REVIEW PAPER
Systemic anticoagulation during continuous renal replacement therapy – practical aspects
 
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1
Department of Anaesthesiology and Intensive Care, Voivodship Specialist Hospital in Olszyn Poland
2
Department of Anaesthesiology and Intensive Care, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Poland
3
Department of Anaesthesiology and Intensive Care, University Clinical Hospital in Olsztyn, Poland
CORRESPONDING AUTHOR
Dariusz Onichimowski   

Department of Anaesthesiology and Intensive Care, Voivodship Specialist Hospital in Olsztyn, Żołnierska 18, 10-561 Olsztyn, Poland. Tel.: +48 501 173 866, Fax: +4889 538 65 50.
Online publication date: 2019-07-31
Submission date: 2018-09-17
Final revision date: 2018-11-29
Acceptance date: 2018-11-30
 
Pol. Ann. Med. 2019;26(2):165–169
KEYWORDS
TOPICS
ABSTRACT
Introduction:
Extracorporeal blood purification techniques have become a well-established part of routine practice in intensive therapy units. Ensuring appropriate anticoagulation to prevent the clotting of the circuit is the major concern while applying these techniques.

Aim:
The aim of this paper is to present methods of systemic anticoagulation which are currently used in continuous extracorporeal blood purification techniques.

Material and methods:
This work is based on the available literature and the experience of the authors.

Results and discussion:
The prevention of clotting in the extracorporeal circuit may be achieved through regional or systemic anticoagulation. Systemic anticoagulation is usually achieved by administration of unfractionated heparin. The most common complications include bleeding; additionally, there is a risk of type II thrombocytopenia occurring. Systemic anticoagulation may also be provided through administration of low molecular weight heparins. Some research papers have discussed the use of thrombin antagonists (argatroban, bivalirudin) and heparinoids (danaparoid, fondaparinux), as well as platelet inhibitors as systemic anticoagulants. It is also possible to conduct extracorporeal blood purification without anticoagulation.

Conclusions:
The introduction of continuous extracorporeal blood purification techniques into everyday practice of intensive care units has brought many unquestioned benefits to the patients treated in this setting. On the other hand, it means that doctors need to show an in-depth knowledge of the anticoagulation methods. Despite the wider use of regional anticoagulation during continuous renal replacement therapy, systemic anticoagulation is still important. This is especially when therapies with high blood flow are performed and contraindications to citrate use are present.

 
REFERENCES (24)
1.
Bai M, Zhou M, He L, et al. Citrate versus heparin anticoagulation for continuous renal replacement therapy: an updated metaanalysis of RCTs. Intensive Care Med. 2015;41(12):2098––2110. https://doi.org/10.1007/s00134....
 
2.
Joannidis M, Oudemans-van Straaten HM. Clinical review: Patency of the circuit in continuous renal replacement therapy. Crit Care. 2007;11(4):218. https://doi.org/10.1186/cc5937.
 
3.
Sponholz C, Bayer O, Kabisch B, et al. Anticoagulation Strategies in Venovenous Hemodialysis in Critically Ill Patients: A Five-Year Evaluation in a Surgical Intensive Care Unit. ScientificWorldJournal. 2014. http://dx.doi.org/10.1155/2014....
 
4.
Oudemans-van Straaten HM, Kellum JA, Bellomo R. Clinical rewiew: Anticoagulation for continuous replacement therapy – heparyn or citrate? Crit Care. 2011;15(1):202. https://doi.org/10.1186/cc9358.
 
5.
Osterman M, Dickie H, Tovey L, Treacher D. Heparin algorithm for anticoagulation during continuous renal replacement therapy. Crit Care. 2010;14(3):419–420. https://doi.org/10.1186/cc9003.
 
6.
McAvoy TJ, The biologic half-life of heparin. Clin Pharmacol Ther. 1979;25(3):3372–379. https://doi.org/10.1002/cpt197....
 
7.
van de Wetering J, Westendorp RG, van der Hoeven JG, Stolk B, Feuth JD, Chang PC. Heparin use in continuous renal replacement procedures: the struggle between filter coagulation and patient hemorrhage. J Am Soc Nephrol. 1996;7(1):145.
 
8.
Davenport A, Will EJ, Davidson AM. Comparison of the use of standard heparin and prostacyclin anticoagulation in spontaneous and pump-driven extracorporeal circuits in patients with combined acute renal and hepatic failure. Nephron. 1994;66:431–437. https://doi.org/10.1159/000187....
 
