Effects of regional citrate anticoagulation in continuous veno-venous hemofiltration of severe burn patients

Objective: To investigate the effects of application of citrate anticoagulation in bedside continuous blood purification (CBP) of severe burn patients with sepsis, so as to provide reference for choosing anticoagulants in CBP of these patients. Methods: Thirty severe burn patients with sepsis, conforming to the study criteria, were admitted to our burn intensive care unit from January 2014 to July 2017. Patients were divided into heparin group and citrate group according to computer randomization method, with 15 cases in each group. Patients in two groups all received bedside CBP treatment. Patients in heparin group used local heparin anticoagulation, while patients in citrate group used local citrate anticoagulation. Time of predicted single-time CBP treatment, time of single-time CBP treatment, time of accumulative CBP treatment, and rate of reaching the standard of CBP treatment time were counted. Changes of prothrombin time (PT), activated partial thromboplastin time (APTT), international normalized ratio (INR), fibrinogen, serum procalcitonin, and C-reactive protein (CRP) of patients before and after treatment were monitored. Hemorrhage in wounds, incision on trachea, and arteriovenous intubation point, and other complications during and after CBP treatment were observed. Data were processed with independent sample t test and chi-square test. Results: (1) Time of predicted single-time CBP treatment of patients in the two groups was equal. Time of single-time CBP treatment and time of accumulative CBP treatment of patients in citrate group were longer than those in heparin group. Rate of reaching the standard of CBP treatment time of patients in citrate group was significantly higher than that in heparin group (χ(2)=16.655, P<0.01). (2) There was no statistically significant difference in PT, APTT, INR, fibrinogen, serum procalcitonin, and CRP of patients in the two groups before CBP treatment (t=0.203, -1.006, 0.203, 0.039, -1.591, -0.824, P>0.05). PT and APTT of patients in citrate group after CBP treatment were (14.2±1.6) and (45±7) s, respectively, significantly shorter than (15.5±1.4) and (53±6) s in heparin group (t=2.395, 3.321, P<0.05 or P<0.01). INR of patients in citrate group after CBP treatment was 1.13±0.12, significantly lower than 1.24±0.12 in heparin group (t=2.395, P<0.05). Fibrinogen of patients in citrate group after CBP treatment was (3.5±0.6) g/L, significantly higher than (3.0±0.6) g/L in heparin group (t=-2.427, P<0.05). Serum procalcitonin and CRP of patients in citrate group after CBP treatment were significantly lower than those in heparin group (t=2.520, 2.710, P<0.05). Decreased degree of serum procalcitonin and CRP of patients in citrate group after CBP treatment were (1.8±0.6) ng/mL and (143±69) mg/L, respectively, significantly higher than (0.9±0.6) ng/mL and (95±50) mg/L in heparin group (t=-4.033, -2.170, P<0.05 or P<0.01). (3) During CBP treatment, patients in heparin group experienced 21 times of exacerbation of wound hemorrhage and 10 times of new hemorrhage, including 2 times of hemorrhage at incision on trachea and 8 times of hemorrhage at arteriovenous intubation point. No exacerbation of hemorrhage or new hemorrhage happened in patients of citrate group. After CBP treatment, no electrolyte disturbance happened in patients of heparin group, but 1 patient in citrate group experienced hypocalcemia. Conclusions: Application of citrate anticoagulation in bedside CBP of severe burn patients with sepsis shows light impact on systematic coagulation status, and can effectively decrease inflammation reaction of burn sepsis with low rate of hemorrhage.

