Heparin-Free Prolonged Intermittent Hemodialysis Using Calcium-Free Citrate Dialysate in Critically Ill Patients

Faguer, Stanislas; Saint-Cricq, Morgane; Nogier, Marie-Béatrice; Labadens, Isabelle; Lavayssière, Laurence; Kamar, Nassim; Cointault, Olivier

doi:10.1097/ccm.0000000000002694

Cited by 24 publications

(24 citation statements)

References 33 publications

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“…These therapies were widely applied to hemodynamically unstable adults that required inotropic support. Recently, their use in pediatric renal replacement therapy (RRT) has started to emerge . Children developing acute kidney injury (AKI) in a critical care setup usually arise secondarily and therefore, require vasopressor support and are hypotensive with poor cardiac function.…”

Section: Introductionmentioning

confidence: 99%

Pediatric Continuous Renal Replacement Therapy (PCRRT) expert committee recommendation on prescribing prolonged intermittent renal replacement therapy (PIRRT) in critically ill children

Sethi

Mittal

Nair

et al. 2020

Hemodialysis International

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Introduction: Recently, prolonged intermittent renal replacement therapies (PIRRT) have emerged as cost-effective alternatives to conventional CRRT and their use in the pediatric population has started to become more prominent. However, there is a lack of consensus guidelines on the use of PIRRT in pediatric patients in an intensive care setting.Methods: A literature search was performed on PubMed/Medline, Embase, and Google Scholar in conjunction with medical librarians from both India and the Cleveland Clinic hospital system to find relevant articles. The Pediatric Continuous Renal Replacement Therapy workgroup analyzed all articles for relevancy, proposed recommendations, and graded each recommendation for their strength of evidence. Results:Of the 60 studies eligible for review, the workgroup considered data from 37 studies to formulate guidelines for the use of PIRRT in children. The guidelines focused on the definition, indications, machines, and prescription of PIRRT.Conclusion: Although the literature on the use of PIRRT in children is limited, the current studies give credence to their benefits and these expert recommendations are a valuable first step in the continued study of PIRRT in the pediatric population.

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Section: Introductionmentioning

confidence: 99%

Pediatric Continuous Renal Replacement Therapy (PCRRT) expert committee recommendation on prescribing prolonged intermittent renal replacement therapy (PIRRT) in critically ill children

Sethi

Mittal

Nair

et al. 2020

Hemodialysis International

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“…Regional anticoagulation with citrate is highly effective but requires citrate and calcium infusions and is, therefore, more complex to monitor . Citrate dialysates without calcium have also been advocated but still require a calcium infusate . Alternatively, and for many years, heparin‐free hemodialysis has consisted in periodic saline flushes to rinse the extracorporeal circuit .…”

Section: Introductionmentioning

confidence: 99%

“…2,3 Citrate dialysates without calcium have also been advocated but still require a calcium infusate. 4,5 Alternatively, and for many years, heparin-free hemodialysis has consisted in periodic saline flushes to rinse the extracorporeal circuit. 6,7 However, this technique is time-consuming for the nurses and may induce fluid overload.…”

Section: Introductionmentioning

confidence: 99%

Hemodialysis without anticoagulation: Less clotting in conventional hemodialysis than in predilution hemodiafiltration

Krummel

Cellot

Thiéry³

et al. 2019

Hemodialysis International

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Introduction Hemodialysis patients with contraindication to systemic anticoagulation require a heparin‐free hemodialysis technique. Among several alternatives to heparin, predilution hemodiafiltration (HDF) is often used, albeit without any confirmation of its effectiveness. Methods Patients hospitalized in a nephrology ICU and hemodialysed for stage 5 CKD or AKI and with contraindication to systemic anticoagulation were randomized to either standard HD with a polysulfone membrane, or to predilution HDF with the same membrane. Coagulation activation was evaluated clinically by the need for premature termination and by the measurement of D‐dimers. Findings Two hundred dialysis sessions were performed in 155 patients. Survival curves showed better circuit survival in HD (P = 0.046). In HD, 12% of sessions were interrupted for coagulation versus 23% in predilution HDF (P = 0.04). Discussion Predilution HDF was associated with more premature clotting than conventional HD without improvement in dialysis duration or performance epuration indices. When aiming for a 4‐hour duration session, conventional heparin‐free hemodialysis can be safely proposed in most patients with high bleeding risk.

