nach oben

Die Nephrologie

Erschienen in:

13.02.2017 | Akutes Nierenversagen | CME

Regionale Zitratantikoagulation

verfasst von: Dr. C. Nusshag, PD Dr. T. Brenner, MHBA, Prof. Dr. M. Zeier, Prof. Dr. M. A. Weigand, Prof. Dr. C. Morath

Erschienen in: Die Nephrologie | Ausgabe 2/2017

Einloggen, um Zugang zu erhalten

Zusammenfassung

Kontinuierliche Nierenersatzverfahren (CRRT) sind die dominierende Behandlungsform des akuten Nierenversagens (AKI) bei intensivmedizinischen Patienten. Die Wahl der Antikoagulation (AK) hat dabei Einfluss auf Sicherheit und Therapieeffektivität. Relevante Blutungskomplikationen unter systemischer AK sind nicht selten und beeinflussen das Behandlungsergebnis entscheidend. Die regionale Zitratantikoagulation (RCA) stellt dabei eine Alternative mit reduzierten Blutungskomplikationen, äquivalenter Behandlungseffektivität, längerer Filterlebenszeit und geringerem Transfusionsbedarf dar. Unter adäquatem Therapiemanagement und Monitoring ist die RCA auch bei Risikopatienten ein sicheres Therapieverfahren. Die Beurteilung der Kosteneffizienz zwischen RCA und Heparin bleibt Gegenstand zukünftiger Untersuchungen.

Marshall MR, Creamer JM, Foster M et al (2011) Mortality rate comparison after switching from continuous to prolonged intermittent renal replacement for acute kidney injury in three intensive care units from different countries. Nephrol Dial Transplant 26:2169–2175CrossRefPubMed

Prowle JR, Bellomo R (2010) Continuous renal replacement therapy: recent advances and future research. Nat Rev Nephrol 6:521–529. doi:10.1038/nrneph.2010.100 CrossRefPubMed

Schindler R, Hutagalung R, Jorres A et al (2014) Versorgung des akuten Nierenversagens in Deutschland – Eine strukturelle Analyse. Dtsch Med Wochenschr 139:1701–1706. doi:10.1055/s-0034-1370272 CrossRefPubMed

Schneider AG, Bellomo R, Bagshaw SM et al (2013) Choice of renal replacement therapy modality and dialysis dependence after acute kidney injury: a systematic review and meta-analysis. Intensive Care Med 39:987–997CrossRefPubMed

Uchino S, Bellomo R, Morimatsu H et al (2007) 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 33:1563–1570CrossRefPubMed

Brophy PD, Somers MJG, Baum MA et al (2005) Multi-centre evaluation of anticoagulation in patients receiving continuous renal replacement therapy (CRRT). Nephrol Dial Transplant 20:1416–1421CrossRefPubMed

Oudemans-van Straaten HM, Wester JPJ, de Pont ACJM, Schetz MRC (2006) Anticoagulation strategies in continuous renal replacement therapy: can the choice be evidence based? Intensive Care Med 32:188–202CrossRefPubMed

Tolwani AJ, Wille KM (2009) Anticoagulation for continuous renal replacement therapy. Semin Dial 22:141–145CrossRefPubMed

Ward DM, Mehta RL (1993) Extracorporeal management of acute renal failure patients at high risk of bleeding. Kidney Int Suppl 41:237–244

10.

Fiaccadori E, Maggiore U, Clima B et al (2001) Incidence, risk factors, and prognosis of gastrointestinal hemorrhage complicating acute renal failure. Kidney Int 59:1510–1519CrossRefPubMed

11.

Joannidis M, Oudemans-van Straaten HM (2007) Clinical review: Patency of the circuit in continuous renal replacement therapy. Crit Care 11:218CrossRefPubMedPubMedCentral

12.

Palevsky PM, Zhang JH, O’Connor TZ et al (2008) VA/NIH Acute Renal Failure Trial Network: Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med 359:7–20CrossRefPubMed

13.

Tan HK, Baldwin I, Bellomo R (2000) Continuous veno-venous hemofiltration without anticoagulation in high-risk patients. Intensive Care Med 26:1652–1657CrossRefPubMed

14.

