Analysis of the influencing factors on circuit life during continuous renal replacement therapy with regional citrate anticoagulation_West China Medical Journal

Authors：

TANG Qianrong ^1,2 ,  MA Liang ¹ , ZHANG Ling ¹ , WANG Fang ¹ , TANG Xue ¹ , HE Xuancheng ¹ , FU Ping ¹

1. Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;
2. Department of Nephrology, Second People’s Hospital of Yibin, Yibin, Sichuan 644000, P. R. China;

Corresponding author：

MA Liang, Email: liang_m@scu.edc.cn

Keywords：

Continuous renal replacement therapy; regional citrate anticoagulation; circuit life; influencing factor

DOI：

10.7507/1002-0179.202205162

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Objective To observate the influencing factors on circuit life during continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA), so as to provide data support for further optimization of RCA anticoagulation strategy. Methods Patients who underwent CRRT with RCA in West China Hospital of Sichuan University between March 2021 and April 2022 were retrospectively selected. Analyze the basic information of patients and the impact of relevant indicators before or within 12 hours of treatment on the circuit life. Results A total of 116 patients were included. Among the included patients, a total of 225 cases were treated with CRRT for 11 051.7 hours, the median circuit life was 57.0 (25.4, 72.0) h. 142 cases (63.1%) were terminated due to coagulation, the median circuit life was 30.3 (20.5, 52.8) h. The results of multivariate Cox regression analysis showed that pH value [hazard ratio (HR)=0.002, 95% confidence interval (CI) (0.0001, 0.127), P=0.003], the maximam postfilter ionized calcium [HR=0.039, 95%CI (0.004, 0.437), P=0.008], blood flow [HR=1.051, 95%CI (1.027, 1.075), P<0.001] and catheter dysfunction [HR=5.701, 95%CI (3.777, 8.605), P<0.001] were the four influential factors affected circuit life. Kaplan Meier survival curve showed that RCA had the best effect when the postfilter ionized calcium was in the range of 0.25 ~ 0.35 mmol/L. Conclusions During CRRT treatment of RCA, pH value, postfilter ionized calcium, blood flow and catheter function are the independent influencing factors of circuit life. The above parameters should be carefully monitored and optimized in the treatment process to minimize the risk of coagulation, prolong the circuit life and maintain the continuty of CRRT treatment. The postfilter ionized calcium was recommended to be maitained at 0.25-0.35mmol/L, pH value maintained above 7.38, blood flow no more than 145 mL/min and catheter maitained patency to ensure the adequate anticoagulation.

Citation： TANG Qianrong, MA Liang, ZHANG Ling, WANG Fang, TANG Xue, HE Xuancheng, FU Ping. Analysis of the influencing factors on circuit life during continuous renal replacement therapy with regional citrate anticoagulation. West China Medical Journal, 2022, 37(7): 1001-1008. doi: 10.7507/1002-0179.202205162 Copy

