Circuit Coagulation Research Articles

Development and validation of a nomogram for circuit lifespan of regional citrate anticoagulation-continuous renal replacement therapy in intensive care patients with acute kidney injury.

Regional citrate anticoagulation-continuous renal replacement therapy (RCA-CRRT) has a wide range of applications in clinical practice, but unplanned downtime due to RCA-CRRT circuit coagulation is as high as 15.75%-66.70%. To build a nomogram model for predicting the lifespan circuits of RCA-CRRT. A prospective observational cohort study was conducted in Sichuan, China. The collected clinical data from 404 RCA-CRRT sessions involving 135 patients were utilized. The patients' basic information, laboratory indicators and RCA-CRRT parameters were used as independent variables, and the survival status and survival time of RCA-CRRT circuits were used as dependent variables. A Cox multivariate analysis was performed to build the nomogram model for predicting the lifespan of RCA-CRRT circuits. The model was validated internally and externally. The median lifespan of RCA-CRRT circuits was 28.0 (12.0-46.5) h, and the unplanned downtime rate was 23.76%. In the Cox multivariate analysis, venous pressure, haemoglobin, Sequential Organ Failure Assessment (SOFA), lactate, and blood transfusion were identified as statistically significant predictive factors for the lifespan of RCA-CRRT circuits (p < .05). Subsequently, a nomogram model for predicting the lifespan of RCA-CRRT circuits was developed. The AUC values for internal and external validation within the 12-72-h timeframe ranged from 0.648 to 0.816 and 0.613 to 0.956, respectively. Both the calibration curve and clinical decision curve demonstrated the model's good performance. The nomogram model developed in this study demonstrates its efficacy in accurately predicting the lifespan circuits of RCA-CRRT. Clinical nurses can use the prediction model to assess the lifespan of RCA-CRRT circuits, so as to formulate a personalized RCA-CRRT treatment plan for patients, thus reducing the unplanned downtime of RCA-CRRT.

Coagulation Risk Predicting in Anticoagulant-Free Continuous Renal Replacement Therapy.

Continuous renal replacement therapy (CRRT) is a prolonged continuous extracorporeal blood purification therapy to replace impaired renal function. Typically, CRRT therapy requires routine anticoagulation, but for patients at risk of bleeding and with contraindications to sodium citrate, anticoagulant-free dialysis therapy is necessary. However, this approach increases the risk of CRRT circuit coagulation, leading to treatment interruption and increased resource consumption. In this study, we utilized artificial intelligence machine learning methods to predict the risk of CRRT circuit coagulation based on pre-CRRT treatment metrics. We retrospectively analyzed 212 patients who underwent anticoagulant-free CRRT from October 2022 to October 2023. Patients were categorized into high-risk and low-risk groups based on CRRT circuit coagulation within 24 h. We employed eight machine learning methods to predict the risk of circuit coagulation. The performance of the model was evaluated using the area under the curve (AUC) of the receiver operating characteristic. 5-fold cross-validation was used to validate the machine learning models. Feature importance and SHAP plots were used to interpret the model's performance and key drivers. We identified 88 patients (41.51%) at high risk of circuit coagulation within 24 h of CRRT. Our machine learning models showed excellent predictive performance, with ensemble learning achieving an AUC of 0.863 (95% CI: 0.860-0.868), outperforming individual algorithms. Random forest was the best single-algorithm model, with an AUC of 0.819 (95% CI: 0.814-0.823). The top three features identified as most important by the SHAP summary plot and feature importance graph are platelet, filtration fraction (FF), and triglycerides. We created a model using machine learning to predict the risk of circuit coagulation during anticoagulant-free CRRT therapy. Our model performs well (AUC 0.863) and identifies key factors like platelets, FF, and triglycerides. This facilitates the development of personalized treatment strategies by clinicians aimed at reducing circuit coagulation risk, thereby enhancing patient outcomes and reducing healthcare expenses.