Uchino S, Fealy N, Baldwin I et al (2004) Continuous venovenous hemofiltration without anticoagulation. ASAIO J 50:76–80CrossRefPubMed

15.

Fiaccadori E, Maggiore U, Parenti E et al (2007) Sustained low-efficiency dialysis (SLED) with prostacyclin in critically ill patients with acute renal failure. Nephrol Dial Transplant 22:529–537CrossRefPubMed

16.

du Cheyron D, Bouchet B, Bruel C et al (2006) Antithrombin supplementation for anticoagulation during continuous hemofiltration in critically ill patients with septic shock: a case-control study. Crit Care 10:R45CrossRefPubMedPubMedCentral

17.

Morabito S, Guzzo I, Solazzo A et al (2003) Continuous renal replacement therapies: anticoagulation in the critically ill at high risk of bleeding. J Nephrol 16:566–571PubMed

18.

Morabito S, Pistolesi V, Tritapepe L, Fiaccadori E (2014) Regional citrate anticoagulation for RRTs in critically ill patients with AKI. Clin J Am Soc Nephrol 9:2173–2188CrossRefPubMedPubMedCentral

19.

Oudemans-van Straaten HM, Ostermann M (2012) Bench-to-bedside review: citrate for continuous renal replacement therapy, from science to practice. Crit Care 16:249CrossRefPubMedPubMedCentral

20.

Hetzel GR, Schmitz M, Wissing H et al (2011) Regional citrate versus systemic heparin for anticoagulation in critically ill patients on continuous venovenous haemofiltration: a prospective randomized multicentre trial. Nephrol Dial Transplant 26:232–239CrossRefPubMed

21.

Kutsogiannis DJ, Gibney RTN, Stollery D, Gao J (2005) Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 67:2361–2367CrossRefPubMed

22.

Monchi M, Berghmans D, Ledoux D et al (2004) Citrate vs. heparin for anticoagulation in continuous venovenous hemofiltration: a prospective randomized study. Intensive Care Med 30:260–265CrossRefPubMed

23.

Schilder L, Nurmohamed SA, Bosch FH et al (2014) Citrate anticoagulation versus systemic heparinisation in continuous venovenous hemofiltration in critically ill patients with acute kidney injury: a multi-center randomized clinical trial. Crit Care 18:472CrossRefPubMedPubMedCentral

24.

Betjes MGH, van Oosterom D, van Agteren M, van de Wetering J (2007) Regional citrate versus heparin anticoagulation during venovenous hemofiltration in patients at low risk for bleeding: similar hemofilter survival but significantly less bleeding. J Nephrol 20:602–608PubMed

25.

Morabito S, Pistolesi V, Tritapepe L et al (2012) Regional citrate anticoagulation in cardiac surgery patients at high risk of bleeding: a continuous veno-venous hemofiltration protocol with a low concentration citrate solution. Crit Care 16:R111CrossRefPubMedPubMedCentral

26.

Bellomo R, Cass A, Cole L et al (2009) RENAL Replacement Therapy Study Investigators: intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med 361:1627–1638. doi:10.1056/NEJMoa0902413 CrossRefPubMed

27.

Tolwani A, Wille KM (2012) Advances in continuous renal replacement therapy: citrate anticoagulation update. Blood Purif 34:88–93CrossRefPubMed

28.

Oudemans-van Straaten HM, Kellum JA, Bellomo R (2011) Clinical review: anticoagulation for continuous renal replacement therapy – heparin or citrate? Crit Care 15:202CrossRefPubMedPubMedCentral

29.

Stucker F, Ponte B, Tataw J et al (2015) Efficacy and safety of citrate-based anticoagulation compared to heparin in patients with acute kidney injury requiring continuous renal replacement therapy: a randomized controlled trial. Crit Care 19:813–819CrossRef

30.

Wu MY, Hsu YH, Bai CH et al (2012) Regional citrate versus heparin anticoagulation for continuous renal replacement therapy: a meta-analysis of randomized controlled trials. Am J Kidney Dis 59:810–818CrossRefPubMed

31.

