There are several factors which cause the the hemodialysis filter to clog up with clots and debris, and there are several measures which can be taken to prevent this from happening.
Strategy | Advantages | Disadvantages |
Nothing whatsoever (+/- regular saline flushes) |
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High flow rate |
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Pre-dilution |
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Unfractionated heparin |
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Regional anticoagulation with heparin and protamine |
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Low molecular weight heparin |
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Warfarin |
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Platelet function inhibitors: NSAIDs, aspirin, etc |
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Citrate |
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Direct thrombin inhibitors: Hirudin / Lepirudin Bivalirudin / Argatroban |
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Heparinoids (Danaparoid) |
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Xa inhibitors: Fondaparinux |
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Serine protease inhibitors: Nafamostat |
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Prostacyclin (PGI2) |
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This article offers a nice overview of anticoagulation in CRRT:
Jamshid Amanzadeh and Robert F. Reilly, Jr. Anticoagulation and Continuous Renal Replacement Therapy Seminars in Dialysis—Vol 19, No 4 (July–August) 2006 pp. 311–316
For a definitive treatment of all of this, you ought to pay homage to the gigantic and all-encompassing "Critical Care Nephrology" by Ronco Bellomo and Kellum (2009).
Finally, the Gambro and Fresenius websites have been an excellent source of information.
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Fiaccadori, Enrico, et al. "Continuous haemofiltration in acute renal failure with prostacyclin as the sole anti-haemostatic agent." Intensive care medicine 28.5 (2002): 586-593.
Han, Sang Jin, et al. "Use of nafamostat mesilate as an anticoagulant during extracorporeal membrane oxygenation." Journal of Korean medical science26.7 (2011): 945-950.
Hu, Z. J., et al. "Time course of activated coagulation time at various sites during continuous haemodiafiltration using nafamostat mesilate." Intensive care medicine 25.5 (1999): 524-527.
Akizawa, T., et al. "Nafamostat mesilate: a regional anticoagulant for hemodialysis in patients at high risk for bleeding." Nephron 64.3 (1993): 376-381.
Wester, J. P., et al. "Low-dose fondaparinux in suspected heparin-induced thrombocytopenia in the critically ill." Neth J Med 65.3 (2007): 101-108.
Mahieu, Elien, et al. "Anticoagulation With Fondaparinux for Hemodiafiltration in Patients With Heparin‐Induced Thrombocytopenia: Dose‐Finding Study and Safety Evaluation." Artificial organs 37.5 (2013): 482-487.
Morabito, Santo, et al. "Continuous renal replacement therapies: anticoagulation in the critically ill at high risk of bleeding." Journal of nephrology16.4 (2003): 566-571.
Tan, H. K., I. Baldwin, and R. Bellomo. "Continuous veno-venous hemofiltration without anticoagulation in high-risk patients." Intensive care medicine 26.11 (2000): 1652-1657.
Tolwani, Ashita J., and Keith M. Wille. "THE CLINICAL APPLICATION OF CRRT—CURRENT STATUS: Anticoagulation for Continuous Renal Replacement Therapy." Seminars in dialysis. Vol. 22. No. 2. Blackwell Publishing Ltd, 2009.
Davies, H. T., et al. "A randomized comparative crossover study to assess the affect on circuit life of varying pre-dilution volume associated with CVVH and CVVHDF." The International journal of artificial organs 31.3 (2008): 221-227.
Davenport, Andrew. "Pre-dilution or post-dilution fluid replacement for continuous veno-venous hemofiltration: that is the question." Nephron Clinical Practice 94.4 (2004): c83-c84.
Davies, Hugh, and Gavin Leslie. "Maintaining the CRRT circuit: non-anticoagulant alternatives." Australian Critical Care 19.4 (2006): 133-138.
Reeves, John H., et al. "A controlled trial of low-molecular-weight heparin (dalteparin) versus unfractionated heparin as anticoagulant during continuous venovenous hemodialysis with filtration." Critical care medicine 27.10 (1999): 2224-2228.
Jeffrey, R. F., et al. "Anticoagulation with low molecular weight heparin (Fragmin) during continuous hemodialysis in the intensive care unit." Artificial organs 17.8 (1993): 717-720.
Wilkieson, Trevor J., et al. "Low-intensity adjusted-dose warfarin for the prevention of hemodialysis catheter failure: a randomized, controlled trial."Clinical Journal of the American Society of Nephrology 6.5 (2011): 1018-1024.
Teraoka, Satoshi, et al. "Heparin-free hemodialysis with an oral anti-platelet agent." ASAIO journal 38.3 (1992): M560-M563.
De Pont, Anne-Cornelie JM, et al. "Pharmacokinetics and pharmacodynamics of danaparoid during continuous venovenous hemofiltration: a pilot study."Critical Care 11.5 (2007): R102.
Haase, Michael, et al. "Use of fondaparinux (ARIXTRA®) in a dialysis patient with symptomatic heparin-induced thrombocytopaenia type II." Nephrology Dialysis Transplantation 20.2 (2005): 444-446.
Ho, Grace, et al. "Use of fondaparinux for circuit patency in hemodialysis patients." American Journal of Kidney Diseases 61.3 (2013): 525-526.