Experience with Tandem Pre-Dilution Online Hemodiafiltration and Centrifugal Plasma Exchange in Pretransplant Desensitization for Abo-Incompatible Kidney Transplantation: A Case Report

In the use of therapeutic plasma exchange (TPE) as antibody removal therapy for ABO-incompatible (ABOi) kidney transplantation, it is technically possible to perform online hemodiafiltration (OHDF) and TPE simultaneously for patients who are receiving OHDF. In this study, we report tandem therapy of pre-dilution OHDF and centrifugal plasma exchange (cTPE), instead of membrane plasma exchange, which is the mainstay of TPE in Japan. A total of 14 sessions of tandem cTPE and pre-dilution OHDF were performed as preoperative antibody removal therapy for 6 ABOi kidney transplant recipients. cTPE intra-circuit pressure, decreased antibody titer, and adverse events were evaluated. The study was carried out following the ethical standards of the Declaration of Helsinki and Istanbul. Donors were not prisoners or individuals who were coerced or paid. The tandem therapy was completed safely in 12 of the 14 sessions, with no problems such as pressure upper and lower limit alarms or circuit coagulation. In 2 sessions, the tandem therapy had to be interrupted due to coagulation on the dialysis circuit side. Antibody titers were reduced by a median of 3-fold for both IgG and IgM. There was no acute antibody-associated rejection. In preoperative apheresis therapy for ABOi kidney transplantation, tandem therapy of pre-dilution OHDF and cTPE may be a useful treatment option that can be performed safely and results in sufficient reduction of antibody levels.

Differences in chamber structure contribute to the incidence of venous air trap chamber coagulation during AN69ST-CHF: clinical and in vitro evaluation

BackgroundDuring continuous kidney replacement therapy (CKRT) in patients with sepsis and critical conditions, circuit coagulation can occur, often for unclear reasons. In this study, we investigate how the structure of the venous air trap chamber may contribute to venous air trap chamber coagulation. Clinical data were evaluated and experiments were performed.MethodsThe clinical evaluation involved patients who underwent continuous hemofiltration (CHF) using an acrylonitrile-co-methallyl sulfonate surface-treated (AN69ST) hemofilter (AN69ST-CHF) and either an ACH-Σ or Prismaflex CKRT machine in our ICU from April to July 2019. The patient data were divided into two groups based on CKRT machine and the percentage of CHF procedures that could continuously be performed for 22 h (CHF target achievement rate), and coagulation sites were evaluated. Statistical analysis was performed by the Mann–Whitney U test and Pearson’s chi-square test. For in vitro experiments, a system was constructed to circulate a 33% glycerol solution at a flow rate of 150 ml/min. In a venous air trap chamber, fluid dye disappearance times and fluid movements were visually evaluated.ResultsThe clinical evaluation included 22 procedures (8 patients) in the ACH-Σ group and 22 procedures (11 patients) in the Prismaflex group, without significant differences in patient backgrounds between the groups. The CHF target achievement rate was 72.7% (16/22) in the ACH-Σ group and 77.3% (17/22) in the Prismaflex group, revealing no significant difference (p = 0.73). However, significantly fewer venous air trap chamber coagulations were observed in the Prismaflex group (1/5) than in the ACH-Σ group (5/6) (p < 0.01). In vitro evaluation found that the dye disappearance time was significantly shorter when using the Prismaflex device (17.5 s ± 0.7 s) than the ACH-Σ device (51.2 s ± 0.7 s; p < 0.05). Visual evaluation revealed that in the ACH-Σ venous air trap chamber the upper layer of the accumulated fluid was quite stagnant, whereas fluid flowed with uniform agitation through the Prismaflex venous air trap chamber. Hence, differences were observed in fluid flow and retention in the vein air trap chambers, depending on the chamber structure.ConclusionChamber structure may contribute to the occurrence of venous air trap chamber coagulation during CKRT.

