Regional anticoagulation with citrate is superior to systemic anticoagulation with heparin in critically ill patients undergoing continuous venovenous hemodiafiltration

Korean J Intern Med. 2011 Mar;26(1):68-75. doi: 10.3904/kjim.2011.26.1.68. Epub 2011 Mar 2.


Background/aims: Short hemofilter survival and anticoagulation-related life-threatening complications are major problems in systemic anticoagulation with heparin (SAH) for continuous renal replacement therapy (CRRT). The present study examined if regional anticoagulation with citrate (RAC) using commercially available solutions can overcome the associated problems of SAH to produce economical benefits.

Methods: Forty-six patients were assigned to receive SAH or RAC. We assessed the coagulation state, clinical outcomes, and adverse events. A Kaplan-Meier analysis was used to estimate hemofilter life span. The economical benefit related to the prolonged hemofilter survival was examined on the basis of the average daily cost.

Results: The mean age of patients was 66.5 ± 13.8 years and the majority were male (60.9%). While elective discontinuation was most common cause of early CRRT interruption in the RAC group (34.3%, p < 0.01), hemofilter clotting was most prevalent in the SAH group (82.2%, p < 0.01). The patient metabolic and electrolyte control and survival rate were not different between the two groups. When compared with the RAC group, the anticoagulation-associated bleeding was a major complication in the SAH group (15.0% vs. 61.5%, p < 0.01). Regional anticoagulated hemofilters displayed a significantly longer survival time than systemic anticoagulated hemofilters (59.5 ± 3.8 hr vs. 15.6 ± 1.3 hr, p < 0.01). Accordingly, the mean daily continuous venovenous hemodiafiltration costs in the RAC and SAH groups were $575 ± 268 and $1,209 ± 517, respectively (p < 0.01).

Conclusions: RAC prolonged hemofilter survival, displaying an economical benefit without severe adverse effects. The present study therefore demonstrates that RAC, using commercially available solutions, may be advantageous over SAH as a cost-effective treatment in CRRT.

Keywords: Anticoagulation; Citric acid; Heparin; Renal replacement therapy.

MeSH terms

  • Adult
  • Aged
  • Anticoagulants / pharmacology*
  • Citric Acid / pharmacology*
  • Critical Illness
  • Female
  • Health Care Costs
  • Hemodiafiltration* / adverse effects
  • Hemodiafiltration* / economics
  • Hemodiafiltration* / mortality
  • Heparin / pharmacology*
  • Humans
  • Kaplan-Meier Estimate
  • Male
  • Middle Aged


  • Anticoagulants
  • Citric Acid
  • Heparin