Renal replacement therapy and anticoagulation

Brandenburger, Timo; Dimski, Thomas; Slowinski, Torsten; Kindgen‐Milles, Detlef

doi:10.1016/j.bpa.2017.08.005

Cited by 51 publications

(47 citation statements)

References 71 publications

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“…Such adaptations were rarely performed and might have prevented the occurrence of some moderate or severe acid-base alterations. Similarly, the observed hypocalce- Several cohorts have reported a lower rate of hemorrhagic complication [3,4,[19][20][21]. We have not observed such difference.…”

Section: Comparison With Previous Studiessupporting

confidence: 68%

Complications of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy: An Observational Study

et al. 2020

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Introduction: Regional citrate anticoagulation (RCA) is the recommended anticoagulation modality for continuous renal replacement therapy (CRRT). RCA was associated with a low rate of complications in randomized controlled trials. However, little is known about the type and rate of complications in real life. We sought to describe complications associated with RCA in comparison with those associated with heparin anticoagulation. Methods: In our institution, RCA has been the default anticoagulation modality for CRRT in all patients without contraindications since 2013. We have retrospectively reviewed all consecutive patients who received CRRT between January and December 2016 in our institution. For each CRRT session, we have assessed circuit duration, administered dose, as well as therapy-associated complications. Those parameters were compared according to whether the circuit was run in continuous veno-venous hemodialysis (CVVHD) mode with RCA or continuous veno-venous hemofiltration (CVVH) mode with heparin anticoagulation. Results: We analyzed 691 CRRT sessions in 121 patients. Of those 400 (57.9%) were performed in CVVHD-RCA mode and 291 (42.1%) in CVVH-Heparin Mode. Compared with CVVH-Heparin mode, CVVHD-RCA mode was associated with a longer circuit lifespan (median duration 54.9 interquartile range [IQR 44.6] vs. 15.3 h [IQR 22.4], p < 0.0001). It was associated with a higher rate of metabolic acidosis 77 (20.2%) vs. 18 (7.2%), (p < 0.0001), alkalosis 186 (48.7%) vs. 43 (17.1%), (p = 0.0001), and hypocalcemia 96 (25.07%) vs. 26 events (10.79%), p < 0.0001. However, the majority of these alterations were of benign or moderate severity. Only one possible citrate intoxication was observed. Conclusions: CVVHD-RCA was associated with a much longer circuit life but an increased rate of minor metabolic complications, in particular acid-base derangements. Some of these complications might have been prevented by therapy adaptation. Medical and nursing staff education is of major importance in the implementation of an RCA protocol.

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Section: Comparison With Previous Studiessupporting

confidence: 68%

Complications of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy: An Observational Study

et al. 2020

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“…Clot-related membrane dysfunction is associated with decreased solute clearance, particularly for middle molecular weight molecules (500 D to 60 kD) such as B2-microglobulin and light chain proteins. 69,75,77,78 Therefore, effective anticoagulation is paramount to prevent clotting of the circuit and to optimize filter efficiency. There are two major anticoagulation strategies: systemic and regional ( Table 2).…”

Section: Anticoagulationmentioning

confidence: 99%

“…Systemic anticoagulation with unfractionated heparin (UFH) is low cost, the activated partial thromboplastin time is easy to monitor, and uses protamine as a reversal agent; therefore, it is the most widely method used worldwide. 78 The UFH is usually delivered to the patient by a separate intravenous line. Nevertheless, UFH use is associated with increased risk of bleeding (particularly in critically ill patients), 79 heparin-induced thrombocytopenia (HIT), 80 and potentially deleterious pro-inflammatory effects because it binds to the lysyl-residue of antithrombin and accelerates the interaction between thrombin and antithrombin, thereby inhibiting the anti-inflammatory action of antithrombin, 81 and triggering the release of inflammatory mediators from endothelial cells.…”

Section: Systemic Anticoagulationmentioning

confidence: 99%

Renal replacement therapy: a practical update

Alvarez

Chrusch

Hulme

et al. 2019

Can J Anesth/J Can Anesth

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Acute kidney injury (AKI) is defined as an abrupt decrease in kidney function, with the most severe form requiring some method of renal replacement therapy (RRT). The use of RRT is required in 5-10% of critically ill patients who develop severe AKI. Renal replacement therapy can be provided as either intermittent hemodialysis or one of the various modes of continuous renal replacement therapy (CRRT), with CRRT potentially conferring an advantage with respect to renal recovery and dialysis independence. There is no difference in mortality when comparing low (\ 25 mLÁkg -1 Áhr -1 ) vs high ([ 40 mLÁkg -1 Áhr -1 ) RRT dosing. Continuous renal replacement therapy may be run in different modes of increasing complexity depending on a given patient's clinical needs. Regional citrate anticoagulation is recommended as the therapy of choice for the majority of critically ill patients requiring CRRT.

