Regional citrate anticoagulation versus no-anticoagulation for continuous venovenous hemofiltration in patients with liver failure and increased bleeding risk: A retrospective case-control study.

Yan Yu,Lu Li,Meilan Zhou,Lijuan Zhao,Li Li,Yangping Li,Wei Zhang,Ming Bai,Feng Ma,Shiren Sun,Chiara Lazzeri

doi:10.1371/journal.pone.0232516

Abstract

ObjectiveThere are controversial opinions on anticoagulation for continuous venovenous hemofiltration (CVVH) in patients with liver failure (LF) and increased bleeding risk. Therefore, we conducted a retrospective study to evaluate the efficacy and safety of regional citrate anticoagulation (RCA) versus no-anticoagulation for CVVH in these patients.MethodsThe included patients were divided into RCA and no-anticoagulation group according to the CVVH anticoagulation strategy they accepted for CVVH. Filter lifespan, bleeding, citrate accumulation, catheter occlusion, and totCa/ionCa ratio were evaluated as outcomes.ResultsIn the original cohort, the filter lifespan of the RCA group (41 patients, 79 filters) was significantly longer than the no-anticoagulation group (62 patients, 162 filters) (> 72 hours vs 39.5 hours (IQR 31.2–47.8), P = 0.002). The adjusted results demonstrated that RCA could significantly reduce the risk of filter failure (HR = 0.459, 95%CI 0.26–0.82, P = 0.008). Four episodes of totCa/ionCa > 2.5 were observed in the RCA group and continuously accepted RCA-CVVH after the reduction of citrate dose and blood flow. No obvious citrate accumulation was observed in these patients. In the matched cohort, the filter lifespan of the RCA group was significantly longer than the no-anticoagulation group (P = 0.013) as well. No significant difference in the episodes of totCa/ionCa > 2.5 was observed between the two matched groups (P = 0.074). Both in the original cohort and the matched cohort, the bleeding, acidosis, alkalosis, and catheter occlusion incidences were not significantly different between the two groups.ConclusionsIn LF patients with increased bleeding risk who underwent CVVH, RCA could prolong the filter lifespan and be safely used with careful blood gas monitoring and citrate dose adjusting. Further prospective, randomized, control studies are warranted to obtain robust evidences.

Highlights

Continuous venovenous hemofiltration (CVVH) is commonly used in critically ill patients for the management of acute kidney injury (AKI), severe metabolic disorder, and refractory fluid overload
Our previous meta-analysis demonstrated that regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) could prolong the filter lifespan and decrease the bleeding risk, compared with heparin anticoagulation [5]
In clinical practice, we observed that parts of liver failure (LF) patients underwent CVVH with no-anticoagulation would result in relatively shorter filter lifespan

Summary

Introduction

Continuous venovenous hemofiltration (CVVH) is commonly used in critically ill patients for the management of acute kidney injury (AKI), severe metabolic disorder, and refractory fluid overload. AKI were observed in 40–85% of acute liver failure (LF) [1], 24% of liver cirrhosis [2], and 10–30% of liver transplantation patients [3, 4]. In clinical practice, we observed that parts of LF patients underwent CVVH with no-anticoagulation would result in relatively shorter filter lifespan. We found out that all of the current evidences were limited in observational cohort study and none of the included studies evaluated the safety and efficacy of RCA versus no-anticoagulation (strategy recommended by the KDIGO guideline) in LF patients with increased bleeding risk [16]

Methods

Results

Conclusion