Citrate vs. heparin for anticoagulation in continuous venovenous hemofiltration: a prospective randomized study

Monchi, Mehran; Berghmans, Denis; Ledoux, Didier; Canivet, Jean-Luc; Dubois, Bernard; Damas, Pierre

doi:10.1007/s00134-003-2047-x

Cited by 323 publications

(278 citation statements)

References 16 publications

Supporting

Mentioning

242

Contrasting

Unclassified

Order By: Relevance

“…Although the use of standard sodium concentration CRRT solutions has also been reported in RCA protocols adopting hypertonic citrate formulations (68,69), these solutions are usually combined with customized low-sodium dialysis/replacement fluids to prevent hypernatremia. As long as a well designed protocol is implemented, hypertonic citrate solutions can be used to perform RCA with all modalities of CRRT ( Figure 2, Table 1) (15,16,18,46,47,49). RCA protocols based on hypertonic citrate solutions use citrate as the primary buffer, regardless of CRRT modality.…”

Section: High-concentration Citrate Solutions (Hypertonic In Sodium)mentioning

confidence: 99%

“…Several studies comparing citrate-based protocols with heparin-based protocols have reported better filter survival and/or fewer bleeding events during RCA (14)(15)(16)(17)(18)(19). Two separate meta-analyses, including six randomized trials comparing RCA with systemic anticoagulation with heparin, confirmed a significant decrease of bleeding events in the citrate arm (70,71); however, they provided slightly different results about filter survival.…”

Section: Safety and Efficacy Of Rcamentioning

confidence: 99%

“…The meta-analysis of Wu et al (71), which excluded one of six randomized controlled trials from the analysis of filter life, confirmed the lower risk of bleeding with RCA without showing significant advantages in terms of circuit survival. Transfusion needs were also reduced with the use of RCA (14,15,17). Compared with unfractioned heparin, RCA was associated with a marked reduction in transfusion requirements in 20 patients treated with CVVH (0.2 versus 1.0 blood units/d, P,0.001) (15).…”

Section: Safety and Efficacy Of Rcamentioning

confidence: 99%

“…A number of recent clinical studies has shown advantages of regional citrate anticoagulation (RCA) compared with heparin in terms of prolonged circuit life, reduced incidence of hemorrhagic complications, and lower transfusion needs (14)(15)(16)(17)(18)(19). On the basis of these data, the 2012 Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for Acute Kidney Injury recommend use of RCA as the preferred anticoagulation modality for continuous RRT (CRRT) in patients without contraindications for citrate, even in the absence of an increased bleeding risk or deranged coagulation (20).…”

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Morabito

Pistolesi

Tritapepe

et al. 2014

Clinical Journal of the American Society of Nephrology

124

130

View full text Add to dashboard Cite

Hemorrhagic complications have been reported in up to 30% of critically ill patients with AKI undergoing RRT with systemic anticoagulation. Because bleeding is associated with significantly increased mortality risk, strategies aimed at reducing hemorrhagic complications while maintaining extracorporeal circulation should be implemented. Among the alternatives to systemic anticoagulation, regional citrate anticoagulation has been shown to prolong circuit life while reducing the incidence of hemorrhagic complications and lowering transfusion needs. For these reasons, the recently published Kidney Disease Improving Global Outcomes Clinical Practice Guidelines for Acute Kidney Injury have recommended regional citrate anticoagulation as the preferred anticoagulation modality for continuous RRT in critically ill patients in whom it is not contraindicated. However, the use of regional citrate anticoagulation is still limited because of concerns related to the risk of metabolic complications, the complexity of the proposed protocols, and the need for customized solutions. The introduction of simplified anticoagulation protocols based on citrate and the development of dialysis monitors with integrated infusion systems and dedicated software could lead to the wider use of regional citrate anticoagulation in upcoming years.

show abstract

Section: High-concentration Citrate Solutions (Hypertonic In Sodium)mentioning

confidence: 99%

Section: Safety and Efficacy Of Rcamentioning

confidence: 99%

Section: Safety and Efficacy Of Rcamentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Morabito