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“…[1][2][3][4] Nevertheless, heparin-free hemodialysis is often warranted as in postoperative states, in patients with bleeding diathesis, and in critically ill patients in the intensive care unit. [5][6][7][8][9] Conventionally, this is achieved through normal saline flushes, or with the application of regional citrate anticoagulation. 1,[6][7][8][9] We recently encountered a set of converging clinical scenarios in which a male patient on home hemodialysis (HHD) using an NxStage machine had to be discharged home from hospital on heparin-free HHD; despite large-volume saline flushes, he had continued to clot his extracorporeal circuits and filters with resulting inadequate HHD.…”

mentioning

confidence: 99%

“…[5][6][7][8][9] Conventionally, this is achieved through normal saline flushes, or with the application of regional citrate anticoagulation. 1,[6][7][8][9] We recently encountered a set of converging clinical scenarios in which a male patient on home hemodialysis (HHD) using an NxStage machine had to be discharged home from hospital on heparin-free HHD; despite large-volume saline flushes, he had continued to clot his extracorporeal circuits and filters with resulting inadequate HHD. The use of heparin or warfarin was contraindicated, and the patient and the caregiver (wife) were considering stopping HHD.…”

mentioning

confidence: 99%

Timed Controlled Repeated Rotation of the CAR-170-C NXSTAGE Chronic Cartridge Hemodialysis Filter: A Novel Approach to Enabling Heparin-Free Frequent Daily Home Hemodialysis

Locke

Bushey

LaCroix

et al. 2021

Mayo Clinic Proceedings: Innovations, Quality & Outcomes

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Heparin-free hemodialysis is often warranted in postoperative states, bleeding diathesis, and critically ill patients. Conventionally, this is achieved through normal saline flushes or regional citrate anticoagulation. An 87-year-old white man with end-stage renal disease and atrial fibrillation, who was taking warfarin and using maintenance home hemodialysis (HHD) with an NxStage machine, underwent laparoscopic appendicectomy. The procedure was complicated by intra-abdominal abscess, sepsis, and tamponade from a bloody pericardial effusion. He needed emergent therapeutic pericardiocentesis. Warfarin was promptly discontinued. He was discharged home with heparin-free HHD. Prior heparin anticoagulation for HHD was an initial bolus of 4000 units of heparin. He continued to clot his extracorporeal system with resultant very high venous pressures and compromised HHD. Heparin anticoagulation was still contraindicated. Flushes with 250-500 mL normal saline, delivered in aliquots every 15-30 minutes, failed to prevent the frequent clotting. The first author, our HD Senior Technician, had astutely observed that the horizontally placed hemodialysis filter exhibited early "clot" formation at the 12-o'clock position, despite the saline flushes. Through trial and error, he discovered that rotating the horizontally placed hemodialysis filter along its long axis, 60 degrees clockwise for 15 minutes, return to the neutral position for 15 minutes, rotating the filter another 60 degrees counterclockwise for 15 minutes, with this repeated cycle of rotations "did the trick." It promptly and consistently resolved the clotting problem. The lines stopped clotting, and he has not needed saline flushes for smooth heparin-free HHD for more than 7 months. To our knowledge, this is the first such report. Further study is justified. We have hypothesized a mechanism and have named this the "Locke-Onuigbo Maneuver."

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Heparin-Free Prolonged Intermittent Hemodialysis Using Calcium-Free Citrate Dialysate in Critically Ill Patients

Cited by 24 publications

References 33 publications

Pediatric Continuous Renal Replacement Therapy (PCRRT) expert committee recommendation on prescribing prolonged intermittent renal replacement therapy (PIRRT) in critically ill children

Pediatric Continuous Renal Replacement Therapy (PCRRT) expert committee recommendation on prescribing prolonged intermittent renal replacement therapy (PIRRT) in critically ill children

Hemodialysis without anticoagulation: Less clotting in conventional hemodialysis than in predilution hemodiafiltration

Timed Controlled Repeated Rotation of the CAR-170-C NXSTAGE Chronic Cartridge Hemodialysis Filter: A Novel Approach to Enabling Heparin-Free Frequent Daily Home Hemodialysis

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