Oudemans-van Straaten HM, Bosman RJ, Koopmans M et al (2009) Citrate anticoagulation for continuous venovenous hemofiltration. Crit Care Med 37:545–552CrossRefPubMed

32.

Zhang Z, Hongying N (2011) Efficacy and safety of regional citrate anticoagulation in critically ill patients undergoing continuous renal replacement therapy. Intensive Care Med 38:20–28CrossRefPubMed

33.

Mariano F, Morselli M, Bergamo D et al (2011) Blood and ultrafiltrate dosage of citrate as a useful and routine tool during continuous venovenous haemodiafiltration in septic shock patients. Nephrol Dial Transplant 26:3882–3888CrossRefPubMed

34.

Swartz R, Pasko D, Toole OJ, Starmann B (2004) Improving the delivery of continuous renal replacement therapy using regional citrate anticoagulation. Clin Nephrol 61:134–143CrossRefPubMed

35.

Martin TJ, Kang Y, Robertson KM et al (1990) Ionization and hemodynamic effects of calcium chloride and calcium gluconate in the absence of hepatic function. Anesthesiology 73:62–65CrossRefPubMed

36.

Davenport A, Tolwani A (2009) Citrate anticoagulation for continuous renal replacement therapy (CRRT) in patients with acute kidney injury admitted to the intensive care unit. NDT Plus 2:439–447PubMedPubMedCentral

37.

Kramer L, Bauer E, Joukhadar C et al (2003) Citrate pharmacokinetics and metabolism in cirrhotic and noncirrhotic critically ill patients. Crit Care Med 31:2450–2455CrossRefPubMed

38.

Zheng Y, Xu Z, Zhu Q et al (2013) Citrate pharmacokinetics in critically ill patients with acute kidney injury. PLOS ONE 8:e65992CrossRefPubMedPubMedCentral

39.

Balik M, Zakharchenko M, Leden P et al (2013) Bioenergetic gain of citrate anticoagulated continuous hemodiafiltration – a comparison between 2 citrate modalities and unfractionated heparin. J Crit Care 28:87–95CrossRefPubMed

40.

Mariano F (2013) Focusing on the basic principles of dialysis to optimize regional citrate anticoagulation. J Crit Care 28:99–100CrossRefPubMed

41.

Iacobazzi V, Infantino V (2014) Citrate – new functions for an old metabolite. Biol Chem 395:387–399CrossRefPubMed

42.

Böhler J, Schollmeyer P, Dressel B et al (1996) Reduction of granulocyte activation during hemodialysis with regional citrate anticoagulation: dissociation of complement activation and neutropenia from neutrophil degranulation. J Am Soc Nephrol 7:234–241PubMed

43.

Dhondt A, Vanholder R, Tielemans C et al (2000) Effect of regional citrate anticoagulation on leukopenia, complement activation, and expression of leukocyte surface molecules during hemodialysis with unmodified cellulose membranes. Nephron 85:334–342CrossRefPubMed

44.

Gabutti L, Ferrari N, Mombelli G et al (2004) The favorable effect of regional citrate anticoagulation on interleukin-1beta release is dissociated from both coagulation and complement activation. J Nephrol 17:819–825PubMed

45.

Gritters M, Grooteman MPC, Schoorl M et al (2006) Citrate anticoagulation abolishes degranulation of polymorphonuclear cells and platelets and reduces oxidative stress during haemodialysis. Nephrol Dial Transplant 21:153–159CrossRefPubMed

46.

Bryland A, Wieslander A, Carlsson O et al (2012) Citrate treatment reduces endothelial death and inflammation under hyperglycaemic conditions. Diab Vasc Dis Res 9:42–51CrossRefPubMedPubMedCentral

47.

Fiaccadori E, Regolisti G, Cademartiri C et al (2013) Efficacy and safety of a citrate-based protocol for sustained low-efficiency dialysis in AKI using standard dialysis equipment. Clin J Am Soc Nephrol 8:1670–1678CrossRefPubMedPubMedCentral

48.

Khadzhynov D, Schelter C, Lieker I et al (2014) Incidence and outcome of metabolic disarrangements consistent with citrate accumulation in critically ill patients undergoing continuous venovenous hemodialysis with regional citrate anticoagulation. J Crit Care 29:265–271CrossRefPubMed

49.

