Heparin versus citrate anticoagulation for continuous renal replacement therapy in intensive care: the RRAM observational study

Regional Citrate Anticoagulation Versus Systemic Heparin in Continuous Kidney Replacement Therapy: Examining the Role of Evidence in Health Technology Assessment

INTRODUCTION

Continuous kidney replacement therapy (CKRT) is an established treatment supporting kidney function in patients with severe acute kidney disease. Systemic heparin and regional citrate anticoagulation (RCA) are the main anticoagulation strategies to prevent dialysis filter loss due to clotting, a complication of all KRT, including CKRT. The present study aims to comprehensively compare two anticoagulation strategies by collecting available clinical and economic evidence for an adult population under CKRT through a systematic literature review and meta-analysis.

METHODS

Randomized controlled trials, prospective/retrospective observational studies and economic analyses, involving systemic heparin or RCA, were searched through PubMed and Web of Science databases. Extracted data focused on clinical parameters, adverse events and cost items. Meta-analyses were conducted on data points with numeric outcomes to compare the two anticoagulation techniques. An evaluation of the quality of the evidence was also conducted using the GRADE system.

RESULTS

Seventy-two studies were eligible for this meta-analysis. Statistically significant differences between heparin and RCA were observed in ionized calcium levels (mmol/l; heparin 1.19, RCA 1.13), bleeding events (heparin 12.6%, RCA 2.4%), filter lifespan (hours; heparin 16.43, RCA 36.69), clotting issues (heparin 50.7%, RCA 21.3%), filter failure rate (heparin 67.7%, RCA 13.5%), hypocalcemia (heparin 0.1%, RCA 4.4%) and alkalosis (heparin 0.4%, RCA 6.6%) rates. Limitations include heterogeneity across studies, particularly for RCA, and potential biases, although the overall methodological quality ranged from moderate to low.

CONCLUSIONS

Based on the evidence presented, despite higher rates of hypocalcemia and alkalosis, RCA demonstrates advantages over heparin, including a reduction in bleeding events, prevention of filter clotting and improvement in filter lifespan. Additionally, the cost outcome demonstrated comparable statistics depending on the RCA protocol considered, which supports the potential cost-effectiveness of RCA. RCA provides clear clinical and potential organizational benefits and comparable cost statistics with a reasonable level of confidence in the evidence for the economic data.

Effective management of pediatric septic shock: a case study utilizing continuous renal replacement therapy with cytosorb and citrate in a leukemic patient with hyper-interleukin (IL)-6-naemia and severe thrombocytopenia

BACKGROUND

Sepsis is a critical condition characterized by a dysregulated immune response to infection, often resulting in organ dysfunction. Interleukin-6 (IL-6) is a key proinflammatory cytokine associated with sepsis and its complications. This case study explored the use of Continuous Renal Replacement Therapy (CRRT) combined with Cytosorb in managing pediatric patients with leukemia, severe thrombocytopenia, and elevated IL-6 levels.

CASE PRESENTATION

A 10-year-old boy with Fanconi anemia presented with pancytopenia, fever, and necrotic lesions, indicative of mucormycosis. Following the diagnosis of acute myeloid leukemia (AML), the patient experienced severe complications, including septic shock. Despite appropriate treatment, inflammatory markers, such as C-reactive protein (CRP), procalcitonin (PCT), and IL-6, were significantly elevated. CRRT with Cytosorb was initiated to manage hypercytokinemia and improve the patient's clinical status.

INTERVENTION

The CRRT procedure utilizes citrate as an anticoagulant because of severe thrombocytopenia. The treatment lasted for 20 h, during which the inflammatory biomarkers were monitored. The post-treatment results indicated a significant reduction in IL-6 levels within 24 h and a decrease in PCT levels at 8 h. CRP levels gradually declined over 40 h.

OUTCOME

The patient exhibited marked clinical improvement, with significant healing of cutaneous lesions and stabilization of inflammatory markers, allowing transfer to the ward for continued chemotherapy.

CONCLUSION

This case suggests that CRRT combined with cytosorb may be a valuable adjunctive therapy for managing complex cases of septic shock. The observed reduction in inflammatory markers, particularly IL-6, warrants further investigation. Concurrent antimicrobial, antifungal, and dexamethasone treatments for IRIS may have influenced the observed outcomes in this single case. Controlled studies are needed to evaluate the specific contribution of Cytosorb-CRRT and assess its long-term efficacy and safety in similar patient populations, particularly in resource-limited settings.

CLINICAL TRIAL NUMBER

Not applicable.

Study on the application of a segmented sodium citrate solution anticoagulation strategy in critically ill patients receiving CRRT: a prospective, randomized controlled study

BACKGROUND

To explore the feasibility and effectiveness of a segmented sodium citrate solution anticoagulation strategy in patients receiving CRRT.

METHODS

A prospective, randomized controlled study was conducted.

RESULTS

According to the inclusion and exclusion criteria, 80 patients were included and randomly divided into two groups. Moreover, coagulation indices, liver function indices, renal function indices, and SOFA and APACHE II scores did not significantly differ between the two groups (P > 0.05). The coagulation grade of the venous ports in the experimental group was lower than that in the control group and the two groups of filters, but the difference was not statistically significant (P = 0.337). Both sodium citrate solution infusion methods maintained a low blood calcium concentration (0.25-0.45 mmol/L) in the peripheral circulation pathway, and no patient developed hypocalcaemia (< 1.0 mmol/L). The lifespans of the extracorporeal circulation tube in the experimental group and the control group were 69.43 ± 1.49 h and 49.39 ± 2.44 h, respectively (t = 13.316, P = 0.001).

