Clinical review: Patency of the circuit in continuous renal replacement therapy

Michael Joannidis, Heleen M Oudemans-van Straaten, Michael Joannidis, Heleen M Oudemans-van Straaten

Abstract

Premature circuit clotting is a major problem in daily practice of continuous renal replacement therapy (CRRT), increasing blood loss, workload, and costs. Early clotting is related to bioincompatibility, critical illness, vascular access, CRRT circuit, and modality. This review discusses non-anticoagulant and anticoagulant measures to prevent circuit failure. These measures include optimization of the catheter (inner diameter, pattern of flow, and position), the settings of CRRT (partial predilution and individualized control of filtration fraction), and the training of nurses. In addition, anticoagulation is generally required. Systemic anticoagulation interferes with plasmatic coagulation, platelet activation, or both and should be kept at a low dose to mitigate bleeding complications. Regional anticoagulation with citrate emerges as the most promising method.

Figures

Figure 1
Figure 1
Mechanism of contact activation by hemofilter membranes. ADP, adenosine diphosphate; C, complement factor; GP, glycoprotein; HMWK, high molecular weight kininogens; PAF, platelet activating factor released by polymorphonuclear cells; plt., platelets; RBC, red blood cells; TF, tissue factor expressed by adhering monocytes; TXA, thromboxane A2.
Figure 2
Figure 2
Features of vascular access contributing to extracorporeal blood flow. ICV, inferior caval vein; P, pressure; Q, blood flow; RA, right atrium.

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