Abstract
BackgroundFlexitrate, an innovative regional citrate anticoagulation (RCA) protocol, was compared to traditional RCA (tRCA) and Heparin anticoagulation protocols in intensive care patients treated with continuous renal replacement therapy (CRRT).MethodsA single-center, retrospective, cohort study, was done in a 26-bed intensive care unit in a large community hospital. Eighty dialysis sessions (Flexitrate = 2852 h, tRCA = 3580 h and Heparin = 2026 h), performed in 53 patients, were evaluated for filter life, RCA control, and metabolic control.ResultsIn the Flexitrate cohort, 3.8% of filters clotted, compared to 16.9% with tRCA and 28.3% with Heparin (p < 0.001 for Flexitrate compared to either tRCA or Heparin). Filter survival was significantly improved with Flexitrate compared to tRCA (HR 0.24, p = 0.018) or Heparin (HR 0.14, p = 0.004).Anticoagulation control was superior with Flexitrate with Patient Ionized Calcium out of target a median of 16% of the time, compared to 27% for tRCA (p < 0.001). Filter Ionized Calcium was out of target a median of 6.8% of the time, compared to 23% for tRCA (p = 0.03).Flexitrate produced significantly less alkalosis, hypernatremia, and hypocalcemia than tRCA, and overall metabolic control was comparable to Heparin anticoagulation. The only adverse metabolic outcome with Flexitrate was increased hypomagnesemia.ConclusionsThe Flexitrate protocol extended filter life, delivered more consistent anticoagulation, and provided superior metabolic control compared to a tRCA protocol. Filter life was superior to Heparin anticoagulation, with similar metabolic control. A randomized control trial comparing these protocols is recommended.
Highlights
Flexitrate, an innovative regional citrate anticoagulation (RCA) protocol, was compared to traditional RCA and Heparin anticoagulation protocols in intensive care patients treated with continuous renal replacement therapy (CRRT)
This paper describes a retrospective analysis of consecutive treatments from the Flexitrate pilot period compared to historical treatments provided to consecutive CRRT recipients who received either traditional RCA or Heparin in the nine months preceding the pilot
For the Flexitrate protocol, only 3.8% of filters clotted, compared to 16.9% in the traditional RCA (tRCA) protocol and 28.3% in the Heparin protocol (p < 0.001 for Flexitrate compared to either tRCA or Heparin; No significant difference between tRCA and Heparin)
Summary
Flexitrate, an innovative regional citrate anticoagulation (RCA) protocol, was compared to traditional RCA (tRCA) and Heparin anticoagulation protocols in intensive care patients treated with continuous renal replacement therapy (CRRT). Continuous renal replacement therapy (CRRT) is widely used in intensive care settings for the treatment of acute kidney injury in critically ill patients [1]. CRRT is optimally performed with continuous anticoagulation to allow for adequate and uninterrupted treatments. Anticoagulation is generally provided using either a continuous heparin infusion or a regional citrate anticoagulation protocol (RCA) [2]. The use of RCA has been shown to have potential benefits over heparin anticoagulation in both reduced bleeding risk and extended filter life [3]. The use of high concentration citrate solutions (2–4%) in most protocols leads to metabolic complications [5–7]
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