Citrate versus heparin anticoagulation in continuous renal replacement therapy in small children

Raymakers-Janssen, Paulien; Lilien, Marc R.; Kessel, Ingrid A. van; Veldhoen, Esther S.; Asperen, Roelie M. Wösten–van; Gestel, Josephus P. J. van

doi:10.1007/s00467-017-3694-4

Cited by 33 publications

(23 citation statements)

References 14 publications

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“…Furthermore, citrate dosing is based on blood flow, which is disproportionately high (as per kg BW) in small children, due to technical limitations of adult CRRT devices. Thus frequent citrate accumulation (70% patients, 25% of circuits) in our population was to be expected and is also reported in some other studies (30% of the patients had t/iCa > 2.4 in Rico et al), especially in patients with liver failure (70% of patients had t/iCa > 2.5 for > 48 h in Rodriguez et al), but many other studies report no problems with citrate accumulation …”

Section: Discussionsupporting

confidence: 88%

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

et al. 2019

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Continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) in newborns and infants is challenging and accumulation of citrate can occur.There are only a few studies reporting the detailed data on RCA. We aimed to analyze RCA-CRRT at our institution with focus on citrate accumulation. Critically ill newborns and infants up to 11 kg of body weight (BW), treated with RCA-CRRT in the 2011-2016 period were included in this retrospective observational study.Prismaflex(R) and Multifiltrate-CiCa(R) dialysis monitors were used with either automated or manual RCA. Data was collected regarding the circuit lifetime, parameters of RCA, markers of citrate accumulation (total/ionized calcium ratio > 2.5), and metabolic complications. We included 10 children with mean age of 2.6 ± 3.8 months and BW of 4.6 ± 2.7 kg. In-hospital mortality was 60%. RCA-CRRT parameters were: blood flow 46 ± 9 mL/min (12 ± 5 mL/min/kg BW), citrate dose 2.8 ± 0.6 mmol/L of blood resulting in estimated citrate load to the patient of 1.7 ± 0.8 mmol/h/kg BW. In total, 57 dialysis circuits were used with mean filter lifetime of 39 ± 29 h. Citrate accumulation (total/ionized calcium ratio > 2.5) was observed in 7/10 patients and in 14/57 (25%) of circuits; those circuits were performed in children with lower age and BW, had higher relative blood flow and citrate load, while citrate dose was similar. When citrate load to the patient was used to predict citrate accumulation, AUC under the ROC curve was 0.78 and 1.7 mmol/h/kg BW was considered the optimal cutoff value (sensitivity 71% and specificity 72%). CRRT with RCA using equipment, developed for adult population, is feasible in newborns and infants. Signs of citrate accumulation developed relatively often. To prevent it, we suggest avoiding citrate loads above 1.7 mmol/h/kg BW, which can best be achieved by keeping the blood flow below 9 mL/min/kg BW. K E Y W O R D Scitrate accumulation, continuous renal replacement therapy, infants, newborns, regional citrate anticoagulation 498 | PERSIC Et al.

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Section: Discussionsupporting

confidence: 88%

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

et al. 2019

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“…3,9 In contrast, effect of citrate is limited to the extracorporeal circuit and does not induce thrombocytopenia, which also reduces bleeding risk. 10 However, citrate carries the risk of metabolic disturbances (alkalosis or acidosis) and electrolyte imbalances (hypercalcemia, hypocalcemia, and hypernatremia). 4,11 Although there are many studies in adult patient groups, very few controlled trials and observational studies have been carried out in pediatric patients on CRRT with citrate.…”

Section: Discussionmentioning

confidence: 99%

Regional citrate versus systemic heparin anticoagulation for continuous renal replacement therapy in critically ill children

