Please select the eligibility criteria that correspond to the clinical trial below.
Title: A Comparison of Dilute Unfractionated Heparin and Standard Concentrated Unfractionated Heparin Protocols for Anticoagulation of the Extra-corporeal Circuit During Continuous Renal Replacement Therapy in the ICU
Brief Summary: Heparin is commonly used for anticoagulation of the extracorporeal circuit during continuous renal replacement therapy (CRRT) but the optimal mode of delivery has not yet been validated. Our study will compare dilute heparin to a standard concentration of heparin. The investigators hypothesize that heparin delivered in a dilute solution will augment coating of the filter fibers with anticoagulants, decreasing clotting events and increasing filter life. By improving delivery of heparin to the filter and circuit, where clotting events can disrupt dialysis, less heparin would be required for the extra-corporeal circuit and thus less heparin would be delivered back to the patient with blood return from the machine. By exposing the patient to less heparin it is hypothesized that fewer bleeding events would occur, making the dialysis treatment safer. If more of the filter's fibers remain patent and the filter is functional for a longer period of time, the CRRT would also be more effective.


Options:
A: Inclusion Criteria:

* Male or female \> or equal to 19 yrs of age
* ARF defined by at least one of the following:

  * Volume overload from inadequate urine output despite diuretic agents.
  * Oliguria (urine output \< 200 ml/12hrs) despite fluid resuscitation and diuretic administration.
  * Anuria (urine output \< 50 ml/12 hrs).
  * Acute azotemia (BUN \> or equal to 80 mg/dl).
  * Acute hyperkalemia not responsive to medication (K+ \> or equal to 6.5mmol/L)
  * An increase in serum creatinine of \> 2.5 mg/dl from normal values or a sustained rise in serum creatinine of \> or equal to 1 mg/dl over baseline.

Exclusion Criteria

* Patients with end stage renal disease
* Patients who have had more than one previous dialysis session for acute or chronic renal failure during the current hospitalization
* Patient weight greater than 125 kg
* Patient weight less than 50 kg
* Pregnancy
* Prisoner
* Non-candidacy for continuous renal replacement therapy (CRRT)
* Patient/surrogate refusal
B: Inclusion Criteria:

* Admitted in intensive care unit (ICU)
* Requiring hemodialysis
* Clinicians have the choice between jugular and femoral routes

Exclusion Criteria:

* Chronic renal failure requiring long term dialysis
C: Inclusion Criteria:

* Age greater than 18 years
* Renal failure, electrolyte disturbance, or volume overload requiring continuous venovenous hemodialysis (CVVHD) as determined by the Nephrology consult service

Exclusion Criteria:

* Age less than 18 years
* Active bleeding
* Coagulopathy as defined by baseline INR \> 1.8, aPTT \> 45 seconds, or platelet count \< 50 thousand/μL
* Active administration of systemic anticoagulation (such as warfarin, therapeutic unfractionated heparin, or therapeutic enoxaparin)
* Contraindication to heparin (allergy, thrombocytopenia with platelet count \< 50, known or suspected heparin induced thrombocytopenia \[HIT\])
* Contraindication to systemic anticoagulation (recent surgical or other invasive procedure, significant bleeding disorder, concern for intracranial bleeding, or other contraindication as determined by treating physician)
* Administration of drotrecogin (Xigris™)
* Anticipated surgical or other invasive procedure that would necessitate withdrawal of anticoagulation within 72 hours
* Expected termination of continuous renal replacement therapy (CRRT) or death in \< 24 hours
* The need for more than 500 cc an hour of IV fluids delivered proximal to the filter for the purpose of performing continuous venovenous hemofiltration (CVVH) or continuous venovenous hemodiafiltration (CVVHDF)
D: Inclusion Criteria:

1. Adult patients (over 16 years of age) admitted to a participating ICU
2. Serum creatinine increase of ≥ 50% from baseline
3. Hemodynamic instability as defined by the cardiovascular component of the SOFA score of ≥ 1
4. Attending physician deems the patient a candidate for RRT for at least one of the following reasons:

   1. Presence of oliguria, defined as a urine output of \< 100 mL in the preceding 4 hours
   2. metabolic acidosis (HCO3- \< 15 mmol/L and pH \< 7.25)
   3. refractory hyperkalemia (K \> 6.0 mmol/L)
   4. azotemia (BUN \> 50 mmol/L)
   5. suspected uremic organ involvement (pericarditis, encephalopathy, neuropathy or myopathy)

Exclusion Criteria:

1. renal replacement therapy within the previous 2 months
2. presence of renal obstruction
3. receipt of a kidney transplant in the previous year
4. diagnosis of rapidly progressive glomerulonephritis, vasculitis, or acute interstitial nephritis
5. indication for intermittent hemodialysis, specifically severe hyperkalemia, dialyzable drug or toxin
6. terminal illness with associated life expectancy less than 2 months
7. patients who are moribund
8. prior enrollment in this study
9. enrollment in a competing ICU interventional study
10. no CRRT machine available
11. acute renal replacement ongoing for \> 36 hours

Answer: C