Citrate vs. heparin for anticoagulation in continuous venovenous hemofiltration: a prospective randomized study

Abstract Objective: To compare the efficacy and safety of adjusted-dose unfractionated heparin with that of regional citrate anticoagulation in intensive care patients treated by continuous venovenous hemofiltration (CVVH). Design and setting: Prospective, randomized, clinical trial
in a 32-bed medical and surgical ICU in a university teaching hospital. Patients: ICU patients with acute renal failure requiring continuous renal replacement therapy, without cirrhosis, severe coagulopathy, or known sensitivity to heparin. Interventions: Before the first CVVH run
patients were randomized to receive anticoagulation with heparin or trisodium citrate. Patients eligible for another CVVH run received the other study medication in a crossover fashion until the fourth circuit. Measurements and results: Fortynine circuits (hemofilters) were analyzed: 23 with heparin and 26 with citrate. The median lifetime of hemofilters was 70 h (interquartile range 44–140) with citrate anticoagulation and 40 h (17–48) with heparin (p=0.0007). One major
bleeding occurred during heparin anticoagulation and one metabolic alkalosis (pH=7.60) was noted with citrate after a protocol violation. Transfusion rates (units of red cells per day of CVVH) were, respectively, 0.2 (0.0–0.4) with citrate and 1.0 (0.0–2.0) with heparin (p=0.0008).
Conclusions: Regional citrate anticoagulation seems superior to heparin for the filter lifetime and transfusion requirements in ICU patients treated by continuous renal replacement therapy.