Citrate anticoagulation for continuous venovenous hemofiltration*

Straaten, Heleen M. Oudemans–van; Bosman, Rob J.; Koopmans, Matty; Voort, Peter H. J. van der; Wester, J. P. J.; Spoel, J. I. van der; Dijksman, Lea M.; Zandstra, D. F.

doi:10.1097/ccm.0b013e3181953c5e

Cited by 288 publications

(306 citation statements)

References 38 publications

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“…Furthermore, citrate may be directly involved as a signal molecule in several cellular processes related to inflammation and balance of oxidative species (31). On this basis, citrate may behave as a true anti-inflammatory agent (10,18).…”

Section: Rca: Basic Principles and Citrate Metabolismmentioning

confidence: 99%

“…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%

“…A different approach, using pharmacymade solutions, was adopted to perform RCA in continuous venovenous hemofiltration (CVVH). This approach used a very high-concentration citrate solution (500 mmol/L) along with a variable bicarbonate concentration in the replacement fluid (18). Specifically, a buffer-free Figure 2.…”

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

confidence: 99%

“…Citrate accumulation represents the most common complication of RCA, with a reported incidence of 0%-12% of patients depending on the RCA protocol used and the patient case mix (14,16,18,19,(44)(45)(46)(47)(48)(49)(50)(51). Because hepatic clearance represents the main metabolic fate of endogenous and exogenous citrate, citrate metabolism may be significantly slowed in clinical conditions where liver function is impaired, with a higher risk of citrate accumulation and consequent acid-base and electrolyte complications.…”

Section: Citrate Accumulation Risk and Rca Monitoringmentioning

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%

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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

127

130

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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.

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Section: Rca: Basic Principles and Citrate Metabolismmentioning

confidence: 99%

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

confidence: 99%

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

confidence: 99%

Section: Citrate Accumulation Risk and Rca Monitoringmentioning

confidence: 99%

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

127

130

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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

193

174

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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.

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Continuous Kidney Replacement Therapy Practices in Pediatric Intensive Care Units Across Europe

et al. 2022

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ImportanceContinuous kidney replacement therapy (CKRT) is the preferred method of kidney support for children with critical illness in pediatric intensive care units (PICUs). However, there are no data on the current CKRT management practices in European PICUs.ObjectiveTo describe current CKRT practices across European PICUs.Design, Setting, and ParticipantsThis cross-sectional survey of PICUs in 20 European countries was conducted by the Critical Care Nephrology Section of the European Society of Pediatric and Neonatal Intensive Care from April 1, 2020, to May 31, 2022. Participants included intensivists and nurses working in European PICUs. The survey was developed in English and distributed using SurveyMonkey. One response from each PICU that provided CKRT was included in the analysis. Data were analyzed from June 1 to June 30, 2022.Main Outcome and MeasuresDemographic characteristics of European PICUs along with organizational and delivery aspects of CKRT (including prescription, liberation from CKRT, and training and education) were assessed.ResultsOf 283 survey responses received, 161 were included in the analysis (response rate, 76%). The attending PICU consultant (70%) and the PICU team (77%) were mainly responsible for CKRT prescription, whereas the PICU nurses were responsible for circuit setup (49%) and bedside machine running (67%). Sixty-one percent of permanent nurses received training to use CKRT, with no need for certification or recertification in 36% of PICUs. Continuous venovenous hemodiafiltration was the preferred dialytic modality (51%). Circuit priming was performed with normal saline (67%) and blood priming in children weighing less than 10 kg (56%). Median (IQR) CKRT dose was 35 (30-50) mL/kg/h in neonates and 30 (30-40) mL/kg/h in children aged 1 month to 18 years. Forty-one percent of PICUs used regional unfractionated heparin infusion, whereas 35% used citrate-based regional anticoagulation. Filters were changed for filter clotting (53%) and increased transmembrane pressure (47%). For routine circuit changes, 72 hours was the cutoff in 62% of PICUs. Some PICUs (34%) monitored fluid removal goals every 4 hours, with variation from 12 hours (17%) to 24 hours (13%). Fluid removal goals ranged from 1 to 3 mL/kg/h. Liberation from CKRT was performed with a diuretic bolus followed by an infusion (32%) or a diuretic bolus alone (19%).Conclusions and RelevanceThis survey study found a wide variation in current CKRT practice, including organizational aspects, education and training, prescription, and liberation from CKRT, in European PICUs. This finding calls for concerted efforts on the part of the pediatric critical care and nephrology communities to streamline CKRT education and training, research, and guidelines to reduce variation in practice.

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Citrate anticoagulation for continuous venovenous hemofiltration*

Cited by 288 publications

References 38 publications

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

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

Continuous Kidney Replacement Therapy Practices in Pediatric Intensive Care Units Across Europe

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