RRAM: Renal Replacement Anticoagulant Management
Background
Acute kidney injury, which prevents their kidneys from working properly, is common in patients being treated in an intensive care unit. Patients with acute kidney injury are treated with a machine that takes over the kidney functions – a process called continuous renal replacement therapy. Traditionally, as part of continuous renal replacement therapy, heparin (an anticoagulant that stops the blood from clotting) is added to the blood as it enters the CRRT machine. Recently citrate anticoagulation (an alternative to heparin) has been increasingly used in UK intensive care units. However, the increased use of citrate is happening without evidence that it is better for patients and cost effective for the NHS.
We aimed to find out whether changing to citrate anticoagulation for continuous renal replacement therapy is more beneficial for patients with AKI and treated in an ICU. We also looked at whether changing to citrate is cost-effective for the NHS.
Design
We used routinely collected data from the Case Mix Programme national clinical audit to identify 69,001 patients who received continuous renal replacement therapy in an intensive care unit in England or Wales between 1 April 2009 and 31 March 2017. To get a more comprehensive view of the long-term effects of changing to citrate, we ‘linked’ data from the 69,001 patients together with other routinely collected datasets to get information on their hospital admissions, longer-term kidney problems and survival after leaving the ICU. We combined this information with a survey of anticoagulant use in intensive care units in England and Wales to compare patients who received continuous renal replacement therapy with heparin and citrate.
Results
We found that the change to citrate was not associated with a significant change in the death rate at 90 days but was more expensive for hospitals.
Conclusion
Our findings suggest the change regional citrate-based anticoagulation, may have been premature, and should cause clinicians in intensive care units that are still using systemic heparin anticoagulation to pause before changing.
Who led this study?
Professor Peter Watkinson, Professor of Intensive Care Medicine and NHS consultant in intensive care at the Oxford University Hospitals NHS Foundation Trust
This study was funded by the National Institute for Health Research (NIHR) – Health Technology Assessment (HTA) Programme (Project: 16/111/136)
Publications
Gould DW, Doidge J, Sadique MZ, Borthwick M, Hatch R, Caskey FJ, Forni L, Lawrence RF, MacEwen C, Ostermann M, Mouncey PR, Harrison DA, Rowan KM, Young JD, Watkinson PJ. Heparin versus citrate anticoagulation for continuous renal replacement therapy in intensive care: the RRAM observational study. Health Technol Assess 2022; 26(13):1-58. http://dx.doi.org/10.3310/zxhi9396 Gould DW, Doidge J, Zia Sadique M, Borthwick M, Caskey FJ, Forni L, Lawrence RF, MacEwen C, Mouncey PR, Ostermann M, Harrison DA, Rowan KM, Duncan Young J, Watkinson PJ. Renal replacement anticoagulant management: Protocol and analysis plan for an observational comparative effectiveness study of linked data sources. J Intensive Care Soc 2022; 23(3):311-7. http://dx.doi.org/10.1177/1751143720913417 Doidge JC, Gould DW, Sadique Z, Borthwick M, Hatch RA, Caskey FJ, Forni L, Lawrence RF, MacEwan C, Ostermann M, Mouncey PR, Harrison DA, Rowan KM, Young JD, Watkinson PJ. Regional citrate anticoagulation versus systemic heparin anticoagulation for continuous kidney replacement therapy in intensive care. J Crit Care 2023; 74:154218. http://dx.doi.org/10.1016/j.jcrc.2022.154218
