Regional Citrate Anticoagulation Research Articles

COVID-19-induced extracorporeal circulation coagulation during continuous renal replacement therapy: A cross-sectional study.

After the control policies of the COVID-19 epidemic were lifted in China from December 5th, 2022, there was an increase in the demand for hemodialysis and continuous renal replacement therapy (CRRT) at our center, and patients experienced hypercoagulable blood states more frequently. This study aimed to investigate the effect of COVID-19 on extracorporeal coagulation during CRRT. All CRRT records were gathered from the Hemodialysis Center at our hospital from December 5th, 2022 to February 4th, 2023, and analyzed the incidence and risk factors associated with extracorporeal coagulation. COVID-19 substantially increased the likelihood of extracorporeal coagulation during CRRT. Venous pressure and transmembrane pressure were proportional to the severity of extracorporeal coagulation. Additionally, non-tunnel type conduit vascular access, and acute kidney injury had a positive correlation with the severity of coagulation. Blood tests demonstrated that COVID-19 altered 4 coagulation indices. Moreover, mitigation of coagulation can be achieved through increasing the dosage of low molecular weight heparin and administering regional citrate anticoagulation. Patients who fail anticoagulation may be switched to peritoneal dialysis. In conclusion, COVID-19 poses a heightened risk of extracorporeal coagulation during CRRT. This study underscores the importance of anticoagulant treatment in CRRT for infected patients with kidney failure and holds significant implications for clinical practice. In future, the epidemics of COVID-19 or any other pandemic, the metrics in this study can be referenced to determine coagulation risk, as well as relevant therapeutic practices may be considered.

Optimizing Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation: Insights from the ORCA Trial-A Retrospective Study on 10 Years of Practice.

(1) Background: Citrate is preferred in continuous renal replacement therapy (CRRT) for critically ill patients because it prolongs filter life and reduces bleeding risks compared to unfractionated heparin (UFH). However, regional citrate anticoagulation (RCA) can lead to acid-base disturbances, citrate accumulation, and overload. This study compares the safety and efficacy of citrate-based CRRT with UFH and no anticoagulation (NA) in acute kidney injury (AKI) patients. (2) Methods: A retrospective analysis was conducted on adult patients (≥18 years) who underwent CRRT from July 2010 to June 2021 in an intensive care unit. (3) Results: Among 829 AKI patients on CRRT: 552 received RCA, 232 UFH, and 45 NA. The RCA group had a longer filter lifespan compared to UFH and NA (56 h [IQR, 24-110] vs. 36.0 h [IQR, 17-63.5] vs. 22 h [IQR, 12-48]; all Padj < 0.001). Bleeding complications were fewer in the RCA group than in the UFH group (median 3 units [IQR, 2-7 units] vs. median 5 units [IQR, 2-12 units]; Padj < 0.001) and fewer in the NA group than in the UFH group (median 3 units [IQR, 1-5 units] vs. 5 units [IQR, 2-12 units]; Padj = 0.03). Metabolic alkalosis was more common in the RCA group (32.5%) compared to the UFH (16.2%) and NA (13.5%) groups, while metabolic acidosis persisted more in the UFH group and NA group (29.1% and 34.6%) by the end of therapy vs. the citrate group (16.8%). ICU mortality was lower in the RCA group (52.7%) compared to the UFH group (63.4%; Padj = 0.02) and NA group (77.8%; Padj = 0.003). (4) Conclusions: Citrate anticoagulation outperforms heparin-based and no anticoagulation in filter patency, potentially leading to better outcomes through improved therapy effectiveness and reduced transfusion needs. However, careful monitoring is crucial to limit potential complications attributable to its use.

Regional Citrate Anticoagulation: Going around in Circles!

Regional Citrate Anticoagulation: Going around in Circles!

Hyperparathyroidism as a Cause of Low Calcium Requirement during Regional Citrate Anticoagulation: Two Case Reports

Hyperparathyroidism as a Cause of Low Calcium Requirement during Regional Citrate Anticoagulation: Two Case Reports

Regional Citrate Anticoagulation (RCA) Compared with No Heparin in Continuous Kidney Replacement Therapy (CKRT) among Liver Patients: A Single-Center, Retrospective, Interim Analysis

Regional Citrate Anticoagulation (RCA) Compared with No Heparin in Continuous Kidney Replacement Therapy (CKRT) among Liver Patients: A Single-Center, Retrospective, Interim Analysis

Anticoagulation Strategies for Continuous Renal Replacement Therapy in France: A Survey of Practices

