Anticoagulation strategies in continuous renal replacement therapy: can the choice be evidence based?

Straaten, Heleen M. Oudemans–van; Wester, J. P. J.; Pont, Anne-Cornélie J. M.; Schetz, Miet

doi:10.1007/s00134-005-0044-y

Cited by 123 publications

(116 citation statements)

References 108 publications

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“…4,5,18 Patients admitted to ICU, however, present an increased risk of bleeding associated with multiple organ dysfunction syndrome and its consequences, disseminated intravascular coagulation, thrombocytopenia, hepatic failure, and uremia. 19 Several anticoagulant drugs have been employed in CRRT, such as UFH, LMWH, trisodium citrate, prostacyclin among others.…”

Section: Discussionmentioning

confidence: 99%

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Enoxaparin versus unfractioned heparin as anticoagulant for continuous venovenous hemodialysis: a randomized open-label trial

et al. 2010

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Aim: In this study we aimed to compare the efficacy and safety of enoxaparin with unfractioned heparin (UFH) as anticoagulant for continuous venovenous hemodialysis (CVVHD). Methods: An open-label randomized controlled trial was carried out in an intensive care unit (ICU) where 40 patients with acute renal failure (ARF) who needed continuous renal replacement therapy were randomized to receive UFH (n = 21) or enoxaparin (n = 19). Coagulation parameters were evaluated, and antithrombotic activity of UFH was measured by activated partial thromboplastin time (aPTT) and for enoxaparin by anti-factor Xa activity. Primary outcomes were thrombosis of the extracorporeal circuit and bleeding, classified as major or minor. Results: Minor bleeding episodes were observed only in patients anticoagulated with enoxaparin (26 vs. 0%, p = 0.018). Comparing patients with or without bleeding after 24 hours of therapy, the level of anticoagulation tended to be higher (anti-factor Xa: 1.62 vs. 1.13 IU/mL, p = 0.09) and the platelet count to be lower [107 ± 53 vs. 229 ± 84 (×10 3 /μL), p = 0.09] in patients who bled, but without statistical difference. Filter life span of enoxaparin and UFH groups was similar (43 ± 15 vs. 52 ± 18 hr, p = 0.10), as well as the proportion of circuit clotting. Conclusion: Weightunadjusted enoxaparin in patients with ARF in CVVHD was associated with an increased rate of bleeding, a finding that addresses the need to adjust drug dose and to monitor anti-factor Xa activity during dialysis. No benefit to prolong dialysis circuit survival was found with enoxaparin. In patients who do not present contraindication for systemic anticoagulation, UFH remains an effective and low-cost option.

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Section: Discussionmentioning

confidence: 99%

“…However, circuit survival time will be shorter. 4 Unfractioned heparin (UFH) is the most widely used anticoagulant. 5 Theoretical advantages are its low-cost, short half-life, easy reversion of its effect with protamine, and easy monitoring by the activated partial thromboplastin time (aPTT).…”

Section: Introductionmentioning

confidence: 99%

Enoxaparin versus unfractioned heparin as anticoagulant for continuous venovenous hemodialysis: a randomized open-label trial

et al. 2010

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“…However, a high incidence of hemorrhagic complications has been documented in patients undergoing RRT in the intensive care unit (ICU), with wide variability (5%-30%) related to differences in patient populations and anticoagulation protocols (4)(5)(6)(7). Thus, the choice of the anticoagulant strategy, possibly limited to the extracorporeal circuit (i.e., regional anticoagulation), represents a key issue for safe and effective RRT in AKI.…”

