Anticoagulation Strategies in Continuous Renal Replacement Therapy

Clotting and clogging during continuous renal replacement therapy (CRRT) are undesirable phenomena that decrease filter patency and negatively impact treatment delivery. Clinicians adopt non-pharmacological and pharmacological strategies to decrease their occurrence. The former mainly consist in modulating treatment modalities and flows prescription to decrease the filtration fraction, while the latter aim at hindering coagulation and/or platelet aggregation systemically or into the extracorporeal circuit with different drugs. The two most employed pharmacological techniques are systemic anticoagulation with unfractionated heparin and regional citrate anticoagulation (RCA). The Kidney Disease Improving Global Outcomes (KDIGO) guidelines on acute kidney injury suggest RCA as the best anticoagulation strategy for CRRT in patients without contraindication for citrate administration. Nonetheless, RCA is still not used worldwide, mainly for its costs, the increased work for nurses, and the lack of approval from the Food and Drug Administration, which precludes its use in the United States. Several other techniques have been developed, although their safety margin is sometimes arguable and their use is limited in Europe.