Comparison of different anticoagulation strategies for renal replacement therapy in critically ill patients with COVID-19: a cohort study

Abstract

Background Critically ill coronavirus disease 2019 (COVID-19) patients have a high risk of acute kidney injury (AKI) that requires renal replacement therapy (RRT). A state of hypercoagulability reduces circuit life spans. To maintain circuit patency and therapeutic efficiency, an optimized anticoagulation strategy is needed. This study investigates whether alternative anticoagulation strategies for RRT during COVID-19 are superior to administration of unfractionated heparin (UFH). Methods Retrospective cohort study on 71 critically ill COVID-19 patients (≥18 years), admitted to intensive care units at a tertiary health care facility in the southwestern part of Germany between February 26 and May 21, 2020. We collected data on the disease course, AKI, RRT, and thromboembolic events. Four different anticoagulatory regimens were administered. Anticoagulation during continuous veno-venous hemodialysis (CVVHD) was performed with UFH or citrate. Anticoagulation during sustained low-efficiency daily dialysis (SLEDD) was performed with UFH, argatroban, or low molecular weight heparin (LMWH). Primary outcome is the effect of the anticoagulation regimen on mean treatment times of RRT. Results In patients receiving CVVHD, mean treatment time in the UFH group was 21.3 h (SEM: ±5.6 h), in the citrate group 45.6 h (SEM: ±2.7 h). Citrate anticoagulation significantly prolonged treatment times by 24.4 h (P = .001). In patients receiving SLEDD, mean treatment time with UFH was 8.1 h (SEM: ±1.3 h), with argatroban 8.0 h (SEM: ±0.9 h), and with LMWH 11.8 h (SEM: ±0.5 h). LMWH significantly prolonged treatment times by 3.7 h (P = .008) and 3.8 h (P = .002), respectively. Conclusions UFH fails to prevent early clotting events in the dialysis circuit during COVID-19. For patients, who do not require effective systemic anticoagulation, regional citrate dialysis is the most effective strategy. For patients, who require effective systemic anticoagulation, the usage of LMWH results in the longest circuit life spans. The proposed anticoagulatory strategies are safe, can easily be monitored, and allow an individualized treatment. Graphical abstract

COVID-19 impact on the renal system: Pathophysiology and clinical outcomes

“…Therefore COVID-19 patients can benefit, although it needs to be evaluated more carefully and has many logistical limitations during the current pandemic, including transmission, lack of resources, and experienced personnel ( 47 ). Specialists have also acknowledged the need to establish specific anticoagulation regimens in COVID-19 patients with a predisposition for hypercoagulability ( 42 , 55 ). Future research should include the use of kidney biopsies to elucidate the specific histopathology of a patient’s AKI, the potential to target treatments, and the cost-benefit of performing these procedures in at-risk patient populations.…”

“…Termination can reduce the gross quality of dialysis, metabolic imbalances, fluid overload increased blood loss due to more frequent changes in the system and is likely to promote further complications for patients. ( 55 ). Therefore, specialists have acknowledged the urgent need to establish specific anticoagulation regimens in patients with COVID-19 requiring RRT ( 42 , 55 ).…”

“…( 55 ). Therefore, specialists have acknowledged the urgent need to establish specific anticoagulation regimens in patients with COVID-19 requiring RRT ( 42 , 55 ). Nadim et al has suggested the use of continuous veno-venous hemodialysis or continuous veno-venous hemodialysis filtration to decrease filtration fraction and reduce the risk of circuit clotting if using CRRT ( 49 ).…”

COVID-19 and the Kidney: A Worrisome Scenario of Acute and Chronic Consequences

“…To conserve resources and prolong CKRT filter life, anticoagulation strategies have been put in place. A retrospective cohort study compared anticoagulation alternatives in 23 critically ill patients who required KRT for CoV-AKI, and who received either continuous veno-venous hemodialysis (CVVHD) or sustained low-efficiency daily dialysis (SLEDD) [ 104 ]. Outcomes were reported as mean hours of treatment.…”

Efficacy and Complications of Regional Citrate Anticoagulation During Continuous Renal Replacement Therapy in Critically Ill Patients with COVID-19

“…Moreover, a systematic analysis of citrate-induced complications during RCA-CRRT in COVID-19 patients is lacking. The available evidence is solely based on a limited number of literature with small sample size and signi cant patient-and RRT-level heterogenity, comparing the anticoagulations strtegies during different modalities of RRT [18][19][20]. A recent retrospective and small study compared different anticoagulation strategies during RRT in COVID-19 patients [20].…”