Coagulation, Fibrinolysis and Inhibitors in Failing Filters during Continuous Venovenous Hemofiltration in Critically Ill Patients with Acute Kidney Injury: Effect of Anticoagulation Modalities

Abstract

Introduction: The mechanisms of early filter failure and clotting with different anticoagulation modalities during continuous venovenous hemofiltration (CVVH) are largely unknown. Methods: Citrate, heparin and no anticoagulation were compared. Blood was drawn pre- and post filter up to 720 min. Concentrations of the thrombin-antithrombin (TAT), activated protein C-protein C inhibitor (APC-PCI), and type I plasminogen activator inhibitor (PAI-1) were determined. Results: In case of early filter failure (<24 h), inlet concentrations of TAT and APC-PCI were higher over time, irrespective of anticoagulation. There was more production of APC-PCI and platelet-derived PAI-1 in the filter after 10 min in the heparin group than in other groups. In clotting filters, production of APC-PCI and PAI was also higher with heparin than citrate. Conclusion: Coagulation activation in plasma and inhibition of anticoagulation in plasma and filter may partly determine early CVVH filter failure due to clotting, particularly when heparin is used. Regional anticoagulation by citrate circumvents the inhibition of anticoagulation and fibrinolysis by platelet activation following heparin.

Continuous renal replacement therapy without anticoagulation in critically ill patients at high risk of bleeding: A systematic review and meta‐analysis

“…The inclusion flow chart is showed in Figure 1. Finally, 20 studies 14,[22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40] with 1615 patients were included in our present meta-analysis.…”

“…The anticoagulation-free CRRT protocols in the included studies were detailed in Table 2. As a control, the anticoagulation-free group was compared with heparin group in nine studies, 14,[22][23][24][25][26]31,34,40 citrate group in one study, 28 heparin and citrate groups in four studies, 27,30,35,39 and nafamostat mesilate group in four studies, 33,[36][37][38] respectively. One study 32 conducted comparison between two anticoagulation-free groups with or without saline flush and the remaining one study 29 compared the efficacy of anticoagulation-free CRRT between liver failure patients and patients with sepsis or hematological disease.…”

“…The remaining nine studies [23][24][25][26][27]31,35,39,40 were considered to be highquality study with a score of 7.…”

The effect of regional citrate anti-coagulation on the coagulation system in critically ill patients receiving continuous renal replacement therapy for acute kidney injury - an observational cohort study

“…It is also unknown whether citrate has any clinically important direct or indirect effects on fibrinolysis or platelet function [ 5 – 7 ]. Finally, not all events within the circuit are represented by systemic clotting results, and it has been argued that coagulation and fibrinolysis need to be studied separately in the patient and in the extracorporeal circuit [ 8 ]. We report our protocol to study the effects of citrate on coagulation and fibrinolysis pathways.…”

A Prediction Model of Sufficient Filter Lifespan in Anticoagulation-free CRRT&nbsp;Patients

“…According to the optimal cut-off value of the development model, 18 out of the 28 patients with su cient lter lifespan were discriminated and the sensitivity, speci city, PPV, and NPV were 0.64, 0.81, 0.85, and 0.56, respectively. The median lter lifespan was signi cantly longer in patients above the cut-off value (32 hours vs. 23 [16][17][18][19][20][21][22][23][24][25][26][27][28][29] hours, P = 0.03, Additional le 9: Figure S5B). The overall median lter lifespan in the validation cohort was 26.5 (21-46.2) hours.…”