Document Detail

Continuous renal replacement therapies: anticoagulation in the critically ill at high risk of bleeding.
MedLine Citation:
PMID:  14696760     Owner:  NLM     Status:  MEDLINE    
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.
Santo Morabito; Isabella Guzzo; Angela Solazzo; Lina Muzi; Remo Luciani; Alessandro Pierucci
Publication Detail:
Type:  Comparative Study; Journal Article    
Journal Detail:
Title:  Journal of nephrology     Volume:  16     ISSN:  1121-8428     ISO Abbreviation:  J. Nephrol.     Publication Date:    2003 Jul-Aug
Date Detail:
Created Date:  2003-12-30     Completed Date:  2004-02-12     Revised Date:  2006-11-15    
Medline Journal Info:
Nlm Unique ID:  9012268     Medline TA:  J Nephrol     Country:  Italy    
Other Details:
Languages:  eng     Pagination:  566-71     Citation Subset:  IM    
Department of Clinical Sciences, Division of Nephrology, Umberto I Hospital, "La Sapienza" University, Rome, Italy.
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MeSH Terms
Analysis of Variance
Anticoagulants / adverse effects*,  therapeutic use
Blood Coagulation Disorders / etiology*,  mortality,  physiopathology
Blood Coagulation Tests
Cardiac Surgical Procedures / adverse effects,  methods
Cohort Studies
Critical Illness
Hemorrhage / epidemiology*,  etiology,  physiopathology
Heparin / adverse effects,  therapeutic use
Intensive Care Units
Kidney Failure, Acute / etiology,  mortality,  therapy*
Prospective Studies
Protamines / adverse effects,  therapeutic use
Renal Replacement Therapy / adverse effects,  methods*
Risk Factors
Severity of Illness Index
Statistics, Nonparametric
Survival Analysis
Thrombocytopenia / etiology*,  mortality,  physiopathology
Reg. No./Substance:
0/Anticoagulants; 0/Protamines; 9005-49-6/Heparin

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