Application effects of bundle nursing of citric acid extracorporeal anticoagulation on continuous renal replacement therapy of severe burn patients

Objective: To explore the effects of citric acid on patients with severe burn complicated with acute renal injury treated by continuous renal replacement therapy (CRRT). Methods: Medical records of 83 patients with large area of burn complicated with acute renal injury admitted to intensive care unit (ICU) of our department from January 2015 to December 2018 and meeting the inclusion criteria were analyzed retrospectively. The patients were divided into heparin group [n=43, 25 males and 18 females, aged (35.0±2.5) years] and citric acid group [n=40, 22 males and 18 females, aged (37.0±6.6) years] according to different anticoagulation methods. After admission, routine support treatment and CRRT were performed after being diagnosed with acute renal injury in patients in 2 groups. Patients in heparin group were treated with low molecular weight heparin for anticoagulation with first dosage of 20 U/kg and an increase of 2.5 to 5.0 U per hour, and patients in citric acid group were given citric acid of 0.02 g/mL with dosage of 150~200 mL/h for anticoagulation. The use time of blood filter, recovery time of urine volume, and time of staying in ICU, and platelet count, activated partial thromboplastin time (APTT), prothrombin time (PT), and serum creatinine, urea nitrogen, cystatin C, procalcitonin, C-reactive protein, and neutrophil, leukocyte count, blood sugar, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and heart rate, body temperature, and mean arterial pressure before treatment and post treatment hour (PTH) 24 were recorded. Besides, occurrence of hemorrhage, hypocalcemia, metabolic acidosis, metabolic alkalosis, and death within 28 days post injury were recorded. Data were processed with t test and chi-square test. Results: The use time of blood filter of patients in citric acid group was (28.7±3.2)h, significantly longer than (19.4±2.6) h in heparin group (t=14.139, P<0.01). The recovery time of urine volume and time of staying in ICU of patients in citric acid group were respectively (7.6±0.9) and (9.6±1.3) d, significantly shorter than (9.2±1.5) and (11.2±1.8) d in heparin group (t=5.516, 4.697, P<0.01). Before treatment, there were no statistically significant differences in platelet count, APTT, and PT of patients in 2 groups (t=1.235, 0.515, 1.279, P>0.05). At PTH 24, the platelet count of patients in citric acid group was significantly higher than that in heparin group (t=10.947, P<0.01), and APTT and PT of patients in citric acid group were significantly shorter than those in heparin group (t=7.069, 9.142, P<0.01). Before treatment, there were no statistically significant differences in serum creatinine, urea nitrogen, and cystatin C of patients in 2 groups (t=1.684, 1.878, 1.472, P>0.05). At PTH 24, the serum creatinine, urea nitrogen, and cystatin C of patients in citric acid group were significantly lower than those in heparin group (t=7.778, 9.776, 5.117, P<0.01). Before treatment, there were no statistically significant differences in serum procalcitonin and C-reactive protein of patients in 2 groups (t=1.413, 0.898, P>0.05). At PTH 24, the serum procalcitonin and C-reactive protein of patients in citric acid group were significantly lower than those in heparin group (t=2.635, 2.297, P<0.05). Before treatment, there were no statistically significant differences in neutrophil, leukocyte count, blood sugar, AST, and ALT of patients in 2 groups (t=0.555, 0.816, 0.470, 1.896, 0.982, P>0.05). At PTH 24, the neutrophil, leukocyte count, blood sugar, AST, and ALT of patients in citric acid group were significantly lower than those in heparin group (t=2.054, 3.314, 7.185, 2.151, 3.013, P<0.05 or P<0.01). Before treatment, there were no statistically significant differences in heart rate, body temperature, and mean arterial pressure of patients in 2 groups (t=1.406, 0.474, 0.720, P>0.05). At PTH 24, the heart rate, body temperature, and mean arterial pressure of patients in citric acid group were significantly lower than those in heparin group (t=2.307, 4.498, 2.056, P<0.05 or P<0.01). The incidence of hemorrhage of patients in citric acid group while in hospital was significantly lower than that in heparin group (χ(2)=4.949, P<0.05). There were no statistically significant differences in incidence of hypocalcemia, metabolic acidosis, metabolic alkalosis, and death rate within 28 days post injury of patients in 2 groups while in hospital (χ(2)=3.346, 0.884, 0.297, 0.324, P>0.05). Conclusions: Citric acid has significant anticoagulant effect on patients with large area of burn complicated with acute renal injury treated by CRRT, which can prolong the use time of the blood filter, shorten the recovery time of urine volume and time of staying in ICU, improve renal function indexes, blood biochemical indexes, and inflammation indexes, maintain the stability of internal environment, and reduce the risk of hemorrhage.

