Background/Objectives: Regional citrate anticoagulation (RCA) is guideline-preferred for continuous renal replacement therapy (CRRT), yet implementation requires expertise, calcium protocols, and reliable monitoring. Evidence for standardized low-molecular-weight heparin strategies without routine anti-Xa monitoring remains limited. Methods: We retrospectively analyzed adult ICU patients receiving protocolized divided-dose enoxaparin during CRRT from January 2020 to December 2024. Enoxaparin 1.5 mg/kg/24 h was divided into six equal prefilter doses every 4 h. The primary outcome was circuit clotting; death and hemodynamic instability were treated as competing termination events. Safety endpoints were ISTH major bleeding, clinically relevant non-major bleeding (CRNMB), minor bleeding, thrombosis, and suspected heparin-induced thrombocytopenia (HIT). Results: The cohort included 200 patients and 223 CRRT runs, contributing 8829.8 CRRT-hours. Median run duration was 35.0 h (IQR, 27.2–52.1). Circuit clotting occurred in 31 runs (13.9%; 95% CI, 9.6–19.1), equivalent to 0.35 events per 100 CRRT-hours. Kaplan–Meier clotting-free survival at 48 h was 89.8% (95% CI, 84.3–95.2), and the competing-risk cumulative incidence of clotting was 9.0%. Any classified bleeding occurred in 10 runs (4.5%; 95% CI, 2.2–8.1), including one ISTH major bleeding event and one CRNMB event. No thrombotic or HIT events were identified. In a prespecified four-variable Cox model with patient-level cluster-robust standard errors, no predictor was significantly associated with clotting. Conclusions: In a citrate-unavailable or citrate-not-routinely-implemented ICU setting, this standardized divided-dose enoxaparin protocol showed low observed major/clinically relevant bleeding rates and acceptable clotting-free circuit performance. Prospective comparative evaluation is warranted.
TOPRAK et al. (Wed,) studied this question.
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