Safety and efficacy of fondaparinux use in hemodialysis patients with heparin-induced thrombocytopenia: a systematic review.

Background: Heparin-induced thrombocytopenia (HIT) is a severe primary hypercoagulable disorder, particularly concerning in hemodialysis (HD) patients frequently exposed to heparin. Fondaparinux has emerged as a potential alternative anticoagulant, though supporting evidence is limited. This systematic review aimed to evaluate the safety and efficacy of fondaparinux in HD patients with HIT.

Methods: We searched PubMed/MEDLINE, Web of Science, Scopus, CENTRAL, ClinicalTrials.gov, and SCIndeks up to March 2, 2025. Eligible studies included clinical trials, observational studies, and case reports/series on fondaparinux use in adult HD patients with HIT. Data on demographics, clinical characteristics, diagnostics, dosing, administration routes, and outcomes were extracted and narratively synthesized.

Results: Seventeen studies with 37 patients (aged 38-88 years) were included. Dosing regimens and monitoring strategies varied widely across dialysis modalities, with the most common initial fondaparinux dose being 2.5 mg/day. Platelet recovery was observed in most cases. Bleeding occurred in 10.8% of patients, thrombotic events in 5.4%, and overall mortality was 16.2%. Vascular access thrombosis was reported in two patients (5.4%) following the initiation of fondaparinux. Some clotting of the extracorporeal circuit was reported during select sessions in 7 patients undergoing non-continuous dialysis modalities (18.9%), including five on high-flux HD, one on unspecified intermittent HD, and one on post-dilution hemodiafiltration.

Conclusions: Fondaparinux may be a potential alternative anticoagulant in HD patients with HIT, especially when first-line agents are unavailable. However, its use should be approached with caution and tailored to individual clinical circumstances, pending confirmation of its safety, efficacy, and optimal dosing and monitoring through larger prospective studies.