Ptns commencing CRRT are commonly receiving an anticoagulant to avoid thrombosis of the DX filter;
Regional citrate anticoagulation (RCA) is superior to systemic heparin for anticoagulation with continuous renal replacement therapy (CRRT) (Nov 2020)
Ptns commencing CRRT are commonly receiving an anticoagulant to avoid thrombosis of the DX filter; the choice of anticoagulation plan is in continuous debate. A randomized trial conducting about 600 ptns with critical illness + AKI ttt with CRRT, ptns ttt with RCA, have been compared with those ttt with infused systemic heparinization, showed a longer filter life span (47 vs 26 hs), however, there is also an increased frequency of new infectious episodes (68 vs 55 %). The Rate of 90 d MR were the same among these groups. To conclude, this trial is supporting the preferability of the regimen of RCA over the traditional systemic heparinization to the anticoagulated critically ill ptns in ICU/CCU via their CRRT.
Zarbock A, Küllmar M, Kindgen-Milles D, et al. Effect of Regional Citrate Anticoagulation vs Systemic Heparin Anticoagulation During Continuous Kidney Replacement Therapy on Dialysis Filter Life Span and Mortality Among Critically Ill Patients with Acute Kidney Injury: A Randomized Clinical Trial. JAMA 2020; 324:1629.
o RCA: Regional citrate anticoagulation.
o UFH: Unfractionated heparin.
o RCT: randomized controlled trials
o US: The United States.
o AKI: Acute kidney injury.
o CI: Contraindications.
o CRRT/CKRT: Continuous kidney/renal replacement therapy.
Ptns with repeated clotting of the hemofilter
If the dialyzer hemofilter cannot be kept with no anticoagulation for minimally 24 hs, anticoagulation can be addressed unless the clotting was related to access malfunction. If RCA is available and the RCA was not contraindicated, we can admit RCA module rather than UFH. RCA is efficacious with an increased hemofilter lifespan and low risk of bleeding and transfusion facilities as compared to the UFH. For ptns having CI or cannot tolerate RCA, or if RCA is not feasible, UFH can be permitted.
Multiple RCT & meta-analyses have reported that RCA is superior to heparin in keeping filter patency with a lowered risk of untoward effects, e.g., bleeding. It seems that there is not a survival benefit of either heparin or RCA (see above). The largest meta-analysis (11 RCT, 992 ptns) comparing RCA with either systemic (9 trials) or regional (2 trials) heparin. The reported risk of circuit loss was lowered in RCA treated ptns as compared with regional heparin & systemic heparin (SH). Bleeding risk, however, was lowered with RCA as compared to SH & the same between RCA & regional heparin. No difference can be detected in survival between groups. However, another meta-analysis including different reports showed No overall advantage for citrate in circuit clotting but documented a decline in the major bleeding events related to RCA as compared to UFH. Another large trial, comparing SH, RCA resulted in an extended filter life span but with a higher frequency of infectious episodes. Consistent with previous studies, NO difference has been reported in survival between different groups. RCA is NOT approved by the US FDA for CKRT; moreover, the commercial fluid required for RCA for CKRT are currently not available in the US.