Abstract
Objective
To compare the efficacy and safety of adjusted-dose unfractionated heparin with that of regional citrate anticoagulation in intensive care patients treated by continuous venovenous hemofiltration (CVVH).
Design and setting
Prospective, randomized, clinical trial in a 32-bed medical and surgical ICU in a university teaching hospital.
Patients
ICU patients with acute renal failure requiring continuous renal replacement therapy, without cirrhosis, severe coagulopathy, or known sensitivity to heparin.
Interventions
Before the first CVVH run patients were randomized to receive anticoagulation with heparin or trisodium citrate. Patients eligible for another CVVH run received the other study medication in a cross-over fashion until the fourth circuit.
Measurements and results
Forty-nine circuits (hemofilters) were analyzed: 23 with heparin and 26 with citrate. The median lifetime of hemofilters was 70 h (interquartile range 44–140) with citrate anticoagulation and 40 h (17–48) with heparin (p=0.0007). One major bleeding occurred during heparin anticoagulation and one metabolic alkalosis (pH=7.60) was noted with citrate after a protocol violation. Transfusion rates (units of red cells per day of CVVH) were, respectively, 0.2 (0.0–0.4) with citrate and 1.0 (0.0–2.0) with heparin (p=0.0008).
Conclusions
Regional citrate anticoagulation seems superior to heparin for the filter lifetime and transfusion requirements in ICU patients treated by continuous renal replacement therapy.
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References
Ward DM, Mehta RL (1993) Extracorporeal management of acute renal failure patients at high risk of bleeding. Kidney Int 4:S237–S244
Reeves JH, Cumming AR, Gallagher L, O’Brien JL, Santamaria JD (1999) A controlled trial of low-molecular-weight heparin (dalteparin) versus unfractionated heparin as anticoagulant during continuous venovenous hemodialysis with filtration. Crit Care Med 27:2224–2228
Fiaccadori E, Maggiore U, Rotelli C, Minari M, Melfa L, Cappe G, Cabassi A (2002) Continuous haemofiltration in acute renal failure with prostacyclin as the sole anti-haemostatic agent. Intensive Care Med 28:586–593
Ohtake Y, Hirasawa H, Sugai T, Oda S, Shiga H, Matsuda K, Kitamura N (1991) Nafamostat mesylate as anticoagulant in continuous hemofiltration and continuous hemodiafiltration. Contrib Nephrol 93:215–217
Tan HK, Baldwin I, Bellomo R (2000) Continuous veno-venous hemofiltration without anticoagulation in high-risk patients. Intensive Care Med 26:1652–1657
Uchino S, Fealy N, Baldwin I, Morimatsu H, Bellomo R (2003) Continuous is not continuous: the incidence and impact of circuit “down-time” on uraemic control during continuous veno-venous haemofiltration. Intensive Care Med 29:575–578
Cutts MW, Thomas AN, Kishen R (2000) Transfusion requirements during continuous veno-venous haemofiltration: the importance of filter life. Intensive Care Med 26:1694–1697
Palsson R, Niles JL (1999) Regional citrate anticoagulation in continuous venovenous hemofiltration in critically ill patients with a high risk of bleeding. Kidney Int 55:1991–1997
Kutsogiannis DJ, Mayers I, Chin WD, Gibney RT (2000) Regional citrate anticoagulation in continuous venovenous hemodiafiltration. Am J Kidney Dis 35:802–811
Ronco C, Bellomo R, Homel P, Brendolan A, Dan M, Piccinni P, La Greca G (2000) Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 356:26–30
Mehta RL, McDonald BR, Aguilar MM, Ward DM (1990) Regional citrate anticoagulation for continuous arteriovenous hemodialysis in critically ill patients. Kidney Int 38:976–981
Gabutti L, Marone C, Colucci G, Duchini F, Schonholzer C (2002) Citrate anticoagulation in continuous venovenous hemodiafiltration: a metabolic challenge. Intensive Care Med 28:1419–1425
Tolwani AJ, Campbell RC, Schenk MB, Allon M, Warnock DG (2001) Simplified citrate anticoagulation for continuous renal replacement therapy. Kidney Int 60:370–374
Le Gall JR, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957–2963
Le Gall JR, Klar J, Lemeshow S, Saulnier F, Alberti C, Artigas A, Teres D (1996) The Logistic Organ Dysfunction system. A new way to assess organ dysfunction in the intensive care unit. ICU Scoring Group. JAMA 276:802–810
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Monchi, M., Berghmans, D., Ledoux, D. et al. Citrate vs. heparin for anticoagulation in continuous venovenous hemofiltration: a prospective randomized study. Intensive Care Med 30, 260–265 (2004). https://doi.org/10.1007/s00134-003-2047-x
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DOI: https://doi.org/10.1007/s00134-003-2047-x