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“…Unfractionated heparin (UFH) is the most widely used anticoagulant for CRRT worldwide [3]. However, critically ill patients are commonly complicated with impaired coagulation or increased bleeding risk [4].…”

Section: Introductionmentioning

confidence: 99%

“…Acc, accuracy; AUC, area under the curve; AIC, Akaike Information Criterion; BS, bootstrapping; CI, con dence interval; DOR, diagnostic odds ratio; mfp, Multiple Fractional Polynomial; NPV, negative predictive value; PLR, positive likelihood ratio; PPV, positive predictive value; NLR, negative likelihood ratio; Sen, sensitivity; Spe, speci city 1. backward stepwise variables selection based on AIC; 2 stepwise model bootstrapping 1000 times;3 nal model was generated based on mfp; 4 full model; 5 full model bootstrapping 1000 times…”

mentioning

confidence: 99%

A Prediction Model of Sufficient Filter Lifespan in Anticoagulation-free CRRT Patients

Zhang¹,

Bai²,

Zhang³

et al. 2020

Preprint

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Background: Anticoagulation-free continuous renal replacement therapy (CRRT) was recommended by the current clinical guideline for patients with increased bleeding risk and contraindications of citrate and resulted in heterogeneous filter lifespan. There was no prediction model to identify the patients would have sufficient filter lifespan when they have to accept CRRT without the use of any anticoagulation. The purpose of our present study is to develop a clinical prediction model of sufficient filter lifespan in anticoagulation-free CRRT patients.Method: Patients who underwent anticoagulation-free CRRT in our center between June 2013 and June 2019 were retrospectively included. The primary outcome was sufficient filter lifespan (≥ 24 hours). The final model was established by using multivariable logistic regression analysis. And, the prediction model was validated in an external cohort. Results: A total of 170 patients were included in the development cohort. Sufficient filter lifespan were observed in 80 patients. The probability of sufficient filter lifespan could be calculated using the following regression formula: P (%) = exp (Z)/1 + exp (Z), where Z = 0.49896-(0.08552*BMI)+(0.44107*T)+(0.03373*MAP)-(0.03389*WBC)+(1.51579*[vasopressor=1])-(0.01132*PLT)+(0.00422*ALP)-(2.66910*pH)-(0.00214*UA)+(0.05992*BUN)+(0.00400*Db)–(0.00014*D-dimer)+(0.02818*APTT). The area under the curve (AUC) of the stepwise model and internal validation model was 0.82 (95%CI [0.76-0.88]) and 0.8 (95%CI [0.74-0.87]), respectively. At the optimal cut-off value of -0.1052, the positive predictive value and the negative predictive value of the stepwise model was 0.77 and 0.79, respectively. The AUC of the external model was 0.82 (95%CI [0.69-0.96]). Conclusion: The use of a prediction model instead of an assessment based only on coagulation parameters could facilitate the identification of the patients with filter lifespan of ≥ 24 hours when they accepted anticoagulation-free CRRT.

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Renal replacement therapy and anticoagulation

Cited by 51 publications

References 71 publications

Complications of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy: An Observational Study

Complications of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy: An Observational Study

Renal replacement therapy: a practical update

A Prediction Model of Sufficient Filter Lifespan in Anticoagulation-free CRRT Patients

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Renal replacement therapy and anticoagulation

Cited by 51 publications

References 71 publications

Complications of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy: An Observational Study

Complications of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy: An Observational Study

Renal replacement therapy: a practical update

A Prediction Model of Sufficient Filter Lifespan in Anticoagulation-free CRRT&nbsp;Patients

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A Prediction Model of Sufficient Filter Lifespan in Anticoagulation-free CRRT Patients