Evaluation of anticoagulant effect and predicted dose of low molecular weight heparin in hemodialysis by anti-Ⅹa factor activity

The purpose of this study was to explore the reasonable dose of low molecular weight heparin (LMWH) in hemodialysis (HD) and the strategy of preventing extracorporeal circuit coagulation (ECC). A retrospective case-control study included patients who used LMWH for anticoagulation during maintenance hemodialysis (MHD) in the Hemodialysis Center of Beijing Hospital from December 2020 to January 2021. Basic data such as weight, height, basic kidney disease, dialysis age and anti-Ⅹa factor activity before, during and after dialysis were collected. A total of 46 patients were enrolled in this study, including 5 patients in coagulation group (10.9%) and 41 patients in non-coagulation group (89.1%). The anti-Ⅹa factor activity reached its peak at 0.5 h after the start of HD. The level of anti-Ⅹa factor was incorporated into the receiver operating characteristic curve (ROC curve). The results showed that the area under the ROC curve (AUC) was 0.802 (95% confidence interval: 0.651-0.54, P=0.029), and the cutoff was 0.31 IU/ml (sensitivity 1, specificity 0.683). It is suggested that the body surface area should be used as the basis to estimate the anticoagulant dose of LMWH in HD, and the activity of HD 4 h anti-Ⅹa factor ≤0.31 IU/ml, which is of diagnostic value for ECC. In addition, the results of binary logistic regression analysis showed that dialysis age was an independent risk factor for ECC (OR value 1.319, 95%CI 1.052-1.654, P=0.017). In summary, this study reveals that dialysis age may be a risk factor for ECC and that the activity of HD 4 h anti-Ⅹa factor ≤0.31 IU/ml can be used as a potential diagnostic cut-off point for ECC in HD patients, which provides a scientific basis for monitoring strategies to prevent blood coagulation in HD filters.

Correlation between bradykinin concentration and blood pressure during Rheocarna therapy: A single-center case series.

A novel LDL (low-density lipoprotein) apheresis therapeutic option, Rheocarna, has garnered attention as an alternative therapy for chronic limb-threating ischemia (CLTI). Bradykinin-mediated vasodilation is involved in the effects of LDL apheresis and a decrease in blood pressure (BP), but the changes in bradykinin concentration during Rheocarna therapy are unknown. The study involved patients with CLTI treated with Rheocarna at our hospital, from April 2022 to August 2023. After Rheocarna therapy, skin ulcers improved in 80% of the patients. Circuit coagulation was observed in two patients with high fibrinogen levels. A decrease in BP was observed at approximately the same time when the bradykinin concentration peaked. The peak bradykinin concentration in a patient undergoing hemodialysis at the same time was considerably lower than that in the other patients. This is the first report on the changes in bradykinin concentration under Rheocarna therapy.

Change in prefilter pressure as a key determinant in the decision to return blood in continuous renal replacement therapy: An observational study.

During continuous renal replacement therapy (CRRT), circuit coagulation is an important event that can result in suboptimal outcomes. Nurses must remain alert throughout the treatment and observe machine pressures. Transmembrane pressure (TMP) is commonly used for monitoring but it is sometimes too late to return blood to the patient. To compare the capacity of prefilter pressure (FP) versus TMP to predict the risk of circuit coagulation in adult patients with acute renal failure on CRRT. An observational, longitudinal, prospective study. This study was carried out in a tertiary referral hospital over 2 years. Data collected included the following variables: TMP, filter or FP, effluent pressure, venous and arterial pressure, filtration fraction, and ultrafiltration constant of each circuit. Means and their trends over time were collected, for both diffusive and convective therapy and for two membrane types. A total of 151 circuits (24 polysulfone and 127 acrylonitrile) were analysed, from 71 patients (n = 22 [34%] women; mean age, 66.5 [36-84] years). Of the total treatments, 80 were diffusive, and the rest were convective or mixed. In the diffusive circuits, a progressive rise in FP was observed without an increase in TMP and with an increasing trend in effluent pressure. Circuit lifespan was between 2 and 90 h. In 11% (n = 17) of the cases, the blood could not be returned to the patient. These findings allowed the creation of graphs that indicate the appropriate point to return blood to the patient. FP was a major determinant in this decision; in most cases, TMP was not a reliable parameter. Our findings are applicable to convective, diffusive, and mixed treatments as well as both types of membranes used in this acute setting. This study provides two clear reference graphs showing risk scales for the assessment of circuit pressures in CRRT. The graphs proposed here can be used to evaluate any machine on the market and the two types of membranes used in this acute setting. Both convective and diffusive circuits can be assessed, allowing safer evaluation in patients who change treatment.

