Skip to main content
SpringerLink
Log in

Regionale Zitratantikoagulation bei Nierenersatzverfahren auf der Intensivstation

Empfehlungen der Sektionen Niere der DGIIN, ÖGIAIN und DIVI

Regional citrate anticoagulation in renal replacement therapy in the intensive care station

Recommendations from the renal section of the DGIIN, ÖGIAIN and DIVI

  • Leitlinien und Empfehlungen
  • Published:
Medizinische Klinik - Intensivmedizin und Notfallmedizin Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Die regionale Zitratantikoagulation (RCA) ermöglicht eine effektive Antikoagulation des Dialysekreislaufs, ohne die systemischen Nebenwirkungen einer Heparinisierung zu haben. Insbesondere ist sie bei den kontinuierlichen Verfahren gut etabliert und stellt ein sicheres Verfahren dar, das zu längeren Filterlaufzeiten und weniger Blutungskomplikationen führt.

Ziel der Arbeit

Um Indikation, Vor- und Nachteile sowie die Anwendung der RCA aufzuzeigen, werden aktuelle Empfehlungen der Sektionen Niere der Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN), der Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin (ÖGIAIN) und der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI) dargestellt.

Material und Methoden

Die Empfehlungen dieser Arbeit basieren auf den aktuellen KDIGO-Leitlinien (Kidney Disease: Improving Global Outcomes), diversen sonstigen publizierten Leitlinien und Protokollen sowie der Expertenmeinung und klinischen Erfahrung der Autoren.

Ergebnisse

Maßgeblich für die Sicherheit der RCA bei Nierenersatzverfahren ist eine hinreichende Schulung, die Verwendung konfektionierter Systeme mit gekoppelten Pumpensystemen und die feste regionale Etablierung des Verfahrens optimaler Weise mit Standardarbeitsanweisungen (SOP). Auch bei Patienten mit Leberversagen oder Kreislaufschock mit Laktatacidose besteht entgegen früherer Empfehlungen keine absolute Kontraindikation zur RCA mehr, jedoch sollte insbesondere hier auf die Zeichen einer möglichen Zitratakkumulation geachtet werden

Abstract

Background

Regional citrate anticoagulation (RCA) in continuous renal replacement therapy can effectively anticoagulate dialysis circuits without having adverse effects on systemic heparin application. In particular, in continuous renal replacement therapy RCA is well established and represents a safe procedure with longer filter lifetimes and fewer bleeding complications.

Objectives

To provide guidance on the indications, advantages and disadvantages, and use of RCA, current recommendations from the renal section of the DGIIN (Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin), ÖGIAIN (Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin) and DIVI (Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin) are stated.

Materials and methods

The recommendations in this paper are based on the current KDIGO (Kidney Disease: Improving Global Outcomes) guidelines, other published guidelines and protocols as well as the expert knowledge and clinical experience of the authors.

Results

The use of commercially available machines with coupled pumps and integrated safety features, effective personal training and standardized protocols for clinical usage (SOP) is particularly important for the safe clinical use of RCA in renal replacement therapy. Contrary to previous recommendations, even liver failure or shock with lactic acidosis may no longer be an absolute contra-indication for RCA. However, these particular patients have to be carefully monitored for signs of citrate accumulation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1

Literatur

  1. Bai M et al (2015) Citrate versus heparin anticoagulation for continuous renal replacement therapy: an updated meta-analysis of RCTs. Intensive Care Med 41:2098–2110

    Article  PubMed  CAS  Google Scholar 

  2. Balik M et al (2005) Prostacyclin versus citrate in continuous haemodiafiltration: an observational study in patients with high risk of bleeding. Blood Purif 23:325–329

    Article  PubMed  CAS  Google Scholar 

  3. Beige J et al (2017) Durchführung intermittierender Dialysen mit zitratbasierter regionaler Antikoagulation nach den Regeln des Medizinproduktegesetzes. Positionspapier der Deutschen Gesellschaft für Nephrologie. Nephrologe 12:43–44

    Article  Google Scholar 

  4. Buturovic-Ponikvar J (2016) Is regional citrate anticoagulation the future of hemodialysis? Ther Apher Dial 20:234–239

    Article  PubMed  Google Scholar 

  5. Buturovic-Ponikvar J et al (2008) Regional citrate anticoagulation for hemodialysis: calcium-free vs. calcium containing dialysate—a randomized trial. Int J Artif Organs 31:418–424

    Article  PubMed  CAS  Google Scholar 

  6. Buturovic-Ponikvar J et al (2005) Citrate anticoagulation for single-needle hemodialysis: safety and efficacy. Ther Apher Dial 9:237–240

    Article  PubMed  CAS  Google Scholar 

  7. Calatzis A et al (2001) Citrate anticoagulation for extracorporeal circuits: effects on whole blood coagulation activation and clot formation. Nephron 89:233–236