Introduction: Anticoagulation for continuous renal replacement therapy (CRRT) can be performed using systemic anticoagulation or regional citrate anticoagulation (RCA). The 2012 Kidney Disease Improving Global Outcomes guidelines support the use of RCA as the first-line strategy in patients requiring CRRT, with and without bleeding risk. Implementing RCA in the intensive care unit (ICU) implies involving all medical and nursing staff. The primary objective of this study was to report and describe the various anticoagulation strategies for CRRT in French ICUs. The secondary objectives were to determine the rate of RCA use and to identify the factors limiting its implementation. Methods: An online questionnaire containing 40 questions was sent to attending physicians and fellows practicing in French ICUs between May and September 2021. The questionnaire was sent via several networks: mailing list from the French Society of Anesthesia and Intensive Care Medicine and mailing lists of RRT manufacturers. Results: A total of 597 responses were analyzed. RCA was used by most of the participants for patients with (81%) and without (80%) increased bleeding risk. The preferred CRRT modality of the participants while using RCA was continuous veno-venous hemodialysis (48%). The clinical situations frequently reported as an absolute contraindication to RCA were uncontrolled shock associated with liver failure and drug poisoning impairing citrate metabolism (62% and 52%, respectively). In case of a higher risk of citrate accumulation, most participants claimed to perform closer biological monitoring (57%) or to modify the CRRT protocol (61%). Among the participants who did not prescribe RCA as a first-line strategy, the main factors limiting its implementation were the lack of nurse (50%) or physician (34%) training. Conclusion: RCA is the main anticoagulation strategy prescribed for CRRT in France. Providing medical and nursing staff easy access to training may facilitate the understanding and use of RCA as the first-line anticoagulation strategy for CRRT.

Impact of increasing post-filter ionised calcium target on regional citrate anticoagulation efficacy in ICU continuous renal replacement therapy: the non-inferiority randomised controlled Ca-CIBLE protocol

IntroductionContinuous renal replacement therapy (CRRT) is a critical therapeutic intervention for patients with severe acute kidney injury in intensive care. However, premature filter clotting remains a significant challenge during CRRT,...

Sterile water and regional citrate anticoagulation: A simple CRRT strategy for safe correction of severe hyponatraemia.

Hyponatraemia is a prevalent electrolyte disturbance observed in critically ill patients. The rapid correction of low plasma sodium levels by continuous renal replacement therapy (CRRT) carries the risk of developing osmotic demyelination syndrome (ODS), which can be prevented by implementing an individualized CRRT method. This study aims to introduce a CRRT protocol for the safe and gradual correction of severe hyponatraemia. This retrospective case series study was conducted in an intensive care unit (ICU). All four patients with severe hyponatraemia (<125 mmol/L) and renal failure between October 1, 2022, and September 30, 2023, were treated by CRRT with sterile water and regional citrate anticoagulation (RCA). Data on patient demographics, laboratory biochemical parameters, urine outputs and CRRT-related adverse events were collected. Laboratory parameters and urine outputs were compared by paired t-tests before and after CRRT. After CRRT, sodium levels were significantly increased (112.7 ± 6.7 vs. 141.9 ± 2.8 mmol/L, p = .005). Abnormal urine outputs, potassium, creatinine and bicarbonate were corrected (p for all <.05). Safe and gradual correction of hyponatraemia and internal environmental dysregulation was achieved in all patients without any complications related to CRRT, particularly ODS. It is a novel and simple strategy to correct severe hyponatraemia effectively while ensuring the safety of patients that can be easily implemented by experienced nurse staff. The sterile water-based protocol for postfilter dilution is safe to correct severe hyponatraemia with RCA and can be easily performed by experienced critical care nurses according to the precalculated formula. CRRT-trained, experienced ICU nurses are competent to initiate and adjust sterile water infusion discretely to prevent overcorrection of hyponatraemia.

Characteristics of initiation timing and anticoagulation of continuous renal replacement therapy in patients following cardiac surgery: A retrospective analysis of 28 patients.