Hemostasis in patients with acute kidney injury secondary to acute liver failure

Objective: To investigate the changes of activated partial thromboplastin time (APTT), prothrombin time (PT), thrombin time(TT), fibrinogen(FIB) and platelet counts(PLT) in plasma of patients with glioma, and to explore the correlations between PT, APTT, TT, FIB and PLT with malignant grades of glioma. Methods: One hundred and seventy-two patients with glioma and 47 health controls were investigated in a retrospective analysis. All patients were diagnosed and identified the WHO grade by pathologist after operation. Including 40 cases with glioblastoma multiforme, WHO Ⅳ grade, 45 cases with anaplastic astrocytoma, WHO Ⅲ grade, 46 cases with astrocytoma and oligodendroglia astrocytoma, WHO Ⅱ grade, and 41 cases with pilocytic astrocytoma. Results: PT was significantly shorter in patients with WHO Ⅰ-Ⅳ grade glioma than that in normal controls (P<0.05); APTT was significantly shorter in patients with WHO Ⅲ and Ⅳ grade glioma than that in normal controls and WHO Ⅰ grade glioma patients (P<0.05); FIB of WHO Ⅳ grade glioma was higher than that in normal control and WHO Ⅰ to Ⅲ grade glioma (P<0.05). While, there was no significant difference of TT and PLT among patients with WHO Ⅰ to Ⅳ and normal controls (P>0.05). Spearman correlation analysis showed that there was negative correlation between APTT and WHO grade (r=-0.200, P=0.007) as well as positive correlation between FIB and WHO grade (r=0.175, P=0.020); Pearson linear correlation analysis showed that there was negative correlation between APTT and Ki67 in patients with glioma. Conclusions: the levels of FIB and APTT in patients with glioma were correlated with WHO grade of glioma, and higher FIB, shorter APTT and PT in patients with WHO Ⅳ grade glioma indicated that there exist hypercoagulation states.

Introduction: The distribution of anti-factor Xa activity (AXA) values, prothrombin time (PT), and activated partial thromboplastin time (APTT) in patients administered each factor Xa (FXa) inhibitors (apixaban, edoxaban, and rivaroxaban) has not fully been assessed. Purpose: To clarify the distribution of AXA, PT, and APTT in patients taking FXa inhibitors. Methods: Trough and peak AXA values, PT, and APTT were measured in 85 patients taking apixaban, 105 patients taking edoxaban, and 27 patients taking rivaroxaban. The patients were further divided into three groups based on the dosage. Results: At trough time of apixaban, the AXA values in patients administered 20 mg were significantly higher than those administered 5 mg or 10 mg (P &lt; 0.001). PT in patients administered 20 mg were significantly higher than those administered 5 mg or 10 mg (P = 0.006). At peak time, the AXA values in patients administered 20 mg were significantly higher than those administered 5 mg or 10 mg (P &lt; 0.001). PT in patients administered 20 mg was significantly higher than those administered 5 mg or 10 mg (P &lt; 0.001). APTT in patients administered 20 mg was significantly higher than those administered 5 mg or 10 mg (P &lt; 0.001). At peak time of edoxaban, the AXA values in patients administered 60 mg were significantly higher than those administered 15 mg or 30 mg (P &lt; 0.001). PT in patients administered 60 mg were significantly higher than those administered 15 mg or 30 mg (P = 0.006). APTT in patients administered 60 mg was significantly higher than those administered 30 mg (P = 0.003). At trough time of rivaroxaban, the AXA values in patients administered 30 mg were significantly higher than those administered 10 mg or 15 mg (P = 0.001). At peak time, AXA values in patients administered 30 mg were significantly higher than those administered 15 mg (P = 0.028). Conclusion: This study determined the distribution of AXA, PT, and APTT in patients administered apixaban, edoxaban, and rivaroxaban.

