Comparison of different anticoagulation strategies for renal replacement therapy in critically ill patients with COVID-19: a cohort study

BMC Nephrol. 2020 Nov 16;21(1):486. doi: 10.1186/s12882-020-02150-8.


Background: Critically ill coronavirus disease 2019 (COVID-19) patients have a high risk of acute kidney injury (AKI) that requires renal replacement therapy (RRT). A state of hypercoagulability reduces circuit life spans. To maintain circuit patency and therapeutic efficiency, an optimized anticoagulation strategy is needed. This study investigates whether alternative anticoagulation strategies for RRT during COVID-19 are superior to administration of unfractionated heparin (UFH).

Methods: Retrospective cohort study on 71 critically ill COVID-19 patients (≥18 years), admitted to intensive care units at a tertiary health care facility in the southwestern part of Germany between February 26 and May 21, 2020. We collected data on the disease course, AKI, RRT, and thromboembolic events. Four different anticoagulatory regimens were administered. Anticoagulation during continuous veno-venous hemodialysis (CVVHD) was performed with UFH or citrate. Anticoagulation during sustained low-efficiency daily dialysis (SLEDD) was performed with UFH, argatroban, or low molecular weight heparin (LMWH). Primary outcome is the effect of the anticoagulation regimen on mean treatment times of RRT.

Results: In patients receiving CVVHD, mean treatment time in the UFH group was 21.3 h (SEM: ±5.6 h), in the citrate group 45.6 h (SEM: ±2.7 h). Citrate anticoagulation significantly prolonged treatment times by 24.4 h (P = .001). In patients receiving SLEDD, mean treatment time with UFH was 8.1 h (SEM: ±1.3 h), with argatroban 8.0 h (SEM: ±0.9 h), and with LMWH 11.8 h (SEM: ±0.5 h). LMWH significantly prolonged treatment times by 3.7 h (P = .008) and 3.8 h (P = .002), respectively.

Conclusions: UFH fails to prevent early clotting events in the dialysis circuit during COVID-19. For patients, who do not require effective systemic anticoagulation, regional citrate dialysis is the most effective strategy. For patients, who require effective systemic anticoagulation, the usage of LMWH results in the longest circuit life spans. The proposed anticoagulatory strategies are safe, can easily be monitored, and allow an individualized treatment.

Keywords: Acute kidney injury; Anticoagulation; COVID-19; Critical care; Emerging communicable diseases; Renal replacement therapy; SARS-CoV-2.

Publication types

  • Comparative Study

MeSH terms

  • Acute Kidney Injury / blood
  • Acute Kidney Injury / epidemiology
  • Acute Kidney Injury / therapy*
  • Adult
  • Aged
  • Anticoagulants / administration & dosage*
  • Arginine / analogs & derivatives
  • Betacoronavirus*
  • Blood Coagulation
  • COVID-19
  • Citric Acid / administration & dosage
  • Comorbidity
  • Coronavirus Infections / blood
  • Coronavirus Infections / epidemiology*
  • Critical Care
  • Critical Illness
  • Equipment Failure
  • Female
  • Germany / epidemiology
  • Heparin / administration & dosage
  • Heparin, Low-Molecular-Weight / administration & dosage
  • Humans
  • Male
  • Middle Aged
  • Pandemics
  • Pipecolic Acids / administration & dosage
  • Pneumonia, Viral / blood
  • Pneumonia, Viral / epidemiology*
  • Renal Replacement Therapy / instrumentation
  • Renal Replacement Therapy / methods*
  • Retrospective Studies
  • SARS-CoV-2
  • Sulfonamides
  • Tertiary Care Centers


  • Anticoagulants
  • Heparin, Low-Molecular-Weight
  • Pipecolic Acids
  • Sulfonamides
  • Citric Acid
  • Heparin
  • Arginine
  • argatroban