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

Abstract

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.

Complications of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy: An Observational Study

“…The observed longer filter life and lower rate of circuit clotting associated with RCA are largely consistent with previously reported data [5,[12][13][14][15][16]. In particular, it is similar to that observed in cohorts using a similar RCA protocol [11].…”

“…In particular, it is similar to that observed in cohorts using a similar RCA protocol [11]. The short lifespan observed in the heparin group is consistent with previous reports [12,17].…”

Effects of Brief Citrate Interruption on Regional Citrate Anticoagulation During Continuous Renal Replacement Therapy

“…RCA has been shown to have potential bene ts over heparin anticoagulation for reducing bleeding risk and extending lter life [14,15]. Moreover, because calcium ions contribute to coagulation, platelet aggregation, and leukocyte activation, which are important factors in the alternative complement pathway activation [16], RCA has also been found to inhibit the activation of platelets, white blood cells, and complement extracorporeal circulation [4,17]. Hence, RCA has become the mainstream CRRT anticoagulation method recommended by the KDIGO.…”

“…Since then, the safety and effectiveness of RCA have been broadly evaluated. Several studies have shown that the incidence of RCA in line loss, lter coagulation, bleeding, and heparin-related thrombocytopenia is lower than that in systemic or local heparin-protamine anticoagulation [4][5][6]. The 2012 Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommend CRRT anticoagulation as the rst choice for RCA after the exclusion of contraindications [7].…”

Introductory Chapter: Principles and Methods of Acute Therapies

“…Regional citrate anticoagulation (RCA) is the more preferred and recommended method of anticoagulation, where it has been associated with significantly less bleeding [6], less blood transfusion [7], and extended life of the extracorporeal circuit [8].…”