Citrate which chelates ionized calcium can be used as regional anticoagulation in continuous venovenous hemofiltration (CVVH). This is the first study conducted to examine the potentially additive benefit effect of regional citrate anticoagulation (RCA) on polymorphonuclear (PMN) cell degranulation of myeloperoxidase (MPO) and cytokines production in patients with critically acute kidney injury (AKI) undergoing CVVH treatment. This prospective randomized controlled trial was conducted in 20 critically ill patients with AKI who underwent CVVH. The patients were randomized into regional citrate group (n=10) and heparin group (n=10). The pre-dilution CVVH with polyethersulfone dialyzers were utilized in both groups. The levels of pre-filter and post-filter MPO as well as inflammatory and anti-inflammatory cytokines were measured at baseline, 6h, and 24 h after initiating CVVH. In the heparin group, the post-filter serum MPO levels were significantly higher than the pre-filter (median 49.0 vs. 60.5 ng/mL, P<0.05) at 6 h. There were no significant differences between pre- and post-dialyzer MPO levels in the citrate group. Citrate could significantly decrease systemic pre-filter serum MPO levels from baseline at 6 h (median 43.5 vs. 17.3 ng/mL, P<0.01) as well as IL-8 levels (P<0.05) whereas heparin provided only significant TNF-α reduction (P<0.05). The CVVH circuit survival in the citrate group was longer than the heparin group. In conclusion, citrate, utilized as a regional anticoagulant in CVVH, can reduce both membrane bioincompatibility-induced and systemic oxidative stress and inflammation, and can prolong CVVH circuit survival time.

To determine whether regional anticoagulation of continuous renal replacement therapy circuits using citrate and calcium prolongs circuit life and/or affects circulating cytokine levels compared with regional anticoagulation using heparin and protamine. Multicenter, parallel group randomized controlled trial. Seven ICUs in Australia and New Zealand. Critically ill adults requiring continuous renal replacement therapy. Patients were randomized to receive one of two methods of regional circuit anticoagulation: citrate and calcium or heparin and protamine. The primary outcome was functional circuit life measured in hours, assessed using repeated events survival analysis. In addition, we measured changes in interleukin-6, interleukin-8, and interleukin-10 blood levels. We randomized 212 subjects who were treated with 857 continuous renal replacement therapy circuits (median 2 circuits per patient [interquartile range, 1-6], 390 in citrate group vs 467 in heparin group). The groups were well matched for baseline characteristics. Patients receiving regional continuous renal replacement therapy anticoagulation with heparin and protamine were more likely to experience circuit clotting than those receiving citrate and calcium (hazard ratio, 2.03 [1.36-3.03]; p < 0.0005; 857 circuits). The median lifespan of the first study circuit in each patient was 39.2 hours (95% CI, 32.1-48.0 hr) in the citrate and calcium group versus 22.8 hours (95% CI, 13.3-34.0 hr) in the heparin and protamine group (log rank p = 0.0037, 204 circuits). Circuit anticoagulation with citrate and calcium had similar effects on cytokine levels compared with heparin and protamine anticoagulation. There were more adverse events in the group assigned to heparin and protamine anticoagulation (11 vs 2; p = 0.011). Regional citrate and calcium anticoagulation prolongs continuous renal replacement therapy circuit life compared with regional heparin and protamine anticoagulation, does not affect cytokine levels, and is associated with fewer adverse events.

Patients with severe hypernatremia who receive conventional treatment are often undertreated. Data on the management of acute hypernatremia using continuous venovenous hemofiltration (CVVH) are limited to anecdotes. This study aimed to evaluate the efficacy and safety of CVVH treatment for acute severe hypernatremia in critically ill patients in a retrospective cohort. A total of 95 patients who were admitted to our ICU between January 2009 and January 2014 were analyzed as the original cohort. These patients were divided into CVVH and conventional treatment groups. The patients in the conventional and CVVH groups were then matched by age, reason for ICU admission, vasopressor dependency, basic serum sodium concentration, and Glasgow scores. A Cox regression model was used to adjust the confounding variables. In the original cohort, the 28-day survival rates were 41.9% and 25.0% for the CVVH and conventional treatment groups, respectively. Conventional treatment (HR = 2.1, 95% CI 1.1-3.8, P = 0.019) was an independent predictor of patient mortality in the multivariate Cox regression model. In the matched cohort, the two groups were not significantly different in baseline characteristics. The CVVH group had a significantly greater reduction in the serum sodium concentration (0.78 [0.63-1.0] mmol/L/h versus 0.13 [0.009-0.33] mmol/L/h), P < 0.001) and an improved 28-day survival rate (34.8% vs. 8.7%, P = 0.002) compared with the conventional treatment group. The two groups did not differ significantly in treatment-related complications. CVVH treatment is possibly more effective than conventional treatment for the management of acute severe hypernatremia in critically ill patients.

