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

Abstract

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.

Regional citrate anticoagulation for continuous renal replacement therapy in newborns and infants: Focus on citrate accumulation

“…RCA is often needed in newborns and infants due to postoperative status or coagulopathy and was used in 56% of circuits in the pediatric CRRT registry . Despite growing knowledge and experience in performing CRRT with RCA in the pediatric population, RCA in newborns and infants remains challenging, mainly due to relative overdosing of citrate (imbalance between blood flow and BW), which increases the risk of citrate accumulation. Unfortunately, even the newly developed devices, designed specifically for infants (eg, CARPEDIEM and NIDUS systems), do not yet provide automated RCA.…”

“…Unfortunately, even the newly developed devices, designed specifically for infants (eg, CARPEDIEM and NIDUS systems), do not yet provide automated RCA. To our best knowledge, only a few studies have reported detailed data on performance of RCA during CRRT in newborns and infants and further reporting on citrate use has been recommended in a recent review …”

The Safety and Efficacy of Regional Citrate Anticoagulation in Albumin-Assisted Liver Dialysis for Extracorporeal Liver Support in Pediatric Patients

“…Systemic anticoagulation with heparin risks disrupting the balanced coagulation defects was seen in LF toward severe bleeding, while insufficient anticoagulation can disrupt circuit life due to thrombosis and potentiate systemic inflammation [12,21]. Citrate metabolism occurs not only in the liver, but also in the kidneys, intestines, and skeletal muscle as well with evidence of safe and effective use in the LF population continuing to emerge [8,12,19,21].…”

“…We choose RCA as our primary anticoagulation for ELS and CRRT. We have previously published safety and efficacy data regarding RCA for CRRT in pediatric LF [19].…”

“…RCA is the standard of care at our institution for all patients requiring CRRT. We have recently reported on the safety and efficacy of RCA in pediatric patients with LF [19].…”