CONCLUSION

The segmented citrate solution anticoagulation strategy could extend the lifespan of the extracorporeal circulation tube and improve CRRT efficacy.

TRIAL REGISTRATION

The Chinese Clinical Trial Registry number is ChiCTR2200057272. Registered on March 5, 2022.

Citrate anticoagulation in plasma exchange followed by continuous renal replacement therapy in critically ill children

OBJECTIVE

To investigate the effectiveness and safety of regional citrate-anticoagulated (RCA) plasma exchange (PE) and whether citrate-related metabolic disorders can be improved by sequential RCA continuous renal replacement therapy (CRRT).

METHODS

This retrospective, single-center observational study included 79 critically ill children requiring PE followed by CRRT (June 2018 to June 2021) at the Pediatric Intensive Care Unit of Hunan Children's Hospital, China. Patients were divided into the RCA-PE (n = 30) and systemic heparin anticoagulation (SHA-PE) (n = 49) groups. Filter level comparison post-PE assessed RCA-PE efficacy, and metabolic changes occurring pre- and post-PE and CRRT were used to evaluate the effect of CRRT on RCA-based anticoagulation safety.

RESULTS

The RCA-PE group had a better overall filter performance than the SHA-PE group. Two hours after PE, pH and HCO₃- levels increased more significantly for the RCA-PE than the SHA-PE group. The RCA-PE incidence of metabolic alkalosis was 48.3%, higher by 4.2% (p < 0.001) compared to the SHA-PE group. In the RCA-PE group, pH and HCO₃- decreased significantly 4 h after CRRT; the metabolic alkalosis caused by RCA-PE decreased to 13.8% (p = 0.005). No significant difference in pH, HCO₃-, and metabolic alkalosis incidence was observed between the two groups 4 h after CRRT.

CONCLUSIONS

The overall filtration performance of RCA-PE is superior to that of SHA-PE followed by CRRT. The metabolic complications associated with RCA-PE are mainly metabolic alkalosis that can be improved by using CRRT after RCA-PE and this is a better alternative for anticoagulation during PE in critically ill children.

Real-life effects, complications, and outcomes in 39 critically ill neonates receiving continuous kidney replacement therapy

BACKGROUND

Continuous kidney replacement therapy (CKRT) has been expanded from simple kidney replacement therapy to the field of critical illness in children. However, CKRT is rarely used in critically ill neonates in the neonatal intensive care unit (NICU). This study aimed to describe patients' clinical characteristics at admission and CKRT initiation, CKRT effects, short-term outcomes, and predictors of death in critically ill neonates.

METHODS

A 7-year single-center retrospective study in a tertiary NICU.

RESULTS

Thirty-nine critically ill neonates received CKRT between May 2015 and April 2022 with a mortality rate of 35.9%. The most common primary diagnosis was neonatal sepsis in 15 cases (38.5%). Continuous veno-venous hemodiafiltration and continuous veno-venous hemofiltration were applied in 43.6% and 56.4% of neonates, respectively. The duration of CKRT was 44 (18, 72) h. Thirty-one patients (79.5%) had complications due to CKRT-related adverse events, and the most common complication was thrombocytopenia. Approximately 12 h after the CKRT initiation, urine volume, mean arterial pressure, and pH were increased, and serum creatinine, blood urea nitrogen, and blood lactate were decreased. In the multivariate logistic regression analysis, neonatal critical illness score [odds ratio 0.886 (0.786 ~ 0.998), P = 0.046] was an independent risk factor for death in critically ill neonates who received CKRT.

CONCLUSIONS

CKRT can be an effective and feasible technique in critically ill neonates, but the overall mortality and CKRT-related complications are relatively high. Furthermore, the probability of death is greater among neonates with greater severity of illness at CKRT initiation. A higher resolution version of the Graphical abstract is available as Supplementary information.

Analysis of the extracorporeal anticoagulation effect of modified citrate infusion during continuous renal replacement therapy in critically ill patients

INTRODUCTION

To analyze the anticoagulation effect of different local infusion methods of citrate underwent continuous renal replacement therapy (CRRT) in critically ill patients.

METHODS

The study adopted a single-centre retrospective design. Critically ill patients were divided into conventional group and modified group based on the infusion methods of citrate.

RESULTS

The modified group had a longer mean treatment time (67.67 ± 18.69  hours vs. 52.11 ± 24.26 hours, p = 0.007), a lower transmembrane pressure (147.77 ± 66.85 cm H₂ O vs. 200.63 ± 118.66 cm H₂ O, p = 0.038), fewer citrate bag replacements (1.43 ± 0.50 times vs. 10.60 ± 3.19 times, p < 0.001), and more steady ionized calcium at the venous end (0.35 ± 0.06 mmol/L vs. 0.40 ± 0.05 mmol/L, p = 0.006) compared to the conventional group patients, with statistically significant differences. The incidences of citrate accumulation and tubing coagulation were marginally lower in the modified group.

CONCLUSION

The modified local citrate infusion method can prolong treatment time, while reducing both the nursing workload and the occurrence of citrate accumulation.