When acute tubular necrosis requiring renal replacement therapy (RRT) develops in a patient with heparin-induced thrombocytopenia (HIT), the presence of HIT is a critical determinant of how anticoagulation must be managed during RRT.
This protocol addresses acute tubular necrosis in patients with confirmed or suspected heparin-induced thrombocytopenia. HIT represents a direct contraindication to continued heparin exposure; any RRT anticoagulation strategy must account for this condition from the outset.
The approach requires immediate cessation of all heparin and substitution with an agent from an alternative anticoagulant class — either a direct thrombin inhibitor or a Factor Xa inhibitor — to safely support RRT. Specific agent selection depends on individual patient factors; the complete guidance is in the full protocol.
In a patient with heparin-induced thrombocytopenia (HIT), all heparin must be stopped and we recommend using direct thrombin inhibitors (such as argatroban) or Factor Xa inhibitors (such as danaparoid or fondaparinux) rather than other or no anticoagulation during RRT.
In a patient with HIT who does not have severe liver failure, we suggest using argatroban rather than other thrombin or Factor Xa inhibitors during RRT.
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