Link A, Klingele M, Speer T et al (2012) Total-to-ionized calcium ratio predicts mortality in continuous renal replacement therapy with citrate anticoagulation in critically ill patients. Crit Care 16:R97CrossRefPubMedPubMedCentral

50.

Meier-Kriesche HU, Gitomer J, Finkel K, DuBose T (2001) Increased total to ionized calcium ratio during continuous venovenous hemodialysis with regional citrate anticoagulation. Crit Care Med 29:748–752CrossRefPubMed

51.

Nurmohamed SA, Jallah BP, Vervloet MG et al (2013) Continuous venovenous haemofiltration with citrate-buffered replacement solution is safe and efficacious in patients with a bleeding tendency: a prospective observational study. BMC Nephrol 14:202CrossRef

52.

Mariano F, Tedeschi L, Morselli M et al (2010) Normal citratemia and metabolic tolerance of citrate anticoagulation for hemodiafiltration in severe septic shock burn patients. Intensive Care Med 36:1735–1743CrossRefPubMed

53.

Bakker AJ, Boerma EC, Keidel H et al (2006) Detection of citrate overdose in critically ill patients on citrate-anticoagulated venovenous haemofiltration: use of ionised and total/ionised calcium. Clin Chem Lab Med 44:962–966. doi:10.1515/cclm.2006.164

54.

Hetzel GR, Taskaya G, Sucker C et al (2006) Citrate plasma levels in patients under regional anticoagulation in continuous venovenous hemofiltration. Am J Kidney Dis 48:806–811CrossRefPubMed

55.

Meier-Kriesche HU, Finkel KW, Gitomer JJ, DuBose TD (1999) Unexpected severe hypocalcemia during continuous venovenous hemodialysis with regional citrate anticoagulation. Am J Kidney Dis 33:e8CrossRefPubMed

56.

Schultheiß C, Saugel B, Phillip V et al (2012) Continuous venovenous hemodialysis with regional citrate anticoagulation in patients with liver failure: a prospective observational study. Crit Care 16:R162CrossRefPubMedPubMedCentral

57.

Bouchard J, Madore F (2009) Role of citrate and other methods of anticoagulation in patients with severe liver failure requiring continuous renal replacement therapy. NDT Plus 2:11–19PubMed

58.

Morabito S, Pistolesi V, Tritapepe L et al (2013) Continuous venovenous hemodiafiltration with a low citrate dose regional anticoagulation protocol and a phosphate-containing solution: effects on acid-base status and phosphate supplementation needs. BMC Nephrol 14:1563CrossRef

59.

Saner FH, Treckmann JW, Geis A et al (2012) Efficacy and safety of regional citrate anticoagulation in liver transplant patients requiring post-operative renal replacement therapy. Nephrol Dial Transplant 27:1651–1657CrossRefPubMed

60.

Slowinski T, Morgera S, Joannidis M et al (2015) Safety and efficacy of regional citrate anticoagulation in continuous venovenous hemodialysis in the presence of liver failure: the Liver Citrate Anticoagulation Threshold (L-CAT) observational study. Crit Care 19(1):349

61.

Morgera S, Schneider M, Slowinski T et al (2009) A safe citrate anticoagulation protocol with variable treatment efficacy and excellent control of the acid-base status. Crit Care Med 37:2018–2024CrossRefPubMed

62.

Morgera S, Scholle C, Melzer C et al (2004) A simple, safe and effective citrate anticoagulation protocol for the genius dialysis system in acute renal failure. Nephron Clin Pract 98:c35–40CrossRefPubMed

63.

Morita Y, Johnson RW, Dorn RE, Hall DS (1961) Regional anticoagulation during hemodialysis using citrate. Am J Med Sci 242:32–43CrossRefPubMed

64.

Morabito S, Pistolesi V, Tritapepe L et al (2013) Regional citrate anticoagulation in CVVH: a new protocol combining citrate solution with a phosphate-containing replacement fluid. Hemodial Int 17:313–320CrossRefPubMed

65.

