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Studies have shown an association between continuous renal replacement therapy (CRRT) and thrombocytopenia. Patients on CRRT usually receive unfractionated heparin (UFH), and heparin-induced thrombocytopenia (HIT) is frequently suspected as a potential cause of thrombocytopenia. In the setting of HIT suspicion, changes in anticoagulation may put pa...
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... doses of bivalirudin in patients receiving CVVHD and those receiving CVVH were 0.118 mg/kg/h and 0.070 mg/kg/h, respectively (P = .431). There was no significant correlation between dose and ultrafiltration rate for argatroban (R 2 < 0.001) or bivalirudin (R 2 = 0.082), but patients treated with bivalirudin had a trend toward requiring higher therapeutic doses with higher CRRT flow rates (Figure 3). ...
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There remains no optimal anticoagulation protocol for continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) in pediatric patients with elevated D-dimer levels. We aimed to assess the effects of different anticoagulation strategies on the risk of CRRT filter clotting in these patients. Pediatric patients undergoing...
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... If HIT is suspected or proven, all heparin administration must be completely stopped including the use of flushes and "heparin locks." Anticoagulation may be initiated using thrombin inhibitors like Argatroban or Bivalirudin, 170 or Factor Xa inhibitors like Danaparoid and Fondaparinux. Argatroban may be preferable in the absence of hepatic dysfunction as it has a short half-life and may be monitored by aPTT levels. ...
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Acute kidney injury (AKI) is a complex syndrome with a high incidence and considerable morbidity in critically ill patients. Renal replacement therapy (RRT) remains the mainstay of treatment for AKI. There are at present multiple disparities in uniform definition, diagnosis, and prevention of AKI and timing of initiation, mode, optimal dose, and discontinuation of RRT that need to be addressed. The Indian Society of Critical Care Medicine (ISCCM) AKI and RRT guidelines aim to address the clinical issues pertaining to AKI and practices to be followed for RRT, which will aid the clinicians in their day-to-day management of ICU patients with AKI.
How to cite this article:
Mishra RC, Sodhi K, Prakash KC, Tyagi N, Chanchalani G, Annigeri RA, et al. ISCCM Guidelines on Acute Kidney Injury and Renal Replacement Therapy. Indian J Crit Care Med 2022;26(S2):S13-S42.
... If HIT is suspected or proven, all heparin administration must be completely stopped including the use of flushes and "heparin locks." Anticoagulation may be initiated using thrombin inhibitors like Argatroban or Bivalirudin, 170 or Factor Xa inhibitors like Danaparoid and Fondaparinux. Argatroban may be preferable in the absence of hepatic dysfunction as it has a short half-life and may be monitored by aPTT levels. ...
Indian Society of Critical Care Medicine (ISCCM) AKI and RRT guidelines
Lead author for
First Indian guidelines on acute kidney injury with the steering team including eminent critical care physicians and nephrologists
... This addition was based on previous studies reporting that patients with renal dysfunction with or without renal replacement therapy (RRT), required lower doses of bivalirudin (mean dose 0.03-0.07 mg/kg per hour) to achieve desired anticoagulant effects [14][15][16][17]. The initial dose of argatroban was also decreased based on recent studies showing that critically ill patients, particularly those with multi-organ failure required reduced dosing (0.5 mcg/ kg per minute or less with tight aPTT monitoring during the initial 24-h period) to balance the bleeding and thromboembolic risks [8][9][10][11][12][13][14][15][16][17][18][19][20]. ...
... mg/kg per hour) to achieve desired anticoagulant effects [14][15][16][17]. The initial dose of argatroban was also decreased based on recent studies showing that critically ill patients, particularly those with multi-organ failure required reduced dosing (0.5 mcg/ kg per minute or less with tight aPTT monitoring during the initial 24-h period) to balance the bleeding and thromboembolic risks [8][9][10][11][12][13][14][15][16][17][18][19][20]. When comparing the intensive care unit (ICU) patients and the non-ICU patients, one study found that the mean doses of argatroban were 0.82 mcg/kg per minute and 1.25 mcg/kg per minute, respectively [33]. ...
A recent heparin shortage related to an outbreak of African Swine Flu in China led to substantial increase in the use of direct thrombin inhibitors (DTI) as an alternative. We evaluated the safety and efficacy of DTIs by assessing the anticoagulation assays within the initial 48 h of therapy comparing before and during shortage. A retrospective evaluation of bivalirudin and argatroban was conducted at a single center before (May 24, 2018 through August 25, 2019) and during heparin shortage (August 26, 2019 through February 20, 2020). The primary outcome was time to first therapeutic activated partial thromboplastin time (aPTT). Secondary outcomes included the percentage of time in therapeutic aPTT range, in-hospital mortality, incidence of recurrent thrombosis, and hemorrhagic events. Of the 204 patients included in the study, 95 patients [bivalirudin (n = 35), argatroban (n = 60)] were included in the pre-shortage cohort and 109 patients [bivalirudin (n = 68), argatroban (n = 41)] were during shortage. No significant difference was observed in the time to first therapeutic aPTT pre- and during shortage (8.9 h ± 10.8 vs 8.8 h ± 10.2, P = 0.62). Compared to pre-shortage cohort, a greater percentage of time was spent in therapeutic aPTT range within the initial 48 h (32% (0–50) vs. 41.6% (0–63), P = 0.04) during shortage without statistically significant differences in the rates of in-hospital mortality, thrombosis, or bleeding. While the optimal DTI protocol is still be determined, the protocols presented in this study allowed for wide-spread utilization of DTIs during a critical heparin shortage without compromising patient safety and effectiveness, likely reflective of the enhancement of DTI protocols, clinician education, and multidisciplinary collaboration and guidance from pharmacy and hematology.
Continuous renal replacement therapy is an important, yet challenging, treatment of critically ill patients with kidney dysfunction. Clotting within the dialysis filter or circuit leads to time off therapy and impaired delivery of prescribed treatment. Anticoagulation can be used to prevent this complication; however, doing so introduces risk for unintended complications such as bleeding or metabolic derangements in patients who are already critically ill. A thorough understanding of indications, therapeutic options, and monitoring principles is necessary for safe and effective use of this strategy. This review provides clinicians important information regarding when to anticoagulate, differences in pharmacologic agents, recommended doses, routes of drug delivery, and appropriate laboratory monitoring for patients receiving anticoagulation to support continuous renal replacement therapy.
As patients transition between dialysis modalities, and from the intra- to the inter-dialytic period, medications with a narrow therapeutic index that are cleared in dialysis may require dose adjustments and close monitoring. Three cases of patients receiving bivalirudin while converting from continuous to prolonged intermittent renal replacement therapy are reported. Details provided include flow rates and ultrafiltrate volume. In these cases, it appears pre-emptive dose adjustments may be unwarranted, and clinicians should be aware of potential rebound after cessation of dialysis.