POS-645 Investigation on blood removal failure by direct puncture of the internal jugular vein and femoral vein during blood purification therapy

Direct puncture of the internal jugular vein or the femoral vein is done as vascular access (VA) during the acute phase of blood purification therapy or when problems occur such as VA obstruction. Blood removal failure by direct puncture is often experienced clinically, and it is known to cause circuit coagulation and decrease dialysis efficiency. In this study, we examined whether there is a difference in the frequency of blood removal failure between the internal jugular vein and femoral vein.

Non-pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy.

Non-pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy.

MO395EPIDEMIOLOGY AND OUTCOME OF PATIENTS WITH ACUTE KIDNEY INJURY REQUIRING DIALYSIS: ABOUT 230 CASES

Abstract Background and Aims Acute renal injury (ARI) is a frequent pathology. Rarer are the studies dedicated specifically to the subgroup requiring dialysis. The objective of our study is to identify: The epidemiological profiles of patients with ARI requiring dialysis. The course of the dialysis sessions to determine the dialysis’ prescription and the different accidents. Method This is a descriptive cross-sectional study including patients admitted to the different departments of Sousse University Hospitals in Tunisia who presented an ARI requiring emergency dialysis. Our study was conducted from February 2015 until August 2018. The data collected were analysed by the SPSS software. Results During three and a half years, 230 patients presented ARI requiring dialysis. The average age was 60 ± 16 years old. The sex ratio was 1.61. A history of hypertension, diabetes, heart disease, dyslipidaemia, hyperuricemia, uropathy and neoplasia was noted in respectively 34.9%, 27.1%, 21.6%, 22.7%, 25.5%, 22.7% and 14.3% cases. The causes of ARI were dominated by organic, obstructive and functional causes in 66.2%, 21.7% and 7.4% of cases, respectively. For organic causes, we noted acute tubular necrosis in 70.4% of cases, a glomerular cause in 14.5% of cases, an interstitial cause in 7.9% of cases and a vascular cause in 7.2% of cases. Dialysis indications were dominated by severe acidosis, pulmonary oedema, uremic syndrome and hyperkalaemia in 27.4%, 24.3%, 16.5% and 14.3% of cases, respectively. Among our patients, 26.7% presented a hemodynamic instability with catecholamine use in 16.8% of cases and the use of isovolumic connection at the beginning of the session in 21.2% of cases. The median ultrafiltration was 444 ml / hour IQR [166, 67-750] with extremes of 0 to 1333 ml/hour. The median blood flow was 250 ml/min IQR [250-280] with extremes of 180 to 300 ml/min. The median duration of dialysis’ session was 180 minutes IQR [180,240] with extremes of 15 to 360 minutes. We noted dialysis incidents in 12% of dialysis’ sessions. These events were dominated by hypotension, hypoglycaemia, extracorporeal circuit coagulation, death and chest pain in 13.8%, 4.8%, 2.6%, 2.1% and 0.7% of cases, respectively. The cessation of dialysis sessions was noted in 22 sessions (11.1%). Concerning the evolution of patients: 33.1% of patients recovered normal renal function, 23.9% of patients maintained renal failure, 22.2% of patients died and 20.8% of patients were lost from seen or the duration of their follow-up was less than three months not making it possible to conclude as to the chronicity of the renal insufficiency. Conclusion ARI is a common and serious pathology. Dialysis is an important evolutionary step. It is associated with a high risk of progression to chronic renal failure and mortality. Optimal management of ARI is required.

Direct hemoperfusion using a polymyxin B-immobilized polystyrene column for COVID-19.