1.	Ronco C, Cruz D, Bellomo R. Continuous renal replacement in critical illness. Contrib Nephrol, 2007, 156: 309-319.
2.	Oudemans-van Straaten HM, Bosman RJ, Koopmans M, et al. Citrate anticoagulation for continuous venovenous hemofiltration. Crit Care Med, 2009, 37(2): 545-552.
3.	Kindgen-Milles D, Brandenburger T, Dimski T. Regional citrate anticoagulation for continuous renal replacement therapy. Curr Opin Crit Care, 2018, 24(6): 450-454.
4.	Zarbock A, Küllmar M, Kindgen-Milles D, et al. Effect of regional citrate anticoagulation vs systemic heparin anticoagulation during continuous kidney replacement therapy on dialysis filter life span and mortality among critically ill patients with acute kidney injury: a randomized clinical trial. JAMA, 2020, 324(16): 1629-1639.
5.	陈香美. 血液净化标准操作规程(2020 版). 北京: 人民军医出版社, 2020: 150-154.
6.	KDIGO clinical practice guideline for acute kidney injury. (2012-03)[2022-05-01]. https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-AKI-Guideline-English.pdf.
7.	Kim IB, Fealy N, Baldwin I, Bellomo R. Premature circuit clotting due to likely mechanical failure during continuous renal replacement therapy. Blood Purif, 2010, 30(2): 79-83.
8.	Morgan D, Ho K, Murray C, et al. A randomized trial of catheters of different lengths to achieve right atrium versus superior vena cava placement for continuous renal replacement therapy. Am J Kidney Dis, 2012, 60(2): 272-279.
9.	Baldwin I. Factors affecting circuit patency and filter ‘life’. Contrib Nephrol, 2007, 156: 178-184.
10.	Califano AM, Bitker L, Baldwin I, et al. Circuit survival during continuous venovenous hemodialysis versus continuous venovenous hemofiltration. Blood Purif, 2020, 49(3): 281-288.
11.	Zhang Z, Ni H, Lu B. Variables associated with circuit life span in critically ill patients undergoing continuous renal replacement therapy: a prospective observational study. ASAIO J, 2012, 58(1): 46-50.
12.	Tsujimoto H, Tsujimoto Y, Nakata Y, et al. Pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy. Cochrane Database Syst Rev, 2020, 3(3): CD012467.
13.	Tsujimoto Y, Miki S, Shimada H, et al. Non-pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy. Cochrane Database Syst Rev, 2021, 9(9): CD013330.
14.	Sansom B, Sriram S, Presneill J, et al. Low blood flow continuous veno-venous haemodialysis compared with higher blood flow continuous veno-venous haemodiafiltration: effect on alarm rates, filter life, and azotaemic control. Blood Purif, 2022, 51(2): 130-137.
15.	Baldwin I, Fealy N, Carty P, et al. Bubble chamber clotting during continuous renal replacement therapy: vertical versus horizontal blood flow entry. Blood Purif, 2012, 34(3/4): 213-218.
16.	Davies H, Leslie G. Maintaining the CRRT circuit: non-anticoagulant alternatives. Aust Crit Care, 2006, 19(4): 133-138.
17.	唐小琰, 陈德政, 张凌, 等. 局部枸橼酸抗凝在血液净化领域中的应用进展. 中华肾脏病杂志, 2021, 37(6): 534-538.
18.	Calatzis A, Toepfer M, Schramm W, et al. Citrate anticoagulation for extracorporeal circuits: effects on whole blood coagulation activation and clot formation. Nephron, 2001, 89(2): 233-236.
19.	Fealy N, Aitken L, Toit Ed, et al. Continuous renal replacement therapy: current practice in Australian and New Zealand intensive care units. Crit Care Resusc, 2015, 17(2): 83-91.
20.	Uchino S, Bellomo R, Morimatsu H, et al. Continuous renal replacement therapy: a worldwide practice survey. The beginning and ending supportive therapy for the kidney (B. E. S. T. kidney) investigators. Intensive Care Med, 2007, 33(9): 1563-1570.
21.	Fealy N, Aitken L, du Toit E, et al. Faster blood flow rate does not improve circuit life in continuous renal replacement therapy: a randomized controlled trial. Crit Care Med, 2017, 45(10): e1018-e1025.
22.	Ling Z, Tanaka A, Zhu G, et al. Patterns and mechanisms of artificial kidney failure during continuous renal replacement therapy. Blood Purif, 2016, 41(4): 254-263.
23.	李佩芸, 林丽, 张凌, 等. 连续性肾脏替代治疗体外循环寿命的影响因素分析. 中国血液净化, 2020, 19(9): 610-613.
24.	Kakajiwala A, Jemielita T, Hughes JZ, et al. Membrane pressures predict clotting of pediatric continuous renal replacement therapy circuits. Pediatr Nephrol, 2017, 32(7): 1251-1261.
25.	Parienti J, Mégarbane B, Fischer M, et al. Catheter dysfunction and dialysis performance according to vascular access among 736 critically ill adults requiring renal replacement therapy: a randomized controlled study. Crit Care Med, 2010, 38(4): 1118-1125.
26.	Kim IB, Fealy N, Baldwin I, et al. Insertion side, body position and circuit life during continuous renal replacement therapy with femoral vein access. Blood Purif, 2011, 31(1/2/3): 42-46.
27.	Tsujimoto Y, Fujii T. How to prolong filter life during continuous renal replacement therapy?. Crit Care, 2022, 26(1): 62.
28.	Kleger GR, Fässler E. Can circuit lifetime be a quality indicator in continuous renal replacement therapy in the critically ill?. Int J Artif Organs, 2010, 33(3): 139-146.
29.	Dunn WJ, Sriram S. Filter lifespan in critically ill adults receiving continuous renal replacement therapy: the effect of patient and treatment-related variables. Crit Care Resusc, 2014, 16(3): 225-231.
30.	樊启晨, 丁峰. 血液净化治疗中局部枸橼酸抗凝时的钙管理. 上海医药, 2018, 39(9): 6.
31.	James MF, Roche AM. Dose-response relationship between plasma ionized calcium concentration and thrombelastography. J Cardiothorac Vasc Anesth, 2004, 18(5): 581-586.
32.	Schneider M, Liefeldt L, Slowinski T, et al. Citrate anticoagulation protocol for slow extended hemodialysis with the genius dialysis system in acute renal failure. Int J Artif Organs, 2008, 31(1): 43-48.
33.	王妍, 张北源, 郭晓芳, 等. 重症患者局部枸橼酸抗凝行连续性静脉-静脉血液滤过离子钙浓度的探讨. 肾脏病与透析肾移植杂志, 2021, 30(2): 119-123.
34.	Tolwani A, Wille KM. Advances in continuous renal replacement therapy: citrate anticoagulation update. Blood Purif, 2012, 34(2): 88-93.
35.	李镇洲, 万建新. 局部枸橼酸抗凝在连续性肾脏替代治疗中的应用要点. 中国血液净化, 2021, 20(12): 797-800.
36.	Morgera S, Schneider M, Slowinski T, et al. A safe citrate anticoagulation protocol with variable treatment efficacy and excellent control of the acid-base status. Crit Care Med, 2009, 37(6): 2018-2024.

