Beyond the Randomized Clinical Trial: Citrate for Continuous Renal Replacement Therapy in Clinical Practice

Tovey, Linda; Dickie, Helen A.; Gangi, Stefania Di; Terblanche, Marius; McKenzie, Catherine; Beale, Richard; Treacher, David; Ostermann, Marlies

doi:10.1159/000355550

Cited by 9 publications

(14 citation statements)

References 19 publications

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“…Circuit failure remains the Achilles' heel of CRRT, decreasing the delivery of the prescribed dialysis dose and increasing cost and workload [4]. Investigators have designed strategies to prolong circuit lifespan by mean of improved circuit anticoagulation [10][11][12][13]. .01 § Epoprostenol.…”

Section: Relationship To Previous Studiesmentioning

confidence: 99%

Circuit Survival during Continuous Venovenous Hemodialysis versus Continuous Venovenous Hemofiltration

et al. 2020

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Background: Continuous renal replacement therapy (CRRT) technique may affect circuit lifespan. A shorter circuit life may reduce CRRT efficacy and increase costs. Methods: In a before-and-after study, we compared circuit median survival time during continuous venovenous hemofiltration (CVVH) versus continuous venovenous hemodialysis ( CVVHD). We performed log-rank mixed effects univariate analysis and Cox mixed effect regression modeling to define predictors of circuit lifespan. Results: We compared 197 CVVHD and 97 CVVH circuits in 39 patients. There was no overall difference in circuit lifespan. When no anticoagulation was used, median circuit survival time was shorter for CVVH circuits (5 h, 95% CI 3-7 vs. 10 h, 95% CI 8-13, p < 0.01). Moreover, CVVHD, lower platelets levels, and longer activated partial thromboplastin time independently predicted longer circuit median survival time. Conclusions: CVVHD is associated with longer circuit median survival time than CVVH when no anticoagulation is used and is an independent predictor of circuit survival.

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Section: Relationship To Previous Studiesmentioning

confidence: 99%

Circuit Survival during Continuous Venovenous Hemodialysis versus Continuous Venovenous Hemofiltration

et al. 2020

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“…This echoes findings of other studies that used similar models. 7,10,16,18,22 Additionally, a review of the reasons for stopping CRRT showed the percentage of filters stopped due to transfer needs, access problems or sudden death were similar across both citrate and heparin protocols. However, there was a noticeably higher percentage of heparin filters stopped due to clotting.…”

Section: Filter Life Spanmentioning

confidence: 99%

“…This was a common observation in similar evaluation studies, which again, reinforces citrate's superiority in prolonging filter life whilst reducing blood and filter wastage. 10,22…”

Section: Filter Life Spanmentioning

confidence: 99%

“…[7][8][9] While randomised controlled trials (RCTs) and meta-analyses demonstrate the advantages of citrate over heparin, they also discuss potential disadvantages, such as increased complexity of the protocol, as well as potential metabolic and electrolytes disturbances and possible higher financial costs. 10 This is likely why citrate has been slow to gain popularity with less than 10% of all patients on CRRT for AKI receiving citrate in a worldwide survey in 2007 11 and none of the UK units using citrate in 2008. 4 Moreover, meta-analyses of RCTs question the power of these trials, as well as the generalisability of the results due to the great heterogeneity of the studies in terms of modalities, machines and filters used, patient groups and protocols used.…”

Section: Introductionmentioning

confidence: 99%

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Evaluating the safety and efficacy of regional citrate compared to systemic heparin as anticoagulation for continuous renal replacement therapy in critically ill patients: A service evaluation following a change in practice

Borg

Ugboma

Walker

et al. 2017

Journal of the Intensive Care Society

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Following the implementation of citrate anticoagulation for continuous renal replacement therapy, we evaluate its first year of use and compare it to the previously used heparin, to assess whether our patients benefit from the recently reported advantages of citrate. We retrospectively analysed 2 years of data to compare the safety and efficacy of citrate versus heparin. The results have shown that 43 patients received continuous renal replacement therapy with heparin, 37 patients with citrate. We found no significant difference in metabolic control of pH, urea and creatinine after 72 h. Filters anticoagulated with citrate had significantly longer median lifespan (33 h vs 17 h; p ¼ 0.001), shorter downtime (0 h vs 5 h; p ¼ 0.015) and less filter sets per patient day (0.37 vs 0.67; p ¼ 0.002). Filters anticoagulated with heparin were commonly interrupted due to clotting (50% vs 16.4%), whereas filters anticoagulated with citrate were often stopped electively (53.4% vs 24.6%). Patients on heparin filters had significantly higher APPTs, some at potentially dangerous levels (>180 s), whilst patients on citrate filters had significantly higher levels of bicarbonate. Therefore, we conclude that citrate is superior in terms of safety and efficacy, with longer filter lifespan. It has become our first line anticoagulant for continuous renal replacement therapy.

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“…21,[31][32][33][34] With some protocols, a citrate solution is infused before the filter in the CRRT circuit in relation to blood flow rate. 32,34,35 With this method, the amount of ionized calcium in the circuit after the filter is monitored routinely; the typical goal is a concentration less than 0.35 mmol/L to ensure that the calcium level is low enough to suppress clotting. 21,31,34 The citrate infusion is then adjusted accordingly.…”

Section: Wwwccnonlineorgmentioning

confidence: 99%

Continuous Renal Replacement Therapy and Anticoagulation:

Dirkes

Wonnacott

2016

Critical Care Nurse

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Continuous renal replacement therapy is currently used as a standard treatment for acute kidney injury in the intensive care unit, particularly for patients with unstable hemodynamic status. Because this therapy is continuous, for days or weeks, and the extracorporeal blood circuit is large, the circuit is prone to clotting. Several methods of keeping the extracorporeal circuit patent are available, including heparin infusion, flushes with physiological saline, use of thrombin inhibitors, and citrate. This article reviews methods for continuous renal replacement therapy, anticoagulation, efficacy, and implications for bedside critical care. (Critical Care Nurse. 2016;36[2]:34-42)

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Beyond the Randomized Clinical Trial: Citrate for Continuous Renal Replacement Therapy in Clinical Practice

Cited by 9 publications

References 19 publications

Circuit Survival during Continuous Venovenous Hemodialysis versus Continuous Venovenous Hemofiltration

Circuit Survival during Continuous Venovenous Hemodialysis versus Continuous Venovenous Hemofiltration

Evaluating the safety and efficacy of regional citrate compared to systemic heparin as anticoagulation for continuous renal replacement therapy in critically ill patients: A service evaluation following a change in practice

Continuous Renal Replacement Therapy and Anticoagulation:

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