Anticoagulation for Pediatric Continuous Renal Replacement Therapy (CRRT)

Anticoagulation Options for Pediatric CRRT

The American Journal of Kidney Diseases suggests regional citrate anticoagulation as the preferred method for pediatric patients undergoing CRRT when there are no contraindications, guided by patient characteristics, local expertise, and available monitoring capabilities 1, 2
Monitoring should include evaluation of anticoagulant effect, filter efficacy, circuit life, and complications, as recommended by the American Journal of Kidney Diseases 3
Regular assessment of post-filter and serum-ionized calcium should be performed to appropriately titrate the dose of citrate and calcium replacement solutions, according to Kidney International 2
Monitoring of systemic acid-base balance is advisable in patients at high risk for citrate accumulation, as stated in Kidney International 2

The American Journal of Kidney Diseases recommends assessing bleeding risk and considering anticoagulation if the patient has no increased bleeding risk or impaired coagulation 1
If the patient has increased bleeding risk, the American Journal of Kidney Diseases suggests considering regional citrate or no anticoagulation 1
Severe liver dysfunction and severe shock with muscle hypoperfusion are contraindications for citrate use, as noted in the American Journal of Kidney Diseases and Kidney International 1, 2

The American Journal of Kidney Diseases notes that citrate is not FDA-approved as an anticoagulant for CRRT in the United States, and commercially available citrate solutions are hypertonic, which may increase the risk of metabolic complications 3, 4
Standardized citrate administration and monitoring protocols are essential for safe implementation, as emphasized by the American Journal of Kidney Diseases 3
Danaparoid, fondaparinux, and hirudin are all renally excreted with extended half-lives in AKI and have no specific antidote, and should be used with caution, according to the American Journal of Kidney Diseases 3
For patients with heparin-induced thrombocytopenia (HIT), the American Journal of Kidney Diseases recommends using direct thrombin inhibitors (such as argatroban) or Factor Xa inhibitors 1
Argatroban has been used at doses ranging between 0.7 and 1.7 μg/kg/min as anticoagulation for CRRT in patients with HIT, as reported in the American Journal of Kidney Diseases 3