Comparison of different anticoagulation strategies for renal replacement therapy in critically ill patients with COVID-19: a cohort study

  1. Frederic Arnold
  2. Lukas Westermann
  3. Siegbert Rieg
  4. Elke Neumann-Haefelin
  5. Paul Marc Biever
  6. Gerd Walz
  7. Johannes Kalbhenn
  8. Yakup Tanriver

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Abstract

Background

Critically ill coronavirus disease 2019 (COVID-19) patients have a high risk of acute kidney injury (AKI) that requires renal replacement therapy (RRT). A state of hypercoagulability reduces circuit life spans. To maintain circuit patency and therapeutic efficiency, an optimized anticoagulation strategy is needed. This study investigates whether alternative anticoagulation strategies for RRT during COVID-19 are superior to administration of unfractionated heparin (UFH).

Methods

Retrospective cohort study on 71 critically ill COVID-19 patients (≥18 years), admitted to intensive care units at a tertiary health care facility in the southwestern part of Germany between February 26 and May 21, 2020. We collected data on the disease course, AKI, RRT, and thromboembolic events. Four different anticoagulatory regimens were administered. Anticoagulation during continuous veno-venous hemodialysis (CVVHD) was performed with UFH or citrate. Anticoagulation during sustained low-efficiency daily dialysis (SLEDD) was performed with UFH, argatroban, or low molecular weight heparin (LMWH). Primary outcome is the effect of the anticoagulation regimen on mean treatment times of RRT.

Results

In patients receiving CVVHD, mean treatment time in the UFH group was 21.3 h (SEM: ±5.6 h), in the citrate group 45.6 h (SEM: ±2.7 h). Citrate anticoagulation significantly prolonged treatment times by 24.4 h ( P  = .001). In patients receiving SLEDD, mean treatment time with UFH was 8.1 h (SEM: ±1.3 h), with argatroban 8.0 h (SEM: ±0.9 h), and with LMWH 11.8 h (SEM: ±0.5 h). LMWH significantly prolonged treatment times by 3.7 h ( P  = .008) and 3.8 h ( P  = .002), respectively.

Conclusions

UFH fails to prevent early clotting events in the dialysis circuit during COVID-19. For patients, who do not require effective systemic anticoagulation, regional citrate dialysis is the most effective strategy. For patients, who require effective systemic anticoagulation, the usage of LMWH results in the longest circuit life spans. The proposed anticoagulatory strategies are safe, can easily be monitored, and allow an individualized treatment.

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  1. Version published to 10.1186/s12882-020-02150-8
  2. ScreenIT

    SciScore for 10.1101/2020.06.26.20140699: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementIRB: Analysis and publication of the data was approved by the local ethics committee (155/20 to SR and 1016/20 to JK, Chairman Prof. R. Korinthenberg).
    RandomizationEvery ICU is operated by an independent department (medicine, anaesthesiology, cardiovascular surgery and general surgery) and patients were randomly assigned to the different ICUs.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    All statistical analyses were performed using Prism (Version 8.0.2), GraphPad Software, San Diego, California.
    Prism
    suggested: (PRISM, RRID:SCR_005375)
    GraphPad
    suggested: (GraphPad Prism, RRID:SCR_002798)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Despite its limitations, our study data can therefore guide clinical decisions for patients requiring anticoagulation for RRT during this ongoing pandemic. Ultimately, a better understanding of COVID-19 associated hypercoagulability is required to offer tailored anticoagulation strategies to maintain extracorporeal circuit patency and reduce overall mortality from thromboembolic events.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

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  3. Version published to 10.1101/2020.06.26.20140699v1 on medRxiv