Continuous haemofiltration in acute renal failure with prostacyclin as the sole anti-haemostatic agent

Objective: To investigate the safety and efficacy of a synthetic prostacyclin analogue (epoprostenol) for circuit maintenance during continuous veno-venous haemofiltration (CVVH) in patients with acute renal failure (ARF). Design: Observational case study. Setting: University-affiliated six-bed intermediate renal care unit in a nephrology and internal medicine department of a 1300-bed teaching hospital. Patients: A consecutive series of critically ill ARF patients in whom prostacyclin was the sole anti-haemostatic agent used for CVVH. Interventions: Bicarbonate-based CVVH in pre-dilution (1.5 l/h); blood flow rate at 200 ml/min; prostacyclin at 4 ng/kg per min infusion in the extracorporeal circuit before the haemofilter, Measurements and main results: Fifty-one ARF patients (mean APACHE II 27.2, SD 7.8; acute tubular necrosis in 44/51, 83%; mechanical ventilation 14151, 21%; in-hospital mortality 28/51, 54%) underwent CVVH for a total of 4040 h (230 circuits, median number 4 circuits per patient, range 1-13). Four patients out of 51 (7.8%) experienced major bleeding during CVVH (1.0 episode per 1000 patient-hours of treatment; 95%CI, 0.4-2.6); no death could be attributed to haemorrhage. Therapeutic intervention for hypotension (fluids and/or vasopressors) was required in 15.5% of the CVVH sessions monitored. The median duration of the circuit was 15.0 h (95% Cl, 13.0-16.5). Conclusions: The use of prostacyclin as the sole anti-haemostatic agent for CVVH entails a low risk of haemorrhagic complications, while maintaining the patency of the circuit long enough to allow the delivery of an adequate dose of renal replacement therapy. Further studies are needed to compare this technique to other anti-haemostatic strategies for CVVH.