REVIEW PAPER
Practical issues of regional anticoagulation during continuous renal replacement therapy
 
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1
Department of Anaesthesiology and Intensive Care, Regional Specialist Hospital in Olsztyn, Poland
2
Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Poland
3
Department of Anaesthesiology and Intensive Care, University Clinical Hospital in Olsztyn, Poland
CORRESPONDING AUTHOR
Dariusz Onichimowski   

Wojewódzki Szpital Specjalistyczny w Olsztynie, Żołnierska 18, 10-561 Olsztyn, Poland. Tel.: +48 501 173 866.
Online publication date: 2019-11-24
Submission date: 2018-09-17
Acceptance date: 2019-08-05
 
Pol. Ann. Med. 2020;27(1):68–72
KEYWORDS
TOPICS
ABSTRACT
Introduction:
Extracorporeal blood purification techniques have become a well-established part of routine practice in intensive care units. The issue of major concern while applying these techniques is to ensure appropriate anticoagulation to prevent the clotting of the circuit.

Aim:
The aim of this paper is to present regional anticoagulation as a method which is currently used in continuous extracorporeal blood purification techniques.

Material and methods:
This work is based on the available literature and the authors’ experience.

Results and discussion:
Anticoagulation used to prevent the clotting of the circuit in extracorporeal blood purification techniques may be regional or systemic. Regional anticoagulation inhibits clotting only in the extracorporeal circuit. In this case either sodium citrate together with calcium substitution or heparin with protamine sulfate is used. Systemic anticoagulation involves the inhibition of clotting in the extracorporeal circuit and in the patient’s body. Regional citrate anticoagulation (RCA) is obtained with the use of citrate. With this technique calcium substitution is necessary in order to prevent hypocalcemia. Other possible complications include alkalosis, metabolic acidosis, hypercalcemia and hypomagnesemia. This paper presents also some practical aspects of regional anticoagulation during continuous renal replacement therapy (CRRT)

Conclusions:
The application of RCA has contributed to a wider use of CRRT in intensive therapy units. The greatest advantage of this method is almost complete elimination of bleeding complications associated with the therapy. It enables effective blood purification in the patients in whom the use of heparins is contraindicated. This fact has found confirmation in Kidney Disease: Improving Global Outcomes (KDIGO) guidelines.

CONFLICT OF INTEREST
Dariusz Onichimowski declares that he receives fee for lectures about similar subject from Fresenius Medical care. Others authors declare to have no potential conflict of interest.
FUNDING
None declared.
 
REFERENCES (15)
1.
Bai M, Zhou M, He L, et al. Citrate versus heparin anticoagulation for continuous renal replacement therapy: an updated metaanalysis of RCTs. Intensive Care Med. 2015;41(12):2098–2110. https://doi.org/10.1007/s00134....
 
2.
Davenport A, Tolwani A. Citrate anticoagulation for continuous renal replacement therapy (CRRT) in patients with acute kidney injury admitted to the intensive care unit. NDT Plus. 2009;2(6):439–447. https://doi.org/10.1093/ndtplu....
 
3.
Schneider AG, Journois D, Rimmelé T. Complications of regional citrate anticoagulation: accumulation or overload? Crit Care. 2017;21(1):281–286. https://doi.org/10.1186/s13054....
 
4.
Higgins C. Citrate anticoagulation during CRRT for acute kidney injury. https://acutecaretesting.org/e.... Accessed 9 November, 2019.
 
5.
Schwarzer P, Kuhn S-O, Stracke S, et al. Discrepant post- filter ionized calcium concentration by common blood gas analyzers in CRRT using citrate anticoagulation. Crit Care. 2015;19:321. https://doi.org/10.1186/s13054....
 
6.
Khadzhynov D, Slowinski T, Lieker I, Neumayer HH, Peters H. Evaluation of acid-base control, electrolyte balance, and filter patency of a Prismaflex-based regional citrate anticoagulation protocol for predilution continuous veno-venous hemodiafltration. Clinical Nephrology. 2014;81(5):320–330. https://doi.org/10.5414/cn1078....
 
7.
Ricci D, Panicali L, Facchini MG, Mancini E. Citrate anticoagulation during continuous renal replacement therapy. Contrib Nephrol. 2017;190:19–30. https://doi.org/10.1159/000468....
 
8.
Khadzynov D, Schelter C, Lieker I, et al. Incidence and outcome of metabolic disarragements consistent with citrate accumulation in critically ill patients undergoing continuous venovenous hemodialysis with regional citrate anticoagulation. J Crit Care. 2014;29(2):265–271. https://doi.org/10.1016/j.jcrc....
 
9.
Oudemans-van Straaten HM. Citrate for continuous renal replacement therapy: safer, better and cheaper. Crit Care. 2014;18(6):661. https://dx.doi.org/10.1186%2Fs....
 
10.
Slowinski T, Morgera S, Joannidis M, et al. 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. 2015;19:349. https://doi.org/10.1186/s13054....
 
11.
Tan HK, Baldwin I, Bellomo R. Continuous veno-venous hemofiltration without anticoagulation in high-risk patients. Intensive Care Med. 2000;26(11):1652–1657. https://doi.org/10.1007/s00134....
 
12.
Davenport A, Will EJ, Davidson AM. Comparison of the use of standard heparin and prostacyclin anticoagulation in spontaneous and pump-driven extracorporeal circuits in patients with combined acute renal and hepatic failure. Nephron. 1994;66(4):431–437. https://doi.org/10.1159/000187....
 
13.
Abranson S, Niles JL. Anticoagulation in continuous renal replacement therapy. Curr Opin Nephrol Hypertens. 1999;8(6):701–707. https://doi.org/10.1097/000415....
 
14.
Hoste E, Dhondt A. Clinical review: Use of renal replacement therapies in special groups of ICU patients. Critical care. 2012;16:201. https://doi.org/10.1186/cc1049....
 
15.
KDIGO Acute Kidney Injury Working Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2(1):1–138.