ObjectiveTo evaluate the efficacy and safety of direct hemoperfusion using a polymyxin B‐immobilized polystyrene column (PMX‐DHP) in severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2)‐positive pneumonia patients.MethodsThis study was a case series conducted at a designated infectious diseases hospital. Twelve SARS‐CoV‐2‐positive patients with partial pressure of arterial oxygen/percentage of inspired oxygen (P/F) ratio < 300 were treated with PMX‐DHP on two consecutive days each during hospitalization. We defined day 1 as the first day when PMX‐DHP was performed. PMX‐DHP efficacy was assessed on days 7 and 14 after the first treatment based on eight categories. Subsequently, improvement in P/F ratio and urinary biomarkers on days 4 and 8, malfunctions, and ventilator and extracorporeal membrane oxygenation avoidance rates were also evaluated.ResultsOn day 14 after the first treatment, disease severity decreased in 58.3% of the patients. P/F ratio increased while urine β2‐microglobulin decreased on days 4 and 8. Cytokine measurement pre‐ and post‐PMX‐DHP revealed decreased levels of interleukin‐6 and the factors involved in vascular endothelial injury, including vascular endothelial growth factor. Twenty‐two PMX‐DHPs were performed, of which seven and five PMX‐DHPs led to increased inlet pressure and membrane coagulation, respectively. When the membranes coagulated, the circuitry needed to be reconfigured. Circuit problems were usually observed when D‐dimer and fibrin degradation product levels were high before PMX‐DHP.ConclusionsFuture studies are expected to determine the therapeutic effect of PMX‐DHP on COVID‐19. Because of the relatively high risk of circuit coagulation, coagulation capacity should be assessed beforehand.

P0591AKI TREATMENT WITH CVVH IN THE ICU: A FIFTEEN MONTH SINGLE-CENTER EXPERIENCE

Abstract Background and Aims AKI (Acute Kidney Injury) is a condition associated with elevated morbility and mortality. It determines prolonged hospitalization and severe long-term complications. AKI often complicates the course of patients’ stay in ICU (Intensive Care Units) sometimes requiring CRRT (Continuous Renal Replacement Therapy). Our aim was to prospectively analyze and report our experience on CRRT carried out in our hospital’s ICUs, and to compare it with guideline recommendations and with other international experiences. Method This is a single-center prospective observational study. We collected epidemiologic, clinical and technical data regarding all CRRT treatments performed in the four ICUs (two general ICUs and two cardiological ICUs) at the ASST Spedali Civili of Brescia Italy, between 02/01/2018 and 05/31/2019. AKI was defined according to KDIGO guidelines. Exclusion criteria were: age less than 16 years, chronic dialysis treatment, functioning kidney transplantation. All CRRT were provided in the CVVH (Continuous Veno-Venous Hemofiltration) mode. Results We included 146 incident patients (M: 103; 70%), mean age 71 ± 15 years. Most treatments were performed in the cardiological ICUs (58%) as opposed to the general ICUs (42%). AKI was present at the moment of admission to the ICU in 67% of patients. 53% of patients had previous CKD. The most frequent comorbidities were: hypertension (73%), diabetes (45%), ischemic heart disease (38%). The most frequent reasons for starting CVVH were: severe oliguria (88%) and fluid overload (68%). 57% of patients had stage 3 AKI. At the time of treatment initiation 55% of patients also had congestive heart failure, 52% metabolic acidosis, and 51% sepsis. 23% were recovering from heart surgery and 10% from general surgery. Mechanic ventilation was performed in 40% of patients, non-invasive ventilation in 28%. 82% of patients required vasoactive treatment. The average SOFA score was 10 ± 2,9. Technical details of CVVH prescription are reported in Fig 1. The most common vascular access was a dual lumen femoral vein catheter in 96% of cases. Citrate anticoagulation was used in 32% of treatments, heparin in 27%. Circuit coagulation was the most frequent cause for set substitution (45%). Treatments using citrate had fewer set coagulations compared to heparin (18% vs 32%). The average dialysis dose was 31,2 ml/kg/h. Median treatment duration was 7,6 days, median stay in the ICU was 14,3 days, median global hospitalization lasted 30,9 days. Mortality rate was 47% in the ICU and 64% 90 days after discharge. The most frequent causes of death were MOF (33%), septic shock (20%) and cardiogenic shock (14%). As illustrated in figure 2, multivariate analysis showed that mortality was negatively influenced by the presence of liver cirrhosis, septic shock, cardiogenic shock and rhabdomyolysis. After hospital discharge, 14 patients continued to require chronic dialysis. Conclusion Our experience shows that in patients with AKI requiring CVVH, mortality rate is negatively influenced by the presence of septic and cardiogenic shock, liver cirrhosis and rhabdomyolysis. Treatment prescription respected clinical and technical guideline recommendations, and is mostly comparable to the related international literature.

