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Regional citrate anticoagulation for continuous renal replacement therapy in children

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An Erratum to this article was published on 09 January 2017

Abstract

Background

Anticoagulation of the continuous renal replacement therapy (CRRT) circuit is an important technical aspect of this medical procedure. Most studies evaluating the efficacy and safety of citrate use have been carried out in adults, and little evidence is available for the pediatric patient population. The aim of this study was to compare regional citrate anticoagulation versus systemic heparin anticoagulation in terms of the lifetime of hemofilters in a pediatric population receiving CRRT at a pediatric center in Bogota, Colombia.

Methods

This was an analytical, observational, retrospective cohort study in which we assessed the survival of 150 hemofilters (citrate group 80 hemofilters, heparin group 70 hemofilters) used in a total of 3442 hours of CCRT (citrate group 2248 h, heparin group 1194 h). Hemofilter survival was estimated beginning at placement and continuing until filter replacement due to clotting or high trans-membrane pressures.

Results

Hemofilter survival was higher in the citrate group than in the heparin group (72 vs. 18 h; p <0.0001). Bivariate analysis showed that the hemofilter coagulation risk was significantly increased when heparin was used, regardless of hemofilter size and pump flow (hazard ratio 3.70, standard error 0.82, 95% confidence interval 2.39–5.72; p <0.00001).

Conclusions

Regional citrate anticoagulation could be more effective than heparin systemic anticoagulation in terms of prolonging the hemofilter lifetime in patients with acute renal injury who require CRRT.

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References

  1. Sutherland SM, Alexander SR (2012) Continuous renal replacement therapy in children. Pediatr Nephrol 27:2007–2016

    Article  PubMed  Google Scholar 

  2. Oudemans-van Straaten HM, Kellum JA, Bellomo R (2011) Clinical review: Anticoagulation for continuous renal replacement therapy-heparin or citrate? Crit Care 15:202–211

    Article  PubMed  PubMed Central  Google Scholar 

  3. Hetzel GR, Schmitz M, Wissing H, Ries W, Schott G, Heering PJ, Isgro F, Kribben A, Himmele R, Grabensee B, Rump LC (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

    CAS  Article  PubMed  Google Scholar 

  4. Kutsogiannis DJ, Gibney RT, Stollery T, Gao J (2005) Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 67:2361–2367

    CAS  Article  PubMed  Google Scholar 

  5. Monchi M, Berghmans D, Ledoux D, Canivet JL, Dubois D, Damas P (2004) Citrate vs. heparin for anticoagulation in continuous venovenous hemofiltration: a prospective randomized study. Intensive Care Med 30:260–265

    Article  PubMed  Google Scholar 

  6. Oudemans-Van Straaten HM, Bosman RJ, Koopmans M, Van der Voot P, Wester J, Van der Spoel J, Dijksman L, Zandstra D (2009) Citrate anticoagulation for continuous venovenous hemofiltration. Crit Care Med 37:545–552

    CAS  Article  PubMed  Google Scholar 

  7. Betjes MG, van Oosterom D, van Agteren M, Van de Wetering J (2007) Regional citrate versus heparin anticoagulation during venovenous hemofiltration in patients at low risk for bleeding: similar hemofilter survival but significantly less bleeding. J Nephrol 20:602–608

    CAS  PubMed  Google Scholar 

  8. Fealy N, Baldwin I, Johnstone M, Egi M, Bellomo R (2007) A pilot randomized controlled crossover study comparing regional heparinization to regional citrate anticoagulation for continuous venovenous hemofiltration. Int J Artif Organs 30:301–307

    CAS  PubMed  Google Scholar 

  9. Wu MY, Hsu YH, Bai CH, Bai CH, Lin YF, Wu CH, Tam KW (2012) Regional citrate versus heparin anticoagulation for continuous renal replacement therapy: a meta-analysis of randomized controlled trials. Am J Kidney Dis 59:810–818

    CAS  Article  PubMed  Google Scholar 

  10. Zhang Z, Hongying N (2012) Efficacy and safety of regional citrate anticoagulation in critically ill patients undergoing continuous renal replacement therapy. Intensive Care Med 38:20–28

