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Anticoagulation for continuous renal replacement therapy

Ashita J Tolwani, MD
Keith M Wille, MD
Section Editor
Steve J Schwab, MD
Deputy Editor
Alice M Sheridan, MD


Continuous renal replacement therapies (CRRTs) include dialysis (diffusion-based solute removal) and filtration (convection-based solute and water removal) treatments that operate in a continuous mode [1-5]. CRRT usually requires anticoagulation to prevent clotting of the extracorporeal circuits, although CRRT without anticoagulation may be attempted in certain circumstances [6]. The goal for anticoagulation in CRRT is to reduce clotting in the hemofilter to avoid interruptions in the therapy [1]. Interruptions due to clotting can dramatically reduce the total therapy time (with average reductions from 24 hours per day to 16 hours per day) and efficacy of CRRT [7,8].

This topic reviews approaches to anticoagulation for patients on CRRT. Anticoagulation for patients on intermittent hemodialysis is provided elsewhere, as is an overview of CRRT modalities. (See "Hemodialysis anticoagulation" and "Continuous renal replacement therapies: Overview".)

Heparin — Heparin is the most commonly utilized anticoagulant. A single, optimal regimen for heparin administration during CRRT has not been identified, and heparin administration regimens need to balance the therapeutic benefit of preventing clotting in the extracorporeal circuit with the risk of systemic bleeding. Typically, a bolus dose of between 50 to 2000 units of heparin is administered into the inflow ("arterial") limb of the extracorporeal circuit, followed by a continuous infusion of between 300 to 500 units per hour. Therapy may be monitored by following the partial thromboplastin time (PTT) in the venous limb; the heparin dose should be titrated to maintain a value of 1.5 to 2.0 times control. Larger doses of heparin may be required in patients with recurrent system clotting. Its discontinuation may be necessary in the setting of clinical bleeding or if severe thrombocytopenia develops. (See "Management of heparin-induced thrombocytopenia".)

Citrate — Regional citrate anticoagulation has been widely used as an alternative to heparin in all modalities of CRRT, including continuous venovenous hemodiafiltration (CVVHDF) [9-17]. During citrate anticoagulation, sodium citrate is infused into the inflow ("arterial") limb of the extracorporeal circuit, chelating calcium and, thereby, inhibiting clotting. Intravenous calcium must be infused systemically to maintain a normal ionized serum calcium concentration. The use of citrate anticoagulation may require modification of the dialysate composition.

Since the citrate provides an alkali load, buffers (eg, bicarbonate, lactate) may need to be reduced in concentration or deleted from the dialysate and replacement fluids. The dialysate and replacement fluids should also be calcium free to prevent reversal of the citrate effect in the extracorporeal circuit. If a hypertonic citrate solution is utilized, the sodium concentration in the dialysate and/or replacement fluids will need to be reduced to prevent the development of hypernatremia.


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Literature review current through: Sep 2016. | This topic last updated: Apr 30, 2015.
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