Pistolesi

Tritapepe

et al. 2014

Clinical Journal of the American Society of Nephrology

124

130

View full text Add to dashboard Cite

show abstract

“…Citrate regional anticoagulation has gained significant popularity over the previous decade and is used exclusively in some centers for CRRT. [134][135][136] Two studies document the safety of citrate, avoiding anticoagulation and bleeding, with improved circuit survival compared to heparin in adults. 135,136 Citrate is delivered pre-filter as tri-sodium citrate, which chelates calcium in the circuit with the goal of 0.4 mmol/l ionized calcium at the filter, and calcium is re-infused to the patient to prevent systemic hypocalcaemia.…”

mentioning

confidence: 99%

Renal replacement therapy review

Fleming

2011

Organogenesis

View full text Add to dashboard Cite

Effect of Regional Citrate Anticoagulation vs Systemic Heparin Anticoagulation During Continuous Kidney Replacement Therapy on Dialysis Filter Life Span and Mortality Among Critically Ill Patients With Acute Kidney Injury

Zarbock

Küllmar

Kindgen‐Milles

et al. 2020

JAMA

182

174

View full text Add to dashboard Cite

IMPORTANCEAlthough current guidelines suggest the use of regional citrate anticoagulation (which involves the addition of a citrate solution to the blood before the filter of the extracorporeal dialysis circuit) as first-line treatment for continuous kidney replacement therapy in critically ill patients, the evidence for this recommendation is based on few clinical trials and meta-analyses.OBJECTIVE To determine the effect of regional citrate anticoagulation, compared with systemic heparin anticoagulation, on filter life span and mortality. DESIGN, SETTING, AND PARTICIPANTSA parallel-group, randomized multicenter clinical trial in 26 centers across Germany was conducted between March 2016 and December 2018 (final date of follow-up, January 21, 2020). The trial was terminated early after 596 critically ill patients with severe acute kidney injury or clinical indications for initiation of kidney replacement therapy had been enrolled. INTERVENTIONSPatients were randomized to receive either regional citrate anticoagulation (n = 300), which consisted of a target ionized calcium level of 1.0 to 1.40 mg/dL, or systemic heparin anticoagulation (n = 296), which consisted of a target activated partial thromboplastin time of 45 to 60 seconds, for continuous kidney replacement therapy. MAIN OUTCOMES AND MEASURESCoprimary outcomes were filter life span and 90-day mortality. Secondary end points included bleeding complications and new infections. RESULTS Among 638 patients randomized, 596 (93.4%) (mean age, 67.5 years; 183 [30.7%] women) completed the trial. In the regional citrate group vs systemic heparin group, median filter life span was 47 hours (interquartile range [IQR], 19-70 hours) vs 26 hours (IQR, 12-51 hours) (difference, 15 hours [95% CI, 11 to 20 hours]; P < .001). Ninety-day all-cause mortality occurred in 150 of 300 patients vs 156 of 296 patients (Kaplan-Meier estimator percentages, 51.2% vs 53.6%; unadjusted difference, -2.4% [95% CI, -10.5% to 5.8%]; unadjusted hazard ratio, 0.91 [95% CI, 0.72 to 1.13]; unadjusted P = .38; adjusted difference, -6.1% [95% CI, -12.6% to 0.4%]; primary adjusted hazard ratio, 0.79 [95% CI, 0.63 to 1.004]; primary adjusted P = .054). Of 38 prespecified secondary end points, 34 showed no significant difference. Compared with the systemic heparin group, the regional citrate group had significantly fewer bleeding complications (15/300 [5.1%] vs 49/296 [16.9%]; difference, -11.8% [95% CI, -16.8% to -6.8%]; P < .001) and significantly more new infections (204/300 [68.0%] vs 164/296 [55.4%]; difference, 12.6% [95% CI, 4.9% to 20.3%]; P = .002).CONCLUSIONS AND RELEVANCE Among critically ill patients with acute kidney injury receiving continuous kidney replacement therapy, anticoagulation with regional citrate, compared with systemic heparin anticoagulation, resulted in significantly longer filter life span. The trial was terminated early and was therefore underpowered to reach conclusions about the effect of anticoagulation strategy on mortality.

show abstract

Citrate vs. heparin for anticoagulation in continuous venovenous hemofiltration: a prospective randomized study

Abstract: Regional citrate anticoagulation seems superior to heparin for the filter lifetime and transfusion requirements in ICU patients treated by continuous renal replacement therapy.

Cited by 323 publications

References 16 publications

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Renal replacement therapy review

Effect of Regional Citrate Anticoagulation vs Systemic Heparin Anticoagulation During Continuous Kidney Replacement Therapy on Dialysis Filter Life Span and Mortality Among Critically Ill Patients With Acute Kidney Injury

Contact Info

Product

Resources

About