    Article  PubMed  CAS  Google Scholar 

  8. Dolley-Hitze T et al (2016) Is anticoagulation discontinuation achievable with citrate dialysate during HDF sessions? Int J Nephrol 2016:9185413

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  9. European Best Practice Guidelines Expert Group on Hemodialysis ERA (2002) Section V. Chronic intermittent haemodialysis and prevention of clotting in the extracorporal system. Nephrol Dial Transplant 17(Suppl 7):63–71

    Google Scholar 

  10. Evenepoel P et al (2007) Heparin-coated polyacrylonitrile membrane versus regional citrate anticoagulation: a prospective randomized study of 2 anticoagulation strategies in patients at risk of bleeding. Am J Kidney Dis 49:642–649

    Article  PubMed  CAS  Google Scholar 

  11. Evenepoel P et al (2002) Regional citrate anticoagulation for hemodialysis using a conventional calcium-containing dialysate. Am J Kidney Dis 39:315–323

    Article  PubMed  CAS  Google Scholar 

  12. Gattas DJ et al (2015) A randomized controlled trial of regional citrate versus regional heparin anticoagulation for continuous renal replacement therapy in critically ill adults. Crit Care Med 43(8):1622

    Article  PubMed  CAS  Google Scholar 

  13. Gradwohl-Matis I et al (2015) Renal replacement therapy with regional citrate anticoagulation as an effective method to treat hypercalcemic crisis. ASAIO J 61:219–223

    Article  PubMed  CAS  Google Scholar 

  14. Gritters M et al (2006) Citrate anticoagulation abolishes degranulation of polymorphonuclear cells and platelets and reduces oxidative stress during haemodialysis. Nephrol Dial Transplant 21:153–159

    Article  PubMed  CAS  Google Scholar 

  15. Hetzel GR et al (2011) Regional citrate versus systemic heparin for anticoagulation in critically ill patients on continuous venovenous haemofiltration: a prospective randomized multicentre trial. Nephrol Dial Transplant 26:232–239

    Article  PubMed  CAS  Google Scholar 

  16. Hetzel GR et al (2006) Citrate plasma levels in patients under regional anticoagulation in continuous venovenous hemofiltration. Am J Kidney Dis 48:806–811

    Article  PubMed  CAS  Google Scholar 

  17. Joannidis M et al (2007) Enoxaparin vs. unfractionated heparin for anticoagulation during continuous veno-venous hemofiltration: a randomized controlled crossover study. Intensive Care Med 33:1571–1579

    Article  PubMed  CAS  Google Scholar 

  18. Joannidis M, Oudemans-Van Straaten HM (2007) Clinical review: Patency of the circuit in continuous renal replacement therapy. Crit Care 11:218

    Article  PubMed  PubMed Central  Google Scholar 

  19. Kessler M et al (2015) Anticoagulation in chronic hemodialysis: progress toward an optimal approach. Semin Dial 28:474–489

    Article  PubMed  Google Scholar 

  20. Khadzhynov D et al (2017) Hyperlactatemia, lactate kinetics and prediction of citrate accumulation in critically ill patients undergoing continuous renal replacement therapy with regional citrate Anticoagulation. Crit Care Med 45:e941–e946

    Article  PubMed  CAS  Google Scholar 

  21. Khadzhynov D et al (2014) Evaluation of acid-base control, electrolyte balance, and filter patency of a Prismaflex-based regional citrate anticoagulation protocol for pre-dilution continuous veno-venous hemodiafiltration. Clin Nephrol 81:320–330

    Article  PubMed  CAS  Google Scholar 

  22. Kidney Disease (2012) Improving global outcomes (Kdigo) acute kidney injury work group KDIGO clinical practice guideline for acute kidney injury. Kidney Inter Suppl 2(1):1–138. https://doi.org/10.1038/kisup.2012.1

    Article  Google Scholar 

  23. Lehner GF et al (2017) Hemofiltration induces generation of leukocyte-derived CD31+/CD41- microvesicles in sepsis. Ann Intensive Care 7:89

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  24. Liu C et al (2016) Regional citrate versus heparin anticoagulation for continuous renal replacement therapy in critically ill patients: a meta-analysis with trial sequential analysis of randomized controlled trials. Crit Care 20:1–13

    Google Scholar 

  25. Mehta RL et al (1990) Regional citrate anticoagulation for continuous arteriovenous hemodialysis in critically ill patients. Kidney Int 38:976–981

    Article  PubMed  CAS  Google Scholar 

  26. Meier-Kriesche HU et al (2001) Increased total to ionized calcium ratio during continuous venovenous hemodialysis with regional citrate anticoagulation. Crit Care Med 29:748–752