Continuous renal replacement therapy (CRRT) used in cardiac surgery-associated acute kidney injury (CSA-AKI) may have different characteristics from other diseases. We reviewed the medical records of patients with CSA-AKI requiring CRRT who underwent cardiac surgery from January 2020 to September 2021. Patients with AKI caused by other reasons who received CRRT during the same period were also evaluated. A total of 28 patients with CSA-AKI and 12 patients with AKI caused by other reasons were enrolled in this study. Compared with AKI patients caused by other reasons, patients with CSA-AKI were found to have lower mean arterial pressure, higher level of bilirubin, higher vasoactive-inotropic score, and larger daily diuretic dosage. The patients with CSA-AKI were prescribed CRRT earlier than the patients with AKI caused by other reasons. There was a significant difference in the CRRT anticoagulation method between patients with CSA-AKI and patients with AKI caused by other reasons. Six patients with CSA-AKI were treated with regional citrate anticoagulation (RCA), and the other 22 patients were treated with low molecular weight heparin or without anticoagulants. The timing of CRRT initiation in patients with CSA-AKI is earlier than that in patients with AKI caused by other reasons. Although RCA is recommended as the preferred anticoagulant for patients without contraindications, patients with CSA-AKI often have circulatory dysfunction and severe liver damage, so the risk of citrate accumulation is greater, whether to use RCA should be determined according to the individual condition of the patient.

Protocolized Regional Citrate Anticoagulation during Continuous Renal Replacement Therapy: A Single Center Experience.

Regional citrate anticoagulation (RCA) has emerged as a treatment modality that reduces bleeding risk and filter clotting. With initial experience of using RCA with continuous renal replacement therapy (CRRT), we have formulated a working protocol based on published literature. The study aimed to evaluate the protocol for routine use of RCA during CRRT requiring anticoagulation and evaluation of filter life. It is a single-center, open-label, prospective, non-randomized, non-interventional, single-arm, observational study conducted at a tertiary care hospital between September 2022 and July 2023. All adult patients with acute kidney injury (AKI) or hyperammonemia requiring CRRT and necessitating the use of anticoagulation were enrolled in the study. The study used Prisma Flex M100 AN 69 dialyzer on Prisma Flex (Baxter) CRRT machines during continuous venovenous hemodiafiltration (CVVHDF). The targeted CRRT dose in all the study patients was 25-30 mL/kg/hour. Based on the published literature, we have developed a working protocol (Appendix 1) for managing patients on CRRT using RCA. A total of 159 patients were analyzed for the study. The median [interquartile range (IQR)] filter life using RCA was 30 (12-55) hours. Filter clotting was observed in 33.3% of patients. Citrate accumulation was present in 52.25% of patients, but no CRRT was discontinued as citrate accumulation resolved after following the corrective steps in the protocol. None of the patients had citrate toxicity. Chronic liver disease (CLD) (p ≤ 0.001) and those who were post-living donor liver transplant recipients (p = 0.004) had a statistically significant increase in citrate accumulation. Also, patients who had higher lactate at baseline (6 hours post-CRRT initiation), had a higher chance of citrate accumulation. Our RCA protocol provides a safe approach to regional anticoagulation during CRRT in critically ill patients. Pachisia AV, Kumar GP, Harne R, Jagadeesh KN, Patel SJ, Pal D, et al. Protocolized Regional Citrate Anticoagulation during Continuous Renal Replacement Therapy: A Single Center Experience. Indian J Crit Care Med 2024;28(9):859-865.

CaCl2-Citrate Regional Anticoagulation with Continuous Veno-Venous Haemodialysis Leads to Unwanted Chloride Loading Compared to Continuous Veno-Venous Hemofiltration with Systemic Anticoagulation

Introduction: Chloride transfers during continuous renal replacement therapy (CRRT) have not been adequately described and may differ based on CRRT technique. We aimed to measure chloride mass transfer (JS,Cl) during CRRT and identify associated determinants. Methods: We performed a two-centre, prospective, observational study in France and Australia in ICU patients with CRRT initiated for <24 h. Patients received continuous veno-venous hemofiltration (CVVH) or continuous veno-venous haemodialysis (CVVHD, with citrate-CaCl2 regional anticoagulation). Over a 24 h period, plasma and effluent chloride concentrations were measured every 4 h to compute chloride mass transfer (JS,Cl, in mmol.min-1) using a modality-specific model, with negative value indicating chloride transfer towards the patient. Secondary outcomes were the identification of CRRT settings associated with JS,Cl (using multivariate mixed effects regression). Results are presented with median (interquartile range). Results: Between February 2021 and August 2022, we enrolled 37 patients (64 [56–71] years, 67% male), for a total of 20 CVVHD and 20 CVVH sessions. Over 24 h, plasma chloride concentrations were significantly higher, and JS,Cl significantly lower during CVVHD, compared to CVVH (−0.10 [−0.33 to 0.15] vs. 0.01 [−0.10 to 0.13] mmol.min-1, p < 0.05). With both modalities, net ultrafiltration (QUFNET) and plasma chloride concentrations were the principal determinants of JS,Cl, with higher QUFNET being associated with an increase in JS,Cl during CVVHD. Also, CVVHD sessions demonstrated a concentration gradient between the plasma and the effluent chamber of −6 [−9 to −4] mmol.L-1. Finally, CaCl2 reinjection during CVVHD accounted for 35% [32–60%] of total JS,Cl in sessions with a negative JS,Cl. Conclusion: Compared to CVVH, CVVHD with regional citrate anticoagulation was associated with greater chloride mass transfer to the patient and higher plasma chloride concentrations. This was due to high dialysate chloride concentrations and CaCl2 reinjection. This effect could only be controlled by high net ultrafiltration flow rates.

