Table 4.
Most frequently anticoagulation methods used in pediatric CRRT and their advantages and disadvantages
| Method | Dosing (D) and monitoring (M) | Advantage | Disadvantage |
|---|---|---|---|
| Unfractionated heparin | D: 10–20 IU/kg/h |
• Easily reversible with protamine • Low costs and widely available • wide experience as anticoagulant |
• Risk of patients bleeding • Patients possibly developing heparin induced thrombocytopenia (HIT) • Unpredictable and complex pharmacokinetics resulting in dosing variability |
| M: aPTT 45–60 s or 1.5–2 × NR; ACT 180–200 s | |||
| Low Molecular Weight Heparin | D: Enoxaparin LD 0.15 mg/kg, MD 0.05 mg/kg/h |
• Less risks for HIT • Pharmacokinetics more predictable than unfractionated heparin |
• Higher costs than unfractionated heparin • Less effective reversal with protamine |
| M: Anti-Xa level (0.3–0.7 UI/mL) | |||
| Regional citrate anticoagulation | D: starting dose 3 mmol/La |
• Anticoagulation only of the extracorporeal circuit • Lower risks of bleeding • Longer filter life than heparin |
• Need for training and strict protocols • Higher risks of citrate complications (electrolytes imbalance, citrate accumulation/toxicity) • Need for high dialytic dose (high volume of pre-filter fluid) • May need caution in patients with severe liver failure and lactic acidosis |
| M: extracorporeal iCa 0.25–0.35 mmol/L; intracorporeal iCa 1.1–1.3 mmol/L | |||
| Regional heparin and protamine | D: infuse 1 mg protamine post-filter for 100 IU Heparin |
• Anticoagulation only of the extracorporeal circuit • Lower risks of bleeding |
• Complex metabolism may lead to prolonged anticoagulation • Requires measurement of both circuit and patient APTT • Technically challenging (difficulty in estimating the amount of protamine required to antagonize post-filter heparin) • Possible side effects: hypotension, anaphylaxis, cardiac depression, leukopenia, and thrombocytopenia |
| M: circuit aPTT 45–60 s or 1.5–2 × NR; ACT 180–200 | |||
| Prostacyclin infusion | D: 2–8 ng/kg/min |
• No need for anticoagulation parameter monitoring since inhibits platelets aggregation • Easy to perform |
• Possible hemodynamic impact, dose dependent (vasodilation, systemic hypotension, possible reflex tachycardia) • Possible raised intracranial pressure |
| M: no monitoring tests | |||
| Serine protease inhibitors—nafamostat mesilate, aprotinin | D: Depending on drug |
• Lower costs than regional citrate anticoagulation • Alternative to regional citrate anticoagulation if risk of citrate accumulation |
• Only few studies available in pediatrics • Need for clotting parameter monitoring |
| M: aPTT 45–60 s or 1.5–2 × NR; ACT 180–200 s | |||
| Direct thrombin inhibitors—argatroban, bivalirudin | D: Depending on drug |
• Lower bleeding risk than unfractionated heparin in other context (e.g., ECMO) • Shorter half-life than heparin (bivalirudin the shortest) • Possible use in patients with HIT |
• Only few studies available in pediatrics, evidences from adults • Non-reversible agents available |
| M: aPTT 45–60 s or 1.5–2 × NR; ACT 180–200 s |
LD loading dose, MD maintenance dose, NR normal range
aCitrate flow rate depends on the type of citrate solution used