Regional citrate anticoagulation with a substitute containing calcium for continuous hemofiltration in children

Anticoagulation in patients with acute kidney injury undergoing kidney replacement therapy

Kidney replacement therapy (KRT) is used to provide supportive therapy for critically ill patients with severe acute kidney injury and various other non-renal indications. Modalities of KRT include continuous KRT (CKRT), intermittent hemodialysis (HD), and sustained low efficiency daily dialysis (SLED). However, circuit clotting is a major complication that has been investigated extensively. Extracorporeal circuit clotting can cause reduction in solute clearances and can cause blood loss, leading to an upsurge in treatment costs and a rise in workload intensity. In this educational review, we discuss the pathophysiology of the clotting cascade within an extracorporeal circuit and the use of various types of anticoagulant methods in various pediatric KRT modalities.

Semiautomated Regional Citrate Anticoagulation for Continuous Kidney Replacement Therapy: An Observational Study in Young Children

OBJECTIVES

To review use of semiautomated regional citrate anticoagulation (saRCA) for continuous kidney replacement therapy (CKRT) in young children.

DESIGN

Retrospective cohort study.

SETTING

Three independent PICUs.

PATIENTS

All consecutive children weighing less than 11 kg who received CKRT with saRCA from January 2015 to June 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Twenty-one children weighing less than 11 kg underwent CKRT with saRCA. The total duration of the CKRT was 2,014 hours, with a total of 64 CKRT sessions. Citrate intoxication occurred in four of 64 CKRT sessions (6%). Citrate intoxication was consistently observed in the few CKRT sessions where the initial lactate concentration was greater than 4 mmol/L or the ratio of replacement fluid flow to citrate flow less than 50%. The rate of unscheduled interruptions of CKRT sessions was 25% (16/64).

CONCLUSIONS

We have used saRCA for CKRT in children weighing less than 11 kg. A strict protocol and intensive training are required to minimize complications.

Clinical application of regional citrate anticoagulation for continuous renal replacement therapy in children with liver injury

BACKGROUND

Regional citrate anticoagulation (RCA) is increasingly used for continuous renal replacement therapy (CRRT) in children, but it is rarely used in children with liver injury, especially liver failure (LF). We analyze this issue through the following research.

METHODS

We retrospectively analyzed 75 children with liver injury who underwent RCA-CRRT in the Pediatric Intensive Care Unit (PICU) of Children's Hospital of Chongqing Medical University. The patients were divided into the LF group and liver dysfunction (LD) group. The two groups were compared to evaluate the clinical safety and efficacy of RCA-CRRT in children with liver injury and to explore RCA-CRRT management strategies, in terms of the following indicators: the incidence of bleeding, clotting, citrate accumulation (CA), acid-base imbalance, and electrolyte disturbance, as well as filter lifespans, changes in biochemical indicators, and CRRT parameters adjustment.

RESULTS

The total incidence of CA (TCA) and persistent CA (PCA) in the LF group were significantly higher than those in the LD group (38.6 vs. 16.2%, p < 0.001; 8.4 vs. 1.5%, p < 0.001); and the CA incidence was significantly reduced after adjustment both in the LF (38.6 vs. 8.4%, p < 0.001) and LD groups (16.2 vs. 1.5%, p < 0.001). The incidence of hypocalcemia was significantly higher in the LF group than in the LD group either before (34.9 vs. 8.8%, p < 0.001) or after treatment (12.0 vs. 0%, p < 0.001). The speed of the blood and citrate pumps after adjustment was lower than the initial setting values in both the LF and LD groups. The dialysis speed plus replacement speed were higher than the initial settings parameters.

CONCLUSION

For children undergoing RCA-CRRT, the risks of CA and hypocalcemia are significantly higher in children with liver failure than those with liver dysfunction, but through the proper adjustment of the protocol, RCA-CRRT can still be safely and effectively approached for children with LD and even LF.

A Meta-Analysis of Extracorporeal Anticoagulants in Pediatric Continuous Kidney Replacement Therapy

OBJECTIVE

Continuous kidney replacement therapy (CKRT) is the primary therapeutic modality utilized in hemodynamically unstable patients with severe acute kidney injury. As the circuit is extracorporeal, it poses an increased risk of blood clotting and circuit loss; frequent circuit losses affect the provider's ability to provide optimal treatment. The objective of this meta-analysis is to evaluate the safety and efficacy of the extracorporeal anticoagulants in the pediatric CKRT population.

DATA SOURCES

We conducted a literature search on PubMed/Medline and Embase for relevant citations.

STUDY SELECTION

Studies were included if they involved patients under the age of 18 years undergoing CKRT, with the use of anticoagulation (heparin, citrate, or prostacyclin) as a part of therapy. Only English articles were included in the study.

DATA EXTRACTION

Initial search yielded 58 articles and a total of 24 articles were included and reviewed. A meta-analysis was performed focusing on the safety and effectiveness of regional citrate anticoagulation (RCA) vs unfractionated heparin (UFH) anticoagulants in children.

DATA SYNTHESIS

RCA had statistically significantly longer circuit life of 50.65 hours vs. UFH of 42.10 hours. Two major adverse effects metabolic alkalosis and electrolyte imbalance seen more commonly in RCA compared to UFH. There was not a significant difference in the risk of systemic bleeding when comparing RCA vs. UFH.

CONCLUSION

RCA is the preferred anticoagulant over UFH due to its significantly longer circuit life, although vigilant circuit monitoring is required due to the increased risk of electrolyte disturbances. Prostacyclin was not included in the meta-analysis due to the lack of data in pediatric patients. Additional studies are needed to strengthen the study results further.