    Article  PubMed  Google Scholar 

  11. Davis TK, Neumayr T, Geile K, Doctor A, Hmeil P (2014) Citrate anticoagulation during continuous renal replacement therapy in pediatric critical care. Pediatr Crit Care Med 15:471–485

    Article  PubMed  Google Scholar 

  12. Bunchman TE, Maxvold NJ, Barnett J, Hutchings A, Benfield M (2002) Pediatric hemofiltration: Normocarb dialysate solution with citrate anticoagulation. Pediatr Nephrol 17:150–154

    Article  PubMed  Google Scholar 

  13. Bunchman TE, Maxvold NJ, Brophy PD (2003) Pediatric convective hemofiltration: Normocarb replacement fluid and citrate anticoagulation. Am J Kidney Dis 42:1248–1252

    Article  PubMed  Google Scholar 

  14. Symons JM, Brophy PD, Gregory MJ, Mcafee N, Somers MJ, Bunchman TE, Goldstein SN (2003) Continuous renal replacement therapy in children up to 10 kg. Am J Kidney Dis 41:984–989

    Article  PubMed  Google Scholar 

  15. Elhanan N, Skippen P, Nuthall G, Krahn G, Seear M (2004) Citrate anticoagulation in pediatric continuous venovenous hemofiltration. Pediatr Nephrol 19:208–212

    Article  PubMed  Google Scholar 

  16. Hothi DK, St George-Hyslop C, Geary D, Bohn D, Harvey E (2006) Continuous renal replacement therapy (CRRT) in children using the AQUARIUS. Nephrol Dial Transplant 21:2296–2300

    Article  PubMed  Google Scholar 

  17. Bunchman TE, Hackbarth RM, Maxvold NJ, Winters JW, Barletta GM (2007) Prevention of dialysis disequilibrium by use of CVVH. Int J Artif Organs 30:441–444

    CAS  PubMed  Google Scholar 

  18. Rajasekaran S, Jones DP, Avent Y, Shaffer M, Elbahlawan L, Henderson N, Barfield RC, Morrison R, Tamburro RF (2010) Outcomes of hematopoietic stem cell transplant patients who received continuous renal replacement therapy in a pediatric oncology intensive care unit. Pediatr Crit Care Med 11:699–706

    Article  PubMed  Google Scholar 

  19. Symons JM, Chua AN, Somers MJ, Baum M, Bunchman T, Benfield M, Brophy P, Blowey D, Fortenberry J, Chand D, Flores F, Hackbarth R, Alexander S, Mahan J, Mcbryde K, Goldstein S (2007) Demographic characteristics of pediatric continuous renal replacement therapy: A report of the prospective pediatric continuous renal replacement therapy registry. Clin J Am Soc Nephrol 2:732–738

    Article  PubMed  Google Scholar 

  20. Brophy PD, Somers MJ, Baum MA, Symons J, Mcafee N, Fortenberry J, Rogers K, Barnett J, Blowey D, Baker C, Bunchman T, Goldstein S (2005) Multi-centre evaluation of anticoagulation in patients receiving continuous renal replacement therapy (CRRT). Nephrol Dial Transplant 20:1416–1421

    Article  PubMed  Google Scholar 

  21. Askenazi DJ, Goldstein SL, Koralkar R, Fortenberry J, Baum M, Hackbarth R, Blowey D, Bunchman TE, Brophy PD, Symons J, Chua A, Flores F, Somers MJ (2013) Continuous renal replacement therapy for children ≤10 kg: A report from the prospective pediatric continuous renal replacement therapy registry. J Pediatr 162:587.e3–592.e3

    Article  Google Scholar 

  22. Chadha V, Garg U, Warady B, Alon U (2002) Citrate clearance in children receiving continuous venovenous renal replacement therapy. Pediatr Nephrol 17:819–824

    Article  PubMed  Google Scholar 

  23. Kreuzer M, Bonze K, Buscher R, Offner G, Ehrich J, Pape L (2010) Regional citrate anticoagulation is safe in intermittent high-flux haemodialysis treatment of children and adolescents with an increased risk of bleeding. Nephrol Dial Transplant 25:3337–3342

