DOI QR코드

DOI QR Code

Regional Anticoagulation with Citrate is Superior to Systemic Anticoagulation with Heparin in Critically Ιll Patients Undergoing Continuous Venovenous Hemodiafiltration

  • Park, Joon-Sung (Department of Internal Medicine, Hanyang University College of Medicine) ;
  • Kim, Gheun-Ho (Department of Internal Medicine, Hanyang University College of Medicine) ;
  • Kang, Chong-Myung (Department of Internal Medicine, Hanyang University College of Medicine) ;
  • Lee, Chang-Hwa (Department of Internal Medicine, Hanyang University College of Medicine)
  • Published : 2011.03.01

Abstract

Background/Aims: Short hemofilter survival and anticoagulation-related life-threatening complications are major problems in systemic anticoagulation with heparin (SAH) for continuous renal replacement therapy (CRRT). The present study examined if regional anticoagulation with citrate (RAC) using commercially available solutions can overcome the associated problems of SAH to produce economical benefits. Methods: Forty-six patients were assigned to receive SAH or RAC. We assessed the coagulation state, clinical outcomes, and adverse events. A Kaplan-Meier analysis was used to estimate hemofilter life span. The economical benefit related to the prolonged hemofilter survival was examined on the basis of the average daily cost. Results: The mean age of patients was 66.5 ${\pm}$ 13.8 years and the majority were male (60.9%). While elective discontinuation was most common cause of early CRRT interruption in the RAC group (34.3%, p < 0.01), hemofilter clotting was most prevalent in the SAH group (82.2%, p < 0.01). The patient metabolic and electrolyte control and survival rate were not different between the two groups. When compared with the RAC group, the anticoagulation-associated bleeding was a major complication in the SAH group (15.0% vs. 61.5%, p < 0.01). Regional anticoagulated hemofilters displayed a significantly longer survival time than systemic anticoagulated hemofilters (59.5 ${\pm}$ 3.8 hr vs. 15.6 ${\pm}$ 1.3 hr, p < 0.01). Accordingly, the mean daily continuous venovenous hemodiafiltration costs in the RAC and SAH groups were $575 ${\pm}$ 268 and $1,209 ${\pm}$ 517, respectively (p < 0.01). Conclusions: RAC prolonged hemofilter survival, displaying an economical benefit without severe adverse effects. The present study therefore demonstrates that RAC, using commercially available solutions, may be advantageous over SAH as a cost-effective treatment in CRRT.

Keywords

References

  1. Palsson R, Niles JL. Regional citrate anticoagulation in continuous venovenous hemofiltration in critically ill patients with a high risk of bleeding. Kidney Int 1999;55:1991-1997. https://doi.org/10.1046/j.1523-1755.1999.00444.x
  2. Tolwani AJ, Prendergast MB, Speer RR, Stofan BS, Wille KM. A practical citrate anticoagulation continuous venovenous hemodiafiltration protocol for metabolic control and high solute clearance. Clin J Am Soc Nephrol 2006;1:79-87.
  3. Kutsogiannis DJ, Gibney RT, Stollery D, Gao J. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 2005;67:2361-2367. https://doi.org/10.1111/j.1523-1755.2005.00342.x
  4. Cointault O, Kamar N, Bories P, et al. Regional citrate anticoagulation in continuous venovenous haemodiafiltration using commercial solutions. Nephrol Dial Transplant 2004;19:171-178. https://doi.org/10.1093/ndt/gfg488
  5. Munjal S, Ejaz AA. Regional citrate anticoagulation in continuous venovenous haemofiltration using commercial preparations. Nephrology (Carlton) 2006;11:405-409. https://doi.org/10.1111/j.1440-1797.2006.00653.x
  6. Monchi M, Berghmans D, Ledoux D, Canivet JL, Dubois B, Damas P. Citrate vs. heparin for anticoagulation in continuous venovenous hemofiltration: a prospective randomized study. Intensive Care Med 2004;30:260-265. https://doi.org/10.1007/s00134-003-2047-x
  7. Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 2000;356:26-30. https://doi.org/10.1016/S0140-6736(00)02430-2
  8. Tan HK, Baldwin I, Bellomo R. Continuous veno-venous hemofiltration without anticoagulation in high-risk patients. Intensive Care Med 2000;26:1652-1657. https://doi.org/10.1007/s001340000691
  9. Uchino S, Fealy N, Baldwin I, Morimatsu H, Bellomo R. Continuous is not continuous: the incidence and impact of circuit "down-time" on uraemic control during continuous veno-venous haemofiltration. Intensive Care Med 2003;29:575-578. https://doi.org/10.1007/s00134-003-1672-8
  10. Bagshaw SM, Laupland KB, Boiteau PJ, Godinez-Luna T. Is regional citrate superior to systemic heparin anticoagulation for continuous renal replacement therapy? A prospective observational study in an adult regional critical care system. J Crit Care 2005;20:155-161. https://doi.org/10.1016/j.jcrc.2005.01.001
  11. Uchino S, Bellomo R, Morimatsu H, et al. Continuous renal replacement therapy: a worldwide practice survey. The beginning and ending supportive therapy for the kidney (B.E.S.T. kidney) investigators. Intensive Care Med 2007;33:1563-1570. https://doi.org/10.1007/s00134-007-0754-4
  12. Tolwani AJ, Campbell RC, Schenk MB, Allon M, Warnock DG. Simplified citrate anticoagulation for continuous renal replacement therapy. Kidney Int 2001;60:370-374. https://doi.org/10.1046/j.1523-1755.2001.00809.x
  13. Mehta RL, McDonald BR, Aguilar MM, Ward DM. Regional citrate anticoagulation for continuous arteriovenous hemodialysis in critically ill patients. Kidney Int 1990;38:976-981. https://doi.org/10.1038/ki.1990.300
  14. Brophy PD, Somers MJ, Baum MA, et al. Multi-centre evaluation of anticoagulation in patients receiving continuous renal replacement therapy (CRRT). Nephrol Dial Transplant 2005;20:1416-1421. https://doi.org/10.1093/ndt/gfh817

