title: Beyond the randomized clinical trial: citrate for continuous renal replacement therapy in clinical practice.
abstract: BACKGROUND
  Premature circuit clotting is a major problem during continuous renal replacement therapy (CRRT). Six randomized controlled trials confirmed that regional anticoagulation with citrate is superior to heparin. Our objective was to compare circuit patency with citrate, heparin and epoprostenol in routine clinical practice.
  
  
  METHODS
  We retrospectively analysed data on circuit patency of all circuits used in a single centre between September 2008 and August 2009. We differentiated between premature filter clotting, elective discontinuation and waste.
  
  
  RESULTS
  309 patients were treated with CRRT (n = 2,059 circuits). The mean age was 65.7; 63.8% were male. The methods to maintain circuit patency were unfractionated heparin (42.3%), epoprostenol (23.0%), citrate (14.7%), combinations of different anticoagulants (14.6%) and no anticoagulation (4.7%). Premature clotting was the most common reason for circuit discontinuation among circuits anticoagulated with heparin, epoprostenol or combinations of different anticoagulants (59-62%). Among circuits anticoagulated with citrate the main reason for discontinuation was elective (61%). Hazard regression analysis confirmed significantly better circuit survival with citrate. Changing from heparin to citrate decreased the risk of premature circuit clotting by 75.8%.
  
  
  CONCLUSIONS
  In routine clinical practice, regional anticoagulation with citrate is associated with significantly better circuit patency than heparin or epoprostenol.
authors.affiliation: Department of Critical Care, King's College London, King's Health Partners, Guy's & St Thomas' Foundation Hospital, London, UK.
authors.forename: L
authors.initials: L
authors.lastname: Tovey
authors.forename: H
authors.initials: H
authors.lastname: Dickie
authors.forename: S
authors.initials: S
authors.lastname: Gangi
authors.forename: M
authors.initials: M
authors.lastname: Terblanche
authors.forename: C
authors.initials: C
authors.lastname: McKenzie
authors.forename: R
authors.initials: R
authors.lastname: Beale
authors.forename: D
authors.initials: D
authors.lastname: Treacher
authors.forename: M
authors.initials: M
authors.lastname: Ostermann
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use*; D002614:Chelating Agents / Q000627:therapeutic use; D019343:Citric Acid / Q000627:therapeutic use*; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D008297:Male; D016032:Randomized Controlled Trials as Topic; D017582:Renal Replacement Therapy / Q000009:adverse effects* / Q000379:methods*; D012189:Retrospective Studies; D013927:Thrombosis / Q000209:etiology* / Q000517:prevention & control*; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D002614:Chelating Agents; D019343:Citric Acid