A Meta-Analysis of Extracorporeal Anticoagulants in Pediatric Continuous Kidney Replacement Therapy

Abstract

Objective: Continuous kidney replacement therapy (CKRT) is the primary therapeutic modality utilized in hemodynamically unstable patients with severe acute kidney injury. As the circuit is extracorporeal, it poses an increased risk of blood clotting and circuit loss; frequent circuit losses affect the provider’s ability to provide optimal treatment. The objective of this meta-analysis is to evaluate the safety and efficacy of the extracorporeal anticoagulants in the pediatric CKRT population. Data Sources: We conducted a literature search on PubMed/Medline and Embase for relevant citations. Study Selection: Studies were included if they involved patients under the age of 18 years undergoing CKRT, with the use of anticoagulation (heparin, citrate, or prostacyclin) as a part of therapy. Only English articles were included in the study. Data Extraction: Initial search yielded 58 articles and a total of 24 articles were included and reviewed. A meta-analysis was performed focusing on the safety and effectiveness of regional citrate anticoagulation (RCA) vs unfractionated heparin (UFH) anticoagulants in children. Data Synthesis: RCA had statistically significantly longer circuit life of 50.65 hours vs. UFH of 42.10 hours. Two major adverse effects metabolic alkalosis and electrolyte imbalance seen more commonly in RCA compared to UFH. There was not a significant difference in the risk of systemic bleeding when comparing RCA vs. UFH. Conclusion: RCA is the preferred anticoagulant over UFH due to its significantly longer circuit life, although vigilant circuit monitoring is required due to the increased risk of electrolyte disturbances. Prostacyclin was not included in the meta-analysis due to the lack of data in pediatric patients. Additional studies are needed to strengthen the study results further.

Regional Citrate Anticoagulation and Systemic Anticoagulation during Pediatric Continuous Renal Replacement Therapy: A Systematic Literature Review

“…Unfortunately, according to our findings, RCA seems to be more commonly associated with electrolyte imbalance and metabolic alkalosis. These results are in line with those reported by Raina et al [ 25 ], where metabolic alkalosis and electrolyte imbalance were reported in 71.4% and 40% of patients treated with RCA (vs. 16.7% and 0% of those treated with systemic anticoagulation with heparin). Similar results are not confirmed for adult patients, where RCA is usually considered safe and effective in maintaining electrolytes and acid-base homeostasis.…”

“…Interestingly, despite the substantial differences in the methodology used, our study reports consistent results with those reported by Raina et al [ 25 ] for bleeding events. In particular, no difference was reported between RCA and systemic anticoagulation with heparin in terms of severe bleeding events.…”

“…Raina et al have evaluated the safety and efficacy of the extracorporeal anticoagulants in the pediatric CRRT in a systematic review, including any pediatric study reporting data on anticoagulation (heparin, citrate, or prostacyclin) [ 25 ]. In this systematic review, including 24 studies, the authors have demonstrated the association between RCA and an average prolonged circuit life with a relatively higher risk of electrolytes imbalance.…”

“…Hence, we included three more papers [ 12 , 13 , 14 ] evaluating direct comparison between RCA and heparin, for a total of three hundred and forty patients. Finally, we excluded a paper [ 25 ] included in the analysis by Raina et al, because it considered patients up to twenty years old, who have to be considered as adults, especially from the anticoagulation standpoint.…”

Management of Acute Kidney Injury in Critically Ill Children

“…Anticoagulation is particularly challenging during CKRT, which requires prolonged circuit patency at slow blood flow rates. Unfractionated heparin is used most commonly and is injected into the circuit as an IV bolus, followed by its infusion or intermittent boluses [ 51 ]. In patients with coagulopathy, intermittent flushes with saline can be used to keep the circuit patent during intermittent hemodialysis and short SLED sessions; however, this limits ultrafiltration.…”