    Article  PubMed  CAS  Google Scholar 

  27. Meijers B et al (2012) A prospective randomized open-label crossover trial of regional citrate anticoagulation vs. anticoagulation free liver dialysis by the molecular adsorbents recirculating system. Crit Care 16:R20

    Article  PubMed  PubMed Central  Google Scholar 

  28. Meijers B et al (2017) A noninferiority trial comparing a heparin-grafted membrane plus citrate-containing dialysate versus regional citrate anticoagulation: results of the CiTED study. Nephrol Dial Transplant 32:707–714

    Article  PubMed  Google Scholar 

  29. Meijers BK et al (2014) Heparin-coated dialyzer membranes: is non-inferiority good enough? Kidney Int 86:1084–1086

    Article  PubMed  CAS  Google Scholar 

  30. Morath C et al (2008) Sodium citrate anticoagulation during sustained low efficiency dialysis (SLED) in patients with acute renal failure and severely impaired liver function. Nephrol Dial Transplant 23:421–422

    Article  PubMed  Google Scholar 

  31. Morgera S et al (2009) A safe citrate anticoagulation protocol with variable treatment efficacy and excellent control of the acid-base status. Crit Care Med 37:2018–2024

    Article  PubMed  CAS  Google Scholar 

  32. Morgera S et al (2004) A simple, safe and effective citrate anticoagulation protocol for the genius dialysis system in acute renal failure. Nephron Clin Pract 98:c35–c40

    Article  PubMed  CAS  Google Scholar 

  33. Morita Y et al (1961) Regional anticoagulation during hemodialysis using citrate. Am J Med Sci 242:32–43

    Article  PubMed  CAS  Google Scholar 

  34. Nuthall G et al (2002) Citrate anticoagulation in a piglet model of pediatric continuous renal replacement therapy. Crit Care Med 30:900–903

    Article  PubMed  CAS  Google Scholar 

  35. Oudemans-Van Straaten HM et al (2009) Citrate anticoagulation for continuous venovenous hemofiltration. Crit Care Med 37:545–552

    Article  PubMed  CAS  Google Scholar 

  36. Palsson R et al (2006) Choice of replacement solution and anticoagulant in continuous venovenous hemofiltration. Clin Nephrol 65:34–42

    Article  PubMed  CAS  Google Scholar 

  37. Raimundo M et al (2013) Maintaining normal levels of ionized calcium during citrate-based renal replacement therapy is associated with stable parathyroid hormone levels. Nephron Clin Pract 124:124–131

    Article  PubMed  CAS  Google Scholar 

  38. Richtrova P et al (2011) Evaluation of three different methods to prevent dialyzer clotting without causing systemic anticoagulation effect. Artif Organs 35:83–88

    Article  PubMed  Google Scholar 

  39. Sands JJ et al (2012) Effects of citrate acid concentrate (citrasate®) on heparin N requirements and hemodialysis adequacy: a multicenter, prospective noninferiority trial. Blood Purif 33:199–204

    Article  PubMed  Google Scholar 

  40. Schilder L et al (2014) Citrate confers less filter-induced complement activation and neutrophil degranulation than heparin when used for anticoagulation during continuous venovenous haemofiltration in critically ill patients. BMC Nephrol 15:19

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  41. Schmitz M et al (2015) Treatment of acute renal failure in Germany: analysis of current practice. Med Klin Intensivmed Notfmed 110:256–263

    Article  PubMed  CAS  Google Scholar 

  42. Schmitz M et al (2007) Continuous venovenous haemofiltration using a citrate buffered substitution fluid. Anaesth Intensive Care 35:529–535

    PubMed  CAS  Google Scholar 

  43. Schultheiss C et al (2012) Continuous venovenous hemodialysis with regional citrate anticoagulation in patients with liver failure: a prospective observational study. Crit Care 16:R162

    Article  PubMed  PubMed Central  Google Scholar 

  44. Schwarzer P et al (2015) Discrepant post filter ionized calcium concentrations by common blood gas analyzers in CRRT using regional citrate anticoagulation. Crit Care 19:321

    Article  PubMed  PubMed Central  Google Scholar 

  45. Shum HP et al (2012) Regional citrate anticoagulation in predilution continuous venovenous hemofiltration using prismocitrate 10/2 solution. Ther Apher Dial 16:81–86

    Article  PubMed  CAS  Google Scholar 

  46. Slowinski T et al (2015) Safety and efficacy of regional citrate anticoagulation in continuous venovenous hemodialysis in the presence of liver failure: the Liver Citrate Anticoagulation Threshold (L-CAT) observational study. Crit Care 19:349

    Article  PubMed  PubMed Central  Google Scholar 

  47. Tiranathanagul K et al (2011) Regional citrate anticoagulation reduces polymorphonuclear cell degranulation in critically ill patients treated with continuous venovenous hemofiltration. Ther Apher Dial 15:556–564

