The effect of citrate in cardiovascular system and clot circuit in critically ill patients requiring continuous renal replacement therapy

Abstract

We aimed to evaluate the impact of citrate on hemodynamic responses and secondary outcomes, including the filter life span, metabolic complications, and levels of inflammatory cytokines, in critically ill patients who required CRRT compared with those who underwent the heparin-free method. This prospective, multicenter, open-label randomized trial compared regional citrate anticoagulation (RCA) with a heparin-free protocol in severe acute kidney injury (AKI) patients who received continuous venovenous hemodiafiltration (CVVHDF) in the postdilution mode. We measured hemodynamic changes using the FloTrac Sensor/EV1000™ Clinical Platform at certain time points after starting CRRT (0, 6, 12, 24, 48, and 72 h.). The levels of inflammatory cytokines (IL-1β, IL-6, IL-8, IL-10 and TNF-ɑ) were measured on days 1 and 3. Forty-one patients were recruited and randomized into the heparin (n = 20) and citrate groups (n = 21). The cardiac performances were not significantly different between the 2 groups at any time point. The inflammatory cytokines declined similarly in both treatment arms. The maximum filter survival time was insignificantly longer in the RCA group than in the heparin-free group (44.64 ± 26.56 h. vs p = 0.693 in citrate and heparin free group). No serious side effects were observed for either treatment arm, even in the group of liver dysfunction patients. RCA did not affect hemodynamic changes during CRRT. Inflammatory cytokines decreased similarly in both treatment arms.The filter life span was longer in the citrate group. RCA is a valid alternative to traditional anticoagulation and results in stable hemodynamic parameters.

Anticoagulation options for continuous renal replacement therapy in critically ill patients: a systematic review and network meta-analysis of randomized controlled trials

“…In the RCA group, the post-filter ionized calcium concentration in most studies was kept at 0.25–0.35 mmol/L [ 32 , 37 , 43 – 45 ]. And the targeted systemic ionized calcium levels in most studies were kept at 0.9–1.2 mmol/L or 1.0–1.35 mmol/L [ 41 , 44 – 47 ]. Thus, we consider the assumption of transitivity to be valid.…”

“…Only a small subset of trials provided information on the length of hospital stay, with 4 RCTs [ 43 , 44 , 48 , 49 ] involving 3 anticoagulation options. Therefore, NMA for this outcome was not performed.…”

Comparison of citrate dialysate in pre- and post-dilution online hemodiafiltration: effect on clot formation and adequacy of dialysis in hemodialysis patients

“…However, anticoagulant use is limited by the risk of bleeding. Another technique to limit thrombosis in the extracorporeal circuit is regional citrate anticoagulation or CD, which has shown promising results in previous studies [ 24 , 25 ].…”

Comparison of citrate dialysate in pre- and post-dilution online hemodiafiltration: Effect on clot formation and adequacy of dialysis in hemodialysis patients

“…The clotting scores signi cantly increased in the post-dilution mode compared with the pre-dilution mode, with a maximum value of less than 3. We previously reported that citrate does eliminate the need for heparin during HD [25] but did not prolong the circuit life span in continuous venovenous hemodia ltration in the post-dilution mode [24]. Previous studies have suggested that some clotting did occur during HD or continuous renal replacement therapy and that citrate can attenuate the need for heparin [28,29] but not abolish it entirely.…”

“…However, the use of these anticoagulants is limited by the risk of bleeding. Another technique to limit thrombosis in the extracorporeal circuit is regional citrate anticoagulation or CD, which showed promising results in previous studies [24,25].…”