What is your approach to anticoagulation in a patient with AKI and cirrhosis who has frequent filter clotting on CRRT?

A meta-analysis (Qi et al., PMID 37186766) compared 348 patients from 9 studies receiving RCA to 127 patients from 5 studies receiving heparin anticoagulation. Among the RCA recipients, the incidence of citrate accumulation, metabolic acidosis, and metabolic alkalosis was 5.3%, 26.4%, and 1.8%, resp...

Even though cirrhotic tend to have abnormal PT and INRs, whether they are at risk of more bleeding is not confirmed. Likely, they are not. I would definitely consider giving them anticoagulation unless they are actively bleeding or have a history of varices and GI bleeding that is significant.