The incidence of thrombocytopenia associated with continuous renal replacement therapy in critically ill patients

Abstract

Introduction: Thrombocytopenia in the intensive care unit (ICU) is a commonly experienced complication; the pathology is not always easily understood. Continuous renal replacement therapy (CRRT) provides a method to dialyze unstable critically ill patients. We hypothesized that CRRT may precipitate a form of thrombocytopenia. In trials thrombocytopenia occurred at rates as high as 70%. The etiology remains unknown and results in additional diagnostic workup, as well as possible drug therapy. The extent, duration and temporal relation of thrombocytopenia remain to be determined. Objectives: Identify a pattern in platelet fluctuations after the initiation of CRRT and its impact on health care. Methods: A retrospective study was conducted in patients receiving CRRT for 424 h with no pre-existing thrombocytopenia. Patients initiated on CRRT had daily platelet counts monitored, and CRRT attributes and therapeutic interventions were collected. Platelets were assessed for time to nadir, degree of decline and time to return to baseline after discontinuation of CRRT. Results: Forty-nine patients met inclusion criteria. Thirty-seven percent of patients receiving heparinoids were tested for heparin-induced thrombocytopenia (HIT), during CRRT, with 39% of these patients having therapy changed to non-heparinoid agents due to suspected HIT; no HIT antibodies were positive. Eleven patients (22%) receiving anticoagulants, prophylactically or therapeutically had them held for a drop in platelets. There was a mean decline in platelets of 48% with a mean of 4.6 days to the nadir. An average 2.48 days were observed until rebound to 4150 Â 10

Heparin-induced thrombocytopenia is associated with a high risk of mortality in critical COVID-19 patients receiving heparin-involved treatment

“…This may explain the high mortality in critically ill patients receiving CRRT (93·8%, 15/16). As an important supportive treatment for critically ill patients with sepsis or AKI, CRRT is used to efficiently remove proinflammatory mediators accumulated in the blood and maintain fluid balance in hemodynamically unstable patients, 35 which has been recommended for renal failure and renal replacement therapy in the Chinese Clinical Guidance for COVID-19. 36 However, accumulating clinical data showed that there were nearly no survivors among critical COVID-19 patients who received CRRT treatment, indicating that patients did not benefit from CRRT.…”

How do we approach thrombocytopenia in critically ill patients?

“…Thrombocytopenia is reported to occur in three‐fourths of patients receiving continuous renal‐replacement therapy (Ferreira & Johnson, ). Immune destruction, co‐morbid conditions and secondary to drugs (including heparin) used in these patients are mechanisms described but the dialysis‐specific issues are related to the adherence of platelets to the dialysis‐filtration membrane (Ferreira & Johnson, ). Dialyzer membrane‐induced thrombocytopenia was first noted three decades ago by Vicks et al () prior to routine blood counts when patients developed haemorrhage related to thrombocytopenia.…”

Determining the optimal time for liberation from renal replacement therapy in critically ill patients: a systematic review and meta-analysis (DOnE RRT)

“…However, less is known about the ideal circumstances in which RRT may be successfully discontinued. RRT is a complex and expensive therapy, with complications including catheter-associated infections, hemorrhage, hemodynamic instability, and delayed renal recovery [7][8][9][10][11][12][13][14][15]. It is thus imperative to recognize when a patient may be safely liberated from this treatment.…”