Acquired Deficit of Antithrombin and Role of Supplementation in Septic Patients During Continuous Veno-Venous Hemofiltration

Abstract

Continuous renal replacement therapy (CRRT) is widely used in the management of septic patients with acute renal failure (ARF). Short filter lifespan (<24 hours) is a major concern and may result of a procoagulating state. The aim of this study was to investigate the relationship between antithrombin (AT) deficit and early filter clotting, and whether supplementation of AT could increase filter lifespan. Two different methods for supplementation, bolus and continuous infusion were also compared. We conducted a two-center prospective study from March 2003 to May 2004. Twenty-seven patients with septic shock and ARF were included and treated by CRRT. Unfractionated heparin (UHF) was used for anticoagulation. The initial level of AT was low with a median level at 45.4% (16%-69%). Low AT activity was associated with shorter filter lifespan. Supplementation led to a longer filter lifespan (15.2-33.2 hours) (p < 0.05). Continuous infusion provided better results: 48.5 vs. 27.8 hours for bolus method. This study suggests that AT measurement should be considered in continuous veno-venous hemofiltration with clotting problems as supplementation could increase filter lifespan by more than 100%. Continuous infusion is preferable. Cost effectiveness should be evaluated shortly.

Handling Continuous Renal Replacement Therapy-Related Adverse Effects in Intensive Care Unit Patients: The Dialytrauma Concept

“…predilution mode). Nevertheless, some authors advocate a more dynamic approach to assure circuit patency [55], based on decreasing filtration fraction by adding diffusion as part of the dose, epoprostenol administration, assessment of antithrombin III activity [56] and regional anticoagulation with citrate. Interestingly, citrate anticoagulation has been linked to optimal circuit patency and a better outcome [57].…”

Citrate Formulation Determines Filter Lifespan during Continuous Veno-Venous Hemofiltration: A Prospective Cohort Study

“…However, patients receiving Prismocitrate 18/0 had a significantly lower time-averaged TMP. TMP is a widely accepted substitute for filter functionality [25,26] and is considered to be more relevant for evaluating filter clotting and clogging than, for instance, assessing the pressure drop inside the filter [6,19] . A higher citrate concentration may lower TMP by more efficiently counteracting filter clogging and protein cake formation [13] .…”

“…Secondary outcomes included (1) differences in time-averaged changes in transmembranous pressure (TMP); (2) differences in post-circuit ionized calcium and hematocrit levels; and (3) changes in serial blood platelet counts. We also assessed any predictive determinants for filter clotting and clogging [3,6,8] .…”

“…Apart from mechanical strategies, efforts were undertaken to enhance the anticoagulant activity of unfractionated heparin (UFH) by supplementing antithrombin III [6] or aprotinin [7] . Prostacyclin has been shown to en-hance the effect of UFH to increase filter lifespan while enabling a reduction in the delivered dose of UFH to reduce bleeding risk [8][9][10] .…”

Heparinresistenz und Antithrombinmangel*

“…Ansonsten liegen insgesamt wenige Publikationen zur HR bei Hämodialyse vor. Zwei französische Gruppen [77,78] beschrieben, dass sich bei Patienten mit septischem Schock durch die kombinierte Gabe von UFH und AT der vorzeitige thrombotische Verschluss des CVVH-Filters verhindern ließ.…”