Table 2.
Anticoagulation modalities for continuous renal replacement
| Method | Filter prime | Initial dose | Maintenance dose | Monitoring | Advantages | Disadvantages |
|---|---|---|---|---|---|---|
| Saline solution | 2 L saline | 150–250 mL pre-filter | 100–250 mL/h pre-filter | Visual check | No anticoagulant used | Poor filter patency |
| Heparin | 2 L saline 2500–10000 U | 5–10 U/kg | 3–12/kg/h | ACT 200–250; PTT 1.5–2.0 × normal | Standard method; easy to use; inexpensive | Bleeding risk; thrombocytopenia |
| LMW heparin | 2 L saline | 40 mg | 10–40 mg/6 h | Factor Xa levels; maintained between 0.1–0.41 U/mL | Decreased risk of bleeding | Special monitoring; not available everywhere; expensive |
| Regional heparin | 2500 U/2 L saline | 5–10 U/kg | 3–12 U/kg/h; + protamine post-filter | PTT: post-filter ACT 200–250 | Reduced bleeding risk | Complex; risk of thrombocytopenia; protamine effects; hypotension |
| Regional citrate | 2 L saline | 4% trisodium citrate 150–180 mL/h | 100–180 mL/h 3–7% of BFR, Ca replaced by central line | ACT: 200–250 maintain ionized calcium 0.96–1.2 mmol/L | No bleeding; no thrombocytopenia; improved filter efficacy, longevity | Complex; needs Ca monitoring; alkalosis |
| Prostacyclin | 2 L saline + heparin | 4–8 ng/kg/min | 4–8 ng/kg/min | Usually no monitoring if heparin not required | Alternative to heparin and citrate. Usually in liver failure | May need low-dose heparin addition; hypotension |
| Hirudin | 2 L saline | 625 μg/kg/h | 6–25 μg/kg/h (Monitor carefully in renal failure) | PTT, Ecarin clotting time | Alternative to heparin. Usually used if HITT | Bleeding risk; no reversal agent |
| Danaparoid | 2 L saline | 2500 U bolus | 400 IU/h | PTT antifactor Xa | Alternative to heparin. Usually used if HITT | Bleeding; no reversal agent |
| Argatroban | 2 L saline | – | 2 μg/kg/min (reduce in hepatic dysfunction) | PTT | Alternative to heparin. Usually used if HITT | Bleeding risk; no reversal agent |
| Nafomostat mesilate | 2 L saline | – | 0.1 mg/kg/h | ACT | Alternative to heparin | Bleeding |
Source: Mehta RL. 1992. New developments in continuous arterio-venous hemofiltration/dialysis. In Andreucci VE, Fine L (eds). International Yearbook of Nephrology, 1992. Heidelberg: Springer. Copyright © Springer Verlag. Reproduced with permission from Springer Verlag. NOTE: Dashes mean no loading dose.
Abbreviations: ACT, activated clotting time; BFR, blood flow rate; HITT, heparin induced thrombocytopenia; LMW, low molecular weight; PTT, partial thromboblastin time.