Original Paper Nephron Clin Pract 2013;124:119–123 DOI: 10.1159/000355550
Received: May 8, 2013 Accepted: August 23, 2013 Published online: November 19, 2013
Beyond the Randomized Clinical Trial: Citrate for Continuous Renal Replacement Therapy in Clinical Practice L. Tovey H. Dickie S. Gangi M. Terblanche C. McKenzie R. Beale D. Treacher M. Ostermann Department of Critical Care, King’s College London, King’s Health Partners, Guy’s & St Thomas’ Foundation Hospital, London, UK
Abstract Background: Premature circuit clotting is a major problem during continuous renal replacement therapy (CRRT). Six randomized controlled trials confirmed that regional anticoagulation with citrate is superior to heparin. Our objective was to compare circuit patency with citrate, heparin and epoprostenol in routine clinical practice. Methods: We retrospectively analysed data on circuit patency of all circuits used in a single centre between September 2008 and August 2009. We differentiated between premature filter clotting, elective discontinuation and waste. Results: 309 patients were treated with CRRT (n = 2,059 circuits). The mean age was 65.7; 63.8% were male. The methods to maintain circuit patency were unfractionated heparin (42.3%), epoprostenol (23.0%), citrate (14.7%), combinations of different anticoagulants (14.6%) and no anticoagulation (4.7%). Premature clotting was the most common reason for circuit discontinuation among circuits anticoagulated with heparin, epoprostenol or combinations of different anticoagulants (59–62%). Among circuits anticoagulated with citrate the main reason for discontinuation was elective (61%). Hazard regression analysis confirmed significantly better circuit survival with
© 2013 S. Karger AG, Basel 1660–2110/13/1242–0119$38.00/0 E-Mail [email protected] www.karger.com/nec
citrate. Changing from heparin to citrate decreased the risk of premature circuit clotting by 75.8%. Conclusion: In routine clinical practice, regional anticoagulation with citrate is associated with significantly better circuit patency than heparin or epoprostenol. © 2013 S. Karger AG, Basel
Introduction
The practice of renal replacement therapy (RRT) of critically ill patients in the intensive care unit varies worldwide with differences in the main providers (i.e. nephrology versus critical care team, nurses versus doctors), preferred modalities and type of anticoagulation [1]. Unfractionated heparin is the most commonly used anticoagulant during continuous RRT (CRRT) mainly as a result of familiarity, low cost and ease of administration and monitoring. The obvious drawback is the risk of bleeding. An alternative is citrate which offers regional anticoagulation without systemic anticoagulation. Citrate acts by chelating calcium and therefore inhibits the clotting cascade at several levels. The principle of regional anticoagulation is based on pre-filter infusion of citrate aiming for an ionized Ca concentration [Cai] of
Received: May 8, 2013 Accepted: August 23, 2013 Published online: November 19, 2013
Beyond the Randomized Clinical Trial: Citrate for Continuous Renal Replacement Therapy in Clinical Practice L. Tovey H. Dickie S. Gangi M. Terblanche C. McKenzie R. Beale D. Treacher M. Ostermann Department of Critical Care, King’s College London, King’s Health Partners, Guy’s & St Thomas’ Foundation Hospital, London, UK
Abstract Background: Premature circuit clotting is a major problem during continuous renal replacement therapy (CRRT). Six randomized controlled trials confirmed that regional anticoagulation with citrate is superior to heparin. Our objective was to compare circuit patency with citrate, heparin and epoprostenol in routine clinical practice. Methods: We retrospectively analysed data on circuit patency of all circuits used in a single centre between September 2008 and August 2009. We differentiated between premature filter clotting, elective discontinuation and waste. Results: 309 patients were treated with CRRT (n = 2,059 circuits). The mean age was 65.7; 63.8% were male. The methods to maintain circuit patency were unfractionated heparin (42.3%), epoprostenol (23.0%), citrate (14.7%), combinations of different anticoagulants (14.6%) and no anticoagulation (4.7%). Premature clotting was the most common reason for circuit discontinuation among circuits anticoagulated with heparin, epoprostenol or combinations of different anticoagulants (59–62%). Among circuits anticoagulated with citrate the main reason for discontinuation was elective (61%). Hazard regression analysis confirmed significantly better circuit survival with
© 2013 S. Karger AG, Basel 1660–2110/13/1242–0119$38.00/0 E-Mail [email protected] www.karger.com/nec
citrate. Changing from heparin to citrate decreased the risk of premature circuit clotting by 75.8%. Conclusion: In routine clinical practice, regional anticoagulation with citrate is associated with significantly better circuit patency than heparin or epoprostenol. © 2013 S. Karger AG, Basel
Introduction
The practice of renal replacement therapy (RRT) of critically ill patients in the intensive care unit varies worldwide with differences in the main providers (i.e. nephrology versus critical care team, nurses versus doctors), preferred modalities and type of anticoagulation [1]. Unfractionated heparin is the most commonly used anticoagulant during continuous RRT (CRRT) mainly as a result of familiarity, low cost and ease of administration and monitoring. The obvious drawback is the risk of bleeding. An alternative is citrate which offers regional anticoagulation without systemic anticoagulation. Citrate acts by chelating calcium and therefore inhibits the clotting cascade at several levels. The principle of regional anticoagulation is based on pre-filter infusion of citrate aiming for an ionized Ca concentration [Cai] of
