Anticoagulation in CRRT
Critically ill patients develop acute kidney injury (AKI) and fluid overload as a complication of their illness quickly in their disease course. Many of these patients are hemodynamically unstable and are not candidates for routine intermittent hemodialysis. Continuous renal replacement therapy (CRRT) is a favored modality used to treat these patients while their kidneys recover. Unfractionated heparin has been widely used as a systemic anticoagulant to help extend the CRRT filter life and prevent any unintended interruptions in dialysis. However, systemic anticoagulation with heparin has its negative consequences like life-threatening bleeding and development of heparin-induced thrombocytopenia.
In 1990, Mehta et al. (Kidney Int 38:976–981, 1990) described a technique of regional anticoagulation using trisodium citrate. Since then multiple studies in both adults and children have tried to compare the efficacy and safety of the regional citrate anticoagulation (RCA) protocol versus systemic anticoagulation with heparin. Schilder et al. (Crit Care 18:472, 2014), recently in a large multicenter randomized control trial demonstrated that renal outcome and patient mortality were similar for citrate and heparin anticoagulation during CVVH in the critically ill patient with AKI. However, citrate was superior in terms of safety, efficacy, and costs.
In this chapter, we review the background and protocols for heparin and regional citrate anticoagulation, and a newer approach to CRRT anticoagulation-prostacyclin. We review a brief history and development of these protocols, and attempt to compare the efficacy of each of these techniques in improving circuit survival and decrease in cost.
KeywordsCRRT Prostacyclin Heparin Anticoagulation Pediatric Citrate Acute kidney injury Acute renal failure Renal replacement therapies Regional citrate anticoagulation
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