2019

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Objectives: Anticoagulation is used to prevent filter clotting in patients undergoing continuous renal replacement therapy. Regional citrate anticoagulation is associated with lower rates of bleeding complications and prolongs the filter life span; however, a number of metabolic side effects had been associated with this therapy. The aim of this study was to evaluate the effect and safety of citrate versus heparin anticoagulation for continuous renal replacement therapy in critically ill children. Methods: A retrospective comparative cohort study. Department of Pediatric Intensive Care, Acibadem Mehmet Ali Aydınlar University School of Medicine. Results: From August 2016 to August 2018, 45 patients (19 in the citrate group and 26 in the heparin group) were included. A total of 101 hemofilters were used in all therapies: 44 in the citrate group (total continuous renal replacement therapy time: 2699 h) and 57 in the heparin group (total continuous renal replacement therapy time: 2383 h). The median circuit lifetime was significantly longer for regional citrate anticoagulation (53.0; interquartile range, 40–70 h) than for heparin anticoagulation (40.25; interquartile range, 22.75–53.5 h; p = 0.025). Mortality rates were similar in both groups (31.58% vs 30.77%). The most common indication for dialysis was hypervolemia in both groups. Transfusion rates were 1.65 units (interquartile range, 0.5–2.38) with heparin and 0.8 units (interquartile range, 0.3–2.0) with citrate (p = 0.32). Clotting-related hemofilter failure occurred in 11.36% of filters in the citrate group compared with 26.31% of filters in the heparin group. Conclusion: Our study showed that citrate is superior in terms of safety and efficacy, with longer filter life span. Regional citrate should be considered as a better anticoagulation method than heparin for continuous renal replacement therapy in critically ill children.

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“…In this study, the concentration of sodium citrate in vitro was higher (4 mmol/L) than that reported in other studies using calcium-free substitutes (2.5–3.5 mmol/L). [6,8,11] Additionally, there were only 2 sessions (1.9%) with T/iCa 2+ > 2.5, which usually indicated citrate accumulation. [17–19] This suggested that most children could tolerate a sodium citrate concentration of 4 mmol/L in the extracorporeal circulation.…”

Section: Discussionmentioning

confidence: 99%

“…In recent years, many studies have shown that RCA in CRRT could be used safely and effectively to treat children. [2–11] However, this technique is complicated by the lack of commercially available physiological fluids, the various protocols that use different solutes and strategies, and the meticulous adjustment of citrate and calcium perfusions based on blood flow. [2] Because 4% citrate solution contains high levels of calcium and sodium ions, the substitute should contain less sodium and less or no bicarbonate to avoid acid–base imbalances and hypernatremia.…”

Section: Introductionmentioning

confidence: 99%

Regional citrate anticoagulation with a substitute containing calcium for continuous hemofiltration in children

et al. 2019

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Regional citrate anticoagulation (RCA) was recommended as the first treatment option for adults by the Kidney Disease Improving Global Outcomes Kidney Foundation in 2012, for the characteristic of sufficient anticoagulation in vitro, but almost no anticoagulation in vivo. Traditionally, the substitute for RCA is calcium-free. This study investigated a simplified protocol of RCA for continuous hemofiltration (CHF) in children using a commercially available substitute containing calcium.An analytical, observational, retrospective study assessed 59 pediatric patients with 106 sessions and 3580 hours of CHF. Values before and after treatment were compared, including Na+, ionic calcium (iCa2+) and HCO3− concentrations, pH, and the ratio of total calcium to iCa2+ (T/iCa2+). In addition, in vivo and in vitro iCa2+, treatment time, sessions with continuous transmembrane pressure >200 mm Hg, and sessions with clotting and bleeding were recorded.The average treatment time was 33.8 ± 10.1 hours. In vitro, 88.5% of iCa2+ achieved the target (0.25–0.35 mmol/L), and in vivo, 95.4% of iCa2+ achieved the target (1.0–1.35 mmol/L). There were 8 sessions with a transmembrane pressure >200 mm Hg and 3 sessions with filters clotted. After treatment, there were 2, 1, and 2 sessions with T/iCa2+ > 2.5 (implying citrate accumulation), iCa2+ < 0.9 mmol/L, and iCa2+ > 1.35 mmol/L. No sodium disorders were recorded. There were fewer cases of acidemia and more cases of alkalemia after treatment compared to before.RCA-CHF with a substitute containing calcium and close monitoring could be a safe and effective treatment for children. In addition, the calcium test site in vitro and the adjustment of citrate should be given strict attention.

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Citrate versus heparin anticoagulation in continuous renal replacement therapy in small children

Cited by 33 publications

References 14 publications

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

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

Regional citrate versus systemic heparin anticoagulation for continuous renal replacement therapy in critically ill children

Regional citrate anticoagulation with a substitute containing calcium for continuous hemofiltration in children

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