Predictive factors of circuit coagulation during continuous renal replacement therapy using recombinant human soluble thrombomodulin

Predictive factors of circuit coagulation during continuous renal replacement therapy using recombinant human soluble thrombomodulin

An investigation of coagulation/fibrinolysis biomarkers as predictors of circuit coagulation in continuous blood purification therapy

An investigation of coagulation/fibrinolysis biomarkers as predictors of circuit coagulation in continuous blood purification therapy

Circuit life span of continuous renal replacement therapy in critically ill patients with or without conventional anticoa-gulation: an observational prospective study

The aim of this study was to describe the efficacy, security and viability of an anticoagulation system with continuous infusion of unfractionated heparin (UFH) versus one without any type of anticoagulant using 0.9% physiological saline washings, in critically ill patients with continuous renal replacement therapy (CRRT) and different risks of bleeding. From October 2013 to April 2015 we conducted an observational prospective study in the intensive care unit (ICU). Sixty-one patients with acute kidney injury (AKI) and requiring CRRT were included, with 122 filters. Patients and filters were divided in two groups: anticoagulated (AC) and not anticoagulated (No AC). The main outcome measure was filter life span. Different analytical parameters were also collected at the beginning of treatment and at the moment of circuit coagulation Results. The number of patients was similar in both groups. We did not find statistically significant differences between the two groups in filter life span (30.5 hours AC vs 34.9 hours No AC). Patients with increased morbidity (severe thrombocytopenia, coagulopathy, etc.) were included in the group that did not received anticoagulation but saline flushes. CRRT without anticoagulation with saline flushes is a viable, safe and effective strategy in critically ill patients with high risk of bleeding. This approach achieves a circuit life span similar to that observed in anticoagulated patients with UFH; avoiding the risks and costs associated with anticoagulation.

Safety and Efficacy of Citrate Anticoagulation for Continuous Renal Replacement Therapy for Acute Kidney Injury After Liver Transplantation: A Single-Center Experience

BackgroundAcute kidney injury (AKI) after liver transplantation (LT) is a frequent and serious complication. The incidence of AKI requiring continuous renal replacement therapy (CRRT) ranges from 10% to 30%. Kidney Disease: Improving Global Outcomes guidelines indicate the use of citrate as a locoregional anticoagulant drug for CRRT regardless of the patient's hemorrhagic risk. Despite this indication, however, the use of citrate is still under debate in patients with liver failure and/or LT owing to the potential risk of plasmatic citrate accumulation due to reduced liver clearance. The aim of this study was to evaluate the safety and efficacy of citrate as a locoregional anticoagulation drug in CRRT for AKI after LT. MethodsA retrospective analysis was performed in patients with AKI after liver transplantation who were treated with CRRT using citrate as local anticoagulant. Five patients were enrolled from January to December 2015. ResultsNo patients showed complications related to citrate (metabolic acidosis, hyperlactatemia, hypercalcemia, or hypernatremia). All treatments with heparin were stopped owing to circuit clotting. Treatments with citrate was interrupted where it was no longer needed or when other examinations had to be made. None were stopped because of circuit coagulation. ConclusionsAt our center, 5 patients have been successfully treated with the use of CRRT with citrate for AKI during the post-LT course. Our results, though on a small series of patients, provide evidence that CRRT with citrate can be a safe and promising treatment for AKI after LT.

Safety Management of a Clinical Process Using Failure Mode and Effect Analysis: Continuous Renal Replacement Therapies in Intensive Care Unit Patients.

