Prostacyclin as an Anticoagulant for Continuous Renal Replacement Therapy in Children

Abstract

Effective delivery of continuous renal replacement therapy (CRRT) depends on the longevity of the filter and circuit used in the CRRT machine. Safe and effective anticoagulation is crucial for maintaining the patency of these circuits. In children, heparin and citrate are the commonly used anticoagulants but they are limited by serious side effects and thus calls for meticulous monitoring. In conditions where neither of these can be used, prostacyclin can be an effective alternative. Prostacyclin is a platelet inhibitor that can be safely used as an efficient anticoagulant in CRRT. When combined with heparin, it induces a heparin-sparing effect, which can reduce the dosage and side effects of heparin. Furthermore, there is no need for performing time-consuming monitoring tests. Although prostacyclin seems to be an attractive option, there is scanty evidence about its use as an anticoagulant in CRRT in children. We review the evidence and practicalities, and propose a guideline for the use of prostacyclin as an anticoagulant in children requiring CRRT.

Epoprostenol for the treatment of increasing oxygenator pressure drop during cardiopulmonary bypass. A case report

“…This was anticipated as the most reported side effects of epoprostenol are hypotension due to vasodilatation and an increased incidence of bleeding due to platelet inhibition. 11 In this case, we saw no other side effects; but, epoprostenol can also cause ventilation perfusion mismatch due to vasodilation of the pulmonary vasculature. Other rare adverse events (occurring in <1% of patients) include nausea, vomiting, headache, hypotension, flushing, chest pain, anxiety, dizziness, bradycardia, dyspnoea, abdominal pain and tachycardia.…”

“…This is primarily due to the antiplatelet effects of epoprostenol. 11 CPB and CRRT circuits consist of similar components, but the blood flow differs greatly. The mechanisms described in the CRRT setting might be applicable to CPB.…”

Acute Kidney Injury and Special Considerations during Renal Replacement Therapy in Children with Coronavirus Disease-19: Perspective from the Critical Care Nephrology Section of the European Society of Paediatric and Neonatal Intensive Care

“… Combination of heparin and prostacyclin − In order to minimize the dose of heparin used for anticoagulation as well as heparin-induced side effects while addressing the issue of increased filter clotting, a combination of heparin and prostacyclin can be used (both are administered prefilter). Prostacyclin helps to reduce filter clotting by its anti-platelet and is heparin sparing [ 42 ]. In this setting, heparin at 10 units per kg per hour is combined with prostacyclin given at the rate of 4 ng/kg/min.…”

Effect of adult COVID-19 surge on the provision of kidney replacement therapy in children

“…Prostacyclin is another anticoagulant which helps to reduce the chances of filter clotting due to its antiplatelet and heparin sparing activity. The recommended dosage is between 4 and 8 ng/kg/min [18]. In order to minimize the dose of heparin used for anticoagulation and heparin-induced side effects, a combination of heparin and prostacyclin can be used (both administered prefilter).…”