Deciphering simplified regional anticoagulation with citrate in intermittent hemodialysis: a clinical and computational study

Regional citrate anticoagulation use in intermittent hemodialysis is limited by the increased risk of metabolic complications due to faster solute exchanges than with continuous renal replacement therapies. Several simplifications have been proposed. The objective of this study was to validate a mathematical model of hemodialysis anticoagulated with citrate that was then used to evaluate different prescription scenarios on anticoagulant effectiveness (free calcium concentration in dialysis filter) and calcium balance. A study was conducted in hemodialyzed patients with a citrate infusion into the arterial line and a 1.25 mmol/L calcium dialysate. Calcium and citrate concentrations were measured upstream and downstream of the citrate infusion site and in the venous line. The values measured in the venous lines were compared with those predicted by the model using Bland and Altman diagrams. The model was then used with 22 patients to make simulations. The model can predict the concentration of free calcium, bound to citrate or albumin, accurately. Irrespective of the prescription scenario a decrease in free calcium below 0.4 mmol/L was obtained only in a fraction of the dialysis filter. A zero or slightly negative calcium balance was observed, and should be taken into account in case of prolonged use.

Regional citrate anticoagulation versus LMWH anticoagulation for CRRT in liver failure patients without increased bleeding risk.

The optimal anticoagulation regimen for continuous renal replacement therapy (CRRT) in liver failure (LF) patients without increased bleeding risk remains controversial. Therefore, we conducted a monocentric retrospective study to evaluate the efficacy and safety of the regional citrate anticoagulation (RCA) versus low molecular weight heparin (LMWH) anticoagulation for CRRT in LF without increased bleeding risk. According to the anticoagulation strategy for CRRT, patients were divided into the RCA and LMWH-anticoagulation groups. The evaluated endpoints were patient survival, filter lifespan, bleeding, citrate accumulation, and totCa/ionCa ratio. Totally 167 and 164 filters were used in the RCA and LMWH group, respectively. The median filter lifespan was significantly longer in the RCA group (34 h (IQR = 24-54) versus 24 h (IQR = 18-45.5) [95%CI, 24.5-33]; p < 0.001). The 4-week mortality rate was significantly higher in the LMWH-anticoagulation group (71 (57.72%) vs 53 (40.46%); p = 0.006). After adjusted the important parameters in the multivariate COX regression model, the mortality risk was significantly reduced in the RCA group (HR = 0.668 [95%CI, 0.468-0.955]; p = 0.027). In the LMWH group, 30 bleeding episodes (24,19%) were observed, whereas only 7 (5.34%) occurred in the RCA group (p < 0.001). Two patients (1.5%) in the RCA group occurred citrate accumulation. In LF patients without increased bleeding risk who underwent CRRT, RCA significantly extended the filter lifespan and improved patient survival rate. There was no significant difference in the rate of adverse events between the two groups.

Regional citrate anticoagulation with continuous renal replacement therapy as a cause of hypercalcemia.

Awareness of the causes of hypercalcemia is essential for timely diagnosis of calcium disorders and optimal treatment. Citrate is commonly used as an anticoagulant during continuous renal replacement therapy (CRRT). Accumulation of citrate in the systemic circulation during CRRT may induce several metabolic disturbances, including total hypercalcemia and ionized hypocalcemia. The aim of the present study is to increase awareness of citrate accumulation and toxicity as a cause of hypercalcemia by relating three cases and reviewing the pathophysiology and clinical implications. We utilized electronic health records to examine the clinical cases and outlined key studies to review the consequences of citrate toxicity and general approaches to management. Citrate toxicity is associated with high mortality. A safe threshold for tolerating hypercalcemia during citrate anticoagulation is not clearly defined, and whether citrate toxicity independently increases mortality has not been resolved. Greater attention to citrate toxicity as a cause of hypercalcemia may lead to earlier detection, help to optimize the management of systemic calcium levels, and foster interest in future clinical studies.

