Regional citrate anticoagulation versus no-anticoagulation for continuous venovenous hemofiltration in patients with liver failure and increased bleeding risk: A retrospective case-control study

Abstract

Objective There are controversial opinions on anticoagulation for continuous venovenous hemofiltration (CVVH) in patients with liver failure (LF) and increased bleeding risk. Therefore, we conducted a retrospective study to evaluate the efficacy and safety of regional citrate anticoagulation (RCA) versus no-anticoagulation for CVVH in these patients. Methods The included patients were divided into RCA and no-anticoagulation group according to the CVVH anticoagulation strategy they accepted for CVVH. Filter lifespan, bleeding, citrate accumulation, catheter occlusion, and totCa/ionCa ratio were evaluated as outcomes. Results In the original cohort, the filter lifespan of the RCA group (41 patients, 79 filters) was significantly longer than the no-anticoagulation group (62 patients, 162 filters) (> 72 hours vs 39.5 hours (IQR 31.2-47.8), P = 0.002). The adjusted results demonstrated that RCA could significantly reduce the risk of filter failure (HR = 0.459, 95%CI 0.26-0.82, P = 0.008). Four episodes of totCa/ionCa > 2.5 were observed in the RCA group and continuously accepted RCA-CVVH after the reduction of citrate dose and blood flow. No obvious citrate accumulation was observed in these patients. In the matched cohort, the filter lifespan of the RCA group was significantly longer than the no-anticoagulation group (P = 0.013) as well. No significant difference in the episodes of totCa/ionCa > 2.5 was observed between the two matched groups (P = 0.074). Both in the original cohort and the matched cohort, the bleeding, acidosis, alkalosis, and catheter occlusion incidences were not significantly different between the two groups.

Citrate pharmacokinetics in critically ill liver failure patients receiving CRRT

“…This study reported a higher Ca tot /Ca 2+ ratio (> 2.5) and two ACLF patients (28.5%) showed evidence of citrate accumulation during citrate infusion. Although, many studies have performed CRRT using RCA and reported a low incidence of citrate accumulation via intensive monitoring of the calcium and acid–base status 17 , 28 – 30 , our study showed the potential for citrate accumulation in patients with liver impairment.…”

Continuous Renal Replacement Therapy: A Review of Use and Application in Pediatric Hematopoietic Stem Cell Transplant Recipients

“…Clinicians may choose not to use pharmacologic anticoagulation in patients at high risk of bleeding, but the risk of circuit clotting and interruption of treatment is higher. In a cohort of 103 patients with liver failure on CRRT, filter life was significantly longer in the RCA group versus the no-anticoagulation group (>72 versus 39.5 h) (48). However, bleeding incidence was similar in both groups (5.1% in the RCA group versus 4.3% in the noanticoagulation group), suggesting that RCA use is a safe option in patients with a higher risk of bleeding.…”

Review of Anticoagulation in Continuous Renal Replacement Therapy

“…2,22,23 Reassuringly, a recent case-control study of patients with liver failure receiving CRRT demonstrated longer filter life, fewer filter failures, and no increased bleeding or metabolic complications in those receiving citrate anticoagulation compared with those without anticoagulation. 24 Furthermore, a recent SRMA by Zhang et al 25 addressed this same question. They included 10 studies with 1241 patients with liver dysfunction requiring CRRT.…”

“…Anticoagulation is often deferred for these patients due to the risk of bleeding complications and/or the risk of hypocalcemia and metabolic acidosis related to the inability of the liver to metabolize citrate 2,22,23. Reassuringly, a recent case-control study of patients with liver failure receiving CRRT demonstrated longer filter life, fewer filter failures, and no increased bleeding or metabolic complications in those receiving citrate anticoagulation compared with those without anticoagulation 24. Furthermore, a recent SRMA by Zhang et al25 addressed this same question.…”