1. Ronco C, Cruz D, Bellomo R. Continuous renal replacement in critical illness. Contrib Nephrol, 2007, 156: 309-319.
2. Oudemans-van Straaten HM, Bosman RJ, Koopmans M, et al. Citrate anticoagulation for continuous venovenous hemofiltration. Crit Care Med, 2009, 37(2): 545-552.
3. Kindgen-Milles D, Brandenburger T, Dimski T. Regional citrate anticoagulation for continuous renal replacement therapy. Curr Opin Crit Care, 2018, 24(6): 450-454.
4. Zarbock A, Küllmar M, Kindgen-Milles D, et al. Effect of regional citrate anticoagulation vs systemic heparin anticoagulation during continuous kidney replacement therapy on dialysis filter life span and mortality among critically ill patients with acute kidney injury: a randomized clinical trial. JAMA, 2020, 324(16): 1629-1639.
5. 陈香美. 血液净化标准操作规程(2020 版). 北京: 人民军医出版社, 2020: 150-154.
6. KDIGO clinical practice guideline for acute kidney injury. (2012-03)[2022-05-01]. https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-AKI-Guideline-English.pdf.
7. Kim IB, Fealy N, Baldwin I, Bellomo R. Premature circuit clotting due to likely mechanical failure during continuous renal replacement therapy. Blood Purif, 2010, 30(2): 79-83.
8. Morgan D, Ho K, Murray C, et al. A randomized trial of catheters of different lengths to achieve right atrium versus superior vena cava placement for continuous renal replacement therapy. Am J Kidney Dis, 2012, 60(2): 272-279.
9. Baldwin I. Factors affecting circuit patency and filter ‘life’. Contrib Nephrol, 2007, 156: 178-184.
10. Califano AM, Bitker L, Baldwin I, et al. Circuit survival during continuous venovenous hemodialysis versus continuous venovenous hemofiltration. Blood Purif, 2020, 49(3): 281-288.
11. Zhang Z, Ni H, Lu B. Variables associated with circuit life span in critically ill patients undergoing continuous renal replacement therapy: a prospective observational study. ASAIO J, 2012, 58(1): 46-50.
12. Tsujimoto H, Tsujimoto Y, Nakata Y, et al. Pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy. Cochrane Database Syst Rev, 2020, 3(3): CD012467.
13. Tsujimoto Y, Miki S, Shimada H, et al. Non-pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy. Cochrane Database Syst Rev, 2021, 9(9): CD013330.
14. Sansom B, Sriram S, Presneill J, et al. Low blood flow continuous veno-venous haemodialysis compared with higher blood flow continuous veno-venous haemodiafiltration: effect on alarm rates, filter life, and azotaemic control. Blood Purif, 2022, 51(2): 130-137.
15. Baldwin I, Fealy N, Carty P, et al. Bubble chamber clotting during continuous renal replacement therapy: vertical versus horizontal blood flow entry. Blood Purif, 2012, 34(3/4): 213-218.
16. Davies H, Leslie G. Maintaining the CRRT circuit: non-anticoagulant alternatives. Aust Crit Care, 2006, 19(4): 133-138.
17. 唐小琰, 陈德政, 张凌, 等. 局部枸橼酸抗凝在血液净化领域中的应用进展. 中华肾脏病杂志, 2021, 37(6): 534-538.
18. Calatzis A, Toepfer M, Schramm W, et al. Citrate anticoagulation for extracorporeal circuits: effects on whole blood coagulation activation and clot formation. Nephron, 2001, 89(2): 233-236.
