Comparison of the Efficacy and Safety of Regional Citrate versus Systemic Heparin Anticoagulation on Continuous Renal Replacement Therapy with Critically Ill Patients: A Retrospective Study

Abstract

The efficacy of continuous renal replacement therapy (CRRT) depends on effective anticoagulation to maintain the extracorporeal circuit. CRRT is crucial in critically ill patients with multiple organ failure. The choice of regional citrate anticoagulation (RCA) and systemic unfractionated heparin anticoagulation (SHA) used as anticoagulation in CRRT is still controversial because of the citrate accumulation, the unpredictability of citrate’s in-vivo efficacy and the bleeding complications of SHA. The purpose of this study was to evaluate the effect and safety of RCA versus SHA on CRRT by minimizing the independent variables, was conducted by comparing the first dialysis of the same patients using both methods at different times. Between September 2018 and September 2019, 102 patients who underwent CRRT were examined and 11 patients whose anticoagulation method was changed due to various reasons were included in the study. The filter life time (95% CI: [1.25-53.29]; p=0,042) and ultrafiltration rate (95% CI: [9.43-64.20]; p=0,013) is statistically higher in RCA group. However no significant differences were observed via initial and final values of electrolyte, urea, creatinine and, pH in two groups (p>0,05). RCA is a safe and effective anticoagulation method that can be used especially in critically ill patients undergoing CRRT who may have bleeding complications.

Keywords

• Regional citrate anticoaggulation
• systemic heparin anticoaggulation
• continuous renal replacement therapy
• critically illness.

Kritik Hastalarda Sürekli Renal Replasman Tedavisinde Kullanılan Rejyonel Sitrat ve Sistemik Heparin Antikoagülasyonunun Etkinliği ve Güvenliğinin Karşılaştırılması: Retrospektif Çalışma

Abstract

Sürekli renal replasman tedavisinin (SRRT) etkinliği ekstrakorporeal devrenin sürdürülebilmesi için etkin bir antikoagülasyona bağlıdır. Çoklu organ yetmezliği olan kritik hastalarda SRRT hayat kurtarıcıdır. SRRT’de antikoagülasyon olarak kullanılan rejyonel sitrat antikoagülasyonu (RSA) ve sistemik heparin antikoagülasyonu (SHA) tercihi sitratın akümülasyonunun tehlikeleri in-vivo etkinliğinin öngörülememesi ve SHA’nın kanama komplikasyonları nedeniyle halen tartışmalıdır. Bağımsız değişkenleri en aza indirerek RSA'ya karşı SHA'nın SRRT üzerindeki etkisini ve güvenliğini değerlendirmek için yapılan bu çalışma; aynı hastaların her iki koagülasyon yönteminin farklı zamanlarda kullanıldığı ilk diyalizlerine ait parametreler karşılaştırarak gerçekleştirildi. 2018 Eylül ve 2019 Eylül ayları arasında SRRT uygulanan 102 hasta incelenmiş çeşitli nedenlerden dolayı antikoagülasyon yöntemi değiştirilen 11 hasta çalışmaya dahil edilmiştir. Çalışmamızda RSA yöntemi SRRT’de kullanıldığına SHA yöntemi kullanılmasına göre filtre ömrünün (%95 CI: [1.25-53.29]; p= 0,042) ve ultrafiltrasyon hızının (%95 CI: [9.43-64.20]; p=0,013) istatistiksel olarak anlamlı bir şekilde arttığı gözlendi. Bununla birlikte grupların başlangıç ve bitiş elektrolit, üre,kreatinin ve pH değerleri arasında anlamlı fark tespit edilmedi (p>0,05). RSA özellikle kanama komplikasyonu olabilecek SRRT yapılacak kritik hastalarda SHA yerine kullanılabilecek güvenli ve etkili antikoagülasyon yöntemidir.

Keywords

• Rejyonel sitrat antikoagülasyonu
• sürekli renal replasman tedavisi
• sistemik unfraksiyone heparin antikoagülasyonu
• kritik hasta.
• Regional citrate anticoaggulation
• systemic heparin anticoaggulation
• continuous renal replacement therapy
• critically illness.

References

1. 1. Fearly N, Baldwin I, Bellomo R. The effect of circuit “down-time” on uraemic control during continius venovenous hemofiltration. Crit Care Resusc 2002; 4:266-70.
2. 2. Zarbock A, Küllmar M, Kindgen-Milles D, et al. 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: A Randomized Clinical Trial. JAMA 2020; 324:1-11.
3. 3. KDIGO. KDIGO Clinical Practise Guideline for Acute Kidney Injury. Kidney Int 2012; 2: 1-138.
4. 4. MacEwen C, Watkinson P, Winearls C. Circuit life versus bleeding risk: the impact of achieved activated partial tromboplastin time versus achieved filtration fraction. The Apher Dial 2015; 19:259-66.
5. 5. Kindgen-Miles D, Bradenburger T, Dimski T. Regional citrate anticoagulation for continius renal replacement therapy. Curr Opin Crit Care 2018; 24:450-4.
6. 6. Bai M, Zhou M, He L, Ma F, Li Y, Yu Y, et al. Citrate versus heparin anticoagulation for continuous renal replacement therapy: an updated meta-analysis of RCTs. Intensive Care Med. 2015;41: 2098-110.
7. 7. Slowinski T, Morgea S, Joannidis M, et al. Safety and efficacy of Regional citrate anticoagulation in continious venovenous hemodialysis in presence of liver failure; the Liver Citrate Anticoagulation Thereshold (L-CAT) observational study. Crit Care 2015;19:349.
8. 8. Monchi M, Berghmans D, Ledoux D, et al. Citrate vs heparin for anticoagulation in continous venovenous hemofiltration: A prospective randomized study. Intensive Care Med 2004; 30:260-265.

9. 9. Liu C, Mao Z, Kang H, Hu J and Zhou F. Regional citrate versus heparin anticoagulation for continuous renal replacement therapy in critically ill patients: a meta-analysis with trial sequential analysis of randomized controlled trials. Crit Care 2016; 20:144.
10. 10. Kalb R, Kram R, Morgena S, et al. Regional citrate anticoagulation for high volume continuous venoveneus hemodialysis in surgical patients with high bleeding risk. The Apher Dial 2013; 17:202-212.
11. 11. Park JS, Kim GH, Kang CM, et al. Regional citrate anticoagulation with citrate superior to systemic anticoagulation with heparine in critically ill patients undergoing continuous venoveneus hemodiafiltration. Korean J Intern Med 2011; 26:68-75.
12. 12. Khadzhynow D, Dahlinger A, Schelter C, et al. Hyper lactetatemia , lactate kinetics and prediction of citrate accumulation in critically ill patients undergoing continuous renal replacement therapy with regional citrate anticoagulation. Crit Care Med 2017; 45:e941-e946.
13. 13.Kingele M, Seiler S, Poppleton A, et al. The gap betweencalculated and actual calcium substituation during citrate anticoagulation in an immobilised patient on renal replacement therapy reflects the extent of bone loss: a case report. BMC Nephrol 2014; 15:163.
14. 14.Raimundo M, Crichton S, Lei K, et al. Maintaining normal levels of ionized calcium during citrate-based renal replacementtherapy is associated with stable parathryroid hormone levels,Nephron Clin Pract 2013; 124:124-131.