Clinical Impact of Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy in Critically Ill Patients

Huguet, María Luisa López; Rodas, Lida; Blasco, Miquel; Quintana, Luís F.; Mercadal, J.; Ortiz-Pérez, Josè T.; Rovira, I.; Poch, Esteban

doi:10.5301/ijao.5000633

Cited by 6 publications

(11 citation statements)

References 21 publications

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“…The results of our present study suggested that RCA was more effective than LMWH in prolonging the filter lifespan in severe hypercalcemia patients who underwent CVVH. These results were consistent with previous studies of patients without hypercalcemia [23][24][25][26]. In the RCA group, the estimated median filter lifespan was >72 h, which was comparable with the filter lifespan in previous studies [18][19][20].…”

Section: Discussionsupporting

confidence: 92%

“…The major intervention to maintain patency of the extracorporeal circuit is anticoagulation. Numerous clinical studies have demonstrated that regional citrate anticoagulation (RCA) for CRRT could prolong the filter lifespan and decrease the bleeding risk compared to heparin or low molecular weight heparin (LMWH) anticoagulation [23][24][25][26]. The Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommended RCA as the first choice for CRRT in patients without citrate contraindications [15].…”

Section: Introductionmentioning

confidence: 99%

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Regional citrate anticoagulation versus low molecular weight heparin anticoagulation for continuous venovenous hemofiltration in patients with severe hypercalcemia: a retrospective cohort study

Bai

Zhang

et al. 2020

Renal Failure

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Purpose: We conducted a retrospective study to evaluate the efficacy and safety of regional citrate anticoagulation (RCA) versus those of low molecular weight heparin (LMWH) anticoagulation for CVVH in severe hypercalcemia patients. Methods: Between January 2014 and May 2019, 33 severe hypercalcemia patients underwent CVVH. Patients were divided into the RCA and LMWH groups. Calcium-free replacement solution was used. Serum total calcium reduction rate (RRSeCa), filter lifespan, bleeding, totCa/ionCa ratio, citrate accumulation, and catheter occlusion were evaluated as outcomes. Results: RCA and LMWH were employed for CVVH in 14 and 43 filters, respectively. RRSeCa was not significantly different between the LMWH and RCA groups (p ¼ .320), but RCA-CVVH was more effective in reducing ionized calcium at half of the time points (p < .05). RCA significantly prolonged the median filter lifespan (>72 h vs. 24.0 h [IQR, 15.0-26.0], p ¼ .012). The incidence of filter failure was 55.8% (24/43) in the LMWH group and 21.4% (3/14) in the RCA group (p ¼ .033). The adjusted results demonstrated that RCA could significantly reduce the risk of filter failure (p ¼ .043, 95% CI 0.059-0.957, HR ¼ 0.238). No citrate accumulation or bleeding episodes were observed in the RCA-CVVH group. Seven bleeding episodes (7/43, 16.3%) occurred in the LMWH-CVVH group. Conclusions: In patients with severe hypercalcemia who underwent CVVH, RCA more effectively decreased calcium levels and had a superior filter lifespan and no obvious adverse events compared with LMWH. Further prospective, randomized, controlled studies are warranted to obtain robust evidence.

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Section: Discussionsupporting

confidence: 92%

Section: Introductionmentioning

confidence: 99%

Regional citrate anticoagulation versus low molecular weight heparin anticoagulation for continuous venovenous hemofiltration in patients with severe hypercalcemia: a retrospective cohort study

Bai

Zhang

et al. 2020

Renal Failure

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“…The present results compare well with similar studies, using this protocol in a general intensive care unit (ICU) population (27 h) and postoperative cardiac surgical patients who received RCA predilution continuous hemofiltration (48 h), continuous hemodiafiltration with RCA or heparin (50-58 h) and continuous hemodialysis with RCA (39-61 h) [10,[14][15][16][17][18][19][20].…”

