape.com/viewarticle/569831

Also, as qwerty has said, heparin can be used in the prime at which time it adheres to the dialyzer membrane preventing clotting but none goes into the patient.  I've also heard of beef heparin and this product (mentioned in the above link) made from the heads of leeches.

[nursewratchet]

As Boxman said, Citrasate Bath is the only alternative to Heparin.  The Beef Heparin is no longer in use.  Saline flushes will help to an extent.  But barring heparin altogether, you have to use Citrasate Bath.  You have to watch your calcium levels, if it always runs low, you cna't use it.  We have several people allergic to Heparin, it's the acceptable alternative.  That nurse needs an inservice...

[paddbear0000]

made from the heads of leeches.

Ewwwwwwww!!!  Sorry, but it had to said! 

[monrein]

That was what they used when dialysis was first invented.  It's a very effective anticoagulant as that is how the leeches are able to feed on animal blood.  Their saliva contains the anti-clotting agent so the blood flows freely til they're full and then they drop off.  They were a bit of a nuisance for us when trekking in Nepal and also canoeing in Northern Canada.  No more disgusting than heparin from pig's intestines, I reckon.

[nursewratchet]

AAAWWWWW Monrein, always a wealth of information.  When you think about it, most of medicine, and it's beginning is or was disgusting.   

[kitkatz]

Like dialysis is not already disgusting 

[paddbear0000]

I have no problems with the prok heparin; I eat pigs! Leeches, not so much.   

[monrein]

Do you eat pork's intestines?  Probably not so much.  I find it extremely fascinating how nature contains so much that is useful to us and I personally don't find any of these things disgusting.  Leeches have their place in the ecosystem and are interesting little critters in their own right. 

Medicinal leeches have long been used for a number of therapeutic reasons and that's something to be grateful for.  In the interest of full disclosure, I myself have a dead girl's kidney in me that gave me 23 years of excellent quality of life so I don't disgust easily.

http://www.leeches.biz/  (More info on the usefulness of leeches and their saliva).

[paddbear0000]

I was just trying to be funny! 

[monrein]

I know that Paddbear and I chuckled at your comment too.  My friends get the same "more information" response from me when they say "eww" about my fistula.  Typing is a tricky interaction because we don't get to see each other as we "talk".   

[okarol]

I have no problems with the prok heparin; I eat pigs! Leeches, not so much.   

 

[aharris2]

Thanks to all who replied. I will be printing the thread out and carrying it with us tomorrow.

One more question - Qwerty wrote about pretreating the dialyzer during recirculation. Does that apply to reuse dialyzers only or can it be done with single use filters too? I have become a big advocate of single use based on improper care of the reusables that I have seen.

[nursewratchet]

Can be done for both.  My center is totally NON Reuse.  We do it on some that have clotting problems, though there is a school of thought that says heparin must bind to the protein in blood to be effective.  We do however have some on Citrasate bath.  Also an anticoagulant, blood thinner, for heparin allergies.  It would cause the same bleeding though.

[kitkatz]

I am on non reuse in a reuse facility. I am allergic either to the renalyn use din reuse or to dialyzer fibers in certain dialyzers.  I have bronze/brown topped dialyzer and they have to special order the just for little old me!

[swramsay]

I don't get heparin due to low platelets. I receive 100cc saline flushes every 30 minutes with citrate blocks in the catheter after. I still clot fairly often - sometimes in the machine and sometimes in the catheter itself requiring replacement. They tried 15 minute flushes with no better results but will try that again starting Monday because I clotted again yesterday.

[nursewratchet]

I don't get heparin due to low platelets. I receive 100cc saline flushes every 30 minutes with citrate blocks in the catheter after. I still clot fairly often - sometimes in the machine and sometimes in the catheter itself requiring replacement. They tried 15 minute flushes with no better results but will try that again starting Monday because I clotted again yesterday.

  Ask if they can do a citrisate bath.  I am not sure, but I don't think it affects platelets the same way.  I could be wrong   

[qwerty]

Many clinics may not use citrisates. I inquired about it for our clinic and also was told no way as "too expensive". Nor does any of the Davita clinics in my area. American Renal care in my area doesnt utilize it either. It may not be an option for many patients.  I have pretty good success with pretreatment of the dialyzer membranes as long as we follow with the flushes every half hour. On occasion I have a patient I have to do every 15min. We just add it to the goal. We are strictly dry packs (non-reuse) also.  Most of the time I find clotting issues with the lines when staff fail to ensure all the air is removed from the dialyzer during prime or missing a flush or two as they go or rather than intervene on a bad cannulation they just reduce the blood flow. There are many contributors to clotting issues other than the patient.  I also find if they dont flush the catheters properly post treatment to prevent a "backflow" into the catheter causes issues leading to clotting or diminished flow.

[swramsay]

I'll ask about the citrisate bath. I'm assuming that is a dialysate? I am looking at my chart and the Dialysate says: K: 3.0 (changed to 1K Monday since my potassium was 6.8 ), Ca: 2.5, HCO3: 35.0

I found a new nephrologist this week and when I met with him he commented on the blood flow rate & dialysate flow rates that I have of 500 & 800 respectively. He was surprised with the high rate using a catheter. I have an abnormally high Kt/V yet I still feel pretty toxic and my counts aren't good. He suspects I am cleaning the same blood over and over because of recirculation from the catheter. It makes sense to me I guess. Just curious to know what kind of flow rates most people with catheters have?

[okarol]

We got this email today:

I am not really all that interested in registering, I just wanted to
reply to one question found on this thread:
http://ihatedialysis.com/forum/index.php?PHPSESSID=8ea3ad064b8ff21cc241b077f3b3a421&topic=11851.0

I wanted to let people know that there is an alternative the porcine
based heparin products and that is Arixtra, a totally synthetic
formulation of fondaparinux sodium made by Glaxo Smith Kline.  It was
developed specifically as an anti-clotting agent for treatment &
prevention of VTE, DVT and PE.

I recently was asked to use LMW heparin products and objected as I am
vegan.  At first I was told there was no alternative, but then I found
Arixtra and discussed it with the consultant doctor & pharmacist, both
of whom agreed it was suitable in my case.

So, please pass that info on to the discussion thread and let people
know that they should discuss Arixtra with the health care givers.
(and no, I don't work for GSK).

Thanks