Epoprostenol as an alternative anticoagulant for pediatric aquadex therapy: a safe and feasible option.

BACKGROUND: The Aquadex ultrafiltration system offers a low extracorporeal volume option for the pediatric population. To maintain circuit patency, it relies on conventional anticoagulation, and data on alternative anticoagulation strategies are limited. Epoprostenol, a prostacyclin analog that inhibits platelet aggregation, may provide a safe alternative. The objective of this study was to describe the use of epoprostenol as the sole anticoagulant for Aquadex ultrafiltration therapy in critically ill children and to evaluate its safety, feasibility, and impact on circuit patency. METHODS: We conducted a single-center retrospective study of children (<18 years) who received Aquadex therapy with epoprostenol anticoagulation between September 2022 and September 2025 at UPMC Children's Hospital of Pittsburgh. Safety and efficacy were assessed by platelet count, bleeding events, vasoactive-inotropic scores (VIS), and circuit performance. RESULTS: Forty-six patients underwent 52 treatments. Median (IQR) age was 35.5 (12.5-114) months. Primary indications were fluid overload (88.5%) and acute kidney injury (11.5%). The median therapy duration was 3 [2-9] days, with a filter-to-day ratio of 0.5 (0.3-0.5). Platelet counts rose from a median (IQR) of 113 (×10⁹/L) prior to therapy to 126 (×10⁹/L) at 72 h, with a median of 0 [0-1] platelet transfusions per day. The median VIS was 4 [0-12] prior to therapy and 0 [0-8] at 48 h; vasoactive-inotropic requirements did not increase at any time point. No bleeding events directly attributable to epoprostenol or therapy discontinuations due to hypotension occurred. Circuit patency was maintained, with a median of 0 (0-1) interruptions per course due to clotting or clogging. CONCLUSIONS: Epoprostenol appears to be a feasible anticoagulant for pediatric Aquadex therapy, with preserved circuit function, no increase in vasoactive-inotropic requirements, and no observed bleeding events. These findings support its further evaluation as an alternative anticoagulant for pediatric Aquadex Therapy.