    CAS  Article  PubMed  Google Scholar 

  24. Smoyer WE, McAdams C, Kaplan BS, Sherbotie JR (1995) Determinants of survival in pediatric continuous hemofiltration. J Am Soc Nephrol 6:1401–1409

    CAS  PubMed  Google Scholar 

  25. Fernández SN, Santiago MJ, López-Herce J, García M, Del Castillo J, Alcaraz AJ, Bellón JM (2014) Citrate anticoagulation for CRRT in children: comparison with heparin. Biomed Res Int 2014:786301

    PubMed  PubMed Central  Google Scholar 

  26. Liet JM, Allain-Launay E, Gaillard-LeRoux B, Barrière F, Chenouard A, Dejode JM, Joram N (2014) Regional citrate anticoagulation for pediatric CRRT using integrated citrate software and physiological sodium concentration solutions. Pediatr Nephrol 29:1625–1631

    Article  PubMed  Google Scholar 

  27. Soltysiak J, Warzywoda A, Kociński B, Ostalska-Nowicka D, Benedyk A, Silska-Dittmar M, Zachwieja J (2014) Citrate anticoagulation for continuous renal replacement therapy in small children. Pediatr Nephrol 29:469–475

    Article  PubMed  Google Scholar 

  28. Liao YJ, Zhang L, Zeng XX, Fu P (2013) Citrate versus unfractionated heparin for anticoagulation in continuous renal replacement therapy. Chin Med J 126:1344–1349

    PubMed  Google Scholar 

  29. Basu RK, Devarajan P, Wong H, Wheeler DS (2011) An update and review of acute kidney injury in pediatrics. Pediatr Crit Care Med 12:339–347

    Article  PubMed  Google Scholar 

  30. Fortenberry J, Paden M, Goldstein (2013) Acute kidney injury in children: an update on diagnosis and treatment. Pediatr Clin N Am 60:669–688

    Article  Google Scholar 

  31. Morgera S, Scholle C, Voss G, Haase M, Vargas-Hein O, Krausch D, Melzer C, Rosseau S, Zuckermann-Becker H, Neumayer HH (2004) Metabolic complications during regional citrate anticoagulation in continuous venovenous hemodialysis: single-center experience. Nephron 97:c131–c136

    PubMed  Google Scholar 

  32. Swartz R, Pasko D, O’Toole J, Starmann B (2004) Improving the delivery of continuous renal replacement therapy using regional citrate anticoagulation. Clin Nephrol 61:134–143

    CAS  Article  PubMed  Google Scholar 

  33. Link A, Klingele M, Speer T, Rbah R, Poos J, Lemer-Graber A, Fliser D, Bohm M (2012) Total-to-ionized calcium ratio predicts mortality in continuous renal replacement therapy with citrate anticoagulation in critically ill patients. Crit Care 16:R97

    Article  PubMed  PubMed Central  Google Scholar 

  34. Kozik-Jaromin J, Nier V, Heemann U, Kreymann B, Bohler J (2009) Citrate pharmacokinetics and calcium levels during high-flux dialysis with regional citrate anticoagulation. Nephrol Dial Transplant 24:2244–2251

    CAS  Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

Authors

Corresponding author

Correspondence to Jaime Fernández Sarmiento.

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Conflict of interest

The authors declare there exists no conflict of interest.

Ethics statement

This study was approved by the institutional ethics committee.

Additional information

The original version of this article was revised to correct the rendering of the name of the author Jaime Fernández Sarmiento.

An erratum to this article is available at http://dx.doi.org/10.1007/s00467-016-3568-1.

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Rico, M.P., Fernández Sarmiento, J., Rojas Velasquez, A.M. et al. Regional citrate anticoagulation for continuous renal replacement therapy in children. Pediatr Nephrol 32, 703–711 (2017). https://doi.org/10.1007/s00467-016-3544-9

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  • DOI: https://doi.org/10.1007/s00467-016-3544-9

Keywords

  • Anticoagulation
  • Citrate
  • Heparin
  • Continuous renal replacement therapy
  • Dialysis
  • Children