    Article  PubMed  CAS  Google Scholar 

  48. Tolwani AJ et al (2008) Standard versus high-dose CVVHDF for ICU-related acute renal failure. J Am Soc Nephrol 19:1233–1238

    Article  PubMed  PubMed Central  Google Scholar 

  49. Tolwani AJ et al (2006) A practical citrate anticoagulation continuous venovenous hemodiafiltration protocol for metabolic control and high solute clearance. Clin. J Am Soc Nephrol 1:79–87

    Article  CAS  Google Scholar 

  50. Wald R et al (2012) Optimal Mode of clearance in critically ill patients with Acute Kidney Injury (OMAKI) —a pilot randomized controlled trial of hemofiltration versus hemodialysis: a Canadian Critical Care Trials Group project. Crit Care 16:R205

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Klinik für Nephrologie und Allgemeine Innere Medizin, Städtisches Klinikum Solingen, Gotenstraße 1, 42653, Solingen, Deutschland

    M. Schmitz

  2. Gemeinsame Einrichtung internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Innsbruck, Österreich

    M. Joannidis & S. J. Klein

  3. Medizinische Klinik, Abteilung Klinische Pharmakologie und Pharmakoepidemiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Deutschland

    D. Czock

  4. Abteilung Internistische Intensivmedizin, Medizinische Klinik 8, Paracelsus Medizinische Privatuniversität (PMU) Nürnberg, Universität Erlangen-Nürnberg, Klinikum Nürnberg-Süd, Nürnberg, Deutschland

    S. John

  5. Medizinische Klinik I für Nephrologie, Transplantationsmedizin und internistische Intensivmedizin, Klinikum der Universität Witten/Herdecke, Köln-Merheim, Deutschland

    A. Jörres

  6. Klinik für Notfall- und internistische Intensivmedizin, Klinikum Ernst von Bergmann, Potsdam, Deutschland

    M. Oppert

  7. Klinik für Nieren‑, Hochdruck- und Autoimmunerkrankungen, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Deutschland

    V. Schwenger

  8. Medizinische Klinik V, Nephrologie, Rheumatologie, Blutreinigungsverfahren, Städtisches Klinikum Braunschweig, Braunschweig, Deutschland

    J. Kielstein

  9. Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland

    A. Zarbock

  10. Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Moorenstr. 5, 40225, Düsseldorf, Deutschland

    D. Kindgen-Milles

  11. Medizinische Klinik 4, Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland

    C. Willam

Authors
  1. M. Schmitz
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M. Joannidis
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. D. Czock
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. S. John
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. A. Jörres
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. S. J. Klein
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. M. Oppert
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. V. Schwenger
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. J. Kielstein
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. A. Zarbock
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. D. Kindgen-Milles
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. C. Willam
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to M. Schmitz.

Ethics declarations

Interessenkonflikt

M. Schmitz erhielt Studienunterstützung durch die Firma Fresenius Medical Care. M. Joannidis erhielt Vortrags‑/Konsulentenhonorare von den Firmen Baxter Healthcare Corp, CLS Behring, Fresenius und Astute Medical sowie Forschungsunterstützung von der Firma Fresenius. S. John erhielt Vortragshonorare von der Firma Baxter Healthcare USA und ist dort im Advisory Board tätig. A. Jörres erhielt Berater- und Vortragshonorare von der Firma Fresenius Medical Care. M. Oppert erhielt Vortragshonorar von der Firma Baxter. V. Schwenger erhielt Vortragshonorare von den Firmen Fresenius Medical Care und Baxter. J. Kielstein erhielt Vortragshonorare von den Firmen Fresenius Medical Care, Baxter und Terumo BCT sowie Forschungsunterstützung von der Firma ExThera Medical. A. Zarbock erhielt eine Förderung durch die Deutsche Forschungsgemeinschaft (ZA428/10-1) sowie von den Firmen Astellas und Astute Medical, er erhielt zudem Vortragshonorare von den Firmen Fresenius Medical Care, Baxter, Braun und Astute Medical und ist bei der Firma Quarks Pharmaceuticals im Advisory Board tätig. D. Kindgen-Milles erhielt Studienunterstützung und Vortragshonorare durch die Firma Fresenius Medical Care sowie Vortragshonorare von der Firma Baxter. D. Czock. S.J. Klein und C. Willam geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Additional information

Redaktion

M. Joannidis, Innsbruck

S. John, Nürnberg

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Schmitz, M., Joannidis, M., Czock, D. et al. Regionale Zitratantikoagulation bei Nierenersatzverfahren auf der Intensivstation. Med Klin Intensivmed Notfmed 113, 377–383 (2018). https://doi.org/10.1007/s00063-018-0445-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00063-018-0445-7

Schlüsselwörter

Keywords

Search

Navigation