Tolwani AJ, Prendergast MB, Speer RR et al (2006) A practical citrate anticoagulation continuous venovenous hemodiafiltration protocol for metabolic control and high solute clearance. Clin J Am Soc Nephrol 1:79–87CrossRefPubMed

66.

Fiaccadori E, Pistolesi V, Mariano F et al (2015) Regional citrate anticoagulation for renal replacement therapies in patients with acute kidney injury: a position statement of the Work Group „Renal Replacement Therapies in Critically Ill Patients“ of the Italian Society of Nephrology. J Nephrol 28:151–164CrossRefPubMed

67.

Morabito S, Pistolesi V, Tritapepe L et al (2013) Continuous veno-venous hemofiltration using a phosphate-containing replacement fluid in the setting of regional citrate anticoagulation. Int J Artif Organs 36:845–852CrossRefPubMed

68.

Shum H‑P, Chan K‑C, Yan W‑W (2012) Regional citrate anticoagulation in predilution continuous venovenous hemofiltration using prismocitrate 10/2 solution. Ther Apher Dial 16:81–86CrossRefPubMed

69.

Cubattoli L, Teruzzi M, Cormio M et al (2007) Citrate anticoagulation during CVVH in high risk bleeding patients. Int J Artif Organs 30:244–252PubMed

70.

Khadzhynov D, Slowinski T, Lieker I et al (2014) Evaluation of acid-base control, electrolyte balance, and filter patency of a Prismaflexbased regional citrate anticoagulation protocol for pre-dilution continuous veno-venous hemodiafiltration. Clin Nephrol 81:320–330CrossRefPubMed

71.

Gupta M, Wadhwa NK, Bukovsky R (2004) Regional citrate anticoagulation for continuous venovenous hemodiafiltration using calcium-containing dialysate. Am J Kidney Dis 43:67–73CrossRefPubMed

72.

Brain M, Anderson M, Parkes S, Fowler P (2012) Magnesium flux during continuous venovenous haemodiafiltration with heparin and citrate anticoagulation. Crit Care Resusc 14:274–282PubMed

73.

Mitchell A, Daul AE, Beiderlinden M et al (2003) A new system for regional citrate anticoagulation in continuous venovenous hemodialysis (CVVHD). Clin Nephrol 59:106–114CrossRefPubMed

74.

Kalb R, Kram R, Morgera S et al (2012) Regional citrate anticoagulation for high volume continuous venovenous hemodialysis in surgical patients with high bleeding risk. Ther Apher Dial 17:202–212CrossRefPubMed

75.

Fliser D, Kielstein JT (2006) Technology Insight: treatment of renal failure in the intensive care unit with extended dialysis. Nat Clin Pract Nephrol 2:32–39CrossRefPubMed

76.

Marshall MR, Golper TA (2011) Low-efficiency acute renal replacement therapy: role in acute kidney injury. Semin Dial 24:142–148CrossRefPubMed

77.

Schwenger V, Weigand MA, Hoffmann O et al (2012) Sustained low efficiency dialysis using a single-pass batch system in acute kidney injury – a randomized interventional trial: the REnal Replacement Therapy Study in Intensive Care Unit PatiEnts. Crit Care 16:R140CrossRefPubMedPubMedCentral

78.

Berbece AN, Richardson RMA (2006) Sustained low-efficiency dialysis in the ICU: cost, anticoagulation, and solute removal. Kidney Int 70(5):963–968CrossRefPubMed

79.

Kielstein JT, Kretschmer U, Ernst T et al (2004) Efficacy and cardiovascular tolerability of extended dialysis in critically ill patients: a randomized controlled study. Am J Kidney Dis 43:342–349CrossRefPubMed

80.

Kumar VA, Craig M, Depner TA, Yeun JY (2000) Extended daily dialysis: a new approach to renal replacement for acute renal failure in the intensive care unit. Am J Kidney Dis 36:294–300CrossRefPubMed

81.

Marshall MR, Golper TA, Shaver MJ et al (2001) Sustained low-efficiency dialysis for critically ill patients requiring renal replacement therapy. Kidney Int 60:777–785CrossRefPubMed

82.