Vitamin D and metabolic bone disease in prolonged continuous kidney replacement therapy: a prospective observational study

BackgroundComplications of prolonged continuous kidney replacement therapy (CKRT) have not been well described. Our objective was to describe mineral metabolism and bone findings in children who required prolonged CKRT.MethodsIn this single center prospective observational study, we enrolled 37 patients who required CKRT for ≥ 28 days with regional citrate anticoagulation. Exposure was duration on CKRT and outcomes were 25-hydroxy vitamin D and osteopenia and/or fractures.ResultsThe prevalence of vitamin D deficiency and insufficiency was 17.2% and 69.0%, respectively. 29.7% of patients had radiographic findings of osteopenia and/or fractures. There was no association between vitamin D deficiency or insufficiency with age or ethnicity. Time on CKRT and intact PTH levels were not predictive of vitamin D levels. Children with chronic liver disease were more likely to have osteopenia and/or fractures compared children with other primary diagnoses, odds ratio (3.99 (95%CI, 1.58–2.91), p = 0.003) after adjusting for age and time on CKRT.ConclusionVitamin D deficiency and/or insufficiency, and osteopenia and/or fractures are prevalent among children who require CKRT for a prolonged period. The risk for MBD may be higher with chronic liver disease. Higher doses of vitamin D may be required to maintain normal levels while on CKRT.

Efficacy of Regional Citrate versus Heparin Anticoagulation in Continuous Renal Replacement Therapy

Efficacy of Regional Citrate versus Heparin Anticoagulation in Continuous Renal Replacement Therapy

Factors influencing circuit lifetime in paediatric continuous kidney replacement therapies – results from the EurAKId registry

BackgroundContinuous kidney replacement therapy (CKRT) has recently become the preferred kidney replacement modality for children with acute kidney injury (AKI). We hypothesise that CKRT technical parameters and treatment settings in addition to the clinical characteristics of patients may influence the circuit lifetime in children.MethodsThe study involved children included in the EurAKId registry (NCT 02960867), who underwent CKRT treatment. We analysed patient characteristics and CKRT parameters. The primary end point was mean circuit lifetime (MCL). Secondary end points were number of elective circuit changes and occurrence of dialysis-related complications.ResultsThe analysis was composed of 247 children who underwent 37,562 h of CKRT (median 78, IQR 37–165 h per patient). A total of 1357 circuits were utilised (3, IQR 2–6 per patient). MCL was longer in regional citrate anticoagulation (RCA), compared to heparin (HA) and no anticoagulation (NA) (42, IQR 32-58 h; 24, IQR 14-34 h; 18, IQR 12-24 h, respectively, p < 0.001). RCA was associated with longer MCL regardless of the patient’s age or dialyser surface. In multivariate analysis, MCL correlated with dialyser surface area (beta = 0.14, p = 0.016), left internal jugular vein vascular access site (beta = -0.37, p = 0.027), and the use of HA (beta = -0.14, p = 0.038) or NA (beta = -0.37, p < 0.001) vs. RCA. RCA was associated with the highest ratio of elective circuit changes and the lowest incidence of complications.ConclusionAnticoagulation modality, dialyser surface, and vascular access site influence MCL. RCA should be considered when choosing first-line anticoagulation for CKRT in children. Further efforts should focus on developing guidelines and clinical practice recommendations for paediatric CKRT.Graphical abstractA higher resolution version of the Graphical abstract is available as Supplementary information

A safe and effective protocol for postdilution hemofiltration with regional citrate anticoagulation