Section: Introductionmentioning

confidence: 99%

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Morabito

Pistolesi

Tritapepe

et al. 2014

Clinical Journal of the American Society of Nephrology

124

130

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Hemorrhagic complications have been reported in up to 30% of critically ill patients with AKI undergoing RRT with systemic anticoagulation. Because bleeding is associated with significantly increased mortality risk, strategies aimed at reducing hemorrhagic complications while maintaining extracorporeal circulation should be implemented. Among the alternatives to systemic anticoagulation, regional citrate anticoagulation has been shown to prolong circuit life while reducing the incidence of hemorrhagic complications and lowering transfusion needs. For these reasons, the recently published Kidney Disease Improving Global Outcomes Clinical Practice Guidelines for Acute Kidney Injury have recommended regional citrate anticoagulation as the preferred anticoagulation modality for continuous RRT in critically ill patients in whom it is not contraindicated. However, the use of regional citrate anticoagulation is still limited because of concerns related to the risk of metabolic complications, the complexity of the proposed protocols, and the need for customized solutions. The introduction of simplified anticoagulation protocols based on citrate and the development of dialysis monitors with integrated infusion systems and dedicated software could lead to the wider use of regional citrate anticoagulation in upcoming years.

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“…The most common way of preventing blood from clotting is systemic administration of anticoagulants, which, however, is not feasible in at risk patients. In these cases, alternative methods are often used including regional anticoagulation, minimal heparinization, use of prostaglandins or circuit saline flushes at regular intervals [2,3]. Unfortunately, none of these methods is optimal, as it is costly, inadequately effective, or associated with metabolic risks [2].…”

Section: Introductionmentioning

confidence: 99%

“…Twelve anesthetized and ventilated pigs were randomized to receive either 6 h of CVVH with application of this device (COOL; n = 6) or without it (CONTR; n = 6). Measurements: Before the procedure and in 15, 60, 180, 360 min after starting hemofiltration variables related to: (1) circuit patency [time to clotting (TC), number of alarm-triggered pump stopping (AS), venous and transmembranous circuit pressures (VP, TMP)], (2) coagulation status in the extracorporeal circuit [thrombin-antithrombin complexes (TAT circ ), thromboelastography (TEG)] and (3) animal status (hemodynamics, hemolysis and biochemistry) were assessed.…”

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confidence: 99%

Regional cooling of the extracorporeal blood circuit: a novel anticoagulation approach for renal replacement therapy?

et al. 2008

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Objective: To test the hypothesis that cooling of blood in the extracorporeal circuit of continuous veno-venous hemofiltration (CVVH) enables to realize the procedure without the need of anticoagulation. Design: Experimental animal study. Methods: We developed the device for selective cooling of extracorporeal circuit (20°C) allowing blood rewarming (38°C) just before returning into the body. Twelve anesthetized and ventilated pigs were randomized to receive either 6 h of CVVH with application of this device (COOL; n = 6) or without it (CONTR; n = 6). Measurements: Before the procedure and in 15, 60, 180, 360 min after starting hemofiltration variables related to: (1) circuit patency [time to clotting (TC), number of alarm-triggered pump stopping (AS), venous and transmembranous circuit pressures (VP, TMP)], (2) coagulation status in the extracorporeal circuit [thrombin-antithrombin complexes (TAT circ ), thromboelastography (TEG)] and (3) animal status (hemodynamics, hemolysis and biochemistry) were assessed. Results:The patency of all circuits treated with selective cooling was well maintained within the observation period. By contrast, five of six sessions were prematurely clotted in the untreated group. As a result, the number of AS was significantly higher in the CONTR group. In-circuit thrombus generation in CONTR group was associated with a markedly increasing TAT circ . TEG performed at 180 min of the procedure revealed a tendency to a prolonged initial clotting time and a significant decrease in clotting rate of in-circuit blood in the COOL group. No signs of repeated cooling/rewarming-induced hemolysis were observed in animals treated with ''hypothermic circuit'' CVVH. Conclusion: In this porcine model, regional extracorporeal blood cooling proved effective in preventing in-circuit clotting without the need to use any other anticoagulant.

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Anticoagulation strategies in continuous renal replacement therapy: can the choice be evidence based?

Cited by 123 publications

References 108 publications

Enoxaparin versus unfractioned heparin as anticoagulant for continuous venovenous hemodialysis: a randomized open-label trial

Enoxaparin versus unfractioned heparin as anticoagulant for continuous venovenous hemodialysis: a randomized open-label trial

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Regional cooling of the extracorporeal blood circuit: a novel anticoagulation approach for renal replacement therapy?

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