Citrate anticoagulation for continuous renal replacement therapy in small children

Abstract

BackgroundRegional citrate anticoagulation (RCA) is one of the methods used to prevent clotting in continuous renal replacement therapy (CRRT). The aim of this study was to describe the outcomes and complications of RCA-CRRT in comparison to heparin anticoagulation (HA)-CRRT in critically ill children.MethodsThis study was a retrospective review of 30 critically ill children (16 on RCA- and 14 on HA-CRRT) who underwent at least 24 h of CRRT. The mean body weight of the children was 8.69 ± 5.63 kg. RCA-CRRT was performed with a commercially available pre-dilution citrate solution (Prismocitrate 18/0).ResultsThe mean time on RCA-CRRT and HA-CRRT was 148.73 ± 131.58 and 110.24 ± 105.38 h, respectively. Circuit lifetime was significantly higher in RCA-CRRT than in HA-CRRT (58.04 ± 51.18 h vs. 37.64 ± 32.51 h, respectively; p = 0.030). Circuit clotting was observed in 11.63 % of children receiving RCA-CRRT and 34.15 % of those receiving HA-CRRT. Episodic electrolyte and metabolic disturbances were more common in children receiving RCA-CRRT. The survival at discharge from the hospital was 37.5 and 14.3 % among children receiving RCA-CRRT and HA-CRRT, respectively.ConclusionsIn critically ill children with a low body weight, RCA appeared to be safe and easy to used. Among our patient cohort, RCA was more effective in preventing circuit clotting and provided a better circuit lifetime than HA.

Filter Size Not the Anticoagulation Method is the Decisive Factor in Continuous Renal Replacement Therapy Circuit Survival

“…According to the literature, RCA is not only a safe and effective ACG modality for pediatric CRRT, but it also achieves longer circuit survivals than Hep-ACG; hence, the use of RCA may provide a substantial cost saving and it is an ideal option in a critically ill children after recent surgery or with coagulopathy, for whom systemic ACG is discouraged [11]. Supporting this conclusion in their study, Sołtysiak et al [21] stated that the circuit lifetime was significantly higher in RCA than in Hep-ACG (58.04 h vs. 37.64 h) and early circuit clotting was observed in 11.63% of children receiving RCA and 34.15% of those receiving Hep-ACG. Similarly, in a study by Fernández et al [11], the median RCA circuit survival was 48 hours, while in case of Hep-ACG - 31 hours and the difference was statistically significant.…”

“…Contrary to some of the above quoted studies ([11, 19, 21]), in the present report the investigated filters were divided according to their size and all the statistical analyses (Tables 2-7) addressed a given filter size, what represents a fairly novel approach to the problem. Thanks to such a view, it was demonstrated that filter survival was significantly affected by its size rather than the type of ACG employed (Tables 2, 3, 5).…”

“…Similarly, in a study by Fernández et al [11], the median RCA circuit survival was 48 hours, while in case of Hep-ACG - 31 hours and the difference was statistically significant. Nevertheless, in both the aforementioned studies, the authors considered all the studied filter types as a single homogenous group (HF20, ST60 filters [21], and HF20, ST60, ST100 filters [11]). However, in the study by Rico et al [22], the authors not only proved that the survival of filters was higher in the RCA (72 h) than in the Hep-ACG (18 h) group, but they also showed that the filter coagulation risk was significantly increased when heparin was used, regardless of filter size.…”

“…Here, the employed ACG modality also exerts a significant impact. According to the current literature, the total mean dialysis dose and mean blood flow rate in children are 52 ml/kg/h [21] and 5.2 ml/kg/min [25], respectively. In a study by Fernández et al [11], although the total CRRT dose was higher in the RCA as compared to the Hep-ACG group, the difference was not statistically significant (69 vs. 59 ml/kg/h).…”

Épuration extrarénale en réanimation adulte et pédiatrique. Recommandations formalisées d’experts sous l’égide de la Société de réanimation de langue française (SRLF), avec la participation de la Société française d’anesthésie-réanimation (Sfar), du Groupe francophone de réanimation et urgences pédiatriques (GFRUP) et de la Société francophone de dialyse (SFD)

“…En ce qui concerne la comparaison avec l'héparine, l'étude observationnelle de Brophy et al [92] [93], alors que les concentrations plus faibles peuvent avoir pour conséquence une augmentation des débits d'effluent supérieurs aux doses recommandées [94]. Ces risques doivent être pris en compte dans le choix de la concentration de la solution de citrate, variable selon les prestataires, d'où la nécessité d'une expertise médi-cale pointue.…”