Section: Discussionsupporting

confidence: 85%

Filter life span in postoperative cardiovascular surgery patients requiring continuous renal replacement therapy, using a postdilution regional citrate anticoagulation continuous hemofiltration circuit

et al. 2022

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Background: Regional citrate anticoagulation (RCA) is the recommended standard for continuous renal replacement therapy (CRRT). This study assesses its efficacy in patients admitted to critical care following cardiovascular surgery and the influence of standard antithrombotic agents routinely used in this specific group. Methods: Consecutive cardiovascular surgery patients treated with post-dilution hemofiltration with RCA were included in this prospective observational study. The primary outcome of the study was CRRT circuit life-span adjusted for reasons other than clotting. The secondary outcome evaluated the influence of standard antithrombotic agents (acetylsalicylic acid [ASA], low molecular weight heparin [LMWH] or fondaparinux as thromboprophylaxis or treatment dose with or without ASA) on filter life. Results: Fifty-two patients underwent 193 sessions of CVVH, after exclusion of 15 sessions where unfractionated heparin was administered. The median filter life span was 58 hours. Filter life span was significantly longer in patients receiving therapeutic dose of LMWH or fondaparinux (79 h [2-110]), in comparison to patients treated with prophylactic dose of LMWH or fondaparinux (51 h [7-117], p < 0.001), and patients without antithrombotic prophylaxis (42 h [2-91], p < 0.0001). 12 bleeding episodes were observed; 8 occurred in patients receiving treatment dose anticoagulation, 3 in patients receiving prophylactic dose anticoagulation and 1 in a patient with no antithrombotic prophylaxis. Conclusions:A post dilution hemofiltration with RCA provides prolonged filter life span when adjusted for reasons other than clotting. Patients receiving treatment dose anticoagulation had a significantly longer filter life span than those who were on prophylactic doses or ASA alone.

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“…The observed longer filter life and lower rate of circuit clotting associated with RCA are largely consistent with previously reported data [5,[12][13][14][15][16]. In particular, it is similar to that observed in cohorts using a similar RCA protocol [11].…”

Section: Comparison With Previous Studiessupporting

confidence: 91%

“…The reported incidence of metabolic complications associated with RCA is higher than previously reported [12,14,15]. This is possibly related to our decision to report any anomaly irrespective of its duration and poten-tial clinical significance.…”

Section: Comparison With Previous Studiesmentioning

confidence: 71%

Complications of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy: An Observational Study

et al. 2020

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Introduction: Regional citrate anticoagulation (RCA) is the recommended anticoagulation modality for continuous renal replacement therapy (CRRT). RCA was associated with a low rate of complications in randomized controlled trials. However, little is known about the type and rate of complications in real life. We sought to describe complications associated with RCA in comparison with those associated with heparin anticoagulation. Methods: In our institution, RCA has been the default anticoagulation modality for CRRT in all patients without contraindications since 2013. We have retrospectively reviewed all consecutive patients who received CRRT between January and December 2016 in our institution. For each CRRT session, we have assessed circuit duration, administered dose, as well as therapy-associated complications. Those parameters were compared according to whether the circuit was run in continuous veno-venous hemodialysis (CVVHD) mode with RCA or continuous veno-venous hemofiltration (CVVH) mode with heparin anticoagulation. Results: We analyzed 691 CRRT sessions in 121 patients. Of those 400 (57.9%) were performed in CVVHD-RCA mode and 291 (42.1%) in CVVH-Heparin Mode. Compared with CVVH-Heparin mode, CVVHD-RCA mode was associated with a longer circuit lifespan (median duration 54.9 interquartile range [IQR 44.6] vs. 15.3 h [IQR 22.4], p < 0.0001). It was associated with a higher rate of metabolic acidosis 77 (20.2%) vs. 18 (7.2%), (p < 0.0001), alkalosis 186 (48.7%) vs. 43 (17.1%), (p = 0.0001), and hypocalcemia 96 (25.07%) vs. 26 events (10.79%), p < 0.0001. However, the majority of these alterations were of benign or moderate severity. Only one possible citrate intoxication was observed. Conclusions: CVVHD-RCA was associated with a much longer circuit life but an increased rate of minor metabolic complications, in particular acid-base derangements. Some of these complications might have been prevented by therapy adaptation. Medical and nursing staff education is of major importance in the implementation of an RCA protocol.

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Clinical Impact of Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy in Critically Ill Patients

Abstract: These results suggest that the implementation of CVVHDF with RCA using concentrated citrate solutions prolongs filter lifetime, achieves a longer effective hemodiafiltration time and is a safe and feasible method.

Cited by 6 publications

References 21 publications

Regional citrate anticoagulation versus low molecular weight heparin anticoagulation for continuous venovenous hemofiltration in patients with severe hypercalcemia: a retrospective cohort study

Regional citrate anticoagulation versus low molecular weight heparin anticoagulation for continuous venovenous hemofiltration in patients with severe hypercalcemia: a retrospective cohort study

Filter life span in postoperative cardiovascular surgery patients requiring continuous renal replacement therapy, using a postdilution regional citrate anticoagulation continuous hemofiltration circuit

Complications of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy: An Observational Study

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