Objective To analyze the clinical value of continuous veno-venous hemofiltration (CVVH) treatment in children with severe hand-foot-and-mouth disease (HFMD) complicated with cardio-pulmonary failure, via the prognostic comparison of the general comprehensive treatment and CVVH add-on treatment. Methods Fifty-one cases of severe HFMD with cardiopulmonary failure were divided into a CVVH group (n=19) and a control group (n=32) based on whether CVVH add-on or not. Their physiological and biochemical indicators were recorded and pediatric critical illness score (PCIS) and pediatric risk of mortality score (PRISM III) were calculated within 24 hours, when they were diagnosed with neurogenic pulmonary edema (NPE) /pulmonary hemorrhage. Both groups were treated with endotracheal intubation, mechanical ventilation with high PEEP, corticosteroids, ulinastatin, actively lowering the intracranial pressure, fluid resuscitation, milrinone, dopamine and other vasoactive drugs, high-dose intravenous gamma globulin, the CVVH group were added with CVVH treatment (duration>12 h). Prognosis difference of CVVH add-on treatment after diagnosed with NPE/pulmonary hemorrhage by tracking indicators of the third day. Survival analysis between two groups were compared by 3-day survival rates, 7-day survival rates, 28-day survival rates and the finally survival rates. Results (1) The overall conditions of two groups were comparable when diagnosed with NPE/pulmonary hemorrhage. PCIS, PRISM III, WBC counting, lactic acid, micro-blood sugar, myocardial enzymes and liver enzymes showed no significant difference between two groups. Three days after treatment, WBC and lactic acid decreased, but there was no significant difference (P>0.05), the remaining indicators had significantly improved in the CVVH group than those in the control group (P<0.05). (2) The 3-day survival rate, 7-day survival rate, 28-day survival rate and the finally survival rates in control group and CVVH group were 40.63 % vs.84.21%, 37.50% vs.73.68%, 25.00% vs.63.16%, 18.75% vs.52.63%, the survival rate in CVVH group were significantly higher (P<0.05). (3) The survival curve indicated that the survival time of CVVH group was significantly longer than that of the control group, the median survival time were 17 d and 2 d, respectively, and the difference was statistically significant (P<0.05). (4) In the CVVH group, 15 cases received CVVH after diagnosed with NPE/pulmonary hemorrhage within 12 hours, of which 10 cases (66.67%) ultimately survived, while the other 4 cases received CVVH after 12 h were all end to death, the difference was statistically significant (P<0.05). Further analysis of the impact of the timing of blood purification on the prognosis of children showed that the mortality rates of children received CVVH within 6 hours, 6 to 12 hours, after 12 hours of diagnosis of NPE/pulmonary hemorrhage, were 2/8, 3/7, 4/4, respectively. Conclusion Continuous hemofiltration can significantly improve the prognosis of children with severe HFMD, and may be preferable to perform in early stage. Key words: Continuous hemofiltration; Severe hand-foot-mouth disease; Cardiopulmonary failure; Children

