Efficacy and safety of regional citrate anticoagulation in critically ill patients undergoing continuous renal replacement therapy

Zhang, Zhongheng; Ni, Hongying

doi:10.1007/s00134-011-2438-3

Cited by 141 publications

(107 citation statements)

References 26 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Interruptions of PIRRT caused by impending/irreversible clotting were recorded in 19 sessions (2.4%); blood restitution was complete in 98% of the cases. Major bleeding was observed in six patients (5.2% or 0.4 episodes per 100 person-days on PIRRT), with a hemorrhagic complication rate similar or even lower to that reported in previous studies (4,5,70,71,(88)(89)(90)(91). No citrate accumulation was observed, even in patients with severe liver dysfunction (51).…”

Section: Rca In Prolonged Intermittent Rrtsupporting

confidence: 72%

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

View full text Add to dashboard Cite

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.

show abstract

Section: Rca In Prolonged Intermittent Rrtsupporting

confidence: 72%

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

View full text Add to dashboard Cite

show abstract

“…Compared with previous reports in AKI patients on RRT, the incidence of major bleeding was similar or even lower (15,16,(25)(26)(27)(28)(29)(30). Systemic coagulation remained unchanged, with rare occurrence of ionized hypocalcemia during SLED requiring calcium supplementation; metabolic and fluid control was easily achieved.…”

Section: Discussionmentioning

confidence: 49%

“…Safety of citrate versus unfractionated heparin has been recently demonstrated for continuos RRT (15,16), and confirmed in high hemorrhagic risk AKI patient categories, such as those liver dysfunction (38)(39)(40)(41), burns with septic shock (42), and heart surgery (43). Two major issues of our approach deserve discussion: the hemorrhagic risk and the complications associated with citrate accumulation.…”

Section: Discussionmentioning

confidence: 94%

“…The reported incidence of hemorrhage in patients with AKI on RRT ranges from 4% to 30%-50% (15,16,(25)(26)(27)(28)(29)(30). Data on SLED are scanty: no bleeding was reported in 56 sessions with heparin on 24 patients in one series (23), whereas 2 of 37 patients (5.4%) had bleeding during SLED in another series (11).…”

Section: Discussionmentioning

confidence: 99%

“…The low molecular weight citrate anion is removed by diffusion/ convection, with the patient's citrate load eventually resulting from the balance between citrate administration and its removal by RRT (12). Longer circuit survival with lower bleeding rates (15,16) and improved biocompatibility (17)(18)(19)(20) are recognized advantages of the citrate-based continuous RRT modalities.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Efficacy and Safety of a Citrate-Based Protocol for Sustained Low-Efficiency Dialysis in AKI Using Standard Dialysis Equipment

Fiaccadori¹,

Regolisti²,

Cademartiri³

et al. 2013

Clinical Journal of the American Society of Nephrology

View full text Add to dashboard Cite

SummaryBackground and objectives A simple anticoagulation protocol was developed for sustained low-efficiency dialysis (SLED) in patients with AKI, based on the use of anticoagulant citrate dextrose solution formulation A (ACD-A) and standard dialysis equipment. Patients' blood recalcification was obtained from calcium backtransport from dialysis fluid.Design, setting, participants, & measurements All patients treated with SLED (8-to 12-hour sessions) for AKI in four intensive care units of a university hospital were studied over a 30-month period, from May 1, 2008 to September 30, 2010. SLED interruptions and their causes, hemorrhagic complications, as well as coagulation parameters, ionized calcium, and blood citrate levels were recorded.Results This study examined 807 SLED sessions in 116 patients (mean age of 69.7 years [SD 12.1]; mean Acute Physiology and Chronic Health Evaluation II score of 23.8 [4.6]). Major bleeding was observed in six patients (5.2% or 0.4 episodes/100 person-days follow-up while patients were on SLED treatment). Citrate accumulation never occurred, even in patients with liver dysfunction. Intravenous calcium for ionized hypocalcemia (, 3.6 mg/dl or , 0.9 mmol/L) was needed in 28 sessions (3.4%); in 8 of these 28 sessions (28.6%), low ionized calcium was already present before SLED start. In 92.6% of treatments, SLED was completed within the scheduled time (median 8 hours). Interruptions of SLED by impending/irreversible clotting were recorded in 19 sessions (2.4%). Blood return was complete in 98% of the cases. In-hospital mortality was 45 of 116 patients (38.8%).Conclusions This study protocol affords efficacious and safe anticoagulation of the SLED circuit, avoiding citrate accumulation and, in most patients, systematic calcium supplementation; it can be implemented with commercial citrate solutions, standard dialysis equipment, on-line produced dialysis fluid, and minimal laboratory monitoring.

show abstract

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

View full text Add to dashboard Cite

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.

show abstract

Efficacy and safety of regional citrate anticoagulation in critically ill patients undergoing continuous renal replacement therapy

Cited by 141 publications

References 26 publications

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Efficacy and Safety of a Citrate-Based Protocol for Sustained Low-Efficiency Dialysis in AKI Using Standard Dialysis Equipment

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

Contact Info

Product

Resources

About