Recurring extracorporeal circuit clotting during continuous renal replacement therapy resolved after single‐session therapeutic plasma exchange

Fülöp, Tibor; Cosmin, Adrian; Juncos, Luis A.

doi:10.1002/jca.20291

Cited by 2 publications

(1 citation statement)

References 10 publications

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“…More work is required in the group with coagulation disorders such as decreased anti-thrombin (heparin resistance), PF4-heparin antibodies and elevated fibrinogen. ‘Clotty’ patients have long been recognised as detrimental to CRRT and though the recent expansion of alternatives to heparin (particularly citrate anticoagulation) have broadened therapeutic options these patients still present a challenge frequently cycling through different strategies empirically or unique un-trialled interventions such as plasma exchange for frequent circuit failure with hyperfibrinogenemia [ 85 ].…”

Section: Discussionmentioning

confidence: 99%

Non anti-coagulant factors associated with filter life in continuous renal replacement therapy (CRRT): a systematic review and meta-analysis

et al. 2017

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BackgroundOptimising filter life and performance efficiency in continuous renal replacement therapy has been a focus of considerable recent research. Larger high quality studies have predominantly focussed on optimal anticoagulation however CRRT is complex and filter life is also affected by vascular access, circuit and management factors. We performed a systematic search of the literature to identify and quantify the effect of vascular access, circuit and patient factors that affect filter life and presented the results as a meta-analysis.MethodsA systematic review and meta-analysis was performed by searching Pubmed (MEDLINE) and Ovid EMBASE libraries from inception to 29th February 2016 for all studies with a comparator or independent variable relating to CRRT circuits and reporting filter life. Included studies documented filter life in hours with a comparator other than anti-coagulation intervention. All studies comparing anticoagulation interventions were searched for regression or hazard models pertaining to other sources of variation in filter life.ResultsEight hundred nineteen abstracts were identified of which 364 were selected for full text analysis. 24 presented data on patient modifiers of circuit life, 14 on vascular access modifiers and 34 on circuit related factors. Risk of bias was high and findings are hypothesis generating.Ranking of vascular access site by filter longevity favours: tunnelled semi-permanent catheters, femoral, internal jugular and subclavian last. There is inconsistency in the difference reported between femoral and jugular catheters.Amongst published literature, modality of CRRT consistently favoured continuous veno-venous haemodiafiltration (CVVHD-F) with an associated 44% lower failure rate compared to CVVH. There was a trend favouring higher blood flow rates. There is insufficient data to determine advantages of haemofilter membranes.Patient factors associated with a statistically significant worsening of filter life included mechanical ventilation, elevated SOFA or LOD score, elevations in ionized calcium, elevated platelet count, red cell transfusion, platelet factor 4 (PF-4) antibodies, and elevated fibrinogen.Majority of studies are observational or report circuit factors in sub-analysis. Risk of bias is high and findings require targeted investigations to confirm.ConclusionThe interaction of patient, pathology, anticoagulation, vascular access, circuit and staff factors contribute to CRRT filter life. There remains an ambiguity from published data as to which site and side should be the first choice for vascular access placement and what interaction this has with patient factors and timing. Early consideration of tunnelled semi-permanent access may provide optimal filter life if longer periods of CRRT are anticipated. There remains an absence of robust evidence outside of anti-coagulation strategies despite over 20 years of therapy delivery however trends favour CVVHD-F over CVVH.

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Section: Discussionmentioning

confidence: 99%

Non anti-coagulant factors associated with filter life in continuous renal replacement therapy (CRRT): a systematic review and meta-analysis

et al. 2017

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Effect of Plasmapheresis on the Anti-Factor Xa Activity of Enoxaparin in an Obese Adolescent Patient

et al. 2017

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To our knowledge, the effect of plasmapheresis on the anti-factor Xa activity of enoxaparin has never been reported. We describe a 13-year-old, obese (92-kg) girl who was treated with enoxaparin for a pulmonary embolism while receiving plasmapheresis for suspected autoimmune encephalitis and who experienced clinically significant reductions in anti-factor Xa activity after plasmapheresis. She received five courses of plasmapheresis, with the final two administered during treatment with enoxaparin. Her anti-factor Xa concentrations were highly variable, and we hypothesized that plasmapheresis was affecting these levels. To test this hypothesis, anti-factor Xa concentrations were measured before and immediately after the patient's last plasmapheresis treatment, and then again 2 days after plasmapheresis. The rate of anti-factor Xa activity decline was 0.28 IU/mL/hour with plasmapheresis and only 0.088 IU/mL/hour on the day without plasmapheresis, representing a greater than 3-fold difference. The changes in anti-factor Xa activity due to plasmapheresis altered the final enoxaparin dosage required to remain in the therapeutic range of 0.5-1 IU/mL (0.98 mg/kg/dose while receiving plasmapheresis vs 0.69 mg/kg/dose without plasmapheresis). Our patient's data suggest that plasmapheresis can significantly alter enoxaparin's anticoagulant effect as measured by anti-factor Xa concentrations, which could cause a decreased anticoagulant effect during plasmapheresis and an increased risk of bleeding on plasmapheresis discontinuation. If concurrent enoxaparin-based anticoagulation and plasmapheresis are necessary, close monitoring of anti-factor Xa levels is advisable. Dose escalations and reductions of enoxaparin may be necessary when initiating and discontinuing plasmapheresis, respectively.

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Recurring extracorporeal circuit clotting during continuous renal replacement therapy resolved after single‐session therapeutic plasma exchange

Cited by 2 publications

References 10 publications

Non anti-coagulant factors associated with filter life in continuous renal replacement therapy (CRRT): a systematic review and meta-analysis

Non anti-coagulant factors associated with filter life in continuous renal replacement therapy (CRRT): a systematic review and meta-analysis

Effect of Plasmapheresis on the Anti-Factor Xa Activity of Enoxaparin in an Obese Adolescent Patient

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