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Continuous renal replacement therapies: anticoagulation in the critically ill at high risk of bleeding.
J Nephrol. 2003 Jul-Aug; 16(4):566-71.JN

Abstract

BACKGROUND

The ongoing necessity for systemic heparinization is a well-known disadvantage of continuous renal replacement therapies (CRRT), and alternative methods of anticoagulation may be required. Our aim was to evaluate, in patients with a high risk of bleeding, the possibility of an acceptable filter life with non-anticoagulation CRRT and, in case of early filter failure, the efficacy and safety of bedside monitored regional anticoagulation with heparin and protamine.

METHODS

Fifty-nine patients underwent CRRT for acute renal failure (ARF) following cardiac surgery. Patients who fulfilled one of the following criteria were selected for non-anticoagulation CRRT: spontaneous bleeding, aPTT > 45 sec, thrombocytopenia and recent surgery (< 48 hr). Filter life < 24 hr without anticoagulation was the cut-off point for starting the regional anticoagulation CRRT. Heparin was infused pre-filter and protamine post-filter at an initial ratio of 1 mg protamine:100 IU heparin. The ratio was adjusted to achieve a patient aPTT < 45 sec and a circuit > 55 sec.

RESULTS

Twenty-two (37.3%) patients had been selected for non-anticoagulation. Of them, 12 patients continued to receive non-anticoagulation (filter life: 38.3 +/- 30.5 hr) while 10 switched to regional anticoagulation (filter life: 38.6 +/- 25 hr). During regional anticoagulation no statistical difference was found between baseline aPTT (36.7 +/- 6.4 sec) and patient aPTT (41.5 +/- 12.6 sec) while circuit aPTT (77.7 +/- 43.3 sec) was significantly higher than patient aPTT (p < 0.0001). The probabilities of the circuits remaining free from clotting after 24, 48 and 72 hr were: a) non-anticoagulation: 55.5%, 30.1% and 16.6%, b) regional anticoagulation: 76.2%, 39.6% and 19.8%. There was no rebound anticoagulation observed after regional anticoagulation CRRT ended.

CONCLUSIONS

Non-anticoagulation CRRT allowed an adequate filter life in most patients with a high risk of bleeding for prolonged aPTT and/or thrombocytopenia. Despite concerns regarding the need for careful monitoring, regional anticoagulation with heparin and protamine can be considered as a safe and valid alternative when non-anticoagulation is unsuitable because of early filter failure.

Authors+Show Affiliations

Morabito S
Department of Clinical Sciences, Division of Nephrology, Umberto I Hospital, "La Sapienza" University, Rome, Italy. santo.morabito@uniroma1.it
Guzzo I
No affiliation info available
Solazzo A
No affiliation info available
Muzi L
No affiliation info available
Luciani R
No affiliation info available
Pierucci A
No affiliation info available

MeSH

APACHEAcute Kidney InjuryAnalysis of VarianceAnticoagulantsBlood Coagulation DisordersBlood Coagulation TestsCardiac Surgical ProceduresCohort StudiesCritical IllnessFemaleHemorrhageHeparinHumansIncidenceIntensive Care UnitsMaleProbabilityPrognosisProspective StudiesProtaminesRenal Replacement TherapyRisk FactorsSeverity of Illness IndexStatistics, NonparametricSurvival AnalysisThrombocytopenia

Pub Type(s)

Comparative Study
Journal Article

Language

eng

PubMed ID

14696760

Citation

Morabito, Santo, et al. "Continuous Renal Replacement Therapies: Anticoagulation in the Critically Ill at High Risk of Bleeding." Journal of Nephrology, vol. 16, no. 4, 2003, pp. 566-71.
Morabito S, Guzzo I, Solazzo A, et al. Continuous renal replacement therapies: anticoagulation in the critically ill at high risk of bleeding. J Nephrol. 2003;16(4):566-71.
Morabito, S., Guzzo, I., Solazzo, A., Muzi, L., Luciani, R., & Pierucci, A. (2003). Continuous renal replacement therapies: anticoagulation in the critically ill at high risk of bleeding. Journal of Nephrology, 16(4), 566-71.
Morabito S, et al. Continuous Renal Replacement Therapies: Anticoagulation in the Critically Ill at High Risk of Bleeding. J Nephrol. 2003 Jul-Aug;16(4):566-71. PubMed PMID: 14696760.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Continuous renal replacement therapies: anticoagulation in the critically ill at high risk of bleeding. AU - Morabito,Santo, AU - Guzzo,Isabella, AU - Solazzo,Angela, AU - Muzi,Lina, AU - Luciani,Remo, AU - Pierucci,Alessandro, PY - 2003/12/31/pubmed PY - 2004/2/13/medline PY - 2003/12/31/entrez SP - 566 EP - 71 JF - Journal of nephrology JO - J Nephrol VL - 16 IS - 4 N2 - BACKGROUND: The ongoing necessity for systemic heparinization is a well-known disadvantage of continuous renal replacement therapies (CRRT), and alternative methods of anticoagulation may be required. Our aim was to evaluate, in patients with a high risk of bleeding, the possibility of an acceptable filter life with non-anticoagulation CRRT and, in case of early filter failure, the efficacy and safety of bedside monitored regional anticoagulation with heparin and protamine. METHODS: Fifty-nine patients underwent CRRT for acute renal failure (ARF) following cardiac surgery. Patients who fulfilled one of the following criteria were selected for non-anticoagulation CRRT: spontaneous bleeding, aPTT > 45 sec, thrombocytopenia and recent surgery (< 48 hr). Filter life < 24 hr without anticoagulation was the cut-off point for starting the regional anticoagulation CRRT. Heparin was infused pre-filter and protamine post-filter at an initial ratio of 1 mg protamine:100 IU heparin. The ratio was adjusted to achieve a patient aPTT < 45 sec and a circuit > 55 sec. RESULTS: Twenty-two (37.3%) patients had been selected for non-anticoagulation. Of them, 12 patients continued to receive non-anticoagulation (filter life: 38.3 +/- 30.5 hr) while 10 switched to regional anticoagulation (filter life: 38.6 +/- 25 hr). During regional anticoagulation no statistical difference was found between baseline aPTT (36.7 +/- 6.4 sec) and patient aPTT (41.5 +/- 12.6 sec) while circuit aPTT (77.7 +/- 43.3 sec) was significantly higher than patient aPTT (p < 0.0001). The probabilities of the circuits remaining free from clotting after 24, 48 and 72 hr were: a) non-anticoagulation: 55.5%, 30.1% and 16.6%, b) regional anticoagulation: 76.2%, 39.6% and 19.8%. There was no rebound anticoagulation observed after regional anticoagulation CRRT ended. CONCLUSIONS: Non-anticoagulation CRRT allowed an adequate filter life in most patients with a high risk of bleeding for prolonged aPTT and/or thrombocytopenia. Despite concerns regarding the need for careful monitoring, regional anticoagulation with heparin and protamine can be considered as a safe and valid alternative when non-anticoagulation is unsuitable because of early filter failure. SN - 1121-8428 UR - https://www.unboundmedicine.com/medline/citation/14696760/Continuous_renal_replacement_therapies:_anticoagulation_in_the_critically_ill_at_high_risk_of_bleeding_ DB - PRIME DP - Unbound Medicine ER -