Heparin versus citrate anticoagulation for continuous renal replacement therapy in intensive care: the RRAM observational study

Study on the application of a segmented sodium citrate solution anticoagulation strategy in critically ill patients receiving CRRT: a prospective, randomized controlled study

BACKGROUND

To explore the feasibility and effectiveness of a segmented sodium citrate solution anticoagulation strategy in patients receiving CRRT.

METHODS

A prospective, randomized controlled study was conducted.

RESULTS

According to the inclusion and exclusion criteria, 80 patients were included and randomly divided into two groups. Moreover, coagulation indices, liver function indices, renal function indices, and SOFA and APACHE II scores did not significantly differ between the two groups (P > 0.05). The coagulation grade of the venous ports in the experimental group was lower than that in the control group and the two groups of filters, but the difference was not statistically significant (P = 0.337). Both sodium citrate solution infusion methods maintained a low blood calcium concentration (0.25-0.45 mmol/L) in the peripheral circulation pathway, and no patient developed hypocalcaemia (< 1.0 mmol/L). The lifespans of the extracorporeal circulation tube in the experimental group and the control group were 69.43 ± 1.49 h and 49.39 ± 2.44 h, respectively (t = 13.316, P = 0.001).

CONCLUSION

The segmented citrate solution anticoagulation strategy could extend the lifespan of the extracorporeal circulation tube and improve CRRT efficacy.

TRIAL REGISTRATION

The Chinese Clinical Trial Registry number is ChiCTR2200057272. Registered on March 5, 2022.

Citrate anticoagulation in plasma exchange followed by continuous renal replacement therapy in critically ill children

OBJECTIVE

To investigate the effectiveness and safety of regional citrate-anticoagulated (RCA) plasma exchange (PE) and whether citrate-related metabolic disorders can be improved by sequential RCA continuous renal replacement therapy (CRRT).

METHODS

This retrospective, single-center observational study included 79 critically ill children requiring PE followed by CRRT (June 2018 to June 2021) at the Pediatric Intensive Care Unit of Hunan Children's Hospital, China. Patients were divided into the RCA-PE (n = 30) and systemic heparin anticoagulation (SHA-PE) (n = 49) groups. Filter level comparison post-PE assessed RCA-PE efficacy, and metabolic changes occurring pre- and post-PE and CRRT were used to evaluate the effect of CRRT on RCA-based anticoagulation safety.

RESULTS

The RCA-PE group had a better overall filter performance than the SHA-PE group. Two hours after PE, pH and HCO₃- levels increased more significantly for the RCA-PE than the SHA-PE group. The RCA-PE incidence of metabolic alkalosis was 48.3%, higher by 4.2% (p < 0.001) compared to the SHA-PE group. In the RCA-PE group, pH and HCO₃- decreased significantly 4 h after CRRT; the metabolic alkalosis caused by RCA-PE decreased to 13.8% (p = 0.005). No significant difference in pH, HCO₃-, and metabolic alkalosis incidence was observed between the two groups 4 h after CRRT.

CONCLUSIONS

The overall filtration performance of RCA-PE is superior to that of SHA-PE followed by CRRT. The metabolic complications associated with RCA-PE are mainly metabolic alkalosis that can be improved by using CRRT after RCA-PE and this is a better alternative for anticoagulation during PE in critically ill children.

Real-life effects, complications, and outcomes in 39 critically ill neonates receiving continuous kidney replacement therapy

BACKGROUND

Continuous kidney replacement therapy (CKRT) has been expanded from simple kidney replacement therapy to the field of critical illness in children. However, CKRT is rarely used in critically ill neonates in the neonatal intensive care unit (NICU). This study aimed to describe patients' clinical characteristics at admission and CKRT initiation, CKRT effects, short-term outcomes, and predictors of death in critically ill neonates.

METHODS

A 7-year single-center retrospective study in a tertiary NICU.

RESULTS

Thirty-nine critically ill neonates received CKRT between May 2015 and April 2022 with a mortality rate of 35.9%. The most common primary diagnosis was neonatal sepsis in 15 cases (38.5%). Continuous veno-venous hemodiafiltration and continuous veno-venous hemofiltration were applied in 43.6% and 56.4% of neonates, respectively. The duration of CKRT was 44 (18, 72) h. Thirty-one patients (79.5%) had complications due to CKRT-related adverse events, and the most common complication was thrombocytopenia. Approximately 12 h after the CKRT initiation, urine volume, mean arterial pressure, and pH were increased, and serum creatinine, blood urea nitrogen, and blood lactate were decreased. In the multivariate logistic regression analysis, neonatal critical illness score [odds ratio 0.886 (0.786 ~ 0.998), P = 0.046] was an independent risk factor for death in critically ill neonates who received CKRT.

CONCLUSIONS

CKRT can be an effective and feasible technique in critically ill neonates, but the overall mortality and CKRT-related complications are relatively high. Furthermore, the probability of death is greater among neonates with greater severity of illness at CKRT initiation. A higher resolution version of the Graphical abstract is available as Supplementary information.

Analysis of the extracorporeal anticoagulation effect of modified citrate infusion during continuous renal replacement therapy in critically ill patients

INTRODUCTION

To analyze the anticoagulation effect of different local infusion methods of citrate underwent continuous renal replacement therapy (CRRT) in critically ill patients.

METHODS

The study adopted a single-centre retrospective design. Critically ill patients were divided into conventional group and modified group based on the infusion methods of citrate.

RESULTS

The modified group had a longer mean treatment time (67.67 ± 18.69  hours vs. 52.11 ± 24.26 hours, p = 0.007), a lower transmembrane pressure (147.77 ± 66.85 cm H₂ O vs. 200.63 ± 118.66 cm H₂ O, p = 0.038), fewer citrate bag replacements (1.43 ± 0.50 times vs. 10.60 ± 3.19 times, p < 0.001), and more steady ionized calcium at the venous end (0.35 ± 0.06 mmol/L vs. 0.40 ± 0.05 mmol/L, p = 0.006) compared to the conventional group patients, with statistically significant differences. The incidences of citrate accumulation and tubing coagulation were marginally lower in the modified group.

CONCLUSION

The modified local citrate infusion method can prolong treatment time, while reducing both the nursing workload and the occurrence of citrate accumulation.