Key result
Regional citrate anticoagulation was associated with a longer median circuit lifespan than heparin (54.9 vs. 15.3 hours, p<0.0001), but higher rates of metabolic acidosis and alkalosis.
Why the study?
Little is known about the type and rate of complications associated with regional citrate anticoagulation for continuous renal replacement therapy in real-life practice.
Does regional citrate anticoagulation compared to heparin anticoagulation affect circuit lifespan and complication rates in patients undergoing continuous renal replacement therapy?
Observational (n=121)
No
Does regional citrate anticoagulation compared to heparin anticoagulation affect circuit lifespan and complication rates in patients undergoing continuous renal replacement therapy?
Absolute Event Rate: 54.9% vs 15.3%
p-value: p=< 0.0001
Regional citrate anticoagulation for CRRT significantly prolongs circuit life compared to heparin but is associated with increased rates of minor metabolic complications.
May support citrate for longer CRRT circuits despite metabolic risks; leaves net benefit open pending RCTs.
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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Bianchi et al. (2020) conducted an observational in Continuous renal replacement therapy (CRRT) (n=121). Regional citrate anticoagulation (CVVHD-RCA) vs. Heparin anticoagulation (CVVH-Heparin) was evaluated on Circuit lifespan (median hours) (p=< 0.0001). Regional citrate anticoagulation was associated with a longer median circuit lifespan than heparin (54.9 vs. 15.3 hours, p<0.0001), but higher rates of metabolic acidosis and alkalosis.
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