BackgroundRegional citrate anticoagulation (RCA) is recommended during continuous renal replacement therapy. Compared to systemic anticoagulation, RCA provides a longer filter lifespan with the risk of metabolic alkalosis and impaired calcium homeostasis. Surprisingly, most RCA protocols are designed for continuous veno-venous hemodialysis or hemodiafiltration. Effective protocols for continuous veno-venous hemofiltration (CVVH) are rare, although CVVH is a standard treatment for high-molecular-weight clearance. Therefore, we evaluated a new RCA protocol for postdilution CVVH.MethodsThis is a monocentric prospective interventional study to evaluate a new RCA protocol for postdilution CVVH. We recruited surgical patients with stage III acute kidney injury who needed renal replacement therapy. We recorded dialysis and RCA data and hemodynamic and laboratory parameters during treatment sessions of 72 h. The primary endpoint was filter patency at 72 h. The major safety parameters were metabolic alkalosis and severe hypocalcemia at any time.ResultsWe included 38 patients who underwent 66 treatment sessions. The mean filter lifespan was 66 ± 12 h, and 44 of 66 (66%) filters were patent at 72 h. After censoring for non-CVVH-related cessation of treatment, 83% of all filters were patent at 72 h. The delivered dialysis dose was 28 ± 5 ml/kgBW/h. The serum levels of creatinine, urea and beta2-microglobulin decreased significantly from day 0 to day 3. Metabolic alkalosis occurred in one patient. An iCa++ below 1.0 mmol/L occurred in four patients. Citrate accumulation did not occur.ConclusionsWe describe a safe, effective, and easy-to-use RCA protocol for postdilution CVVH. This protocol provides a long and sustained filter lifespan without serious adverse effects. The risk of metabolic alkalosis and hypocalcemia is low. Using this protocol, a recommended dialysis dose can be safely administered with effective clearance of low- and middle-molecular-weight molecules.Trial registrationThe study was approved by the medical ethics committee of Heinrich-Heine University Duesseldorf (No. 2018-82KFogU). The trial was registered in the local study register of the university (No: 2018044660) on 07/04/2018 and was retrospectively registered at ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT03969966) on 31/05/2019.

Further improvement of circuit survival in citrate based continuous renal replacement therapy.

Continuous renal replacement therapy (CRRT) is the most frequently used modality of renal replacement therapy (RRT) in critical care patients with acute kidney injury (AKI). Adequate CRRT delivery can be challenging, due to problems with circuit patency. To improve circuit patency, we developed a new CRRT protocol using continuous veno-venous hemodiafiltration (CVVHDF) with 3.0mmol/l regional citrate anticoagulation (CVVHDF/RCA3.0) as our first choice RRT modality. Retrospective comparison of efficacy and safety of a CVVHDF/RCA3.0 protocol with our former continuous veno-venous hemofiltration protocol with 2.2 regional citrate anticoagulation (CVVH/RCA2.2) in adult critically ill patients with AKI requiring CRRT between 25 April 2020 and 24 October 2021. In total, 56 patients (257 circuits) and 66 patients (290 circuits) were included in the CVVH/RCA2.2 and CVVHDF/RCA3.0 groups, respectively. Median circuit survival was significantly higher in patients treated with CVVHDF/RCA3.0 (39.6 (IQR 19.5-67.3) hours) compared to patients treated with CVVH/RCA2.2 (22.9 (IQR 11.3-48.6) hours) (P<.001). Higher body weight and higher convective flow were associated with a lower circuit survival. Metabolic control was similar, except for metabolic alkalosis that occurred less frequently during CVVHDF/RCA3.0 (19% of patients) compared to CVVH/RCA2.2 (46% of patients) (P=.006). CRRT circuit survival was longer with CVVHDF/RCA3.0 compared to CVVH/RCA2.2. CRRT circuit survival was negatively associated with higher body weight and higher convective flow.

Citrate and low-dose heparin combined anticoagulation in pediatric continuous renal replacement therapy

There remains no optimal anticoagulation protocol for continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) in pediatric patients with elevated D-dimer levels. We aimed to assess the effects of different anticoagulation strategies on the risk of CRRT filter clotting in these patients. Pediatric patients undergoing CRRT were retrospectively grouped based on pre-CRRT D-dimer levels and anticoagulant: D-RCA group (normal D-dimer, RCA only, n = 22), D+ RCA group (elevated D-dimer, RCA only, n = 50), and D+ RCA+ systemic heparin anticoagulation (SHA) group (elevated D-dimer, RCA combined with SHA, n = 55). The risk of filter clotting and incidence of bleeding were compared among the groups. Among the groups, the D+ RCA+ SHA group had the longest filter lifespan; further, the incidence of bleeding was not increased by concurrent use of low-dose heparin for anticoagulation. Moreover, concurrent heparin anticoagulation was associated with a decreased risk of filter clotting. Contrastingly, high pre-CRRT hemoglobin and D-dimer levels and post-filter ionized calcium level > 0.4 mmol/L were associated with an increased risk of filter clotting. RCA combined with low-dose heparin anticoagulation could reduce the risk of filter clotting and prolong filter lifespan without increasing the risk of bleeding in patients with elevated D-dimer levels undergoing CRRT.