Abstract
BackgroundCoronavirus disease 2019 (COVID-19) may predispose patients to thrombotic events. The best anticoagulation strategy for continuous renal replacement therapy (CRRT) in such patients is still under debate. The purpose of this study was to evaluate the impact that different anticoagulation protocols have on filter clotting risk.MethodsThis was a retrospective observational study comparing two different anticoagulation strategies (citrate only and citrate plus intravenous infusion of unfractionated heparin) in patients with acute kidney injury (AKI), associated or not with COVID-19 (COV + AKI and COV − AKI, respectively), who were submitted to CRRT. Filter clotting risks were compared among groups.ResultsBetween January 2019 and July 2020, 238 patients were evaluated: 188 in the COV + AKI group and 50 in the COV − AKI group. Filter clotting during the first filter use occurred in 111 patients (46.6%). Heparin use conferred protection against filter clotting (HR = 0.37, 95% CI 0.25–0.55), resulting in longer filter survival. Bleeding events and the need for blood transfusion were similar between the citrate only and citrate plus unfractionated heparin strategies. In-hospital mortality was higher among the COV + AKI patients than among the COV − AKI patients, although it was similar between the COV + AKI patients who received heparin and those who did not. Filter clotting was more common in patients with D-dimer levels above the median (5990 ng/ml). In the multivariate analysis, heparin was associated with a lower risk of filter clotting (HR = 0.28, 95% CI 0.18–0.43), whereas an elevated D-dimer level and high hemoglobin were found to be risk factors for circuit clotting. A diagnosis of COVID-19 was marginally associated with an increased risk of circuit clotting (HR = 2.15, 95% CI 0.99–4.68).ConclusionsIn COV + AKI patients, adding systemic heparin to standard regional citrate anticoagulation may prolong CRRT filter patency by reducing clotting risk with a low risk of complications.
Highlights
Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) is an extremely lethal agent that results in coronavirus disease 2019 (COVID-19), which has caused more than a million deaths worldwide [1]
Distribution of continuous renal replacement therapy (CRRT) modalities regarding COVID-19 status and use of heparin are shown in Additional file 1: Table S1
Likewise, when we analyzed only the patients diagnosed with COVID-19, we found that heparin still reduced the risk of filter clotting (Fig. 4)
Summary
Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) is an extremely lethal agent that results in coronavirus disease 2019 (COVID-19), which has caused more than a million deaths worldwide [1]. In patients with severe COVID-19, there have been reports of endothelial damage and subsequent thrombotic events, accompanied by elevated levels of fibrinogen and D-dimer, which are predictors of a poor prognosis [3, 4]. Some retrospective studies have suggested that anticoagulation with heparin is beneficial in patients with severe COVID19 [8] that is still controversial and there is a need for more robust scientific evidence. Hypercoagulability increases the risk of early clotting of the extracorporeal circuit in patients on continuous renal replacement therapy (CRRT). Some reports have suggested that, among critically ill patients on CRRT, the rates of premature filter change and dialysis downtime are higher in those with COVID-19 than in those without [9, 10]. The best anticoagulation strategy for continuous renal replacement therapy (CRRT) in such patients is still under debate. The purpose of this study was to evaluate the impact that different anticoagulation protocols have on filter clotting risk
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