Abstract Introduction Continuous renal replacement therapy (CRRT) is often complicated by clotting. Anticoagulation is commonly required but presents a dilemma in patients with recent bleeding. We describe a case in which low-dose heparin was safely introduced to maintain CRRT circuit patency in a patient with a stable retroperitoneal hematoma and recurrent circuit failure secondary to clotting. Case Report A 43-year-old-male with a history of atrial fibrillation, ESRD and a failed renal transplant, presented with AV fistula thrombosis and septic shock. The patient was started on CRRT for acidosis and hyperkalemia. Despite frequent circuit changes, recurrent filter and line clotting occurred. Initial attempts to manage catheter occlusion with intracatheter heparin and alteplase were unsuccessful. Vascular access was complicated by the patient’s anatomy which included chronic occlusion of multiple central veins and multiple failed AV grafts. Systemic anticoagulation was initially withheld. However, a low-dose unfractionated heparin infusion, with an activated partial thromboplastin time (aPTT) goal of 40-60 seconds, was later initiated to maintain circuit patency due to worsening hyperkalemia and EKG changes. This approach was effective without expansion of the hematoma. As the heparin rate was increased to allow for therapeutic level anticoagulation, the retroperitoneal hematoma expanded. Heparin was discontinued, and the bleed was managed conservatively. Imaging did not reveal an active source of bleeding. Once hemodynamically stable, low-dose heparin infusion was cautiously reinitiated. This approach effectively prevented further clotting without recurrence of hemorrhage. The patient’s hemodynamics improved, CRRT was discontinued, and he was transitioned to intermittent hemodialysis. He was later discharged on low-dose Apixaban. Discussion Current guidelines recommend regional citrate anticoagulation (RCA) as the first-line strategy for CRRT in patients at high-risk of bleeding. However, in patients with shock, RCA may be contraindicated due to impaired citrate metabolism. In such scenarios, evidence guiding anticoagulation management is limited and largely based on expert consensus. Balancing anticoagulation in critically ill patients with concurrent bleeding, clotting and renal failure presents a significant challenge. This case illustrates that carefully titrated, low-intensity anticoagulation can sustain CRRT function while minimizing bleeding risk. Novelty and Importance Few reports describe successful reintroduction of low-dose heparin in patients with retroperitoneal hemorrhage requiring CRRT. This case underscores the feasibility and safety of cautious anticoagulation once bleeding stabilizes. It highlights a practical strategy to prevent recurrent CRRT circuit failure without exacerbating hemorrhage. Further research and development of guidelines is needed to determine the optimal approach particularly in patients at high-risk of clotting and bleeding. This abstract is funded by: None
Kanan et al. (Fri,) studied this question.