9.
Bellomo R, Teede H, Boyce N. Anticoagulant regimens in acute continuous hemodiafiltration: a comparative study. Intensive Care Med. 1993;19(6):329–332. https://doi.org/10.1007/BF0169....
 
10.
Martin PY, Chevrolet JC, Suter P, Favre H. Anticoagulation in patients treated by continuous venovenous hemofiltration: a retrospective study. Am J Kidney Dis. 1994;24(5):806–812. https://doi.org/10.1016/S0272-....
 
11.
Selleng K, Warkentin TE, Greinacher A. Heparin-iduced thrombocytopenia in intensive care patients. Crit Care Med. 2007;35(4):1165–1176. https://doi.org/10.1097/01.CCM....
 
12.
van der Voort PH, Gerritsen RT, Kuiper MA, Egbers PH, Kingma WP, Boerma EC. Filter run time in CVVH: pre-versus post-dilution and nadroparin versus regional heparin-protamine anticoagulation. Blood Purif. 2005;23(3):175–180. https://doi.org/10.1159/000083....
 
13.
Reeves JH, Cumming AR, Gallagher L, O’Brien JL, Santamaria JD. A controlled trial of low-molecular-weight heparin (dalteparin) versus unfractionated heparin as anticoagulant during continuous venovenous hemodialysis with filtration. Crit Care Med. 1999;27(10):2224–2228. https://doi.org/10.1097/000032....
 
14.
de Pont AC, Oudemans-van Straaten HM, Roozendaal KJ, Zandstra DF. Nadroparin versus dalteparin anticoagulation in high-volume, continuous venovenous hemofiltration: a double-blind, randomized, crossover study. Crit Care Med. 2000;28(2):421–425. https://doi.org/10.1097/000032....
 
15.
Joannidis M, Kountchev J, Rauchenzauner M, et al. Enoxaparin vs. unfractioned heparin for anticoagulation during continuous veno-venous hemofiltration: a randomized controlled crossover study. Intensive Care Med. 2007;33(9):1571–1579. https://doi.org/10.1007/s00134....
 
16.
Garces EO, Victorino JA, Thome FS, et al. Enoxaparin versus unfractioned heparin as anticoagulation for continuous venovenous hemodialysis: a randomized open-label trial. Ren Fail. 2010;32(3):320–327. https://doi.org/10.3109/088602....
 
17.
Link A, Girndt M, Selejan S, Mathes A, Böhm M, Rensing H. Argatroban for anticoagulation in continuous renal replacement therapy. Crit Care Med. 2009;37(1):105–110. https://doi.org/10.1097/CCM.0b....
 
18.
Kiser TH, MacLaren R, Fish DN, Hassell KL, Teitelbaum I. Bivalirudin versus unfractioned heparin for prevention of hemofilter occlusion during continuous renal replacement therapy. Pharmacotherapy. 2010;30(11):1117–1126. https://doi.org/10.1592/phco.3....
 
19.
Hoste E, Dhondt A. Clinical review: Use of renal replacement therapies in special groups of ICU patients. Crit care. 2012;16(1):201. https://doi.org/10.1186/cc1049....
 
20.
Langenecker SA, Felfernig M, Werba A, Mueller CM, Chiari A, Zimpfer M. Anticoagulation with prostacyclin and heparin during continuous venovenous hemofiltration. Crit Care Med. 1994;22(11):1774–1781.
 
21.
Balik M, Waldauf P, Plasil P, Pachl J. Prostacyclin versus citrate in continuous haemodiafiltration: an observational study in patients with high risk of bleeding. Blood Purif. 2005;23(4):325–329. https://doi.org/10.1159/000087....
 
22.
Schneider AG, Journois D, Rimmele T. Complications of regional citrate anticoagulation: accumulation or overload?. Crit Care. 2017;21:281. https://doi.org/10.1186/s13054....
 
23.
Shum HP, Yan WW, Chan TM. Risk and benefits of citrate anticoagulation for continuous renal replacement therapy. Hong Kong Med J. 2015;21(2):149–154. https://dx.doi.org/10.12809/hk....
 
24.
Davies H, Leslie G. Maintaining the CRRT circuit: non-anticoagulant alternatives. Aust Crit Care. 2006;19(4):133–138. https://doi.org/10.1016/S1036-....