Marshall MR, Ma T, Galler D et al (2004) Sustained low-efficiency daily diafiltration (SLEDD-f) for critically ill patients requiring renal replacement therapy: towards an adequate therapy. Nephrol Dial Transplant 19:877–884CrossRefPubMed

83.

Clark JA, Schulman G, Golper TA (2008) Safety and efficacy of regional citrate anticoagulation during 8‑hour sustained low-efficiency dialysis. Clin J Am Soc Nephrol 3:736–742CrossRefPubMedPubMedCentral

84.

Farese S, Jakob SM, Kalicki R et al (2009) Treatment of acute renal failure in the intensive care unit: lower costs by intermittent dialysis than continuous venovenous hemodiafiltration. Artif Organs 33:634–640CrossRefPubMed

Titel: Regionale Zitratantikoagulation
verfasst von: Dr. C. Nusshag
PD Dr. T. Brenner, MHBA
Prof. Dr. M. Zeier
Prof. Dr. M. A. Weigand
Prof. Dr. C. Morath
Publikationsdatum: 13.02.2017
Verlag: Springer Medizin
Schlagwörter: Akutes Nierenversagen
Nierenersatzverfahren
Akutes Nierenversagen
Heparin
Metabolische Alkalose
Erschienen in: Die Nephrologie / Ausgabe 2/2017
Print ISSN: 2731-7463
Elektronische ISSN: 2731-7471
DOI: https://doi.org/10.1007/s11560-017-0137-y

Leitlinien kompakt für die Innere Medizin

Mit medbee Pocketcards sicher entscheiden.

^{Seit 2022 gehört die medbee GmbH zum Springer Medizin Verlag}

Kostenlos registrieren

Neu im Fachgebiet Innere Medizin

Notfall-TEP der Hüfte ist auch bei 90-Jährigen machbar

26.04.2024 Hüft-TEP Nachrichten

Ob bei einer Notfalloperation nach Schenkelhalsfraktur eine Hemiarthroplastik oder eine totale Endoprothese (TEP) eingebaut wird, sollte nicht allein vom Alter der Patientinnen und Patienten abhängen. Auch über 90-Jährige können von der TEP profitieren.

Niedriger diastolischer Blutdruck erhöht Risiko für schwere kardiovaskuläre Komplikationen

25.04.2024 Hypotonie Nachrichten

Wenn unter einer medikamentösen Hochdrucktherapie der diastolische Blutdruck in den Keller geht, steigt das Risiko für schwere kardiovaskuläre Ereignisse: Darauf deutet eine Sekundäranalyse der SPRINT-Studie hin.

Bei schweren Reaktionen auf Insektenstiche empfiehlt sich eine spezifische Immuntherapie

25.04.2024 Allergien und Intoleranzreaktionen Nachrichten

Insektenstiche sind bei Erwachsenen die häufigsten Auslöser einer Anaphylaxie. Einen wirksamen Schutz vor schweren anaphylaktischen Reaktionen bietet die allergenspezifische Immuntherapie. Jedoch kommt sie noch viel zu selten zum Einsatz.

Therapiestart mit Blutdrucksenkern erhöht Frakturrisiko

25.04.2024 Hypertonie Nachrichten

Beginnen ältere Männer im Pflegeheim eine Antihypertensiva-Therapie, dann ist die Frakturrate in den folgenden 30 Tagen mehr als verdoppelt. Besonders häufig stürzen Demenzkranke und Männer, die erstmals Blutdrucksenker nehmen. Dafür spricht eine Analyse unter US-Veteranen.

Update Innere Medizin

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Springer Medizin

Zusammenfassung

Bitte loggen Sie sich ein, um Zugang zu diesem Inhalt zu erhalten

Weitere Artikel der Ausgabe 2/2017

Wie machen Schleifendiuretika den Urin sauer?

Welchen Einfluss hat der Fleischkonsum auf das Risiko für chronische Nierenerkrankungen?

Neue Tumortherapien und Hypertonie

Nach SPRINT: Bluthochdruckbehandlung bei CKD

Neue Entwicklungen auf dem Gebiet der Präeklampsie