Anticoagulation strategies in continuous kidney replacement therapy — does one size fit all?

Deep, Akash

doi:10.1007/s00467-022-05567-5

Cited by 5 publications

(4 citation statements)

References 14 publications

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“…First, there is the risk of CRRT circuit clotting because of lower blood flow (4). Any "downtime" in CRRT as a result of circuit clotting also reduces exposure to treatment and increases the risk of morbidity and mortality (5)(6)(7). Second, there is the problem that liver disease leads to abnormal coagulation, but anticoagulation during CRRT still needs titration because of the procoagulant, prothrombotic state of these patients (8)(9)(10)(11).…”

mentioning

confidence: 99%

Epoprostenol (Prostacyclin Analog) as a Sole Anticoagulant in Continuous Renal Replacement Therapy for Critically Ill Children With Liver Disease: Single-Center Retrospective Study, 2010–2019*

Deep,

Alexander,

Khatri

et al. 2023

Pediatric Critical Care Medicine

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OBJECTIVES: Despite deranged coagulation, children with liver disease undergoing continuous renal replacement therapy (CRRT) are prone to circuit clotting. Commonly used anticoagulants (i.e., heparin and citrate) can have side effects. The aim of this study was to describe our experience of using epoprostenol (a synthetic prostacyclin analog) as a sole anticoagulant during CRRT in children with liver disease. DESIGN: Single-center, retrospective study, 2010–2019. SETTING: Sixteen-bedded PICU within a United Kingdom supra-regional center for pediatric hepatology. PATIENTS: Children with liver disease admitted to PICU who underwent CRRT anticoagulation with epoprostenol. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Regarding CRRT, we assessed filter life duration, effective 60-hour filter survival, and effective solute clearance. We also assessed the frequency of major or minor bleeding episodes per 1,000 hours of CRRT, the use of platelet and RBC transfusions, and the frequency of hypotensive episodes per 1,000 hours of CRRT. In the 10 years 2010–2019, we used epoprostenol anticoagulation during 353 filter episodes of CRRT, lasting 18,508 hours, in 96 patients (over 108 admissions). Median (interquartile range [IQR]) filter life was 48 (IQR 32–72) hours, and 22.9% of filters clotted. Effective 60-hour filter survival was 60.5%.We identified that 5.9% of filters were complicated by major bleeding (1.13 episodes per 1,000 hr of CRRT), 5.1% (0.97 per 1,000 hr) by minor bleeding, and 11.6% (2.22 per 1,000 hr) by hypotension. There were no differences in filter life or clotting between patients with acute liver failure and other liver diseases; there were no differences in rates of bleeding, hypotension, or transfusion when comparing patients with initial platelets of ≤ 50 × 109 per liter to those with a higher initial count. CONCLUSIONS: Epoprostenol, or prostacyclin, as the sole anticoagulant for children with liver disease receiving CRRT in PICU, results in a good circuit life, and complications such as bleeding and hypotension are similar to reports using other anticoagulants, despite concerns about coagulopathy in this cohort.

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confidence: 99%

Epoprostenol (Prostacyclin Analog) as a Sole Anticoagulant in Continuous Renal Replacement Therapy for Critically Ill Children With Liver Disease: Single-Center Retrospective Study, 2010–2019*

Deep,

Alexander,

Khatri

et al. 2023

Pediatric Critical Care Medicine

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“…A Cochrane review found UFH for VTE prophylaxis did not have a statistically signi cant difference in new or extended IVH [41]. Newer anticoagulation agents for this population have been reported including prostacyclin and bivalirudin [42].…”

Section: Access and Anticoagulationmentioning

confidence: 99%

Clearance and Nutrition in Neonatal Continuous Renal Replacement Therapy (CRRT) Using the CARPEDIEM™ System

