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R Claure-Del Granado, E Macedo... - NDT ..., 2011 - Abstract INTRODUCTION AND AIMS: Continuous renal replacement therapies (CRRT) are increasingly utilized to treat critically ill patients with acute kidney injury. The efficiency of CRRT depends on circuit longevity which is influenced by anticoagulation and modality ...

INTRODUCTION AND AIMS: Continuous renal replacement therapies (CRRT) are increasingly utilized to treat critically ill patients with acute kidney injury. The efficiency of CRRT depends on circuit longevity which is influenced by anticoagulation and modality operational characteristics. Filter clotting can reduce filter efficacy and prevent the continuous delivery of a prescribed dose. Systemic unfractionated heparin (UFH) and regional citrate are the two most employed methods for anticoagulation. We hypothesized that the use of regional citrate will increase circuit longevity, filter efficacy, and urea clearance.

METHODS: We analyzed data from 229 critically-ill patients from 5 centers in a prospective observational cohort (PICARD) with at least 48 hr. on CRRT who were treated with CVVH, CVVHD, or CVVHDF. Filter anticoagulation strategy was determined by each center (UFH, regional citrate, or saline flushes). We calculated delivered dose using the standard Kt/Vurea equation (Std Kt/Vurea) [Artif Organs 30:178-185, 2006]. In 590 sessions in which effluent urea nitrogen (FUN) was available, filter efficacy was assessed by calculating FUN/BUN ratios.

RESULTS: Filter life was available for 1400 filters; in 824 (59%) UFH was used, in 173 (12%) citrate was used and in 403 (29%) no anticoagulation was used. Median filter life was significantly higher with citrate (48 hr., interquartile range [IQR] (20.3 – 75 hr.) than with UFH (15.9 hr., [IQR 8.5 – 27 hr.]) or saline flushes (17.5 hr., [IQR 9.5 – 32 hr.]; p=0.001). In the 590 filters where FUN/BUN ratio was avalilable, filter efficacy was better in circuits where citrate was used compared to UFH (p = 0.001). Delivered dose of dialysis (Std Kt/Vurea) was similarly better with citrate (8.1 [IQR 5.9 – 10.4]) compared with UFH ( 6.1 [IQR 4.4 – 8.1]) or saline flushes (7.4 [IQR 5.4 – 9.8]). Bleeding complications rates (drop in Hb levels >1.5 gr/d L) and transfusions were similar across the 3 groups (p = 0.253). In-hospital mortality was highest among patients with no anticoagulation. No difference in in-hospital mortality was found between patients who were treated with UFH than those treated with citrate for anticoagulation (47.6% vs. 57.9%; p = 0.21).

CONCLUSIONS: The use of regional citrate was associated with significantly prolonged filter life, increased filter efficacy, and delivered dialysis dose. There were no more bleeding complications or transfusions, suggesting similar safety. No difference was found in in-hospital mortality rate, confounding by indication may explain the latter result. While these and other data suggest that citrate anticoagulation may offer superior technical performance, adequately powered randomized clinical trials comparing alternative anticoagulation strategies are should be performed to evaluate overall safety and efficacy.