19. Fealy N, Aitken L, Toit Ed, et al. Continuous renal replacement therapy: current practice in Australian and New Zealand intensive care units. Crit Care Resusc, 2015, 17(2): 83-91.
20. Uchino S, Bellomo R, Morimatsu H, et al. Continuous renal replacement therapy: a worldwide practice survey. The beginning and ending supportive therapy for the kidney (B. E. S. T. kidney) investigators. Intensive Care Med, 2007, 33(9): 1563-1570.
21. Fealy N, Aitken L, du Toit E, et al. Faster blood flow rate does not improve circuit life in continuous renal replacement therapy: a randomized controlled trial. Crit Care Med, 2017, 45(10): e1018-e1025.
22. Ling Z, Tanaka A, Zhu G, et al. Patterns and mechanisms of artificial kidney failure during continuous renal replacement therapy. Blood Purif, 2016, 41(4): 254-263.
23. 李佩芸, 林丽, 张凌, 等. 连续性肾脏替代治疗体外循环寿命的影响因素分析. 中国血液净化, 2020, 19(9): 610-613.
24. Kakajiwala A, Jemielita T, Hughes JZ, et al. Membrane pressures predict clotting of pediatric continuous renal replacement therapy circuits. Pediatr Nephrol, 2017, 32(7): 1251-1261.
25. Parienti J, Mégarbane B, Fischer M, et al. Catheter dysfunction and dialysis performance according to vascular access among 736 critically ill adults requiring renal replacement therapy: a randomized controlled study. Crit Care Med, 2010, 38(4): 1118-1125.
26. Kim IB, Fealy N, Baldwin I, et al. Insertion side, body position and circuit life during continuous renal replacement therapy with femoral vein access. Blood Purif, 2011, 31(1/2/3): 42-46.
27. Tsujimoto Y, Fujii T. How to prolong filter life during continuous renal replacement therapy?. Crit Care, 2022, 26(1): 62.
28. Kleger GR, Fässler E. Can circuit lifetime be a quality indicator in continuous renal replacement therapy in the critically ill?. Int J Artif Organs, 2010, 33(3): 139-146.
29. Dunn WJ, Sriram S. Filter lifespan in critically ill adults receiving continuous renal replacement therapy: the effect of patient and treatment-related variables. Crit Care Resusc, 2014, 16(3): 225-231.
30. 樊启晨, 丁峰. 血液净化治疗中局部枸橼酸抗凝时的钙管理. 上海医药, 2018, 39(9): 6.
31. James MF, Roche AM. Dose-response relationship between plasma ionized calcium concentration and thrombelastography. J Cardiothorac Vasc Anesth, 2004, 18(5): 581-586.
32. Schneider M, Liefeldt L, Slowinski T, et al. Citrate anticoagulation protocol for slow extended hemodialysis with the genius dialysis system in acute renal failure. Int J Artif Organs, 2008, 31(1): 43-48.
33. 王妍, 张北源, 郭晓芳, 等. 重症患者局部枸橼酸抗凝行连续性静脉-静脉血液滤过离子钙浓度的探讨. 肾脏病与透析肾移植杂志, 2021, 30(2): 119-123.
34. Tolwani A, Wille KM. Advances in continuous renal replacement therapy: citrate anticoagulation update. Blood Purif, 2012, 34(2): 88-93.
35. 李镇洲, 万建新. 局部枸橼酸抗凝在连续性肾脏替代治疗中的应用要点. 中国血液净化, 2021, 20(12): 797-800.
36. Morgera S, Schneider M, Slowinski T, et al. A safe citrate anticoagulation protocol with variable treatment efficacy and excellent control of the acid-base status. Crit Care Med, 2009, 37(6): 2018-2024.

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Analysis of the influencing factors on circuit life during continuous renal replacement therapy with regional citrate anticoagulation

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