A systematic review of 11 retrospective studies found nafamostat mesilate was used for ECMO anticoagulation primarily due to bleeding risk, with hyperkalemia occurring in 15%-18% of patients.
Systematic Review
Is nafamostat mesilate a safe and effective alternative to unfractionated heparin for anticoagulation during ECMO in patients with high bleeding risk?
Nafamostat mesilate is used as an alternative anticoagulant during ECMO for patients at high bleeding risk, but evidence is limited to retrospective studies with conflicting efficacy and a risk of hyperkalemia.
BACKGROUND: Extracorporeal membrane oxygenation (ECMO) represents an advanced option for supporting refractory respiratory and/or cardiac failure. Systemic anticoagulation with unfractionated heparin (UFH) is routinely used. However, patients with bleeding risk and/or heparin-related side effects may necessitate alternative strategies: among these, nafamostat mesilate (NM) has been reported. METHODS: We conducted a systematic literature search (PubMed and EMBASE, updated 12/08/2021), including all studies reporting NM anticoagulation for ECMO. We focused on reasons for starting NM, its dose and the anticoagulation monitoring approach, the incidence of bleeding/thrombosis complications, the NM-related side effects, ECMO weaning, and mortality. RESULTS: The search revealed 11 relevant findings, all with retrospective design. Of these, three large studies reported a control group receiving UFH, the other were case series (n = 3) or case reports (n = 5). The main reason reported for NM use was an ongoing or high risk of bleeding. The NM dose varied largely as did the anticoagulation monitoring approach. The average NM dose ranged from 0.46 to 0.67 mg/kg/h, but two groups of authors reported larger doses when monitoring anticoagulation with ACT. Conflicting findings were found on bleeding and thrombosis. The only NM-related side effect was hyperkalemia (n = 2 studies) with an incidence of 15%-18% in patients anticoagulated with NM. Weaning and survival varied across studies. CONCLUSION: Anticoagulation with NM in ECMO has not been prospectively studied. While several centers have experience with this approach in high-risk patients, prospective studies are warranted to establish the optimal space of this approach in ECMO.
Sanfilippo et al. (Mon,) conducted a systematic review in Extracorporeal membrane oxygenation (ECMO). Nafamostat mesilate vs. Unfractionated heparin (UFH) was evaluated on Incidence of bleeding/thrombosis complications, NM-related side effects, ECMO weaning, and mortality. A systematic review of 11 retrospective studies found nafamostat mesilate was used for ECMO anticoagulation primarily due to bleeding risk, with hyperkalemia occurring in 15%-18% of patients.