Critical Care Medicine-Renal, Electrolyte and Acid Base Disorders>>>>>Renal Replacement Therapy
Question 4#

A 63-year-old female has been admitted to the ICU from another hospital with ongoing acute upper gastrointestinal bleeding, necessitating multiple blood transfusions. She has a history of a previous coronary artery bypass grafting and end-stage renal disease (ESRD) on dialysis. The records from the other hospital indicate that she was recently diagnosed with heparin-induced thrombocytopenia (HIT). She is due to get her dialysis today and feels short of breath after the blood transfusions.

Which of the following is the MOST ideal anticoagulation strategy for hemodialysis in this patient?

A. Low–molecular weight heparin can be safely used in the circuit
B. Regional citrate anticoagulation
C. Dabigatran can be used
D. Dialysis cannot be safely performed at this time and needs to be deferred

Correct Answer is B


Correct Answer: B

All forms of heparin should be avoided in a patient with recent history of HIT. Anticoagulation strategies in patients with HIT requiring hemodialysis include regional anticoagulation with citrate or use of direct thrombin inhibitors. Parenteral direct thrombin inhibitors—argatroban, danaparoid, and lepirudin—have been used for this purpose. Dabigatran, an oral direct thrombin inhibitor is contraindicated in patients with ESRD and hence cannot be used in this patient. Dialysis without anticoagulation can be used in an acutely bleeding patient, requiring hemodialysis, but filter clogging can lead to acute drop in hematocrit from blood lost in the dialysis circuit and is not usually preferred. Regional citrate anticoagulation is an option in patients with HIT, requiring dialysis.


  1. Mariano F, Bergamo D, Gangemi E, Hollo Z. Citrate anticoagulation for continuous renal replacement therapy in critically ill patients: success and limits. Int J Nephrol. 2011;2011:748320.
  2. KDIGO clinical practice guidelines for acute kidney injury. Kidney Int Suppl. 2012;2(1). Chapter 5.3.