Paraquat (PQ) poisoning is a widespread occurrence, especially in underdeveloped areas. The treatment of PQ poisoning has always been difficult, and there is currently no definite effective treatment. Continuous venovenous hemofiltration (CVVH) treatment for PQ poisoning has been widely used in clinical practice; however, its effect remains uncertain. Accordingly, the purpose of this meta-analysis was to evaluate the efficacy of CVVH in the treatment of PQ poisoning. We searched for relevant trials using PubMed, Embase, the Cochrane Library, and 3 Chinese databases, the Chinese BioMedical Literature Database, National Knowledge Infrastructure Database, and Wanfang Database. We included all qualified randomized controlled trials (RCTs) of CVVH treatment for patients with PQ poisoning. The primary outcome was mortality, while the secondary outcomes included the survival time and constituent ratios of death due to respiratory failure and circulatory failure. Three RCTs involving 290 patients were included. The mortality rates of the intervention and control groups were 57.9% and 61.0%, respectively. Pooled analysis demonstrated no significant difference in mortality between the CVVH treatment and control groups (risk ratio [RR] 0.94, 95% confidence interval [CI]: 0.78-1.15, P = .56), with a low level of heterogeneity (X = 1.75, I = 0%). However, the CVVH group was associated with a longer survival time compared to the control group (weighted mean difference 1.73, 95% CI: 0.56-2.90, P = .004). Respiratory failure as the cause of death was more common in the CVVH group, as compared with the control group (RR 1.66, 95% CI: 1.24-2.23, P = .0008), whereas patients in the control group were more likely to die from circulatory failure than in the CVVH group (RR 0.56, 95% CI: 0.40-0.81, P = .002). Although CVVH treatment might not noticeably reduce mortality for patients with PQ poisoning, it can prolong the survival time of the patients and improve the stability of the circulatory system, thereby enabling further treatment.

Background Although patients taking direct oral anticoagulants (DOACs) do not require routine coagulation monitoring, the distribution of anti-factor Xa activity (AXA) values, prothrombin time (PT), PT-international normalized ratio (INR) and activated partial thromboplastin time (APTT) in patients on apixaban, edoxaban and rivaroxaban therapy is still not clear. Purpose The aim is to set the standard values of AXA values, PT, PT-INR and APTT in patients using DOACs. Methods We measured AXA, using chromogenic assay with the HemosIL Liquid Heparin kit, PT, PT-INR and APTT at trough and peak times in 224 patients with non-valvular atrial fibrillation and venous thromboembolism, of whom 90 received apixaban, 100 received edoxaban and 34 received rivaroxaban. The peak time was defined as 3 hours after the intake of apixaban or rivaroxaban, and 2 hours after the intake of edoxaban. The trough time was defined as that immediately before the intake. The AXA values, PT, PT-INR and APTT were measured at least 72 hours after the start of treatment. The dosage of DOACs is defined according to the prescribing information in Japan. Results (The order of results below is apixaban, edoxaban and rivaroxaban, respectively.) The average AXA values were 2.29, 0.23 and 0.39 (IU/mL) at trough time, and 3.04, 1.01 and 1.70 (IU/mL) at peak time. The average PT values were 17.9, 12.9 and 13.1 (s) at trough time, and 19.7, 15.5 and 17.5 (s) at peak time. The average PT-INR values were 1.49, 1.07 and 1.08 at trough time, and 1.65, 1.29 and 1.45 at peak time. The average APPT values were 34.5, 31.3 and 32.0 (s) at trough time, and 39.5, 35.9 and 39.8 (s) at peak time. Conclusion Our findings reveal the standard values of AXA, PT, PT-INR and APTT in patients using apixaban, edoxaban and rivaroxaban in each dosage. The DOACs should be changed if the measured value is out of those standard values in 90% confidence interval. Funding Acknowledgement Type of funding source: None