The failure mode and effect analysis (FMEA) may improve the safety of the continuous renal replacement therapies (CRRT) in the intensive care unit. We use this tool in three phases: 1) Retrospective observational study. 2) A process FMEA, with implementation of the improvement measures identified. 3) Cohort study after FMEA. We included 54 patients in the pre-FMEA group and 72 patients in the post-FMEA group. Comparing the risks frequencies per patient in both groups, we got less cases of under 24 hours of filter survival time in the post-FMEA group (31 patients 57.4% vs. 21 patients 29.6%; p < 0.05); less patients suffered circuit coagulation with inability to return the blood to the patient (25 patients [46.3%] vs. 16 patients [22.2%]; p < 0.05); 54 patients (100%) versus 5 (6.94%) did not get phosphorus levels monitoring (p < 0.05); in 14 patients (25.9%) versus 0 (0%), the CRRT prescription did not appear on medical orders. As a measure of improvement, we adopt a dynamic dosage management. After the process FMEA, there were several improvements in the management of intensive care unit patients receiving CRRT, and we consider it a useful tool for improving the safety of critically ill patients.

Avoidance of systemic anticoagulation during intermittent haemodialysis with heparin-grafted polyacrilonitrile membrane and citrate-enriched dialysate: a retrospective cohort study.

BackgroundSince October 2010, the combination of a heparin-grafted polyacrilonitrile (AN69ST) membrane with a 0.80 mmol/L citric acid-containing dialysate is routinely used in our centre for intermittent haemodialysis, without systemic anticoagulation, in critically ill patients with increased bleeding risk. The primary outcome of this retrospective cohort study was to assess the development of circuit clotting during these dialysis procedures. Secondly, we assessed the impact of clotting on treatment duration, the incidence rate of coagulation-induced retransfusion failure and the association of patient and dialysis characteristics with the occurrence of clotting.MethodsDialysis and patient data on consecutive intermittent haemodialysis procedures, performed at the Intensive Care Unit of Universitair Ziekenhuis Brussel between October 2010 and March 2012, were retrospectively reviewed. We used descriptive statistics as well as a random effects logit model with patient identity as a panel variable to assess associations.ResultsOf a total of 309 treatments combining a heparin-grafted AN69ST membrane and a 0.8 mmol/L citric acid-enriched dialysate in 94 patients, circuit clotting was reported in 17.5% (95% CI 13.2% to 21.7%; N = 54), and in 19% (95% CI 13.6% to 24.4%; N = 40) of sessions with prescribed treatment time ≥ 4 hours (N = 210). Clotting shortened treatment time in 15.2% (95% CI 11.4% to 19.7%; N = 47) of sessions by a median of 55 (IQR 20 to 80) minutes. Complete clotting of the circuit with inability for retransfusion occurred in 4.2% (95% CI 2.2% to 7.0%; N = 13) of sessions. Circuit coagulation was not associated with APACHE II score, patient age, gender, number of treatments, type of vascular access or ultrafiltration rate.ConclusionIntermittent haemodialysis without systemic anticoagulation combining a heparin-grafted AN69ST dialyzer with a citrate-enriched dialysate favourably compares as to clotting complications with the published outcomes of anticoagulation-free intermittent haemodialysis strategies using saline flushes, heparin-coated dialyzer in combination with regular dialysate or regional citrate anticoagulation with calcium supplemented dialysate. The incidence of circuit clotting in our cohort appears to be higher than previously reported for regional citrate anticoagulation with a calcium-free dialysate.

Comparison of circuit coagulation after and before application of an anti-clotting flow chart. A retrospective monocentric analysis

Comparison of circuit coagulation after and before application of an anti-clotting flow chart. A retrospective monocentric analysis

Is anticoagulation required in plasmapheresis? A University Hospital Experience in Bogota, Colombia

Anticoagulation has been considered essential during plasmapheresis. International publications and guidelines state that anticoagulation should be administered during therapy to avoid circuit clotting and impaired effectiveness. However, anticoagulation has also been associated with bleeding, fluid and electrolyte imbalances and hematological alterations. No published studies have looked at the risk to benefit ratio of the common practice of circuit anticoagulation. We describe the experience with 367 plasmapheresis sessions, in the Hospital Universitario San Ignacio, a tertiary care center in Bogota, Colombia, where no anticoagulation is used in any case. Patient characteristics and therapy complications are described. Coagulation of circuit was never reported.