Citrate anticoagulation in pediatric continuous venovenous hemofiltration

Nahum, Elhanan; Skippen, Peter; Nuthall, Gabrielle; Krahn, Gordon; Seear, Michael

doi:10.1007/s00467-003-1328-5

Cited by 34 publications

(6 citation statements)

References 24 publications

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“…No randomized controlled trials and very few observational studies have been carried out in pediatric patients on CRRT treated with citrate [3, 4]. Only 6 randomized controlled trials comparing citrate and heparin anticoagulation have been published in adult patients [7–12].…”

Section: Discussionmentioning

confidence: 99%

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Citrate Anticoagulation for CRRT in Children: Comparison with Heparin

Fernández

Santiago

López‐Herce

et al. 2014

BioMed Research International

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Regional anticoagulation with citrate is an alternative to heparin in continuous renal replacement therapies, which may prolong circuit lifetime and decrease hemorrhagic complications. A retrospective comparative cohort study based on a prospective observational registry was conducted including critically ill children undergoing CRRT. Efficacy, measured as circuit survival, and secondary effects of heparin and citrate were compared. 12 patients on CRRT with citrate anticoagulation and 24 patients with heparin anticoagulation were analyzed. Median citrate dose was 2.6 mmol/L. Median calcium dose was 0.16 mEq/kg/h. Median heparin dose was 15 UI/kg/h. Median circuit survival was 48 hours with citrate and 31 hours with heparin (P = 0.028). 66.6% of patients treated with citrate developed mild metabolic alkalosis, which was directly related to citrate dose. There were no cases of citrate intoxication: median total calcium/ionic calcium index (CaT/I) of 2.16 and a maximum CaT/I of 2.33, without metabolic acidosis. In the citrate group, 45.5% of patients developed hypochloremia and 27.3% hypomagnesemia. In the heparin group, 27.8% developed hypophosphatemia. Three patients were moved from heparin to citrate to control postoperatory bleeding. In conclusion citrate is a safe and effective anticoagulation method for CRRT in children and it achieves longer circuit survival than heparin.

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Section: Discussionmentioning

confidence: 99%

“…However, few observational studies have been published about citrate anticoagulation in pediatric patients [3, 4] and no one has compared the efficacy of heparin and citrate for anticoagulation in critically ill children on CRRT. This is the objective of our study.…”

Section: Introductionmentioning

confidence: 99%

Citrate Anticoagulation for CRRT in Children: Comparison with Heparin

Fernández

Santiago

López‐Herce

et al. 2014

BioMed Research International

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“…Bunchman et al reported filter lifetimes of approximately 72 h on average, in a series of 14 patients on continuous venovenous hemofiltration with dialysis [ 89 ] and in another series of 9 patients on continuous venovenous hemofiltration [ 90 ], without hemorrhagic complications. In a study of 9 patients, Elhanan et al reported filter survival of up to 5 days [ 91 ].…”

Section: Area 2: Technical Aspectsmentioning

confidence: 99%

Renal replacement therapy in adult and pediatric intensive care

Vinsonneau

Allain-Launay

Blayau

et al. 2015

Ann. Intensive Care

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Acute renal failure (ARF) in critically ill patients is currently very frequent and requires renal replacement therapy (RRT) in many patients. During the last 15 years, several studies have considered important issues regarding the use of RRT in ARF, like the time to initiate the therapy, the dialysis dose, the types of catheter, the choice of technique, and anticoagulation. However, despite an abundant literature, conflicting results do not provide evidence on RRT implementation. We present herein recommendations for the use of RRT in adult and pediatric intensive care developed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system by an expert group of French Intensive Care Society (SRLF), with the participation of the French Society of Anesthesia and Intensive Care (SFAR), the French Group for Pediatric Intensive Care and Emergencies (GFRUP), and the French Dialysis Society (SFD). The recommendations cover 4 fields: criteria for RRT initiation, technical aspects (access routes, membranes, anticoagulation, reverse osmosis water), practical aspects (choice of the method, peritoneal dialysis, dialysis dose, adjustments), and safety (procedures and training, dialysis catheter management, extracorporeal circuit set-up). These recommendations have been designed on a practical point of view to provide guidance for intensivists in their daily practice.

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“…Citrate is thought to have the benefits of decreasing inflammation as well as the need for blood products and allows longer circuit survival [ 9 – 14 ]. Most of the citrate is cleared by the CRRT circuit; however, about 1 mmol/kg spills over into the patient’s circulation [ 15 , 16 ]. In the setting of liver failure, metabolism of citrate is impaired and accumulation can lead to a citrate toxicity-often known as “citrate lock” -where there is continued chelation of serum ionized calcium [ 17 ].…”

Section: Introductionmentioning

confidence: 99%

Regional citrate anticoagulation for continuous renal replacement therapy in pediatric patients with liver failure

et al. 2017

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Pediatric liver failure patients frequently develop multiple organ failure and require continuous renal replacement therapy (CRRT) as part of supportive therapy in the pediatric intensive care unit. While many centers employ no anticoagulation for fear of bleeding complications, balanced coagulation disturbance predisposes these patients to clotting as well as bleeding, making maintenance of longer circuit life to deliver adequate dialysis clearance challenging. Regional citrate anticoagulation (RCA) is an attractive option as it avoids systemic anticoagulation, but since citrate metabolism is impaired in liver failure, concerns about toxicity has limited its use. Pediatric data on RCA with liver failure is very scarce. We aimed to establish safety and efficacy of RCA in pediatric liver failure patients on CRRT. Retrospective review of pediatric patients with liver failure receiving CRRT over 30 months. Demographic data and CRRT related data were collected by chart review. Citrate accumulation (CA) was defined as total calcium (mg/dl) /ionized calcium (mmol/L) ratio >2.5 for > 48 hours. Efficacy was assessed by filter life. Safety was assessed by frequency of adverse events ((AEs) defined as bleeding, hemodynamic instability, arrhythmias). Fifty-one patients (median age 3.5 (IQR 0.75–14.2) years) received 861 CRRT days; 70% experienced at least one episode of CA, only 37% were recorded as such in the medical record. AE rate was 93/1000 CRRT days and did not differ between CA days and others. Median filter life was 66 hours (IQR 29–74); 63% filters lasted longer than 48 hrs. Though common, CA was not associated with increased AEs on in pediatric liver failure patients on CRRT receiving RCA. Filter life was adequate. RCA appears an effective anticoagulation for CRRT in pediatric liver failure. Application of a structured definition would increase recognition of CA to allow timely intervention.

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Citrate anticoagulation in pediatric continuous venovenous hemofiltration

Cited by 34 publications

References 24 publications

Citrate Anticoagulation for CRRT in Children: Comparison with Heparin

Citrate Anticoagulation for CRRT in Children: Comparison with Heparin

Renal replacement therapy in adult and pediatric intensive care

Regional citrate anticoagulation for continuous renal replacement therapy in pediatric patients with liver failure

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