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Citrate Anticoagulation During Continuous Renal Replacement Therapy in Pediatric Critical Care

Davis, T. Keefe MD1; Neumayr, Tara MD2; Geile, Kira RN, CPNP1,3; Doctor, Allan MD2; Hmeil, Paul MD, PhD1

Pediatric Critical Care Medicine: June 2014 - Volume 15 - Issue 5 - p 471–485
doi: 10.1097/PCC.0000000000000148
Review Article

Objective: To provide the pediatric intensivist an in-depth understanding of citrate as regional anticoagulant during continuous renal replacement therapy.

Data Sources and Data Selection: We searched the database using the initial key words: citrate anticoagulation [title] AND continuous; citrate [title] AND pediatric AND continuous; prospective pediatric renal replacement AND citrate; and regional citrate anticoagulation. Additional searchers were performed using EMBASE, CINAHL, and SCOPUS with similar keywords and limits. Further articles were gathered from bibliographic references of relevant studies and reviews. Only articles published in English were reviewed.

Data Extraction and Data Synthesis: In the pediatric population, there are no prospective interventional or randomized studies comparing regional versus systemic anticoagulation. However, there are 11 (retrospective and prospective observational studies) in the pediatric population using citrate anticoagulation. These studies have shown that regional citrate anticoagulation in the pediatric population can be effective, provide equivalent circuit survival, and decrease bleeding compared with heparin anticoagulation. In the adult population, there are six prospective randomized controlled trials comparing the efficacy of regional citrate anticoagulation versus heparin. Two systematic reviews with meta-analysis of these six trials have been performed. The adult data on the use of regional citrate anticoagulation during continuous renal replacement therapy show a decreased risk of bleeding and at the least equivalent circuit survival as compared to heparin. Current pediatric and adult studies support regional citrate anticoagulation as an effective alternative to systemic heparin anticoagulation in most patient populations.

Conclusions: Continuous renal replacement therapy is the most common modality of renal replacement in the critical care setting. Regional anticoagulation is an ideal option in a critically ill child after recent surgery or with coagulopathy. Therefore, regional citrate anticoagulation in the pediatric critical care population requiring renal replacement therapy is commonly employed. Complications of citrate anticoagulation can be avoided with a greater understanding of the properties and clearance of citrate. Continued reporting of observational data and the development of prospective multicenter trials using citrate anticoagulation are needed to ensure safe and standardized care in the pediatric population.

1Division of Nephrology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO.

2Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO.

3St. Louis Children’s Hospital, St. Louis, MO.

Dr. Davis, Dr. Neumayr, and Ms. Geile reviewed the primary literature, wrote the initial draft, and designed the figures and tables. Drs. Doctor and Hmiel wrote and provided critical revisions of subsequent drafts.

The authors have disclosed that they do not have any potential conflicts of interest.

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©2014The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies