Comparative Analysis of Fixed Versus Variable Rates of Regional Citrate Anticoagulation in Critically Ill Adult Patients on Continuous Kidney Replacement Therapy.
Nhi TranHuynh, Jenna Holzhausen, Lisa Hall Zimmerman
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引用次数: 0
Abstract
Background: The Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guideline recommends regional citrate anticoagulation during continuous kidney replacement therapy (CKRT) to prolong circuit lifespan. Limited data directly compare citrate dosing strategies.
Objective: Evaluate effectiveness and safety of fixed (FIX) versus variable (VAR) citrate rates in CKRT.
Methods: This single-center, retrospective study evaluated adult ICU patients (≥18 years) receiving CKRT with regional citrate anticoagulation for ≥24 hours between July 2018 and June 2024. Patients with COVID-19 or whose citrate rate was inconsistent with the prescribed order were excluded. FIX versus VAR groups were case-matched based on ICU service, citrate duration, and age. The primary outcome was time from citrate initiation to first filter change. Secondary outcomes included hyper- and hypocalcemia, citrate toxicity, bleeding, and thrombosis.
Results: Of 534 patients screened, 48 (24 FIX, 24 VAR) met inclusion criteria and matched closely in ICU service, citrate duration, and age. Time to first CKRT filter change was similar, 1.5 [0.7, 3.0] FIX versus 1.9 [0.5, 3.1] VAR, days, P = 0.89. Fewer hypocalcemia episodes were associated with FIX (72 vs 141 VAR, episodes, P < 0.0001), as was less calcium supplementation (36 FIX vs 142 VAR, grams, P = 0.0113). Bleeding and thrombosis events were similar between groups, 33% FIX vs 50% VAR (P = 0.19) and 25% FIX vs 13% VAR (P = 0.46), respectively.
Conclusion and relevance: Fixed and variable citrate rates showed similar effectiveness in CKRT. However, the fixed rate was associated with less hypocalcemia and calcium supplementation without a significant increase in bleeding or thrombosis. These findings contribute new comparative data to help guide citrate anticoagulation strategies and suggest that a fixed rate may help minimize electrolyte disturbances and simplify supplementation needs. Given that the study was potentially underpowered, further studies are needed to validate these findings and guide the development of optimal citrate rate guidelines.
背景：肾脏疾病改善总体结果（KDIGO）临床实践指南推荐在持续肾脏替代治疗（CKRT）期间进行局部柠檬酸抗凝以延长肾循环寿命。有限的数据直接比较了柠檬酸盐的剂量策略。目的：评价固定（FIX）与可变（VAR）柠檬酸盐在CKRT中的有效性和安全性。方法：本单中心回顾性研究评估2018年7月至2024年6月期间接受CKRT联合局部柠檬酸盐抗凝治疗≥24小时的成人ICU患者（≥18岁）。排除了COVID-19患者或枸橼酸率与医嘱不一致的患者。FIX组与VAR组根据ICU服务、柠檬酸持续时间和年龄进行病例匹配。主要观察指标是从柠檬酸起始到第一次过滤器更换的时间。次要结局包括高和低钙血症、柠檬酸毒性、出血和血栓形成。结果：筛选的534例患者中，48例（24例FIX， 24例VAR）符合纳入标准，在ICU服务时间、柠檬酸盐持续时间和年龄方面密切匹配。第一次更换CKRT滤镜的时间相似，1.5 [0.7,3.0]FIX vs 1.9 [0.5, 3.1] VAR，天，P = 0.89。低钙血症发作较少与FIX相关（72 vs 141 VAR，发作，P < 0.0001），补钙较少与FIX相关（36 FIX vs 142 VAR，克，P = 0.0113）。两组之间的出血和血栓事件相似，分别为33% FIX vs 50% VAR （P = 0.19）和25% FIX vs 13% VAR （P = 0.46）。结论和相关性：固定和可变柠檬酸盐率在CKRT中表现出相似的疗效。然而，固定的比率与低钙血症和补钙的减少有关，而出血或血栓的发生率没有显著增加。这些发现提供了新的比较数据，有助于指导柠檬酸盐抗凝策略，并表明固定的速率可能有助于减少电解质紊乱和简化补充需求。考虑到这项研究的潜力不足，需要进一步的研究来验证这些发现并指导最佳柠檬酸盐率指南的制定。
期刊介绍：
Annals of Pharmacotherapy (AOP) is a peer-reviewed journal that advances pharmacotherapy throughout the world by publishing high-quality research and review articles to achieve the most desired health outcomes.The articles provide cutting-edge information about the most efficient, safe and cost-effective pharmacotherapy for the treatment and prevention of various illnesses. This journal is a member of the Committee on Publication Ethics (COPE). Average time from submission to first decision: 14 days
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