Anticoagulation is used to prevent filter clotting in patients undergoing continuous renal replacement therapy. Regional citrate anticoagulation is associated with lower rates of bleeding complications and prolongs the filter life span; however, a number of metabolic side effects had been associated with this therapy. The aim of this study was to evaluate the effect and safety of citrate versus heparin anticoagulation for continuous renal replacement therapy in critically ill children. A retrospective comparative cohort study. Department of Pediatric Intensive Care, Acibadem Mehmet Ali Aydınlar University School of Medicine. From August 2016 to August 2018, 45 patients (19 in the citrate group and 26 in the heparin group) were included. A total of 101 hemofilters were used in all therapies: 44 in the citrate group (total continuous renal replacement therapy time: 2699 h) and 57 in the heparin group (total continuous renal replacement therapy time: 2383 h). The median circuit lifetime was significantly longer for regional citrate anticoagulation (53.0; interquartile range, 40-70 h) than for heparin anticoagulation (40.25; interquartile range, 22.75-53.5 h; p = 0.025). Mortality rates were similar in both groups (31.58% vs 30.77%). The most common indication for dialysis was hypervolemia in both groups. Transfusion rates were 1.65 units (interquartile range, 0.5-2.38) with heparin and 0.8 units (interquartile range, 0.3-2.0) with citrate (p = 0.32). Clotting-related hemofilter failure occurred in 11.36% of filters in the citrate group compared with 26.31% of filters in the heparin group. Our study showed that citrate is superior in terms of safety and efficacy, with longer filter life span. Regional citrate should be considered as a better anticoagulation method than heparin for continuous renal replacement therapy in critically ill children.

Regional citrate anticoagulation has advantages over systemic heparin in prolonging filter life and decreasing bleeding risk during continuous renal replacement therapy (CRRT). However, implementing regional citrate anticoagulation in resource-limited intensive care units (ICU) remains challenging due to potential adverse events and the absence of standardized protocols. This study aims to evaluate the efficacy and safety of regional citrate anticoagulation in CRRT for critically ill patients in low-resource settings. This single-center, prospective cohort study enrolled critically ill patients with acute kidney injury (AKI) requiring CRRT at a resource-limited ICU in Vietnam. Patients received either regional citrate anticoagulation or heparin anticoagulation. Primary outcomes included filter lifespan and adverse events; secondary outcomes were renal recovery and in-hospital mortality rate. One hundred twenty-one patients were enrolled, 42 in the citrate group and 79 in the heparin group. The citrate group had a significantly longer filter lifespan (median 56h versus 31h; p < 0.001) and a lower rate of premature (< 24h) filter clotting (4.8% versus 27.2%, p < 0.001). The hemorrhage rate was 6.4% in the citrate group versus 12.9% in the heparin group (p = 0.162). However, hypomagnesemia occurred more frequently in the citrate group (58.7% versus 23.1%, p < 0.001). No significant differences in renal recovery or hospital mortality were observed between groups. Regional citrate anticoagulation effectively maintained filter patency and proved to be safe for CRRT in a resource-limited ICU. Further studies are needed to establish standardized protocols for regional citrate anticoagulation in this setting to minimize citrate-related adverse events.

Objective To evaluate the effect of heparin and argatroban on the coagulating function and the vascular thrombosis in the early period after pediatric living related liver transplantation (LRLT). Method Eighty-four congenital biliary atresia pediatric patients who had performed LRLT were involved in this study. According to the method of anticoagulation, the patients were divided into two groups (heparin group and argatroban group). Antithrombin Ⅲ (AT-Ⅲ) activity, activated partial thromboplastin time (APTT) and international normalized ratio (INR) of two groups were measured in the first 5 days after LRLT. In order to determine whether vascular thrombosis existed, Doppler ultrasound was performed daily. Result There were no significant differences in gender, age, body weight, graft-recipient weight ratio and whether to accept Kassi procedure between two groups. The AT-Ⅲ activity of two groups was low and increased gradually after operation. There was no significant difference between two groups. There were no significant differences in APTT and INR between two groups immediate and at first day after operation. After anticoagulation, the differences in APTT and INR between two groups were significant. The incidence of vascular thrombosis was 4.76% (3/63) and 0(0/21) respectively in heparin and argatroban groups. There was no significant difference between two groups. During treatment, there were no severe complications in two groups, such as active hemorrhage and allergy. Conclusion Argatroban is a direct anticoagulant. It is independent on the level of AT-Ⅲ activity. It may play an important role for preventing vascular thrombosis after pediatric LRLT. Key words: Pediatric; Liver transplantation; Thrombus complication; Argatroban