Cited by

  1. Efficacy and safety of regional citrate anticoagulation in critically ill patients undergoing continuous renal replacement therapy vol.38, pp.1, 2012, https://doi.org/10.1007/s00134-011-2438-3
  2. References vol.2, pp.1, 2012, https://doi.org/10.1038/kisup.2011.38
  3. Regional citrate anticoagulation in cardiac surgery patients at high risk of bleeding: a continuous veno-venous hemofiltration protocol with a low concentration citrate solution vol.16, pp.3, 2012, https://doi.org/10.1186/cc11403
  4. Regional Citrate Versus Heparin Anticoagulation for Continuous Renal Replacement Therapy: A Meta-Analysis of Randomized Controlled Trials vol.59, pp.6, 2011, https://doi.org/10.1053/j.ajkd.2011.11.030
  5. Continuous renal replacement therapy in neonates weighing less than 3 kg vol.55, pp.8, 2011, https://doi.org/10.3345/kjp.2012.55.8.286
  6. Regional citrate anticoagulation for renal replacement therapy vol.20, pp.4, 2011, https://doi.org/10.3918/jsicm.20.577
  7. Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI vol.9, pp.12, 2011, https://doi.org/10.2215/cjn.01280214
  8. Zitratantikoagulation in der akuten Nierenersatztherapie : Methode der Wahl vol.109, pp.5, 2014, https://doi.org/10.1007/s00063-013-0339-7
  9. Regional citrate anticoagulation for renal replacement therapies in patients with acute kidney injury: a position statement of the Work Group “Renal Replacement Therapies in Critically Ill Patie vol.28, pp.2, 2011, https://doi.org/10.1007/s40620-014-0160-2
  10. Simplified Citrate Anticoagulation for CRRT Without Calcium Replacement vol.61, pp.4, 2015, https://doi.org/10.1097/mat.0000000000000226
  11. Nafamostat Mesilate as an Anticoagulant During Continuous Renal Replacement Therapy in Patients With High Bleeding Risk : A Randomized Clinical Trial vol.94, pp.52, 2011, https://doi.org/10.1097/md.0000000000002392
  12. 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 vol.20, pp.None, 2011, https://doi.org/10.1186/s13054-016-1299-0
  13. Evaluating the safety and efficacy of regional citrate compared to systemic heparin as anticoagulation for continuous renal replacement therapy in critically ill patients: A service evaluation followi vol.18, pp.3, 2017, https://doi.org/10.1177/1751143717695835
  14. The Role of Ionized Calcium and Magnesium in Regional Citrate Anticoagulation and its Impact on Inflammatory Parameters vol.40, pp.1, 2011, https://doi.org/10.5301/ijao.5000558
  15. Regional citrate anticoagulation for continuous renal replacement therapy in pediatric patients with liver failure vol.12, pp.8, 2011, https://doi.org/10.1371/journal.pone.0182134
  16. Regional citrate anticoagulation for continuous renal replacement therapy vol.24, pp.6, 2018, https://doi.org/10.1097/mcc.0000000000000547
  17. A cost comparison of regional citrate versus low-dose systemic heparin anticoagulation in continuous renal replacement therapy vol.47, pp.3, 2011, https://doi.org/10.1177/0310057x18824596
  18. Regional Citrate Anticoagulation Protocol for Patients with Presumed Absent Citrate Metabolism vol.2, pp.2, 2011, https://doi.org/10.34067/kid.0005342020