What are the types of anticoagulation that can be used for RRT? What are the advantages and disadvantages of each mode?

Mechanical
  • Optimising CVP
  • Pre-dilution replacement fluid
  • High flowrates
  • Reducing air-blood contact in the bubble trap
Regional
  • Heparin
  • Citrate
Systemic
  • Heparin
  • LMWH
  • Prostacyclin
  • Thrombin Inhibitors:
    • Argatroban
    • Lepirudin
  • Fondaparinux
  • Heparinoids
  • Warfarin
Advantages
Disadvantages
No / Mechanical Anticoagulation
  • Reduced bleeding risk
  • ↓ cost
  • ↑ risk of filter clotting:
    • Shorter filter lifespan
    • Reduced adequacy of RRT
  • Not suitable for patients with HIT who are pro-thrombotic
Unfractionated Heparin
  • Easily titratable
  • Easily monitored
  • Can be reversed with protamine
  • ↑ bleeding risk
  • Risk of HIT
LMWH
  • ↓ cost
  • ↑ familiarity
  • ↑ bleeding risk
  • Not titratable
  • No reversal agent
Prostacyclin
  • Reduced bleeding risk
  • Shorter filter life
  • Causes systemic hypotension
Citrate
  • Good regional anticoagulation with reversal by calcium
  • Reduced bleeding risk
  • Associated with metabolic complications (Hypernatraemia, hypocalcaemia, metabolic alkalosis)
  • Special dialysate required
  • Contraindicated in liver failure
  • Labour intensive