Vuong,

Vega,

Casey

et al. 2023

Preprint

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Background: Infants with end stage kidney disease (ESKD) demonstrate poor growth partly due to obligate fluid and protein restrictions. Delivery of liberalized nutrition on continuous renal replacement therapy (CRRT) is impacted by clinical instability, technical dialysis challenges, solute clearance, and nitrogen balance. We analyzed delivered nutrition and growth in infants receiving CRRT with the Cardio-Renal, Pediatric Dialysis Emergency Machine (CARPEDIEM™). Methods: Single center observational study of infants receiving CRRT with the CARPEDIEM™ between June 1 and December 31, 2021. We collected prospective circuit characteristics, delivered nutrition, anthropometric measurements, and illness severity Score for Neonatal Acute Physiology-II. As a surrogate to normalized protein catabolic rate in maintenance hemodialysis, we calculated normalized protein nitrogen appearance (nPNA) using the Randerson II continuous dialysis model. Descriptive statistics, Spearman correlation coefficient, Mann Whitney, Wilcoxon signed rank, Receiver-Operating Characteristic curves, and Kruskal-Wallis analysis were performed using SAS version 9.4. Results: Eight infants received 31.9 [22.0, 49.7] days of CRRT using mostly (90%) regional citrate anticoagulation. Delivered nutritional volume, protein, calories, enteral calories, nPNA, and nitrogen balance increased on CRRT. Using parenteral nutrition, 90 ml/kg/day should meet caloric and protein needs. Following initial weight loss of likely fluid overload, weight gain occurred after 14 days of CRRT. Despite adequate nutritional delivery, goal weight (z-score=0) and growth velocity were not achieved. Most (62.5%) survived and transitioned to peritoneal dialysis (PD). Conclusions: CARPEDIEM™ is a safe and efficacious bridge to PD in neonatal ESKD. Growth velocity of infants on CRRT appears delayed despite delivery of adequate calories and protein.

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“…The efficacy of CRRT is directly related to the longevity of the circuit as clotting of the circuit increases downtime, leads to blood loss of the patient, and may cause hemodynamic instability during de- and reconnection and increased costs [ 47 , 64 , 65 ]. To increase CL, anticoagulation of the extracorporeal circuit is necessary.…”

Section: Key Aspects Of Crrt Deliverymentioning

confidence: 99%

Continuous renal replacement therapy in neonates and children: what does the pediatrician need to know? An overview from the Critical Care Nephrology Section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

Cortina,

Daverio,

Demirkol

et al. 2023

Eur J Pediatr

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Continuous renal replacement therapy (CRRT) is the preferred method for renal support in critically ill and hemodynamically unstable children in the pediatric intensive care unit (PICU) as it allows for gentle removal of fluids and solutes. The most frequent indications for CRRT include acute kidney injury (AKI) and fluid overload (FO) as well as non-renal indications such as removal of toxic metabolites in acute liver failure, inborn errors of metabolism, and intoxications and removal of inflammatory mediators in sepsis. AKI and/or FO are common in critically ill children and their presence is associated with worse outcomes. Therefore, early recognition of AKI and FO is important and timely transfer of patients who might require CRRT to a center with institutional expertise should be considered. Although CRRT has been increasingly used in the critical care setting, due to the lack of standardized recommendations, wide practice variations exist regarding the main aspects of CRRT application in critically ill children. Conclusion: In this review, from the Critical Care Nephrology section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC), we summarize the key aspects of CRRT delivery and highlight the importance of adequate follow up among AKI survivors which might be of relevance for the general pediatric community. What is Known:• CRRT is the preferred method of renal support in critically ill and hemodynamically unstable children in the PICU as it allows for gentle removal of fluids and solutes.• Although CRRT has become an important and integral part of modern pediatric critical care, wide practice variations exist in all aspects of CRRT. What is New:• Given the lack of literature on guidance for a general pediatrician on when to refer a child for CRRT, we recommend timely transfer to a center with institutional expertise in CRRT, as both worsening AKI and FO have been associated with increased mortality.• Adequate follow-up of PICU patients with AKI and CRRT is highlighted as recent findings demonstrate that these children are at increased risk for adverse long-term outcomes.

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Anticoagulation strategies in continuous kidney replacement therapy — does one size fit all?

Cited by 5 publications

References 14 publications

Epoprostenol (Prostacyclin Analog) as a Sole Anticoagulant in Continuous Renal Replacement Therapy for Critically Ill Children With Liver Disease: Single-Center Retrospective Study, 2010–2019*

Epoprostenol (Prostacyclin Analog) as a Sole Anticoagulant in Continuous Renal Replacement Therapy for Critically Ill Children With Liver Disease: Single-Center Retrospective Study, 2010–2019*

Clearance and Nutrition in Neonatal Continuous Renal Replacement Therapy (CRRT) Using the CARPEDIEM™ System

Continuous renal replacement therapy in neonates and children: what does the pediatrician need to know? An overview from the Critical Care Nephrology Section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

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